Extended limits of co-payments for G.P. consultations: young people and pregnant women [P.80/2020]

STATES OF JERSEY

EXTENDED LIMITS OF CO-PAYMENTS FOR G.P. CONSULTATIONS: YOUNG PEOPLE AND PREGNANT WOMEN

Lodged au Greffe on 16th June 2020 by Deputy C.S. Alves of St. Helier

STATES GREFFE

2020  P.80

PROPOSITION

THE STATES are asked to decide whether they are of opinion

to request the Minister for Health and Social Services, in consultation with the Minister for Social Security and the Council of Ministers, as appropriate, to review his recent decisions on the level of co-payments to be charged to various groups of patients for the delivery of primary care and to –

1. extend the age limit for young people to receive free G.P. consultations from 4 years to 17 years of age;
2. reduce the cost of a pregnancy package' for pregnant women from £120 to zero; and
3. identify the appropriate source for the funding of this improvement.

DEPUTY C.S. ALVES OF ST. HELIER

REPORT

New arrangements for primary care services through the G.P.s were announced on 10th April 2020 with the following words –

"Government workers and G.P.s have finally come together to tackle the coronavirus pandemic, two weeks after the agreement was first announced by the Chief Minister.

106 G.P.s will be employed by the Health Department for the next four months in what's being called 'a landmark agreement for Jersey'.

The G.P.s will carry out tasks such as –

• Working with the ambulance service 24/7 to help treat patients

• Providing more support in care homes

• Working alongside hospital teams in the Emergency Department and Urgent Treatment Centre

• Support out of hospital care where possible

• Provide expert skills to the Health Department

The Minister for Health and Social Services described the agreement as "a landmark agreement for our Island. Our shared priority is to save lives, so we have come together to ensure that Islanders can access health professionals as quickly as possible, at a time when health resources are needed most.

For the next four months, all G.P.s will be directly employed by Health and Social Services. This will provide more resilience for the hospital, as G.P.s will be able to take shifts in the Emergency Department, and G.P.s with specialisms in diabetes or other conditions can cover for specialist colleagues in the hospital."

"This agreement gives Health and Community Services more capacity and more flexibility to adapt to changing needs and puts Jersey's healthcare system in a stronger position to tackle COVID-19." – Deputy Richard Renouf , Health Minister.

This now means that islanders who want to make an appointment with their G.P. will have to call their surgery and not simply turn up. They will get either a telephone or video consultation, a face-to-face consultation or a home visit as deemed appropriate by the G.P.

If a patient has coronavirus symptoms, the G.P. will decide which method of treatment is best. G.P. surgeries will be split into two areas – hot for those with symptoms and cold for those without.

As the need for treatment increases, islanders may have to visit a different G.P. surgery. Meanwhile, the cost of seeing a G.P. in Jersey has been cut in half." [1]

The new scale of charges is below:

Whilst I, like many others, welcome this improvement in access to medical treatment, I am afraid that the Minister for Health and Social Services' proposals to cover the duration of the Covid-19 pandemic, entirely appropriate in the short term, do not form a sound basis in the longer term. My reservations are based on the words of the Children's Commissioner, when in a press release she says –

"I very much welcome the Government's announcement that more than 100 G.P.s will now be employed directly by the Government of Jersey, and that access to G.P.s will now be free of charge for children aged between zero and four years old, as will childhood immunisation. However, I am calling for this to be expanded to all children and young people up to the age of 18.

I also note that pregnancy bundles' have now been capped at £120, however, I would call for this to also become free so as to support good prenatal and childhood health, as supported by a well-established body of research.

The UNCRC is clear that all children and young people up to the age of 18 are entitled to special measures of care and protection, including their right to health. This right applies to every child, as does their right to be free from discrimination under Article 2 of the UNCRC. Any fees to access healthcare services present barriers to children and young people from accessing their right.

The Committee on the Rights of the Child has been clear on this, stating that "barriers to children's access to health services including financial, institutional and cultural barriers should be identified and eliminated.

Every child and young person in Jersey should therefore be able to access healthcare for free regardless of the child or their family's economic situation, or any other factor as children are the rights holders and the State is the duty bearer.

The right to health not only includes the right to access services free of charge, it further means that children have the right to benefit from wider supports to enjoy the maximum standard of health that they can. This includes access to nutritious food, mental health support and wider wellbeing supports. The Government of Jersey must continue to support children to have the best standard of health that they can during the current health emergency and beyond.

It is important to continue to engage with children and young people about what they need support with so that the priorities are guided by the views and experiences of children in Jersey to provide the best possible support in this difficult time. Access to information in clear accessible language to keep children informed and updated is hugely important, and will help to ease children's concerns throughout this time of uncertainty.

Protections for children's rights are just as necessary, if not more so, in times of crisis. However, since this shows that the Government employing G.P.s directly is possible and workable in Jersey, it is hard to see why this could not be extended beyond the Covid-19 outbreak. Ensuring that any child at any point in time can access their  right to healthcare free of charge in Jersey is something that we should strive for at all times."[2]

The Commissioner's calls on the Government must continue to support children to have the best standard of health that they can during the current emergency and beyond –

"Article 24 of the United Nations Convention on the Rights of the Child (UNCRC), is clear that no child should be deprived of their right to access health care services, placing a proactive duty on States to fulfil this obligation and remove any barriers to children accessing it."

The Commissioner, who also wants pregnancy bundles to be free, says half of all children who took part in her island-wide survey said there should be no cost to go the doctor –

"I've got pages and pages of quotes from children saying that they didn't go to the doctor because their parents couldn't afford it and that just isn't good enough.

"Children have the right to the highest attainable standard of health in international law.

"It's the duty of this government to provide it. It's not a nice to have, they must do it."

A letter from UNICEF to the Minister for Health and Social Services, dated 28th May of this year (included in the Appendix to this report), draws the Minister's attention to Article 24 of the rights of the Child, and describes the potential for the Minister to take a "great step forward" in his pledge to "put children first".

The problem with the Minister's proposals in the face of the Covid-19 pandemic, is that in January this year, the Minister accepted, and the Assembly agreed, the following proposition (P.125/2019 Amd.) to request the Minister for Health and Social Services, in consultation with the Council of Ministers, as appropriate, to devise a scheme which improves access to primary care by reducing financial barriers for patients who are financially, clinically or socially vulnerable, by –

1. identifying and prioritising which vulnerable groups are most in need of affordable access to primary care;
2. for the groups identified in (a), reducing the patient co-payment from its current level, supporting the development of multidisciplinary services provided in General Practice, which might include expanded roles for pharmacists, nurses, physiotherapists, mental health workers and community support workers; and
3. identifying the appropriate sources for the funding of such improved services;

and to bring a proposition for debate by the Assembly in the third quarter of 2020, in order that such a scheme can be implemented from 1st January 2021.

Whilst the Minister has brought forward proposals that may be an appropriate response to the pandemic, he has failed to consider the wider assessment required of him to identify and prioritise vulnerable groups as agreed under  P.125/2019. In terms  of identified groups, then it is difficult to justify that a 4 year-old has different health needs and access to that of a 6 year-old or a 10 year old. Equally, a 14 year-old should not be dependent on their parents in having access to appropriate health care. The Independent Jersey Care Inquiry Panel made the same plea on behalf of children and young people in its report R.123/2019 –

"The cost of private G.P. care is a barrier to young people and to vulnerable adults who do not have access to household funds (or do not qualify for income support) getting health services, advice or G.P. support because they cannot pay for appointments or treatment. To enhance protections for children and young people we believe that new policies are required to allow free or fully funded access to G.P. care and advice for vulnerable groups."

Financial and manpower considerations

In the absence of any hard data on the frequency of G.P. consultations for children in Jersey, it is difficult to estimate what the costs may be. United Kingdom data (where consultations are already free) show that under 5s (which will include many neonatal consultations) average almost 6 visits per year, while under 18s average only 3 visits. The additional cost of fully subsidising G.P. consultations for all 14,000 under 18s might be in the order of £1.7 million. Full subsidy for the "pregnancy package", bearing in mind that these visits will be often covered under the Jersey Care Model (JCM) by the practice or community nurse or other professional in the community hub, is in the order of £120,000 annually.

There are no manpower implications.

APPENDIX

Deputy Richard Renouf , Minister for Health

19-21 Broad Street

St Helier

Jersey

JE2 3RR

28 May 2020

Dear Minister

I am writing on behalf of the UK office of the United Nations Children's Fund, UNICEF, to congratulate you on your recent measures in response to the Covid-19 emergency. Deborah McMillan, the Children's Commissioner for Jersey, has kindly informed us that you had announced a temporary G.P. contract for the duration of the emergency within which G.P. services for all children under 5 will be provided free of charge with a flat fee of £10 for children and young people aged 5 to 17. We understand that childhood immunisations remain free as they have been for some time.

We warmly welcome your decision and would respectfully suggest to you to consider to continue with it beyond the Covid-19 emergency but to also extend it to all children. Such a decision would be a huge element of your government support for children and a great step forward in implementing your Common Strategic Policy within which you pledged to "put children first".

Article 24 of the Convention on the Rights of the Child recognises "the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health". It obliges States Parties "to strive to ensure that no child is deprived of his or her right of access to such health care services". Paragraph 2 provides a non-exhaustive list of appropriate measures that States must take in pursuing full implementation of the right, including "to ensure the provision of necessary medical assistance and health care to all children with emphasis on the development of primary health care".

As with other economic, social and cultural rights, the Convention on the Rights of the Child requires States Parties to implement article 24 "to the maximum extent of their available resources". There is no obligation on States Parties, including Jersey, to provide free primary health care but there is a duty to apply all appropriate measure and to move towards full implementation of child rights expeditiously and effectively. Indeed, The UN Committee on the Rights of the Child frequently expresses general concern at lack of access, and lack of free access, to health services, in particular for disadvantaged groups.

UNICEF calls on the Jersey Government to evaluate the extent of the realisation of the right  to  the  highest  attainable  standards  of  health  and  to  devise  strategies  and programmes for their promotion, are not in any way eliminated as a result of resource constraints." Now is the good moment: in January 2021 the UN Committee on the Rights of the Child is going to look into implementation of the Convention in Jersey.

UNICEF very much hopes that Jersey Government will continue its already impressive pace  of  realising  child  rights.  The  forthcoming  reporting  process  is  the  perfect opportunity for Jersey to keep momentum. Let's celebrate another important progress and achievement by Jersey by introducing free primary health care for all children!

Yours sincerely,

Sophie Galois Deputy Executive Director UNICEF UK