Letter from the Minister for Health and Social Services to the HSS Panel re Quarterly Hearing follow up

19-21 Broad Street | St Helier Jersey | JE2 4WE

Deputy Geoff Southern Chair, HSS Panel

BY EMAIL

19 December 2022

Dear Geoff

Re: Quarterly Hearing Follow-up Questions

Thank you for your letter dated 9 December regarding a number of follow-up questions from the Panel. Please see responses to said questions below.

Recruitment and Retention

1. What recruitment drive is currently being undertaken to fill existing vacancy gaps?

HCS is running an international recruitment campaign for theatre nurses, undertaking a social media campaign for radiographers, attending job fairs to attract midwives, and has used a specialist recruitment agency to source doctors.

1. Would the Minister provide the Panel of the most up to date vacancy figures across the service?

At the end of October 2022, HCS had 423 WTE vacancies as shown below.

2. Which areas within health and community services are having the most difficulties recruiting to (we note that mental health is one area)?  

Mental Health is experiencing recruitment challenges in relation to psychiatry and mental health nurses (which is consistent with recruitment challenges in these areas in other jurisdictions). There are also very significant recruitment difficulties in relation to administration staff, with lots of administration staff leaving to take jobs outside of Government (where it is felt that salary and conditions are frequently better). A specific mental health recruitment campaign is planned for early 2023  

HCS continue to experience difficulty in recruiting to midwives, theatre nurses, radiographers, and some specialist doctors.

2. During the Quarterly Hearing, you were asked what the number of interim employees and management posts there are in the Health Department. You explained that you would provide the Panel with a breakdown at a later date. Please could the Panel receive that breakdown?

HCS is currently using 140 agency and locum staff to cover vacancies.

The leadership structure in the department is organised on a tiered basis. 31 staff are in the Tier 1 – 3 structures of which 24 are clinically qualified and provide clinical leadership.

At Tier 4 we have 61 staff of which 36 are clinically qualified as either nurses, doctors, allied health professionals or social workers. In this tier there are also 21 non-clinically qualified roles in environments such as Estates and non-clinical support services.

Who else does this include? Health and Care Board[1]

3. The Panel notes that the Chair of the new Health and Care Board has been appointed, and thanks the Minister for offering a private meeting with the Panel following the appointment. Would the Minister explain to the Panel, what process was used to ensure complete independence?

As advised at the quarterly hearing on Thursday 1 December[2], the process to appoint Professor Mascie- Taylor was overseen by Jersey Appointments Commission with the Chair of the Commission chairing the process.

The search and outreach to potential candidates was undertaken by a specialist executive search firm. A total of 52 potential candidates were considered with 5 being shortlisted for interview.

The interview process included a meeting with a representative group of HCS staff who asked the candidates questions about their approach to improving culture in HCS, followed by a selection panel which included GoJ's Chief Executive Officer and an external GP.

The selection panel recommended two potential candidates. Those candidates met with the Minister for Health and Social Services and the Deputy Chief Minister, prior to the Minister for Health and Social Services making the appointment decision.

1. How did you come to the decision that the appointed Chair was the best candidate?

As discussed at the quarterly hearing on Thursday 1 December, having met the two candidates recommended by the appointment panel, the Deputy Chief Minister and I were satisfied that the candidate who was chosen successfully demonstrated the required credentials for the role.

2. Do you consider there to be any issues of conflict of interest in regard to this appointment?

The Deputy Chief Minister and I gave the matter consideration and concluded that there was no conflict of interest.

Waiting Lists

4. Could the Minister detail which specific departments are of particular concern in respect of their current waiting lists?

Specialties where there are more than 30 patients waiting for a first outpatient appointment and more than 35% of those patients have been waiting over 90 days at the end of November 2022 are:

• Clinical Genetics (off Island)

• Community Health Services Dental

• Clinical Genetics (on Island)

• Bariatric Medicine

• Ophthalmology

• Paediatric Trauma & Orthopaedics

• Gynaecology

• Paediatrics

• Rheumatology

• Orthoptics

• Dermatology

• Respiratory Medicine

For patients waiting for a diagnostic procedure, there are just under 900 patients waiting at the end of November 2022 with 54% having been waiting for 90 days or more.

Specialties where there are more than 30 patients waiting for an elective admission and more than 35% of those patients have been waiting over 90 days at the end of November 2022 are:

• Trauma & Orthopaedics

• General Surgery

• ENT

• Ophthalmology

• Gynaecology

In relation to mental health services, the specific areas of concern are neurodevelopmental services (ADHD & Autism), psychological therapies (including Jersey Talking Therapies), and the dementia diagnosis pathway. In all these areas demand has significantly increased and outstrips available capacity. Work is being undertaken to understand this profile and address the backlog.

5. What progress has been made in recent months in reducing waiting lists?

We have made improvements in outpatient waiting lists for first outpatient appointments. These peaked at 9825 at the end of June 2022 but at the end of November 2022, this has reduced by 8% to 9049. Specialties with significant reduction in the number of patients on the waiting list are Gastroenterology, Physiotherapy, Pain Management, Orthodontics, Orthoptics and Oral Surgery.

Within Community Health Services Dental 88.8% of patients have waited > 90 days for their first appointment. Five Dental practices have now been commissioned address this backlog.

The HCS dental department has focussed on continuity of care for patients already under their care since the pandemic. At the peak of the pandemic 4200 patients were past their recall date, this has reduced to 1688 as of writing. The department set up an emergency triage service with one daily toothache slot that could be filled by a new of follow-up patient experiencing pain. Throughout 2022 the department has seen an average of 7 new patients per week vs an average of 16 new referrals per week, hence the significant growth month on month.

Since the commissioning strategy commenced the average number of new patients seen per week has increased to 33 patients per week (17 additional patients per week than the average number of referrals received), we expect waiting lists to decrease. A trajectory of improvement for the next 34 weeks has been produced to monitor progress.

The number of people waiting for an Endoscopy has reduced by 35% from the start of January to the end of November 2022. Much of this is due to the introduction of the Faecal Immunochemical Testing (FIT) programme.

Planned expenditure to reduce waiting lists was highlighted in the Government Plan but further to recent decisions of the States Assembly regarding the use of the General Reserves/HIF funds, this now needs to be revisited.

6. How will the digital health care plans transform health care services, ensuring shorter wait lists?

The following benefits in relation to waiting list management have been identified as resulting from the implementation of Maxims the new Patient Administration System (PAS)/Electronic Patient Record (EPR):

7. The Chief Minister stated in a hearing with the Corporate Services Panel that, among other things, cultural changes were needed to help reduce waiting lists. We are aware that a new "Speak up Champion" has been engaged to help with cultural changes. How is the new Speak up Champion' supporting change in the work culture within HCS and what feedback has been given that supports this?

The Freedom to Speak Up Champion is due to take up post in the New Year. There is however a bespoke programme of work that is underway in HCS (as part of the Be our Best' improvement plan) under the Director of Culture and Wellbeing that focusses specifically on culture, engagement, and behaviour.  

8. What are the current readmission rates?

The following table shows the readmission rate over the last twelve months.

The indicator is the number of emergency admissions to Jersey General Hospital each month that have been previously discharged from inpatient admission in the prior 30 days. In line with the definitions used in the NHS, obstetrics and oncology patients are excluded along with admissions to day care units (Day Surgery, AEC, MDU, Renal, Oncology Service, Aubin ward). Private patients are also excluded.

Sustainable Health Care Funding

9. When do you aim to produce and publish a Primary Care Strategy in collaboration with the Minister for Social Security?

The Primary Care Strategy will be developed during 2023. We aim to publish a final strategy by end Q1 2024, although engagement and consultation with stakeholders and the public will take place over 2023.

10. What discussions have taken place with the Primary Care Board in respect of the work your department is undertaking on Sustainable Health Care Funding?

The Primary Care Board are aware of this work. Detailed conversations will take place with GPs and other primary care providers in Q2 2023. These conversations will be informed by the household survey to be undertaken in January 2023 (as previously discussed with the Panel).

11. During the public hearing held with the Panel on the 7 November, you informed the Panel that yourself and the Minister for Social Security would be reviewing the Health Access Scheme. When is this work due to begin and when is it due to be completed?

As stated at the meeting on 7 November 2022, the Health Access Scheme will be reviewed as part of the work on sustainable health funding. To date we have contracted specialist health economists who are working to determine current and future health expenditure and will be advising Ministers on future funding options. This work will be progressing throughout 2023, with a view to the Assembly debating future funding options in early 2024.

a.  You also stated that the longer-term goal would be to expand these services to nearer 30% of the population, which could have various indicators such as long- term health conditions and possibly age factors. How do you plan to put this long-term goal in place and, when?

As set out in the Council of Minister's comment to the Proposed Government Plan 2023-26, Amendment 16, decisions as to which populations / groups of people should receive further financial support to access primary care will be considered as part of the sustainable health care funding review. Populations to be considered include high users of primary care, children, and those of lower means not currently eligible for the Health Access Scheme.

30% was referenced as a broad estimate of the numbers of people in Jersey who have long-term health conditions and / or are recipients of income support. It was not intended to be understood as the target percentage of the population that should fall within the Health Access Scheme criteria.

12. During the Quarterly Hearing on the 1 December, the Panel asked where the budget for the Sustainable Health Care funding is coming from. We were told the Jersey Care Model Funding which was indirectly from the Health Insurance Fund. We then asked how much that is costing and were told we could be provided with that figure at a later date. Please could you provide that figure?

The total anticipated spend is £190,000 in 2022 and £112,000 in 2023. Following the Proposed Government Plan 2023-26 debate, the 2023 monies will be funded from General Reserves, not the Heath Insurance Fund.

Jersey Care Model

13. Recommendation 7 of the JCM Review states that the use of the term JCM should cease and that each project should be considered on its own merit as a service development. How will the Minister ensure that each service development will link to the other and achieve an overarching objective?

In light of recent decisions made by the States Assembly, the approach to developing services in the community needs to be revisited.

14. How do you intend to tighten operational controls and increase oversight of implementation?

In light of recent decisions made by the States Assembly, operational controls and oversight need to be revisited.

15. The Review states that the JCM pause has delayed the projects in the planning and design stages which plan to recruit or implement additional clinical services from Q3 onwards and, that there are no new lines of expenditure for these projects. When are the delayed projects due to restart?

In light of recent decisions made by the States Assembly, this will need to be revisited.

16. Do you consider the new discharge policy and its implementation to be successful?

The Discharge best practice guidelines were ratified in November 2022 and have recently been implemented. Considering that it has only just been implemented, it is too early to say if its implementation has been successful.

17. What are your views regarding the HCS 24 programme?

I am supportive of improving access to healthcare for Islanders over a 24-hour period and the development of HCS24 aims to deliver this.

Mental Health

18. When are you hoping to finalise scoping and publish a service-user led mental health strategy?

We aim to have completed the refreshed mental health strategy by the end of 2023.

1. Where is the funding for this work coming from as, the Panel are aware that mental health in young people funding has moved to CYPES?

The work will be funded predominantly from within Mental Health's budgets.

2. The Ministerial Plan states that work will be undertaken on improving quality and access to services for young people affected by severe mental illness. How do you intend to do this?

In the first instance, we will develop an extended 24/7 mental health crisis assessment & support provision for young people (with clear onward pathways into services when needed) and a dedicated transition service between CAMHS and adult mental health. These are both joint initiatives between HCS & CYPES and will be delivered in the 2023. We will also be reviewing and developing the Early Intervention in Psychosis pathway for young people with a developing psychotic illness and reviewing the pathway for people with complex trauma related presentations.

3. How do you intend to improve quality and access to services for young people affected by less severe mental illness?

We will be working on joint initiatives with CAMHS who are leading on this agenda on behalf of the Minister for Children and Education.

19. We asked in a letter dated 24th October 2022, how the £449,000 requested funding for Orchard House will be spent. The Panel were informed that £149,000 would be spent on cashflow in 2023 (payments of retentions)' and £300,000 would be allocated for Estimated outturn costs'. A further question was asked on 17th November, asking for an explanation of what is meant by payments of retentions' and estimated outturn costs', please could you provide a response in this format? Would you please explain what the estimated outturn costs are aimed to cover and how the estimation was generated?

As advised on 9 December, Payments of Retention' is a contractual payment for monies (normally 2.5%) held for 12 months post completion of a phase of works or whole project, and Estimated outturn costs' is the committed expenditure to deliver a project.

1. In addition, the Panel were informed that as of 26th October, £6,069,725 of the allocated budget (8.6m) had been spent. How much of the allocated budget has now been spent to date?

 The spend as of 14 December 2022 is £6,708,299.37.

2. Please provide an update on how the building work is progressing and when it is due to be finalised.

Phase 1 of Clinique Pinel (14 new anti-ligature bedrooms and associate amenity spaces) was handed over on the 12 September 2022. It was occupied from the 22 September 2022.

Rosewood House was handed over on 4 November 2022, however, the Fire Service are yet to sign off on reoccupation.

Unfortunately, the discovery of further non-compliant' fire stopping on the first floor of Clinique Pinel has meant a further delay. Access to this area was only permissible once Phase 1 was achieved.

Accordingly, the contractor is now reporting to have the ground floor of Clinique Pinel (which includes the Article 36 Suite/Place of Safety) and the associated hard landscaping complete by the 15 March 2023 (i.e., the previous estimated completion date) and the first-floor works (including allowance for the additional fire protection works) by the 30 June 2023.

Public Health

20. The Panel understands that you are aiming to support the development of more accurate information about health trends in Jersey during 2023 in order to improve and protect health and monitor progress over time. How exactly will you support this development?

Work has commenced to agree the governance for delivering Jersey's first JSNA, the model will be presented to ELT and COM early in the new year. During Year 1, the Steering Group is expected to agree two JSNA topic areas and pilot the delivery of needs assessments for these areas by year end.

In January, the Public Health Intelligence Team will publish an update to the 2016 Health Profile, which will provide the latest quantitative public health indicators and benchmarking against other jurisdictions and facilitate prioritisation of topics for the wider JSNA.

The COVID Recovery Understanding and Insights Project will match census information to health and other administrative data to support a greater understanding of health inequalities and usage of services. The Qualitative arm of the COVID Recovery Understanding & Insights Project will explore the pandemics impact on health needs which will provide valuable information about the health needs of Islanders from their own perspectives and also the perspectives of professionals working across in public facing roles. The outputs from the 2021 census, including updated population projections will be combined with health data to understand future implications of the disease burden on the Island.

A new update to Healthy Life Expectancy and Disability-Free Life expectancy will also be published in 2023, as well as Jersey's first Screening Profile.

The Public Health Intelligence team is undertaking ongoing work to improve data architecture for Public Health data, to facilitate internal monitoring of health trends in a more timely and accessible fashion. The tri-island Public Health Outcomes Framework is also being populated, which will allow key indicators to be compared with Guernsey and the Isle of Man.

21. Please can you provide a progress update regarding the development of a new public health law.

The new public health law will be developed in 2023. Public Health and wider SPPP colleagues are working together to ensure that appropriate resources and officer capacity are in place to develop the law. The first stage of work on the proposed law is to finalise policy proposals and the drafting instructions. This work will be informed by the key themes and

issues identified from responses to the consultation undertaken in summer 2021. It is anticipated that the draft law will be lodged for States debate in 2024, subject to the necessary stakeholder engagement, scrutiny, and ministerial approval.

1. In your view, what are the principal defects of the existing Law that have led to this development?

The COVID-19 pandemic highlighted weaknesses in the statutory framework for dealing with public health emergencies. The public health legislation available at the beginning of the pandemic – the Loi (1934) sur la Santé Publique – is outdated and provides limited powers or oversight to respond to modern public health risks and hazards. For example, the 1934 Law does not provide:

• clear roles for relevant Ministers and public health officials

• adequate powers that enable restrictions and requirements to be imposed, where necessary and proportionate, to protect people's health

• appropriate thresholds and accountability arrangements for the use of powers to protect people's health; and

• safeguards for people who are subject to those powers.

The inadequacy of the 1934 Law to respond to public health emergencies was demonstrated by the need to bring forward individual pieces of legislation to address the health risks associated with the pandemic. This is not an effective approach to manage a public health emergency, and the range of risks and hazards that threaten people's health.

Moreover, the 1934 Law is from a time when life expectancy was lower, housing and sanitation were of a basic standard, and diseases such as cholera were common in Jersey. The Law is not consistent with modern day public health activities such as surveillance and monitoring, and it does not support action to promote and address public health challenges such as non-communicable diseases.

2. Please explain how the law will provide measures to support the control of infectious disease threats and hazards.

The proposed new public health law presents an opportunity to learn from the COVID- 19 pandemic and improve the Government of Jersey's preparedness and ability to respond to future public health emergencies. The precise scope of the law is yet to be agreed, but it is proposed that it will introduce measures to support the control of infectious disease risks and hazards, including:

• Widening the range of public health risks and hazards to which health protection arrangements apply – such as the aftermath of a chemical spill, an outbreak of tuberculosis, or a pandemic.

• Enhancing the framework for routine public health action when infection or contamination is present, or could be present, and which presents significant threat or hazard to public health.

• Introducing public health emergency powers, including a statutory requirement for Minister/s or the Director of Public Health to develop and maintain emergency preparedness plans, and a broad range of powers for use in response to public health emergencies.

• A statutory requirement for notification of threats to public health, which covers a broader range of threats to public health than presently under the 1934 Law; better defines who is under a duty to report; specifies timeframes and allows for flexibility on the method of reporting to account for technological changes.

These measures will enhance the statutory framework to prevent, prepare for and response to public health risks and hazards. At the same time, the law will include provision to ensure that the measures are necessary and appropriate, establish the circumstances and threshold in which health protection powers could be exercised, and introduce safeguards to protect individuals subject to those powers.

3. How will the law address the health inequalities and ensure a focus on health outcomes across all activities?

The new public health law will provide a modern framework for public health activities in Jersey. This includes providing a statutory basis for public health intelligence, which undertakes surveillance and monitoring of the health of the population and health risks. A statutory basis for these activities will facilitate the continuous, systematic, and timely collection of health-related data across government. The availability of this information provides the evidence-base for public health policies, programmes and services, and support action on the social determinants of health and health inequalities.

There is potential to include within the law a statutory requirement to undertake a Jersey Strategic Needs Assessment (JSNA). Currently, the JSNA is being undertaken on a non-statutory basis. The JSNA will support the collection of data from across government and provide a comprehensive picture of the health and the wellbeing of the Island's population, including where health inequalities exist and where there might be opportunities to reduce those inequalities.

4. Are you still on track for a 2024 debate?

The draft law is on track for debate in 2024, subject to the necessary stakeholder engagement, scrutiny, and ministerial approval. Public Health and wider SPPP colleagues are working to ensure that appropriate resources and officer capacity are in place to develop the legislation in 2023.

22. When is the Public Health Strategy due to be finalised?

The public health strategy is in its final stages of being drafted, following extensive consultation with Islanders (The Big Health and Wellbeing Conversation, October 2022).

The intention is to present the strategy to the States Assembly for an In-Committee debate. Exact timings for the debate are being finalised at the time of writing.

Public Health will seek to brief the Panel ahead of the In-Committee debate. If the Panel would like a private briefing on this, officers will be made available.

23. Your Ministerial Plan states that you are going to conduct a Health and Protection Review in order to inform recommendations on how to protect Islanders from infectious disease and other environmental threats. When will this review take place and what is the estimated timeframe for publication of the recommendations?

The Health Protection Review is in the final stages. The review consisted of interviews with professionals working across Government and colleagues from other Islands. In October 2022, the review was shared with colleagues for feedback. Comments were received and amendments made accordingly, and the review is complete, subject to Ministerial review and sign off, and agreement on the final publication process. Public Health can be made available for a private briefing if required. A shorter, public facing summary will be available in Q1-Q2 2023.

a.  What new arrangements will be put in place to improve the data on infectious diseases?

The Public Health Intelligence team are undertaking ongoing work to improve Public Health data, to facilitate internal monitoring of health trends in a more timely and accessible fashion. The tri-island Public Health Outcomes Framework is also being populated, which will allow key indicators to be compared with Guernsey and the Isle of Man.

Women's Health

24. You have indicated that you will improve the health and wellbeing of woman and girls by beginning work to inform a women's health strategy. Please provide an estimated timeframe for when the strategy may be published.

It is envisaged that, in Q3 2023, there will be an initial public consultation which will seek to understand the health and wellbeing issues that are important to women and girls living in Jersey. This will inform a more detailed consultation document to be issued in Q1 2024, with an inclusive strategy being published by the end of Q4 2024.

The publication of the initial consultation is designed to ensure it does not coincide with the termination of pregnancy consultation which will be launched in Q2 2023.

25. How will the Minister work with the Minister for Education to support Education programmes and schools regarding sexual development, menstrual health, and pregnancy?

The Ministers and their officers will continue to work together as needed to support education programmes and schools in these areas.

26. How will the Maternity Improvement plan be adapted to support pre and postnatal mental health services?

Significant work has already been undertaken across Maternity Services, Adult Mental Health services, CAMHS and community health services to develop a new model of care for pre- and post-natal mental health services. This was successfully funded via a previous business case and will be fully implemented in early 2023. The new team includes a (recently recruited) specialist perinatal midwife and health visitor, and part of the work will be to provide training and support to the maternity services.

Assisted Dying

27. How is the development of the new law progressing?

Details proposed are currently the subject of a public consultation exercise, which will conclude on 14 January 2023. A consultation feedback report will be published in February 2023 with a report and proposition then being lodged for debate by the States Assembly. Pending the outcome of said debate, it is envisaged that the Assembly would debate a draft law in spring / summer 2024. This would then be followed by an 18-month implementation period, with any legislation coming into effect within the agreed timeframe towards the end of 2025.

28. In your Ministerial Plan you stated that you would support the development of end-of- life and palliative care services to ensure no one chooses an assisted death due to the inability to access high quality end of life or palliative care services. Would the Minister explain how she would support the development of these services?

These service developments have been supported through the government plan process with a requested investment for 2023 of approximately £2m.

a.  Is the work still on target for a debate in 2024?  

Yes, as set out above it is envisaged that any assisted dying law would be debated in 2024, subject to decisions taken by the Assembly in Spring 2023.

I trust the above responses are of use to the Panel and please do not hesitate to contact me if you have further questions.

Yours sincerely

Deputy Karen Wilson

Minister for Health and Social Services D +44 (0)1534 440540

E k.wilson2@gov.je

[1] Please note the new board is called the Health and Care Board,' not the Health and Community Services Board' which has been disbanded. In this response all questions and references to the Health and Community Services Board' have been changed to the Health and Care Board' for clarity and posterity.

[2] Transcript: Health and Social Security Panel, Quarterly Hearing, Witness: The Minister for Health and

Social Services, Thursday 1 December 2022.