letter - MHSS to CSSP - People and Culture Follow up Review - Department specific response - 23 August 2023

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

Deputy Mézec Chair, CSSP BY EMAIL

23 August 2023

Dear Chair,

Re: People and Culture Follow-up Review

Thank you for your letter dated 2 August 2023. As requested, please see responses to the Corporate Services Scrutiny Panel’s (“the Panel”) queries with specific reference to my department, Health and Community Services (HCS), as well as some more general narrative on my focus on addressing HCS’ culture.

As the Panel will be aware, the review into Secondary Care[1] highlighted various issues within HCS, some of which related to culture. In my response to that review[2] you will recall that I proposed establishing a board “[to] drive reform, improve governance and address the cultural, structural and practice issues affecting the quality and safety of the care provided.”

In April 2023, I formally brought forward my proposals[3] which, in June 2023, were adopted as amended[4] by the States Assembly. In the Health and Community Services Advisory Board’s (“the Board”) Terms of Reference[5] it states that “the Board will shape a positive, inclusive culture for the Department.”

I would also draw attention to my speech when I stood for the role of Minister[6]. In my speech I stated that I would look to improve the culture within HCS, and this approach continues to underpin how I lead the portfolio; I would note also that following my appointment by the States Assembly, the Chief Minister wrote to me asking that I focus on improving morale and culture in HCS[7].

1. The internal processes and procedures in your department which can be used by employees to address complaints and grievances including for inappropriate behaviour, bullying and harassment. We are aware that there are set States of Jersey policies relating to these matters, however we would like to know the specific process that would be followed by employees within your department.

A draft Freedom to Speak Up policy for HCS has been developed and is currently undergoing internal consultation.

The purpose of this policy is to raise awareness of speaking up, and to encourage and normalise a culture where staff feel safe to raise concerns. This policy will also set out the process for raising concerns within HCS and who employees can raise concerns with, i.e., a line manager, a trade union representative, the newly created Freedom to Speak Up Guardian (“the Guardian”)89, an Executive Director or a Non-Executive Director.

The purpose of the Guardian specifically is to make sure the voices and concerns of staff in HCS are heard and acted upon. They will do so by holding regular walkabouts and drop- in sessions, arranging focus groups, and involving themselves in the induction of new colleagues.

Recognising that prior to this new administration the culture in HCS was considered poor, with many believing there to be a “them and us” culture (particularly between front line staff and management), we have ensured that the Guardian is independent of the Senior Leadership Team (SLT) in HCS. This approach should assure staff that matters raised are kept confidential and only shared with the consent of the person raising the concern or issue. If the Panel would like a private briefing with the Guardian to greater understand their role, this can be arranged.

There are other processes that employees have access to via their professional bodies/unions which is covered under the response to question 2 below.

2. Whether any internal employee processes and procedures followed in your department differ from those within other departments and, if so, how and why. For example, we note that there is a Freedom to Speak Up Guardian in the Health and Community Services Department to ensure that the voices and concerns of staff are heard and acted upon.

Yes, like other departments who employ healthcare professionals (for example, Children, Young People, Education and Skills (CYPES) & Justice and Home Affairs (JHA)) HCS will engage with processes that are unique to the healthcare profession.

Healthcare professionals are registered with/regulated by professional bodies[8] and profession specific Unions[9], which in turn require HCS to adhere to additional processes and regulatory standards, particularly regarding incidents, professional conduct, and complaints, which are not covered by more general corporate policies but are covered by the department’s own policies.

On the department’s own policies, I would note that a number require updating and I can confirm that the department are actively reviewing and actioning as required. Also, please note that HCS’ own internal policies and procedures for medical professionals will not necessarily extend to other government medical professionals in CYPES and/or JHA.

With regard to the Guardian, please refer to the response to question 1.

3. The relevant officer(s) in your department available to employees as a first point of contact to raise concerns or grievances.

In addition to the Guardian and the draft policy discussed in response to question 1, staff can raise concerns and grievances in line with the typical process found in any organisation, i.e., with their direct line manager or a HR officer in the first instance.

4. What management information is available to your senior leadership team to enable you to gauge or measure the numbers of informal or formal concerns, grievances or disciplinary actions and how your management information is gathered and recorded.

The number of employee relations cases are reported to the SLT on a monthly basis. The information is sourced from the central case management team with information being gathered and recorded centrally through corporate processes, which you will already be familiar with.

5. The challenges, if any, within your department in improving and maintaining a satisfactory workplace culture.

Workplaces need structures and frameworks that make people feel safe and supported and systems and process in place that enable the organisation to be run effectively. The challenge for HCS is significant in this context. There is a need to reset the values and behaviours expected of people working in HCS; redesign and rebuild the organisational systems and process so that it can operate more productively; reform and strengthen our approach to clinical practice, quality and safety; involve staff and service users more in the design and development of services; secure more investment for care and digital development in health; work in partnership with the care service industry across the Island and in other parts of the economy; and restore the trust and confidence of the public as to the esteem they hold their local health system.

However, there is no silver bullet. We are at the beginning of this work and critical to its success is the quality of leadership. The leadership challenge therefore is complex and large in scale, with a golden thread starting with my ministerial responsibility all the way through to a front-line clinical leader. HCS must have effective and knowledgeable leaders in place who have the technical capability and relevant senior leadership experience to know how to deliver better health services.

As Minister, I am committed to ensuring the Island gets the best leaders it can in this regard, which is why I proposed the Board - a group of knowledgeable and experienced Non-Executive Directors who know how to strategically guide and advise on health care delivery and reform. The challenges the Board will face will be on several fronts: politically, operationally, and individually.

By establishing the Board, I have signalled the cultural shift required in the quality of leadership to secure openness and transparency, improve accountability, and improve responsibility for delivery and performance, which has over time been the sole domain of one Chief Officer. The challenge for the Board is to make sure it can assure all stakeholders of its value and worth, which will start with them advising on the strategic, operational, and quality changes needed to improve HCS.

The challenge for the SLT in HCS will be to adapt to working in a new governance framework that brings greater oversight of managerial effectiveness and performance. Key challenges include:

1. Reduce bullying and discriminatory behaviours.
2. Continuously focus on promoting staff wellbeing and engagement.
3. Improving health and safety at work.
4. Creating work placed opportunities for career development and training.
5. Securing better workforce outcomes e.g., attrition rates and reduced reliance on locum staff.

As with any department with a transient workforce, it can be a challenge to ensure that bank/temporary/agency/locum staff feel they are part of the organisational culture when they move from team to team based on service demand.

Additionally, it is important to remember that HCS does not only employ health and social care professionals, but also manual workers and administrative staff (porters and ward clerks, for example). We recognise it can be a challenge to ensure our non-clinical staff know that they too are an important part of the HCS workforce and, as such, the department strives to ensure they are always included.

As the Panel will know, the interim Chief Officer for HCS was appointed in April 2023. I have been clear with them about the need for regular engagement with staff and service users to inform and lead service change. The Chief Officer and his leadership team have been meeting with staff, listening to their experiences, and using these sessions to inform the change programme, which includes a drive to reduce bullying and discriminatory behaviours within the department.

Changing the culture of an organisation takes time – a challenge in itself - and it is recognised culture change in HCS will be more than a one-year programme. As part of the new Board approach, I have made patient experience a central element of the cultural change needed and established a public and patient engagement forum aligned to the work of the Board. This is a new concept in HCS; however, the concept has a strong evidence base showing it to be an effective way of driving cultural change in health organisations across the world. The challenge will be to embed this way of working into HCS’ operations and managing the operational and political issues arising when patients’ voices are loud and clear regarding service change and improvement.

It must be noted that a number of external factors also contribute indirectly to a poor workplace culture where discontent and frustration can arise:

1. Lack of ownership of, and accountability for, basic system issues, including, for example, the process for employing health professionals.
2. Problems implementing technology in the health space leading to further inefficiency in terms of productivity, which could be solved by better technological capability and expertise in health systems.
3. Many different systems operating in the clinical practice environment lack standardisation affecting patient safety failures, clinic quality, and performance. Some staff who have joined HCS from other jurisdictions have been known to comment that some of the current practices actually put their registration at risk – this is a major

issue particularly when the approach to using evidence-based guidelines is not embedded and, in some cases, resisted.

6. Whether your department has any trade union shop stewards or representatives and, if so, the type of relationship held with those people to assist with resolving employee matters that are brought to the department’s attention.

Yes, HCS does have trade union representatives representing the medical, midwifery, manual, Allied Health Professionals, and administrative professions[10].

HCS’ relationship with these professions is positive and officers hold regular meetings with staff representatives to ensure that the department is listening and is able to understand any issues that concern them. Also, as you know, they routinely meet with the States Employment Board.

7. Specific actions taken within your department to improve staff wellbeing and morale.

Improving Wellbeing and Morale

Following the recommendations arising from the secondary care review, a comprehensive programme of work named ‘#Be Our Best’ has been implemented across HCS and, as part of this, a workstream has been developed to proactively address cultural and behavioural concerns, including issues of morale and wellbeing.

Improving Culture

A newly developed culture change plan incorporates a range of performance and people change elements with associated initiatives, such as embedding Civility Saves Lives and a restorative, just, and learning culture.

Responding to the BeHeard Survey

Having received the BeHeard 2023 survey results, its findings will inform future care group action plans on an individual basis. These action plans will look to address culture and people, among other elements.

Psychological Support

HCS ensures all staff have access to timely, individual low intensity psychological support through the department’s wellbeing team. Through this team staff can confidentially discuss the difficulties and challenges of working in a healthcare setting.

Engagement and Listening Events

A range of regular engagement and listening events are delivered to ensure staff have a voice and are included in communications, these include:

• Schwartz Rounds[11];

• HCS Our Stars;

• Breakfast with the Chief Officer;

• Ward /service walk arounds; and

• Team HCS Talks.

8. The creation or improvements of strategy, policy, and procedures in your department for the benefit of employee welfare and workplace culture implemented since the start of the new States Assembly term.

Please see previous responses which identify changes that have been implemented and/or are being pursued in this new term.

9. Whether any routine internal department-specific surveys or polls are undertaken regarding people and workplace culture and the frequency and impact thereof.

Currently, no, there are no regular surveys or polls undertaken in HCS however I have requested the interim Chief Officer to introduce more frequent pulse surveys in addition to the corporate-wide BeHeard survey.

10. Whether when an employee leaves the department, they are automatically offered an exit interview and, if not, why.

Yes, all leavers are sent a link to the Government of Jersey’s exit interview questionnaire. In addition, all HCS leavers are afforded the opportunity of a face-to-face exit interview with a member of the HR team.

11. Whether there are any emerging themes that can be taken from previous exit interviews?

An emerging theme is work life balance and flexibility. Often, both are quoted as a reason for joining HCS but also as a reason for leaving, which would suggest that the department is not meeting the expectations of staff in this regard. I have requested some further detailed analysis on these issues so that recruitment and retention strategies can be better informed.

12. Whether the Minister or Chief Officer works with the HR Business Partner to resolve concerns, the process that is followed and whether you have identified any challenges or concerns with the process that you have identified.

It must be noted that as a Minister I am bound by the Ministerial Code to avoid direct engagement with individual investigations[12]. Furthermore, neither I nor the Chief Officer are members of the States Employment Board (SEB), nor can we independently set/adopt corporate-wide policies and/or generally diverge from them.

The Chief Officer does actively work with the HR Business Partner who has been allocated by the central corporate HR function to support HCS. Notably, two challenges have been highlighted:

• Using general policies/approaches for specialist professions, such as those related to recruitment, retention, and resolution; and

• Having HR functions assigned from a central function to departments rather than having these functions based within departments.

13. Any historic concerns or issues in relation to any of the above within your department.

In addition to the challenges highlighted in response to question 12, it should be recognised that there is a possibility that the changes to culture in HCS, such as Freedom to Speak Up, may lead to historic cases coming to light which will then require investigation.

14. Any other issues that the Panel should consider as part of its review in line with the Terms of Reference for the review, which can be found on the review page.

Having passed one year as Minister for Health and Social Services, several issues have been come to my attention which to greater or lesser extents affect staff morale and wellbeing.

Corporate Processes and Support

Based on the comments of staff at various levels within the department and as touched upon earlier in this letter, the corporate processes and functions supporting the recruitment and retention of staff seem lengthy and inefficient and could be improved. This in turn seems to impact on morale as staff are left either having to continue their reliance on locum/agency staff at a significant cost to the public or work additional bank/overtime hours to maintain vital services until such time people are appointed.

Additionally, staff have claimed that applicants have withdrawn their applications due to lengthy HR procedures which, if correct, would mean we have lost potential applicants due to our own systems. I understand the Delivery Unit are undertaking work to address these concerns.

I am yet to be assured that there is expertise available centrally to support managers/leaders with regard to the medical profession/professionals, in turn affecting the ability to effectively support and manage staff, especially in a timely manner.

While I understand what seems to have been the general reasoning for creating the hub- and-spoke model, i.e., having HR and other functions like finance sitting centrally and then maintaining a dotted line to the relevant Chief Officer/Minister, it may be worth the Panel exploring the efficacy of this model and whether or not it needs revision, such as moving resources back to departments rather than holding resources centrally. This is particularly pertinent for a large and complex department like HCS.

Furthermore, I would note that there is a question about accountability. While the Chief Officer for HCS and myself are accountable for the activity of HCS and the staff that work within it, the employment functions that supports staff are accountable to a different Minister and different Chief Officer.

The P.59 Process and the Role of the SEB

When it comes to creating/appointing to some of the much-needed roles within HCS, in addition to the existing lengthy processes, we are required by a decision of the States to follow a further procedure that is colloquially known as the “P.59 process”, which was adopted by the States Assembly in 2011[13]. As the Panel will be aware, the P.59 process can be lengthy and arguably burdensome.

The process requires preparation of papers and liaison with the SEB whose role is it to then approve or reject posts that are endorsed by the Minister, Group Director for HR, the interim Chief Officer/Accountable Officer, and, in my department’s case, the Chair of the Board. There is a future discussion to be had regarding delegating the functions of the SEB to the relevant Ministers and Chief Officers and, in HCS’ case, to the new Board if the Assembly agree that it should continue and whether we should widen its scope.

Furthermore, posts have to go through the P.59 process even when the States Assembly through the Government Plan have approved them, i.e., to establish X service with X number of FTEs.

Finally, I have raised previously with the Chair and the Vice-Chair of the SEB that I am of the view that the SEB would benefit from seeking specialist advice on matters related to the medical profession. This would better place them to scrutinise/challenge the resource implications and the need.

I trust that the above responses are of use to the Panel as part of its review. Yours sincerely,

Deputy Karen Wilson

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

E k.wilson2@gov.je