The official version of this document can be found via the PDF button.
The below content has been automatically generated from the original PDF and some formatting may have been lost, therefore it should not be relied upon to extract citations or propose amendments.
Health, Social Security and Housing Scrutiny Panel
Quarterly Hearing with the Minister for Health and Social Services
THURSDAY, 13th MARCH 2014
Panel:
Deputy J.H. Hilton of St. Helier (Acting Chairman) Deputy J.G. Reed of St. Ouen
Witnesses:
The Minister for Health and Social Services Assistant Minister for Health and Social Services Chief Executive Officer
Director, System Redesign and Delivery Hospital Director
Human Resources Director
Topics Discussed
Serious medical issues page 2 Waiting lists page 2 Mental Health page 13 Consultant vacancies/
Nurse appointments page 17 Pathology page 21 Theatres page 24 Regulation of Care Law page 29 Hospital Prescription Charges page 32 New Model of Primary Care page 35
Deputy J.H. Hilton of St. Helier (Acting Chairman):
Welcome to this public hearing for the Health, Social Security and Housing Scrutiny Panel. We will start by introducing ourselves. I am Deputy Jackie Hilton, Acting Chair of this panel.
Deputy J.A. Hilton:
Thank you very much. If I could draw the public's attention to the notices on the chair. Before we start the meeting I would like to offer the apologies of the Deputy of St. Peter who is currently unwell. I would like to start the meeting by asking you: are you concerned that serious medical issues are not being addressed in a timely fashion?
The Minister for Health and Social Services:
Good morning. That is a very wide question and if you have got evidence to show that they are not addressed in a timely fashion obviously we are concerned about it.
The Deputy of St. Ouen :
Just to put the question back to you; are you aware of any concerns around serious medical issues not being addressed due to the lack of ability for individuals to access consultants and other professionals?
The Minister for Health and Social Services:
It all depends on what area. Obviously people do write to me and we do get complaints and they will go through due process.
The Deputy of St. Ouen :
Is there a specific area where the waiting period is longer than one would expect?
The Minister for Health and Social Services:
Any waiting lists or going through due process of complaints?
The Deputy of St. Ouen :
No, we are talking about people with serious medical conditions not being treated in a timely fashion. I am just asking you is there any particular area where improvements could be made?
The Minister for Health and Social Services:
With our waiting list times we have got various specialities which have longer than desired waiting list times and one of the main ones is orthopaedics and gastroenterology.
Hospital Director:
May I just say that any patient who is categorised as clinically urgent will be seen within a fortnight. So where the consultant reviews the referral and believes them to be a priority they always get in, so I do not have any concerns that we are missing any of our seriously ill patients.
The Deputy of St. Ouen : Within a fortnight?
Hospital Director:
It varies by speciality but that is about the longest they will wait.
Deputy J.A. Hilton:
I would like to just draw your attention to a specific case that I am aware of with regard to biopsy results. I have a constituent who contacted me, who had undergone a biopsy and was told in the clinic that he would be advised of the result between 7 and 10 days. I believe this was contained in a piece of literature that was handed to him. In fact he did not receive that result until 21 days later. Would you like to make a comment about that?
Hospital Director:
I do know the case you are referring to. Seven to 10 days is our normal turnaround for histology and biopsies is part of histology. We have 2 histo pathologists that always check each other's results so they both have to be here to make sure that happens. The particular biopsy in question was turned around in 14 days, so it was slightly outside the time that we would expect but not outside what you would expect elsewhere. It was not an unreasonable timescale. The issue of when the patient is then told will depend upon what the results were, what process that then goes through, multidisciplinary team, consideration by consultants and then the patient is informed. But the turnaround of the histology is slightly outside what we would expect but not significantly.
The Deputy of St. Ouen :
Apart from informing the patient, what other actions would be taken as a result of knowing the biopsy results?
Hospital Director:
It depends on the speciality, it depends on the results, but normally it depends whether there is any concern with the result but we have disciplinary teams.
The Deputy of St. Ouen :
If the biopsy shows that there is a problem what action does the hospital then take?
Hospital Director:
The Histology Department would contact the consultant that sent the biopsy in. That consultant would then discuss it in his multidisciplinary team, which would consist of pathology staff, radiology staff, surgical staff, possibly people from the U.K. (United Kingdom) if it is a specialist interest, and then they make the decision on what are the options for the patient, and then they discuss it with the patient.
The Deputy of St. Ouen :
Are there many occasions where the consultant and patient are being required to wait for results of a particular test before medical help can be provided?
Hospital Director:
I am not concerned that we have got excessive waits, if that is the question. The patient will only receive appropriate treatment after they have gone through that process because otherwise we might give inappropriate treatment.
The Deputy of St. Ouen :
Maybe you could explain to us, presumably in certain cases that timing or the knowing of a particular individual that has got a serious problem and dealing with it is extremely important. My question to you is, as it was the Minister, are there any particular areas where improvements could be made to ensure better outcomes are received for patients?
Hospital Director:
There are always improvements we can make in terms of wait times and delays, if there are any delays in wait times. Whether or not that affects the clinical outcome of the patient I think is a very different question and we would have to look at that by specialty. We are treating all of our high risk patients promptly so I am not currently aware of any particular specialty where I have got problems.
The Deputy of St. Ouen :
Do you monitor a log of the times and outcomes of particular situations, such as the one we have been describing?
Hospital Director:
We monitor the times of when a biopsy is taken, when it is reported, when it is goes to the multidisciplinary team, when the patient is seen, so yes, they are monitored. The clinical outcome, which is possibly months or sometimes years away is something that we are starting to put together in how would we best define what those clinical outcomes are so that we can have a whole raft of measures that we review on a regular basis.
The Deputy of St. Ouen :
Do you monitor the period from when the individual sees the consultant with a concern and the time that they receive treatment?
Hospital Director:
Not as a regular monitoring. We can find that information for individual patients but we do not currently have a system that allows us to easily pull that data out. Is it not normal practice in the U.K. that that basic information is collective and gathered and actually then used to help inform the Health Department, the N.H.S. (National Health Service) Trusts and the like to improve and demonstrate that the service they are providing are both safe and beneficial and provide the best outcome to the patient?
Hospital Director:
The U.K. have a measure called the 18-week measure, which is from referral to treatment. That is measured and most of the hospitals in the U.K. have to adapt their systems to do that. That measure is not a measure that we have as a statutory or standing measure in Jersey so our systems do not measure that. It does not measure clinical outcome. All it does is measure the weight so you do not get any indication from that as to clinical outcome or quality.
The Deputy of St. Ouen :
One last question on the subject: when is it likely that we will have access to that sort of information?
Hospital Director:
We are measuring wait times. We are just measuring them in a different way and unless we invest in our system to upgrade it then we are not going to have that immediately available.
The Deputy of St. Ouen :
You did say currently you are unable to gather that information?
Hospital Director: Yes.
The Deputy of St. Ouen :
So the question is when will you be able to?
Hospital Director:
When we decide it is the right measure for Jersey.
The Deputy of St. Ouen : When will that happen?
Hospital Director:
What I am saying is we have not made that decision, that is something we want to measure.
The Deputy of St. Ouen :
When will the decision be made?
Hospital Director:
I would much rather measure clinical outcomes for patients so that it is ... I would like to see clinical measures as opposed to process measures because what is important at the end of the day is the patient gets high quality treatment with the right outcome, and that is a very different measure.
The Deputy of St. Ouen :
When will we get the measure that you would like to provide?
Hospital Director:
As soon as the clinicians, and we have agreed what they are, and our systems can measure them.
The Deputy of St. Ouen : And when will that be?
Hospital Director: We do not have a date.
Chief Executive Officer:
Can I just add: it is fair to comment that the U.K. are also struggling with finding the right outcome measures, even with the investment they have had in massive information systems.
The Deputy of St. Ouen :
Right, but when will you be able to access the information and outcomes that you want?
Hospital Director:
I cannot answer the question because until we have decided what the measures are we do not know what it is we need to change in our system.
The Deputy of St. Ouen : So it is years?
Hospital Director:
I cannot answer that either. It might be readily available but we have not decided what the outcome measures are.
The Deputy of St. Ouen :
So you do not think it is important that we monitor the outcomes of the medical services we provide?
Hospital Director: Of course I do.
The Deputy of St. Ouen :
So then you should know, if it is important that that monitoring takes place and those outcomes are measured that you should know when we are going to have them.
Hospital Director:
We already measure a lot of outcomes. We measure cancer outcomes. We have a big survey annually. That was in the press not long ago, so we know those. We measure things like how quickly somebody gets to theatre when they have fractured their neck or femur, the hips, because we know that is a good clinical indicator, so we measure that. We ask patients what their mobility and they are called outpatient outcome measures. We ask patients about their outcomes. We are already measuring a raft of these. What I am saying is I would like to expand that.
Deputy J.A. Hilton:
Can I just take you back to the waiting lists? With regard to, I think you mentioned that orthopaedics and gastroenterology are problem areas for the hospital. Can you give us an indication of waiting times for both of those?
Hospital Director:
I can. Orthopaedics, we have just reduced some of the wait so they are still unacceptably long, we accept that. Orthopaedics at the moment, for a first outpatient appointment, outpatients will wait 28 weeks.
Deputy J.A. Hilton:
Could you tell us what the wait is between that first outpatient appointment to receiving treatment?
Hospital Director:
No, that is the bit we cannot measure at the moment conclusively. It depends on the patient. What we are looking at is how many of those patients go on to get surgical treatment and it is actually quite low. It is probably around 20 per cent.
Deputy J.A. Hilton:
After the first appointment only 20 per cent go on to receive surgical treatment?
Hospital Director: Yes.
Deputy J.A. Hilton:
But at the current time you cannot tell us how long that wait is.
Hospital Director:
It is very dependent upon what investigations they need after you have seen them in clinic the first time and then when that decision for surgery is made.
Deputy J.A. Hilton:
Sticking with orthopaedics, 28 weeks is a very, very long time. There was a press release yesterday which talked about different States departments and underspends and I noticed that Health I believe have been allocated £2.28 million. Was that an underspend of yours?
Hospital Director: Yes.
Deputy J.A. Hilton:
I am curious how you achieved that underspend because in the press release it says: "Funding will also be used to increase surgical procedures and waiting lists" and so I am curious to know why you were not using the underspend to reduce waiting lists in the first place.
Chief Executive Officer:
Because that underspend did not come from an underspend on hospital services. The underspend was part of the White Paper monies we were allocated with slippage around doing the additional work that we have briefed Scrutiny about before in terms of re-engaging with hospital doctors and G.P.s (general practitioners) and just testing some of the models further. There was slippage in time. Slippage in time resulted in slippage in expenditure. That money is required this year for the full implementation but it has given us a short term additional amount of money that we are going to profile into reducing waits.
The Minister for Health and Social Services: It is one-off money, so it is not recurring money.
Deputy J.A. Hilton:
Can you explain to us, with regard to orthopaedics, how you intend to use that money to reduce waiting lists?
Hospital Director:
Last year the existing team did additional clinics and additional theatre lists. We have, as part of this money, appointed an arthroscopy nurse, which is a nurse that will be able to follow patients following surgery releasing the doctors, so that they can see new patients and go into the operating theatre. She has already been appointed, so that is in post. We have also developed something called "enhanced recovery" and what this means is a group of professionals with physiotherapy included that see the patients pre-operatively and make sure they are in the optimum state before they have their surgery so that their recovery is faster. We have seen the length of stay reduce on the wards so patients are getting out of hospital faster, which frees up the beds so we can admit more people. We have also got funding this year from June for additional consultant time and we have got an advert out for a locum consultant already and we are reviewing C.V. (curriculum vitaes).
Deputy J.A. Hilton:
Can you just explain, you said from June you have got money available for additional consultant time; what does that mean exactly?
Hospital Director:
It means we can bring in another consultant.
Deputy J.A. Hilton:
So it is one locum consultant coming in from June. I believe last year you said you had a vacancy for an orthopaedic consultant ... no. Are there 4 orthopaedic consultants at the moment?
Hospital Director:
There are 3 at the moment. This would be the fourth.
Deputy J.A. Hilton:
Just going on to gastroenterology. What are the problems there?
Hospital Director:
The waiting times for outpatients are our problems there and they are running higher than orthopaedics. So it is currently about 36 weeks.
[10:45]
Deputy J.A. Hilton:
So that is 36 weeks to first appointment?
Hospital Director: Yes.
Deputy J.A. Hilton:
Would you be surprised to hear that I have had a letter from a constituent who tells me that a member of her family had to wait 13 months before they saw a gastroenterologist?
Hospital Director:
I believe I know that case and that was a little while ago, and we have reduced the wait, so they have been longer.
Deputy J.A. Hilton:
That was the tail end of last year.
Hospital Director:
Yes, and we have had locum consultant clinic cover in the beginning part of this year, and we are going to continue with that to bring those waits down.
Deputy J.A. Hilton:
Okay, but at the moment the waiting list is still at 36 weeks and, again, how are you using the additional monies to reduce that waiting time?
Hospital Director:
By bringing in the locum staff.
Deputy J.A. Hilton:
Can you just remind me how many staff that is going to be there?
Hospital Director:
It is one at a time when you want a consultant but they will concentrate on seeing large clinics, so we will bring the waits down quite rapidly. There are a lot less patients waiting to see gastroenterology compared to orthopaedics so it is a matter of ...
Deputy J.A. Hilton:
So locum consultant, you will bring somebody in from the U.K. so they will ...?
Hospital Director:
U.K. or Guernsey, so off-Island.
Deputy J.A. Hilton:
The consultant will come in and just basically try and clear or see a large clinic just to try and clear the numbers. Would you expect then to see quite a big drop in that wait time of 36 weeks?
Hospital Director: Yes.
Deputy J.A. Hilton:
When would you hope to see that happening?
Hospital Director:
I have not brought the dates that the locums booked for, but they are being booked as we speak, and they are being booked over the next few weeks and months, so I could get back to you with that but I would expect over the next quarter we will see that come down significantly.
The Deputy of St. Ouen :
The £2.28 million of underspend is, from what you have told us, White Paper money that is yet to be spent and therefore available as a surplus one-off sum. You have just highlighted a number of new appointments and additions to the staff. How are you going to continue to provide for them in the following year if this money is destined to deliver other services that have already been agreed and approved?
Hospital Director:
Some of the waiting list work will be non-recurrent so that is fine and what we will do there is what we call reduced backlog. So once you have got rid of the backlog of patients waiting then we see if our current staff or existing staff can maintain a lower wait. In orthopaedics I put a plan in last year, so that is recurrent funding in orthopaedics, so that is not part of that underspend.
The Deputy of St. Ouen :
You are pretty confident that not only will you be able to reduce the waiting time significantly in some of these areas, but they will be able to be maintained at a much lower level or lower period on into the future.
Hospital Director:
That is absolutely the intention.
Deputy J.A. Hilton:
Can I just ask you a question about the dental waiting list as well? How is that being managed at the present time?
Hospital Director:
Dental services are slightly different, the orthodontic service particularly. A member of staff left about 3 years ago and we have been unable to fill that post, and that is a national U.K. issue. It is a speciality where it is very difficult to recruit into. So what we have done is we have increased the hours of our visiting consultants. We have increased the hours of the consultant that is on the Island and we are now looking for a nurse therapist who will be able to be added to the team. Again, we have not got one on Island at the moment, we will have to appoint. They will be able to undertake some of the clinic and the follow-up work, so that has been a very difficult specialty because we just cannot recruit those posts.
Deputy J.A. Hilton:
While we are on the subject of dentists, it is my understanding our dental law has not been updated in a very long time and it restricts what qualified dental nurses can do. Are you planning to look at that law?
Chief Executive Officer:
Yes, it is on the programme at the moment. It is on our departmental programme for review.
Deputy J.A. Hilton:
When do you think that review is likely to be?
Chief Executive Officer:
I do not have the information with me but I would be happy to get that back to you.
Deputy J.A. Hilton:
That would be helpful if you could do that.
The Deputy of St. Ouen :
Equally, and perhaps separately, the media today have picked up on a gentleman that has been waiting a considerable amount of time to access mental health support. Can you just talk us through why there might be the long delays in accessing appropriate support and what you plan to do to address it?
Hospital Director:
Mental health does not fall within my remit. I do know of some of their appointment issues.
The Deputy of St. Ouen :
So the psychiatric consultants would not be part ...
Chief Executive Officer:
It is not a consultant issue, I understand from the item that was raised this morning. It is about access to counselling. I think you probably will recall that we have developed as part of the White Paper changes, the Jersey Talking Therapies Project, and that will expand very significantly the amount of counselling that is available to the public, but perhaps if I could ask Rachel just to say a bit more about that.
Director, System Redesign and Delivery:
I think it is important to know that we are talking about psychological therapies rather than acute mental health services.
The Deputy of St. Ouen :
Can I just stop you there? Just to be clear, just to pick up on the acute bit first because you quite rightly say that I ...
Chief Executive Officer: You need to ... yes.
The Deputy of St. Ouen :
As far as you are aware do we have the appropriate support and access to the qualified professionals within the hospital environment to deal with and treat individuals with mental health issues?
Hospital Director:
If a patient presents to the Accident and Emergency Department with a mental health issue then we have very good access to the psychiatrists and to the community psychiatric nurses. They will come and assess a patient in the hospital. They are not hospital doctors and they are not part of the hospital workforce. They sit in the community services.
The Deputy of St. Ouen :
Can you just help me to understand that? So although we have got - excuse me if I do not have the right term - consultants that deal with mental health issues, are you saying that although it could be considered an acute problem they are not linked directly to the hospital?
Chief Executive Officer:
No, and they would not be in other places either; that model of having them hospital based has long gone. They are specialist services in their own right. Some places you will find a Mental Health Unit on a hospital site but they are generally run by a separate organisation that specialises in mental health services.
The Deputy of St. Ouen :
So where is the link between them and the hospital?
Chief Executive Officer:
The link is through the liaison services with A. and E. (Accident and Emergency).
Hospital Director:
Or a hospital ward. If we need the services of a psychiatrist there is an on-call psychiatrist 24 hours a day and we can have clinicians ring them and they come and assess a patient.
The Deputy of St. Ouen :
What other provision do you make for individuals that suffer with mental health problems within the hospital?
Hospital Director:
We have specialist nurses that visit. We have drug and alcohol nurses. We have nurses for learning and disabled people. We have nurses, the C.P.N.s (community psychiatric nurses), they will come in, if there is a known patient, and they will help us nurse a patient on a ward. So we have very good links and we have some specialist nurse input. But otherwise, if they are on a general ward they are there because their overriding problem is a physical need.
The Deputy of St. Ouen :
What provision do you have for inpatients within the hospital?
Chief Executive Officer:
For inpatient mental health services; none. They are not within the hospital. They are at Orchard House.
The Deputy of St. Ouen :
We have been led to believe that that may not be necessarily the case because in our review that we are undertaking around the Children and Adolescent Mental Health Services we have been reliably informed that young people are directed through Accident and Emergency straight into one of your wards.
Chief Executive Officer:
For children we do, but for adults, which is the bulk of our mental health services, they are at Orchard House and they are in a separate service. The number of children are small. We could not justify specific children services in the mental health services so they are cared for in our children's ward.
The Deputy of St. Ouen :
What age group are we talking about?
Hospital Director:
0 to 16 usually for inpatients.
The Deputy of St. Ouen :
We currently accommodate teenagers within Robin Ward if they required a ward bed. Do you think that is appropriate?
Chief Executive Officer:
I think when we are designing the new and revised hospitals we would be looking to have some sort of adolescent unit, probably aligned with the children's ward but there would be separate space for adolescents. It is not ideal but then the hospital itself is very old and not always as we would want it to be.
Deputy J.A. Hilton:
Before we just leave waiting lists and things, I just wanted to ask you: you spoke about referral to treatment of 18 weeks in the U.K. What would you like to see our target being and how soon do you think we can achieve that, particularly across those specialities that you have spoken about this morning?
Hospital Director:
At the moment we have an unwritten guide that we are looking at 12 weeks to outpatients and then 12 weeks to a procedure. That is what we are trying to work to at the moment and a lot of our specialties are well within that. I would like to see all specialities at least get to that.
Deputy J.A. Hilton:
How soon do you think we will be able to achieve that?
Hospital Director:
That varies by specialty and will have a cost implication. So we have already invested in orthopaedics, so we expect to see that reducing. We are working with gastroenterology so we expect to see that reducing. Some of the other specialities; we think we can do some work around Lean and improving patient throughput. So it is our focus for this year, so I expect to see this changing throughout this year.
Deputy J.A. Hilton:
I just recall that we had a similar conversation about a year ago and then you came back and had to report that there had not been a reduction in the waiting list because there is a great demand and so at what point will the management make a decision to go to the Minister with a business case to address the issue of these really lengthy waiting lists once and for all? At what point do you think that might happen?
Chief Executive Officer:
I think we have to put that in the context of the Medium-Term Financial Plan in process, which as you know, we are in the midst now of the first one of those, 2014. We are already planning for and developing the business cases that sit within the next Medium-Term Financial Plan and obviously there will be a number of business cases which are around enhancing and developing acute services, hospital base services, so any waiting times that we cannot resolve by looking at process, leaning those processes, looking at using current money differently, we would have to take through that process. The challenge for us is that if we have growing waits at the moment because demand is growing or because we have done all the other things and we still cannot get the waits down to the level we would like them, we are restricted to the sum of money which we have been given in M.T.F.P. (Medium-Term Financial Plan) 1. So we would have to look and we would box and cox between sums of money to try and free up the resources to do that. So it is a bit of a moveable feast unfortunately.
The Minister for Health and Social Services:
We do acknowledge that some specialities - I think we need to stress that, in some specialities - is too long, especially with the ageing population. But as we have talked to you many times, it is not just one thing that will fix it unfortunately. I wish it was.
Deputy J.A. Hilton:
I am aware that the respiratory consultant was not replaced, who left in August 2012.
Hospital Director: He has been.
Deputy J.A. Hilton:
He has been replaced now so that person is in post and everything?
Hospital Director:
We interviewed in December. We appointed 2 physicians with specialty interests in respiratory. One is in post and one starts in May.
Deputy J.A. Hilton: Thank you.
The Deputy of St. Ouen :
Are there currently any vacancies for consultants at the moment?
Hospital Director:
We have got a psychiatry consultant vacancy, which again is in the mental health system. They are being interviewed in May. So, no, those respiratory positions were my outstanding posts.
Deputy J.A. Hilton:
So your only vacancy at the current time is in psychiatry?
Hospital Director: Yes.
Deputy J.A. Hilton:
Have you got any vacancies for nurses at the present?
Hospital Director:
There are always vacancies for nurses because of the turnover.
Deputy J.A. Hilton: What is your waiting ...?
Human Resources Director:
I have not seen the latest figures. I can find them for you.
Deputy J.A. Hilton:
Have you any idea at all because I think when you came 6 months ago it was about 28.
Human Resources Director:
It has been as high as 40, but I do not think it is that high now.
Deputy J.A. Hilton:
How often do you use locum nurses because there is a shortage?
Chief Executive Officer: Bank staff.
Deputy J.A. Hilton: Bank staff, sorry,
Human Resources Director:
We have normally used bank nurses. Bank nurses are used pretty much every day.
Deputy J.A. Hilton:
To cover sickness and holidays and things?
Human Resources Director:
To cover sickness, holidays, increased admissions, a variety of reasons. Agency nurses are the locum equivalent for nurses and we use them as infrequently as possible because they are very expensive and difficult to find.
The Deputy of St. Ouen :
So currently the recruitment of nurses is not the problem that it used to be, is that what you are saying?
Human Resources Director:
I think it is always a challenge to recruit nursing. I think every hospital in the U.K. at the moment. is challenging itself to get better at recruiting nurses and we are in that same place. We will be scoping out over the course of this year which major recruitment fairs and which major recruitment activities we will engage in.
The Deputy of St. Ouen :
How will we be doing recruiting of nurses or potential nurses locally?
The Minister for Health and Social Services:
The programme started last September. I remember I think there were 16 nurses on that programme. I think the idea is to do that every 2 years.
[11:00]
The Deputy of St. Ouen : Why not every year?
The Minister for Health and Social Services: Am I right it is every 2 years? Or is it every year?
Chief Executive Officer:
I thought it was every year but we will need to check on that.
The Deputy of St. Ouen :
So it is an ongoing programme that you proceed to recruit 16, 18 new individuals who wish to train as nurses?
Chief Executive Officer: Yes.
The Minister for Health and Social Services:
We have also got to make sure that once they have qualified that there is a job for them.
The Deputy of St. Ouen :
I hear that but if what we have just been told is correct, and there are about 40 vacancies, and recruitment ...
Chief Executive Officer:
But all those vacancies are not for brand new, newly qualified nurses. Many of those vacancies are for experienced nurses to run wards and to do specialist services. So there is a mix of vacancies. It is not all able to be filled by our new nurses coming off the conveyor belt. So you have got to balance it. It is a bit like new teachers and experienced teachers to take on leadership roles.
The Deputy of St. Ouen :
Is it the case that because of the changes that allow certain professional, very qualified nurses to undertake additional tasks, that that has required more individuals that are more highly skilled to come in and fill those positions?
Chief Executive Officer:
Sometimes it is because nurses are doing more. They are taking over certain things that perhaps the doctor did to free the doctor up to do more and that requires certain skills and training and exams that you need to have. So you will have some vacancies for people like that. You will have vacancies for people who are going to be leading a team of nurses or leading a ward, because somebody has moved on with their career, and then you will have vacancies for your entry level nurses on the ward. The mix of that varies from time to time.
The Deputy of St. Ouen :
For those nurses that are already qualified, what opportunities do they have to improve their skills?
Human Resources Director:
We have cohorts going through nurse prescribing training. We have a new contract with the University of Chester, so a significant number of our nurses are now getting further academic qualifications through that model. That has just started. Our nurse education centre is one of the busiest departments in the hospital. There is constant throughput from every ward and every service with nurses acquiring new qualifications and new skills.
The Minister for Health and Social Services:
I think, just to add a point there, our nurses need to be congratulated too because if they go on to degrees or extra training this is on top of their business as usual. Most of them have got families so we have got a very dedicated team who are keen to continue with their professional development.
The Deputy of St. Ouen :
Roughly how many already qualified nurses would be undertaking the training you have just described?
Human Resources Director:
I do not have that detail with me. I can find it for you.
The Deputy of St. Ouen :
Yes, if you could provide them for us that would be useful. Thank you.
Deputy J.A. Hilton:
Last time we met I understand that study leave was suspended for the last 3 months of the year. Has that study leave been reinstated?
Hospital Director: Yes.
Deputy J.A. Hilton:
Thank you very much. Could we just talk about pathology and what the situation is there? Whether you have come to an agreement with existing staff on the service or whether you were still using locums in the U.K.?
Hospital Director:
We are currently still using 6 locums. We agreed a medium-term plan, which was to take on some fixed term contract individuals for a period of 2 years, while we go through a transition phase. Unfortunately we have not come to an agreement with the existing staff, and we interviewed this week for some of those fixed term locums and we have had an extremely good response.
Deputy J.A. Hilton:
The 2-year contract is for the locums that you have been using? Sorry, I may have misunderstood.
Hospital Director: It replaces them.
The Minister for Health and Social Services: It is out of hours.
Deputy J.A. Hilton:
So are these local candidates or do they come from the U.K.?
Hospital Director:
No, they are off-Island candidates.
Deputy J.A. Hilton:
Okay. So there are ongoing difficulties as far as permanent staff are concerned with providing the out-of-hours service?
Hospital Director:
We have had conversations with them about whether or not they could meet the criteria that we now wish to see out of hours and they struggle to be able to meet that criteria while working a day shift and a night shift. So these new people will just work night shifts.
Deputy J.A. Hilton:
How does that differ to what they fulfilled before?
Hospital Director:
We have enhanced the overnight service now. We have people onsite so we get a more rapid response. We have now been able to do some of the work that was left to the next day overnight. We have changed the way we do some of the blood tests overnight. We also want to be able to train the existing staff and by having them on days we can train them more easily. We also wanted to keep the senior leaders on days so they can help us with the modernisation and the changes that are going on in pathology.
Deputy J.A. Hilton:
Would you say at the current time your existing staff are content with the outcome?
Hospital Director:
That would be speaking for them. They have been fully aware of the process that we are going through and they know this was the medium-term plan.
The Deputy of St. Ouen :
Currently have you added 6 individuals to the overall staff and members of the Pathology Department?
Chief Executive Officer: We have.
Hospital Director: It will be 5, but yes.
The Deputy of St. Ouen :
Are there plans to maintain it at that number or ultimately to reduce it down to a smaller level?
Chief Executive Officer:
Longer term the whole thing will be modernised and will look very different. But that 2 years gives us the time to go through that modernisation process.
Hospital Director:
They will be subject to the workforce modernisation programme that is underway in the States and that will then define if we have people working days and nights going into the future.
The Deputy of St. Ouen :
If you have individuals that are reluctant to accept change how do you propose to deal with that?
Chief Executive Officer:
By working with them and introducing new methods of working with new processes and new systems.
The Deputy of St. Ouen :
You have not got to the stage where you are saying to the individuals: "Look, if you are not prepared to provide them enhanced service then there is no longer a place here."
Chief Executive Officer:
No, we are not talking in those terms.
Human Resources Director:
They have a new leader starting very soon who has led these sort of changes many times in other organisations so we anticipate he will be able to lead the change here in the way he has elsewhere.
The Deputy of St. Ouen :
Is that the person that has been brought in from outside or been appointed from within?
Human Resources Director:
He has been appointed from the U.K. with a track record of delivering modern pathology services in hospitals in the U.K. There is no one with that track record on the Island.
Deputy J.A. Hilton:
I just wanted to talk briefly about theatres. I understand that the hospital is working at maximum capacity in the theatres. Is that still the case? I think we spoke about temporary theatres and we were hoping you could give us an update on that.
The Minister for Health and Social Services:
The plans have been approved for the temporary theatres and, as I understand it, it is currently out to tender.
Deputy J.A. Hilton:
How many theatres did that include?
Hospital Director:
The temporary theatres will produce 2 new theatres.
Deputy J.A. Hilton:
That is just south of the A. and E. entrance?
The Minister for Health and Social Services: In the car park.
The Deputy of St. Ouen :
Alongside of that, have you improved the facilities within the hospital?
Hospital Director:
I think you are referring to the minor ops room we have spoken about before. That is having a new airflow system put in so that we can undertake different operations in it. That is going to be commenced in May and will take until August to complete. The reason that is slightly later than we had anticipated, Jersey Property Holdings have connected it to another piece of work that we are doing to change the airflow in Bartlett Ward so we have gone out to one tender, with one contractor, and it has given much better value for money on the 2 jobs together.
The Deputy of St. Ouen :
So how many hours a day are the theatres currently being used?
Hospital Director:
The standing operating is between about 9.00 and 5.30 but we regularly overrun and we run Saturdays and Sundays.
The Deputy of St. Ouen :
For Saturdays and Sundays are we talking for the same period, 9.00 to 5.00?
Hospital Director:
It is usually less on a Sunday. Saturdays can often run all day. That is not all theatres at weekends.
The Deputy of St. Ouen :
While waiting for these temporary theatres to be built, has any consideration been given to extending the period of time that the theatres operate in?
Hospital Director:
We have. We are working with the clinicians. We are talking about whether or not we extend by an hour either side of the working day or run more theatres at weekends. But we have to remember then that means a lot of extra staff and once you go outside certain hours you are into premium staff time, certainly for consultants, and some of the nurses. So that is all part of our waiting list review. But there is a cost implication to running theatres later. There is also some clinical standards that say you should not run theatres into the evening and overnight for safety reasons. Unless it is an emergency you should not go to theatre.
The Deputy of St. Ouen :
Are you saying that the 9.00 to 5.00 type of period is usual and the sort of period of time that theatres would be used within the U.K.?
Hospital Director:
It is not unusual. There are some hospitals that start at 8.00 a.m. but it is not an unusual system but we are looking at how we expand our theatres because these temporary theatres will not be usable for at least a year to 18 months because we are using them as a decant facility to improve the airflow conditioning of all of our main theatres before they will become additional capacity.
The Deputy of St. Ouen :
Just to be clear: is the period of time that our theatres are in use on Island lower than the average in the U.K.?
Hospital Director:
No, we have better utilisation here than we have in the U.K. on the whole, from the data that I have seen.
Deputy J.A. Hilton:
Can I just ask you a question with regard to the tensions between use of theatres with public and private patients and how you manage that?
Hospital Director:
It is relatively clear for the consultants. We allow a mix of private and public patients, and it is never allowed to exceed a 30 per cent private, so there is always 70 per cent public. That is monitored and it is monitored regularly. Nobody ever goes over that.
Deputy J.A. Hilton:
The 30 per cent private usage, does that have to occur or does it mainly occur between 9.00 to 5.00?
Hospital Director:
No. A lot of the Saturday work and the weekend work is private work.
Deputy J.A. Hilton:
So there is not a question that the consultants for their private work have the majority of normal working times and the public are pushed to weekends?
Hospital Director: No.
Deputy J.A. Hilton:
So generally speaking it is the consultants who are using the theatres on a Saturday?
Hospital Director:
Most of the Saturday working is private and there will be some private work in the week but most of the Saturday work is private because that is how we staff the list because that pays for itself.
Deputy J.A. Hilton:
It is a bone of contention among people, especially with the very lengthy waiting lists, when they hear that somebody can access a procedure in the space of weeks that a public patient has to wait months for. Do you ever get complaints around that issue?
Hospital Director:
We get complaints generally that the waits for public patients are too long and that is what we are doing to address that. Occasionally somebody will raise the issue of private work but not very often.
Deputy J.A. Hilton:
How does our system differ to that in the U.K. with regard to private work being carried out in the hospital?
Hospital Director:
On the whole, in the U.K. you have separate private hospitals but not for all specialities. If the specialties, for example, cardiothoracic because it is quite an intensive specialty, that would often been done in an N.H.S. hospital.
Deputy J.A. Hilton:
So that is the difference then, that most private work in the U.K. is carried out in private hospitals, so they are not sharing facilities. It would seem to me then that that is an added pressure for Jersey to have to deal with if it is going to continue to offer a service to private patients.
Hospital Director:
There are a lot of advantages to doing it this way. We have our consultants on site all the time, so they are there for the public patients, even when they are seeing their private patients. We are able to recoup all the costs for the private patients, so that supports our infrastructure and keeps our teams to the size we need them. It attracts the consultants in the first place because they know that they can have private work as well as public work. So I think the advantages of having them on site are quite considerable. In the U.K. you would find a doctor within normal 9.00 to 5.00 hours would not be available in the N.H.S. hospital because they are quite legitimately in their private hospital, and that could be miles away, so we have access to all of our doctors all of the time here, and that is a huge advantage.
Deputy J.A. Hilton:
Do the contracts in Jersey differ from the contracts in the U.K. because when the U.K. consultants are working in a public hospital it is all public work and so the private work in the private hospital is in addition to that, outside normal core hours? Is that how ... I am interested to know how the contrast ...
Hospital Director:
Not necessarily outside core hours in the U.K. Our contracts do differ. We have a standard contract for consultants that pays them for 40 hours a week.
[11:15]
We call them P.A.s (programme activities). There are 10 P.A.s which is 40 hours a week. That has to include their on-calls and because we have very small teams they could be on call one night a week and every third weekend, so we have to give them time back for doing that, and that time back is likely to be in the daytime, Monday to Friday. So every consultant will work their 40 hours that we pay them for and outside those 40 hours they can work on their private practice. So if you look at their timetable it will come to more than 40 hours because we have recognised that we get 40 for public and there will be some additional hours for their private work.
The Deputy of St. Ouen :
When will the Regulation of Care Law be finalised?
The Minister for Health and Social Services:
I met with the Public Health, because it comes under Public Health, and the law officers to finalise timings, et cetera. There is still a bit of tidying up to do with the draft law and it is going out to consultation in a couple of weeks' time, the week beginning 24th May, and it will be a 6-week consultation.
The Deputy of St. Ouen :
A 6 week consultation starting ...?
The Minister for Health and Social Services: Sorry, 24th March.
Deputy J.A. Hilton:
I may have missed it, so in fact we will get the law?
The Minister for Health and Social Services: Yes, the week of the ... I can give you that timetable.
Deputy J.A. Hilton:
I was hoping we could get it as ... I assume that the law is finished and complete now?
The Minister for Health and Social Services: There are just a few tidying ups to do.
Chief Executive Officer: Within the next week.
Deputy J.A. Hilton:
Would it be possible for us to have it as ...
The Minister for Health and Social Services: As soon as I have seen it.
Deputy J.A. Hilton:
Because as you are aware, it puts us under a very, very tight timetable and we are as keen as you are to get the Regulation of Care Law into place but it would be very helpful indeed if we could have sight of that as soon as possible.
The Minister for Health and Social Services: As soon as I can, I will.
Are there specific matters that you will be consulting on?
The Minister for Health and Social Services:
A lot of consultation has been done already with stakeholders, so we probably go to general consultation with the public and some focus groups, but not particularly, not that I can think of, but I can come back to you with that.
The Deputy of St. Ouen :
Just to be clear: it is basically you are going to be presenting the draft Regulation of Care Law to the public and saying: "What do you think?" rather than necessarily: "Are you happy with these particular steps that ..."
Chief Executive Officer:
The specifics of the Regulation of Care Law really do affect the providers of care. We have been working with them as a stakeholder group, so it is several years now, as this law has been debated and then worked through, which why we feel we can hold to a 6-week consultation period because they are all very well up on what it is likely to mean for them. This more general aspect, for the member of the public, I think it is about giving assurance that there will be regulation of care and then extension to what we commonly have which at the moment largely covers nursing and residential homes but nothing much else. Over a period of time the Regulation of Care Law will roll out to cover all providers of care. So that is a big thing in terms of giving reassurance to the public.
The Deputy of St. Ouen :
In the meantime I think at our last Scrutiny hearing in September you told us that there was not currently an all-encompassing inspecting regime that covered the hospital. Has any consideration been given to asking an independent body to undertake a major review or an inspection of current services, which will give you then the benchmark to then monitor the improvements that hopefully will come from the new Regulation of Care Law?
Chief Executive Officer:
I think it is fair to say 2 things. First is that large parts of our services are already inspected and accredited by various professional bodies and inspection regimes, the most recent of course being our Children's Services and the Care Inspectorate, so we already do have elements of service. In terms of all encompassing; while superficially it is attractive the issue is that the system in Jersey is fit for Jersey and it is unique to Jersey. Finding someone external who could come in and inspect our way of providing things in a framework, which does not exist because the Regulation of
Care Law is not yet in place, would be a very difficult task for anyone else to do because they would not have a frame of reference and therefore you could not be too certain whether you could take account of any findings or issues that they raised because they would be referring that back to the systems that they are used to. Whether they come from the U.K. or the U.S. (United States) or from New Zealand or from Europe, they would test the way we do things against the way they do and our systems are different.
The Deputy of St. Ouen :
I can understand that, but maybe I should rephrase the question. Once the States approve the Regulation of Care Law then would it be your intention at that point in time, very early on in the process, to ask for or seek an independent inspection of the services, bearing in mind and acknowledging that some of those inspections have taken place, which any inspector would take account of anyway.
Chief Executive Officer:
The plan for the Regulation of Care Law is that we would create a Regulation Commission. We are currently discussing with Guernsey, and possibly the Isle of Man, doing that together for our Island because our Island systems are unique to our Island but are much more similar to each other than they are to other places. But again I would take the view, and it is not for me to decide, it is a political decision at the end of the day, but to bring in external inspectors who do not have a local frame of reference, I do not think would give us a helpful and critical framed appraisal that inspection should be providing because they would not have that frame of reference.
The Deputy of St. Ouen :
If the Commission is going to be set up then surely those that will be involved in that Commission would benefit from a point of reference so they could say: "That is where we are now ..."
Chief Executive Officer:
It would have to be a relevant point of reference.
The Deputy of St. Ouen :
Exactly, but that is not beyond the scheme. As you say, these services are being inspected anyway.
Chief Executive Officer:
I would not want to second guess a Commission.
The Deputy of St. Ouen :
I mean we either allow the inspections that are being undertaken, as you say in Children's Services and other things, which we do, or we do not. If we rely on those, why not configure and design based around the new Regulation of Care Law an independent inspection which, as I say, just simply gives it.
Chief Executive Officer:
I think that would be a matter for the Commission to decide.
The Minister for Health and Social Services:
That probably will happen in time and that is why working with Guernsey and the Isle of Man so we can all work together will be important. We have had initial discussions with Guernsey because they are at a similar point.
Deputy J.A. Hilton:
I would like to ask you about safeguarding.
The Minister for Health and Social Services:
Can I leave that with you then? If that is helpful. With the dates.
The Deputy of St. Ouen :
What is that, Minister? Can you describe what you are giving us for the transcript?
Chief Executive Officer:
It is just an update on the current situation.
The Minister for Health and Social Services: Dates, timelines for the Regulation of Care.
The Deputy of St. Ouen : Thank you.
The Minister for Health and Social Services: It is tight. We acknowledge it is tight.
The Deputy of St. Ouen :
Finally, withdrawal of the hospital prescription charges proposition, is there now a policy in place to guide consultants on the way that they prescribe medication?
Hospital Director:
Yes. We revised it at that point, and that is implemented now.
The Deputy of St. Ouen : How is that working?
Hospital Director:
It is working very well.
The Deputy of St. Ouen :
Have you noticed a reduction in the non-hospital having any drugs that are being prescribed?
Hospital Director:
We have looked at the details of how many prescriptions are filled in hospital pharmacy from outpatient clinics and it is looking, the early indication - this was from about September, October time - is that it is flattened out, it has smoothed out. We are not seeing the variation but we know we have had some really big clinics in that period of time so what we do need to do is just look at it as a precaution.
The Deputy of St. Ouen :
So there has been no reduction but no increase, is that what you are saying?
Hospital Director:
I think there has been a reduction but just looking at the prescriptions does not tell you the whole story. You have got to look at how many people attended to see the proportion of prescriptions by attendances, so we are doing that work now.
The Deputy of St. Ouen : When will figures be available?
Hospital Director:
It would be nice to see 6 months' worth so that you see a proper trend rather than ...
The Deputy of St. Ouen : Which will be ready?
Hospital Director: May.
The Deputy of St. Ouen : May this year?
Hospital Director: Yes.
The Deputy of St. Ouen :
That we will have a clear indication of how the new policy is working and what savings if any ...
The Minister for Health and Social Services: An indication, some 6 months' worth.
The Deputy of St. Ouen :
Has any consideration been given to the different prescription papers that are used?
Hospital Director:
Yes, that was a discussion that we had with Social Security and there is a legal requirement to be a general practitioner to use a different prescription pad so we have not altered that.
The Deputy of St. Ouen :
So there is still a difference between the pads?
Hospital Director: Yes.
The Deputy of St. Ouen :
So the hospital pharmacy will only issue medication that is supported by a hospital prescription pad?
The Minister for Health and Social Services:
Yes, that a consultant ... that has always been the case.
Hospital Director:
Nothing has changed there.
Chief Executive Officer:
You cannot come in with a G.P. prescription.
The Deputy of St. Ouen :
Why I ask the question is that it should then be relatively easy to work out what the amounts of drugs that are being prescribed by consultants and the types because it is from one point. So we look forward to receiving that information in May.
The Minister for Health and Social Services:
Allow time for the work to be done at the end of the 6 months.
The Deputy of St. Ouen : Before July.
Deputy J.A. Hilton:
How much progress has been made on the new model of primary care, which is supposed to be being delivered in September 2014?
The Minister for Health and Social Services:
It is slow. As I said the other day in the States, it is a challenge. A lot of work was done with all the primary care G.P.s, pharmacists, opticians and the dentists last year and work was done to try and take it forward with procurement. Unfortunately it was more difficult than we envisaged and that procurement process came to an end, with the agreement of everybody on the Procurement Board and some mediation work took place a couple of months ago with the G.P.s of how to progress forward and it has been quite positive since.
Deputy J.A. Hilton:
You said it is a challenge. Why is it a challenge?
The Minister for Health and Social Services:
I think because the primary care body is there and the challenges within working with a primary care body because there are 90-odd G.P.s and how they want to do things and how we need to have a holistic view of primary care to include the dentist and the pharmacist and those 4 groups. But pleased to say that now we are working forward positively. Whether it will reach by September, I do not know.
Deputy J.A. Hilton:
You have somebody leading on that in your department, have you not?
Chief Executive Officer:
Yes, we are looking to create a leadership role with the agreement of members of the primary care body to take forward a piece of work. It is an on-Island initiative. I think one of the challenges that we worked through last year was a degree of disquiet from a number of quarters about potentially bringing some body into the Island to work with us and it was felt that if we could create a system where we used on-Island resources and then brought in specific expertise that would create a more comfortable environment to have the sorts of discussions that we would need to have. So we are going to go for an on-Island partnership approach but bringing in expertise as we need it.
Deputy J.A. Hilton:
Obviously that work is ongoing?
Chief Executive Officer: It is just about to start, yes.
Deputy J.A. Hilton:
So we are not going to have any firm proposals by September 2014?
Chief Executive Officer:
I think that is unlikely. But we would look to pick up the pace on that through the rest of this year.
Deputy J.A. Hilton:
In P.82 proposition it was entitled Health and Social Service: A New Way Forward that was agreed or approved by the States in October 2012. Under the title Sustaining Hospital Services, we were told that a number of operational service changes are already underway and one of the changes identified was better integration in the Emergency Department with G.P. colleagues. What progress has been made in that area?
Director, System Redesign and Delivery:
So you probably heard yesterday morning Dr Minihane speaking on BBC Radio about the work that we have been doing and are continuing to do together.
[11:30]
So it is people from the Emergency Department, the ambulance services and the primary care body talking about what should be the right model for services out of normal office hours and how the Emergency Department, ambulance and G.P.s, in particular, can devise the right model going forward. You probably also heard him talk about the headline that almost 50 per cent of people who turned up to the Emergency Department in a snapshot audit were found to have potentially conditions that could have been seen in primary care and that piece of work, that snapshot audit, was done by some G.P. colleagues working with us around that, so that we can look at what might the demand be for those types of services outside of hours and indeed within hours, and that can help us to identify what is the right balance of emergency and out-of-hours type care wherever that is provided.
The Deputy of St. Ouen :
Thank you. From what you are telling me, although we were told that some of these operational service changes were already underway, actually they have not even started yet.
Director, System Redesign and Delivery:
They have started. It is like with any of the service changes, you make some changes and you have to keep it under review, so you have to make sure ...
The Deputy of St. Ouen :
What changes happened in the Emergency Department with regards to including a co-located G.P. service?
Director, System Redesign and Delivery:
We have been trying to find the right location for the G.P.s to work in, within the Emergency Department, and obviously we have got some space constraints that a future hospital will help us to deal with. One of the things that we have been doing within the Emergency Department, is when patients arrive at reception in the Emergency Department, is triaging, you have probably heard this word on the radio yesterday, and where there is a G.P. physically on site at that time, and that patient could have been seen in primary care, is encouraging the patient to go the primary care route to the G.P. who is in the hospital at the time rather than come in and been seen in the Emergency Department. So helping patients to make the right choice for primary care because there are G.P.s on site in the hospital to care for those patients.
The Deputy of St. Ouen :
So we have G.P.s currently based and working with the Emergency Department, is that what you are saying?
Director, System Redesign and Delivery:
Within the hospital and the pathway of how patients get to them has changed and was changing when we wrote P.82. So there are more patients that are coming into A. and E. now and are then going to see the G.P. that is in the hospital, whereas before they may have automatically just been seen in the Emergency Department.
The Deputy of St. Ouen :
Where would we find these G.P.s if we visited the hospital?
Hospital Director:
The Gwyneth Huelin Wing.
The Deputy of St. Ouen :
In the Outpatients Department?
Hospital Director:
Out of hours. This is out of hours and weekends.
The Deputy of St. Ouen : Not during the day?
Hospital Director:
No. People would expect to go to their normal G.P. practice during the day.
The Deputy of St. Ouen :
That defeats the object a little bit surely because if you talking about integration in the Emergency Department, although I accept that a number of people visit the Emergency Department out of hours, equally a significant number visit the Emergency Department during the day.
Hospital Director:
In the future, the model of care we would like to see is an emergency care centre, which would have the appropriate professions in it to make sure that patients are seen by the most appropriate person. The current set up in our Emergency Department would not allow us to work like that so when we design the new hospital we will design it differently.
The Deputy of St. Ouen :
Maybe this should be directed to the Minister. It is quite easy to say: "Oh well, we have not got the right facilities so we cannot improve on what we have got" when we are already told here, this was not dependent on necessarily a new hospital. Yes, it was identified that a new hospital could help support and improve but there are clearly things that can be done, as explained by your director. Why are they not being done? Why are we not seeing ...
It is working with people, working with the G.P.s and these different services, different pathways are beginning to be put in place but they will change as more things will come in and they may change because something is better to do it this way than that way. But regarding Emergency Department and replacing it with a G.P. there, it is tight in space because there was identified a space within the Emergency Department but the G.P.s did not think that was quite appropriate, which is quite right, so we have to rethink the model again.
Chief Executive Officer:
Can I just add one point? I think P.82 set out a massive transformation programme over a 10-year period and I think we have to recognise that in taking that forward some things go well and they happen quickly. Some things go less well and they do not happen quite so quickly. Sometimes we have to go back round a loop again because we have not always convinced everybody it was the right loop to go around and we are learning as we go. I think we do have to put that in some context that this is a very complex total system change and what we have talked about in other places, not so much today, is there is a great deal of work that has progressed - and I know you are aware of that - and there is work that has not progressed quite so quickly as we would have liked and we are trying to get back on top of that, and we will continue to work forward with it. But I do not think we should lose sight of the complexity of the enterprise that we are engaged in.
The Minister for Health and Social Services:
And it is working with people and taking everybody with us, working with the G.P.s, that is important because we have got to succeed at the end.
Deputy J.A. Hilton:
Thank you. Thank you very much for coming along this morning and taking the time to speak to us. I close the meeting.
[11:35]