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Health and Social Security Scrutiny Panel Quarterly Meeting with the Minister for Health and Social Services
THURSDAY, 1st OCTOBER 2015
Panel:
Deputy R.J. Renouf of St. Ouen (Chairman) Deputy G.P. Southern of St. Helier
Deputy T.A. McDonald of St. Saviour
Witnesses:
Senator A.K.F. Green (Minister for Health and Social Services)
Deputy P.D. McLinton of St. Saviour (Assistant Minister for Health and Social Services) Chief Executive Officer
Hospital Managing Director
Director, System Redesign and Delivery
Director, Finance and Information
Human Resources Director
[09.30]
Deputy R.J. Renouf of St. Ouen (Chairman):
Welcome to the Health and Social Security Scrutiny Panel. This is a hearing held in public to question the Minister for Health and Social Services. The meeting is being recorded so for the record I will ask the panel to do introduction and then if you could introduce yourself and your team. So I am Deputy Richard Renouf and I am chairman of the panel.
The Minister for Health and Social Services:
Our Chief Executive is here ... in on her way. She will be here in a minute and my other Assistant Minister sends his apologies because he has gone for the time being to represent me at Council of Ministers. So that is Constable John Refault. As I said to you, Chairman, before this started, I need to be away sharp today. Occasionally I allow you to run on but I cannot do that today.
The Deputy of St. Ouen :
Very well, I will ask my panel members to make sure that we finish on time, Senator.
The Minister for Health and Social Services: Thank you.
The Deputy of St. Ouen :
Can I go straight in and can I note that you made a submission to the scrutiny panels on the M.T.F.P. (Medium Term Financial Plan) in which you recorded that your growth bids that you had made in the M.T.F.P. for 2016 had been reduced from £7.9 million to about £3.8 million. So can you please tell us what was planned for 2016 which is no longer going forward?
The Minister for Health and Social Services:
I will let Jason go in the detail in a minute but I would just like to set the context and the context of that was looking at our capacity to deliver some of those changes within the time. There is little point in being granted sums of money that were just going to sit there if you did not have the capacity or the timetabling as such meant that it would not be delivered until the next year. So we challenged ourselves, what can we actually deliver. Okay, we need to do it but what can we deliver in 2016? What do we want to deliver but needs to wait for 2017 because either of timetabling or management capacity. That is the reason we changed it. If we had been able to introduce it all at the same time then we would have done.
The Deputy of St. Ouen :
But it did originally form a growth bid?
The Minister for Health and Social Services: Yes, it did.
The Deputy of St. Ouen : Yes.
The Minister for Health and Social Services:
But we looked then at the timetabling of that growth bid. I will let our finance officer take you through it ... director, sorry.
Director, Finance and Information:
There are 2 elements to this. One element is that there was money that we originally had programmed to spend in 2015, this year, which, as part of the initial 2 per cent cut that got incorporated in the 2015 budget we have rephased that to start either later in this year or next year, some of which the Minister has just talked about. Then there is the submissions into the Medium Term Financial Plan for 2016, which of course are the submissions for 2016 through to 2019. The 2016 figures in there have gone through various iterations, the latest one which I think is the one you are probably referring which is from 7.9 to 3.8?
The Deputy of St. Ouen : Yes, in round terms.
Director, Finance and Information:
The reduction in that largely represents the rephasing of some of the P.82 initiatives. I do not have a list of all the ones that were directly impacted as a result of that rephasing in front of me but if we have not provided it to you already we certainly can do. That is rephasing the start dates into a latter year. Of course for the M.T.F.P. at the moment we are doing the detail of 2016 so when those initiatives have come on line ...
The Deputy of St. Ouen :
Sorry, can I ask the Minister where we are at risk by rephasing, by delaying implementation of any of these programmes?
The Minister for Health and Social Services:
We are no more at risk that we were before because what we are actually doing is developing our service so that we have a very different service when we are ready to move into the new hospital. So what we are doing is supporting people in the community, providing more community service, working on primary care. All those things need to be done because if you were to lift the current hospital service - the health service as a whole, not just the hospital service - into the new setting, you need a 400 bed hospital. So ...
The Deputy of St. Ouen :
Yes, but the new hospital must be perhaps 10 years away, Minister, by the time ... 6 at least.
The Minister for Health and Social Services:
I do not know if you heard the interview this morning for Alder Hey Children's Hospital.
The Deputy of St. Ouen : I did some of it.
The Minister for Health and Social Services:
Yes. They took 10 years to plan that change in service, that change ... and that is what we are doing. Because if you wait until such time as we are ready to move then we are going to have a service that does not fit modern requirements and certainly you would need a hospital much different, and a primary care set up much different to the one that we are going to have. So we are on the change. This is all about development of care in the community, developing changes around primary care. The emphasis behind the work that we are doing, and I know Deputy Southern wants to come in, is the hospital is your last option, not your first option.
The Deputy of St. Ouen :
Yes, but I am not specifically talking about the hospital.
The Minister for Health and Social Services: But that is what P.82 is about.
Deputy G.P. Southern :
P.82 is about changing the way in which the service is delivered.
The Minister for Health and Social Services: Exactly.
Deputy G.P. Southern :
What we are talking about here, surely ... sorry you ...
The Deputy of St. Ouen :
Well, there was work planned for 2016 which has been deferred, is that correct?
The Minister for Health and Social Services: That is correct.
The Deputy of St. Ouen :
If it was planned it must have been the intention to carry it out in 2016 but it has now been found that it needs to be deferred and it is not because we are planning to be in a new hospital in 6 years' time.
The Minister for Health and Social Services:
One would hope. It is because we are changing our services, we look at what we need to change against the timetable of where we need to be and if you do not have the management capacity in terms of the numbers to lead big projects, if you are going to just leave that money sitting in the bank rather than using it is right to say: "Hang on, we will take that in 2017, not 2016."
Deputy G.P. Southern :
So some of what is supposed to be happening under P.82 is stalled. It is delays on 2015 money and now we have got to 2016 money so there is ... I do not know, for example, is there staff not being employed or ...
The Minister for Health and Social Services: No, I did not say that. No, I did not say that.
Deputy G.P. Southern : Are we not stalled?
The Minister for Health and Social Services:
No, we are not stalled. We re-evaluated the way that we are going to deliver it. Do not forget we have got a new Minister ...
Deputy G.P. Southern :
What does that mean? That means we are putting off doing the development?
The Minister for Health and Social Services:
No, it is not. It means that we are looking at what we can do now, when we are going to do the rest, when it is right to, is it going to delay the change in moving into the new hospital? No, it is not because change in the service is about that. It is about delivering a very different service for the new hospital. Well, we have not even agreed a site yet, have we?
Deputy G.P. Southern : No, we are aware of that.
The Deputy of St. Ouen :
Can I take a specific ... you told us in the report to scrutiny on M.T.F.P. that the implementation of the mental health strategy may be at a slower pace than preferred. "Funding has been limited within 2015, no further funding in 2016 and 2017."
The Minister for Health and Social Services:
The mental health strategy is going faster than planned but I would like it to go faster. That is what ...
The Deputy of St. Ouen :
But it cannot be going faster than planned if you say it is at a slower pace ...
The Minister for Health and Social Services:
It is going faster than planned. We will have a law as part of that mental health strategy and a capacity law coming forward before the end of this year.
Deputy G.P. Southern :
That is a capacity law, that is not delivery of services ...
The Minister for Health and Social Services:
It is all part of our strategy. You have to have something to work towards.
Deputy G.P. Southern :
Well, you will have a framework on which you can build some delivery.
The Minister for Health and Social Services: Exactly.
Deputy G.P. Southern :
But you are not talking about delivery when there is an urgent mental health need on the Island now. Do you recognise that?
The Minister for Health and Social Services: Exactly, and I am working on that.
Deputy G.P. Southern :
It is slower than you want it to be?
The Minister for Health and Social Services:
I would love it to be quicker but you have to make sure you do it properly.
Deputy G.P. Southern : According to your figures ...
The Minister for Health and Social Services: You do not pay for service ...
Deputy G.P. Southern :
... you are saying we stuck at 2015 funding rather than 2016.
The Minister for Health and Social Services: No, no.
Chief Executive Officer:
Minister, would it be helpful if we did say what we are doing on mental health developments in 2016.
The Deputy of St. Ouen :
I recognise work is going forward but is it the case that further expenditure was planned in 2015, 2016 and 2017 and that further expenditure is no longer available?
The Minister for Health and Social Services:
It is available at a different time, at our request. Because we knew we could not deliver it in that time. There is no point in sticking money in the bank and saying: "I have got my money."
The Deputy of St. Ouen :
So it is a choice, is it, that you deferred this expenditure and it is not going to be spent in 2016, 2017?
The Minister for Health and Social Services:
Let us tell you what we are doing, and it is about being realistic, Chairman, about what can be delivered.
The Deputy of St. Ouen :
So we are spending all that we need to on mental health for the next 2 years, is that correct?
The Minister for Health and Social Services:
We are spending all that we are capable of spending.
Deputy G.P. Southern :
If I could just pin you down to an example. For example, the easiest way not to spend money in a year is to put off recruiting somebody. Has there been jobs not created in order to save the money this year and stick to the 2015 budget rather than 2016?
The Minister for Health and Social Services: I do not know the answer to that question.
Deputy G.P. Southern : Do we know?
Director, Finance and Information:
The simple answer in terms of 2015 is it is simply a matter of the timing of recruitment, some of which relates back to the Minister's point about capacity to bring some of these services ...
Deputy G.P. Southern :
So you deferred recruitment?
Director, Finance and Information:
So, for example, there may be a post that we initially planned to recruit in February, which is now recruited in June, for example. Some of which will be driven by the recruitment market ...
Deputy G.P. Southern :
Some of which will be delivered by choice, we can delay that to save that money.
The Minister for Health and Social Services: It is not that simple.
Director, Finance and Information:
It is about the timing of the implementation of recruitment which is impacted by many, many issues, it is not driven by just one particular issue.
Deputy G.P. Southern :
So this is happenstance that it will save you some money?
Director, Finance and Information:
No, it is a whole range of issues. If you go back to the initial plan for 2015 when the 2 per cent reduction in budget was agreed by the Assembly in the budget in December last year, that required some changes and rephasing of our plans across the service.
Deputy G.P. Southern :
So initiatives and staffing have been deferred or delayed in order to stick within the envelope?
Director, Finance and Information:
There were a whole range of actions that were taken which is ...
Deputy G.P. Southern :
Is that the case, that actions and changes and staffing has been deferred in order to stick within the funding outwork. You are making slower progress than you wanted to, is that case?
Chief Executive Officer:
I do not think it is quite as simple as that. I can see where you are coming from but one of the things that I think that we did learn in the first M.T.F.P. was that it was quite hard to spend the money that we were given. Some of that is to do with us scaling up and having the capacity to do it, but a lot of it is about the system's ability to make change happen, not just with only the Health Department but third sector organisations we work with, a whole raft of people including primary care are all leading to change as we implement our new strategy. You have all recognised that it is a whole system change that we are doing. We did find at times through the first 3 years that we could not spend what we have been given, not because anybody was deliberately doing anything to stop it, but because people just could not work at that pace. Not just physically putting out advert for jobs but people being able to plan what the service needed to look like, recognised the service needed to change. There is a lot of people involved in changing this system and we have to work at a pace that they are all able to work with. The job that Rachel and her team do as commissioners is to try and accelerate that by bringing evidence to bear and all of those things. So I think it is quite legitimate to say: "What is it we are trying to do in 2016 and can we do it all?" Because given that money is very, very tight, for us to say we want X and then not spend some of it - not deliberately not spend but not be able to spend it - would not be right either. So what we have had to try and do is balance what do we realistically think we can do. But there is expenditure being planned 2016 in mental health services and we can tell you what those are if you would be interested in knowing.
Director, System Redesign and Delivery:
It is important to recognise, as the Chief Executive says, that the individuals that are driving these changes in the services are the people that are also delivering care. So there is a balance of people of do you take people away from services in delivering the care and focus them on planning care, which means that there is then less capacity, less appointments, less services for those people that need them. So there is a real balance to be taken here to help people to move at the right pace, because we do want these services and we want them as quick as possible, but without distracting people from being able to also deliver the care that Islanders need, which has to happen at the same time. The last thing we want to do is bring in more ... lots more managers and lots more planners, lots more people who are not delivering care to drive forward changes if the system is not quite ready to move at that pace. We talked about Alder Hey, Canterbury New Zealand is often held up as one of the best examples of whole system change, it took them 10 years to get there. We have delivered and we have managed to do an awful lot in just the first 3 years. Islanders are now telling us that they are seeing the benefit from things like rapid response, re-ablement, being able to be looked after in their own homes instead of the hospital. But these changes are fundamental in the way that people are delivering care. You have to move at the right pace for people. If you impose something, big bang, really quickly it goes wrong really quickly.
[09:45]
That puts people's safety at risk and that is the last thing that we want.
The Deputy of St. Ouen :
Okay, I understand the point you are making but P.82 was agreed in 2012, I think, so there must have been a plan that was chartered out at that time to have all this in place by certain times. So as the programme is adjusted ... now is all this recorded? Is this plotted out?
The Minister for Health and Social Services: Of course.
Director, System Redesign and Delivery: Yes.
The Deputy of St. Ouen :
Okay, yes, I would expect it. So is there something that is available to us as a panel so that we can understand how progress is being made.
The Minister for Health and Social Services: I do not see a problem with that.
Director, System Redesign and Delivery:
Absolutely. You probably saw the response we put to Deputy Vallois' question around what is happening at the moment, what is happening at the end of phase 1, which is the first 3 years.
The Deputy of St. Ouen :
Yes, I did. Yes, but that did not say whether you were on time with what you were doing or whether it was real or late, it did not say how it compared with what was originally planned.
Director, System Redesign and Delivery:
Yes, we can make that information available, that is not a problem. I think this has come out quite strongly in the discussion we just had, we have to keep a check on the pace of service changes and with the best will in the world what you planned 4 years ago now will not come to fruition exactly as you planned it. We have to keep a check on how fast we are going, where we are prioritising, where we are putting investment in and how we are helping services to deliver and to develop as the world changes around us. That is what we have been doing, working with stakeholder across the system. There have been some areas where we have put in priority investment to meet the immediate needs. So, for example, you talked about mental health. In adult mental health, we have put in priority investment in terms of the liaison between the hospital and the community, to help to identify those people in the hospital who have mental health problems and help to bring them out into the community. We have not implemented all of the older adult's mental health changes that we had planned 4 years ago but we are well on track with getting those up and running in totality for 2016. So the priority ... all of the services have had investment that we planned, not all of them have had all of the investment that they have planned because we have to make sure we are moving at the right pace. We have to keep that under review all the time to make sure that we are not just slavishly following down a path that we thought was right 4 years ago and not checking that we are still on the right track.
The Deputy of St. Ouen :
Yes, I understand. Minister, can I ask, are there any areas where we may be at risk as a result of reordering the planning of P.82?
The Minister for Health and Social Services:
If I thought the risk was ... there is always risk, but if I thought the risk was unacceptable then we would have found another way of doing it. But, you know, do not be under illusion ...
The Deputy of St. Ouen :
Where are the greatest pressures?
The Minister for Health and Social Services: In our services?
The Deputy of St. Ouen :
In the delivery of our healthcare services.
The Minister for Health and Social Services:
I will let the officers answer that but I mean where are they not would be probably better.
Chief Executive Officer:
It is true to say there are always desirable things we could do across every single aspect of the services that we provide. What we did do in looking at our rephasing is very much prioritise the key risk areas. So we have maintained investment in children's services, we have maintained investment in mental health services, not at perhaps some of the levels for mental health that we would have perhaps liked but, as we have already explained, there are issue about getting lots of money and then not physically being able to spend it, which is just as bad. We have also looked at prioritising the first sets of changes we need to make in the hospital to create a way of working in acute services that will match eventually the new hospital that we will hope we will get built. The biggest risk we undoubtedly carry day on day, day in day out, year on year is the fabric of the hospital and the quality of the hospital environment that we work very, very hard to keep safe but is increasingly becoming the issue that needs to be resolved and resolved quite urgently now. So obviously we hope to have decisions made in those areas.
The Deputy of St. Ouen :
Okay, well we are not really going to delve into the hospital site today.
The Minister for Health and Social Services: I am so relieved about that.
The Deputy of St. Ouen :
There has been so much discussion. Right, okay, we await with great interest what you are going to suggest at the end of the day.
Deputy G.P. Southern :
On page 82 of the annex to the M.T.F.P. you talk about phasing the continue service transformation set out in P.82 in 2012 and making savings by managing staff turnover and vacancies in order to deliver staff savings. Have you got a figure for what staff savings you have already managed in terms of 2015 and 2016 savings?
Director, Finance and Information:
In terms of 2015, the staff savings we have made are within non-calendar(?) and result in a saving in the staff budget just through natural turnover because where there is a gap between somebody leaving and somebody starting we always cover ourselves very carefully because we need to cover that gap. So historically with a nursing post that would be covered because it is a nursing on ward for example so you need to staff the ward. If it is an administrative post we probably would not cover that. So we obviously extract some savings through that mechanism. That is what we have done in 2015. The levels are not dissimilar to previous years. In terms of moving forward into 2016 we are still working up our plans. Obviously the States has done its voluntary redundancy scheme, some of our staff are in for that and some have been approved. Where there are redundancies we will not be replacing them as posts. I do not have that number to hand. But those are the only cumulative posts ...
Deputy G.P. Southern :
Are saying where those are redundancies, so are they services that no longer being delivered?
The Minister for Health and Social Services: Or being delivered in a different way.
Director, Finance and Information:
Where that post is no longer required to deliver services. That is part of the definition of being able to make a person redundant.
Deputy G.P. Southern :
Have you any idea what savings those entail?
Director, Finance and Information:
I do, but I do not have the figure with me.
Deputy G.P. Southern :
You can supply it? Okay. Can I turn on to paragraph 3 of your annex and talk about the 12 points on that page, which I have asked you about in question time previously? Let us try and explore some details. "In total the department would deliver £7.6 million of savings in 2015/2016." For example, let us pick on one, it is an old chestnut, reviewing the provision of patient transport services.
The Minister for Health and Social Services: Yes, and that the widest ...
Deputy G.P. Southern :
What review is that? What is your thinking there?
The Minister for Health and Social Services:
Well, it is right to review it and that would be in the context of all travel. Travel off the Island and patient transport within the Island. I think it is right to challenge that because what we should be doing is concentrating on what people can do, not what they cannot do. I will give you an example, and it is a real example and it is about me. I had a fairly minor operation on both legs but very debilitating, it is quite minor, you are only in day surgery, but I could not walk without crutches for a month. Now, I could have had patient transport or I could, in my case, have got on the bus if my physio appointment fitted with the bus timetable. They did that, they arranged my physio appointment around the bus timetable. We want patient transport to be there for those that really need it. I can produce evidence, and I do not mind saying it in public, where we have dropped somebody home, they have gone indoors, got the keys to the car and gone shopping. That is not what patient transport is about.
Deputy G.P. Southern : Is that the norm?
The Minister for Health and Social Services:
It has happened. I do not know whether that is the norm.
Deputy G.P. Southern : Is that not the exception?
The Minister for Health and Social Services: No, I do not think it is that exceptional.
Deputy G.P. Southern : Could you go on to the detail?
The Minister for Health and Social Services:
So it is right to review it, and it is also right to look at whether people should make ...
Deputy G.P. Southern :
How you are reviewing the provision of patient transport services.
The Minister for Health and Social Services:
We are looking at it. Officers are looking at it at the moment. Who is using it? Do they need to use it? Can we deliver the service in a different way? If they do need to use it, should they be making a contribution to the cost of it?
Deputy G.P. Southern :
So you want to be charging?
The Minister for Health and Social Services:
I said "should they". I did not say want to be, should they.
Deputy G.P. Southern :
Should they? That question has not been resolved and the savings not ... there is no actual saving on there?
The Minister for Health and Social Services:
Well, savings in these sort of things about reducing waste, about doing things more effectively, about reducing administration, they are dynamic. That is something that good managers do all the time. We will deliver. Those 12 areas on that page, they are not exclusive or exhaustive, there will be other areas of opportunity.
Deputy G.P. Southern :
However, we have to vote shortly as an Assembly on plans for 2016 through to 2020.
The Minister for Health and Social Services: To reduce our expenditure by 12 million overall.
Deputy G.P. Southern :
When we do not know how much or what is being proposed on particular ...
The Minister for Health and Social Services:
That is operational. That is operational. We are committing to reduce waste, reduce duplication, cut out administration and review services.
Deputy G.P. Southern :
Review the provision of patient transport services?
The Minister for Health and Social Services: Yes, why not?
Deputy G.P. Southern :
But we do not know what they are and yet in a matter of days we are going to vote on those actions and those savings.
The Minister for Health and Social Services:
You are not voting specifically, but those are examples of what we are doing.
The Deputy of St. Ouen :
One of the 12 in the list, Minister, is to reduce patient travel subsidies, so we would be voting to reduce and that decision seems to have been taken so what changes are being made to patient travel subsidies?
The Minister for Health and Social Services: Perhaps reduce is a ... yes, actually it is ...
The Deputy of St. Ouen : That is the word you use.
The Minister for Health and Social Services:
No, hang on, hang on, it probably is the right word. We might be able to purchase the way that we help patients travel differently, which is something we are working on. We also want it fairer, whereby some people are paying - you know, who might just be over the line - for everything, they get no support and some people get all of the support. So we are looking at that at the moment and I do not want to go into detail, I do not want to build up people's hopes but the sort of thing we may look at is whether there will be a cap to the cost to an individual who has to go time and time again. Where we purchase ...
The Deputy of St. Ouen :
It seems to me, Minister, it has been looked at because the decision is there to reduce patient transport.
The Minister for Health and Social Services:
We are looking at it. We can purchase cheaper flights, those are the sort of things. It not all negative, you know, some of it actually is about helping patients appropriately.
Deputy G.P. Southern :
That is a new definition of the word "reducing" but never mind.
The Minister for Health and Social Services:
Well, we reduce the cost of some of our surgery by moving from a London hospital to John Radcliffe. Now, I would hold up John Radcliffe as one of the centres of excellence of we are getting clinically as good as, if not better, a result for the patient and yet we are paying less. That is reduction but it is not reduction in service.
Chief Executive Officer:
We can also reduce by bringing work back from those centres where we now have the capacity and the skill sets on Island to do it. So there are a lot of different ways we can do that.
The Deputy of St. Ouen :
So it is being done by reorganisation of services rather than a cost to a patient needing to travel out of the Island?
The Minister for Health and Social Services:
I think we will come up with a - the way we are working, and still working on it, it is still under formation - fairer system.
The Deputy of St. Ouen :
I do look forward to seeing that because it is something that is close to the heart of people who are faced with an emergency suddenly, or an illness in the family and then they have to ...
The Minister for Health and Social Services:
But as the Chief Executive says, the more we can do on Island safely and appropriately the better that is as well.
The Deputy of St. Ouen :
Yes. Okay. Minister, can we ask you about the health charge? This wonderful 2 words that is meant to be our saviour and has a remarkable lack of detail in the M.T.F.P. yet it is meant to raise £35 million and what is this health charge going to be, Minister?
The Minister for Health and Social Services:
As I told you before when we discussed it, Chairman, that is something that the Minister for Treasury is working up and that is one of the single reasons why we do the Medium Term Financial Plan in 2 parts. We do not know what it is going to look like yet. I have a private view and I am not going to share it today because it is not the policy. The Minister for Treasury is working on it. It will be a mixture, of course, of charges made from earnings maybe and some appropriately - where it is appropriate to do it - user pays. But more than that I do not know because the Minister for Treasury knows what is required, that is what he is going to bring back in the second part of the Medium Term Financial Plan. Obviously we will be involved in those discussions but we are not in a position to do that yet. We are genuinely not hiding anything. It has not advanced yet.
The Deputy of St. Ouen :
But this is part of your budget and I cannot imagine that the Minister for Treasury has not shared with you how your budget is going to be raised.
The Minister for Health and Social Services: He has not yet.
The Deputy of St. Ouen :
Are there no working papers putting forward ideas as to how this ...
The Minister for Health and Social Services: No.
The Deputy of St. Ouen : ... money could be raised?
The Minister for Health and Social Services: No.
The Deputy of St. Ouen :
At the very basics, Minister, has any thought been given to an insurance plan rather than a charge?
The Minister for Health and Social Services:
These are questions you need to ask the Minister for Treasury and Resources.
[10:00]
The Deputy of St. Ouen :
But these are questions about raising the budget needed for Health?
The Minister for Health and Social Services:
Exactly, that is the Minister for Treasury and Resources' job. My job is to make bids for the money I need to provide the services I need and to ensure that it is used appropriately and effectively. The Minister for Treasury and Resources' job is to get those funds for me. So those are questions you need to ask him.
The Deputy of St. Ouen :
Have you got any views, Minister, on the insurance system?
The Minister for Health and Social Services:
I have, they are private, they are not policy and I do not wish to discuss them at the present time. But it is something that the Minister for Treasury and Resources and I will discuss in time but he has to come up with the plan. It is not my job to come up with the plan.
Deputy G.P. Southern :
Are you content that he has not come up with a plan yet?
The Minister for Health and Social Services:
I know that he has been incredibly busy on the Medium Term Financial Plan, working on the budget as well because although people might think you pull it out of the back pocket on budget day, you do not. He has been incredibly busy looking at things like that and that is the whole reason why on this occasion the Medium Term Financial Plan has been split. We will be working on it fairly soon. I will have my views given to the Minister for Treasury and Resources but the decision on which way goes will be one for the Council of Ministers, but the decision on what goes before the Council to discuss will be the Minister for Treasury and Resources'.
Deputy G.P. Southern :
Are you, as a Minister, content that what is supposed to be a medium term, ie 4 year, plan has had to be split this year into one plus 3? Therefore avoiding some of the planning that is going on.
The Minister for Health and Social Services:
Let us be honest, it is not ideal but I do not think, given the situation we found ourselves in, there was any way of avoiding that. So I am content this was the right thing to do this time but it is not ideal.
The Deputy of St. Ouen :
Is it acceptable, Minister, that the States are having to vote on the introduction of a health charge without knowing the details of how that will be implemented?
The Minister for Health and Social Services:
You will get the opportunity to vote on the detail when he comes back with the second part of plan. You are just voting for a principle. Now, if you are fundamentally opposed to that principle that is a matter for you or any Member, but the detail will be coming back for the Assembly to vote on. So I think that is acceptable.
The Deputy of St. Ouen :
As a Minister you think that is an acceptable way of ...
The Minister for Health and Social Services:
It is not ideal but we have got to live in the real world. We are where we are and we need to ...
Deputy G.P. Southern :
Do you as Minister for Health recognise that it is a very serious difference between a user pays charge and some other means of charging?
The Minister for Health and Social Services: I do understand that.
Deputy G.P. Southern : That is a serious principle ...
The Minister for Health and Social Services:
Yes, yes, I do understand that, and that is why I said there may be ... it may be appropriate for user pays in some areas. I do not think it will be the answer. That is something I need to discuss with the Minister for Treasury and Resources that some co-payment systems in some places might be right.
Deputy G.P. Southern :
Can you understand why some Members might feel very uncomfortable voting for something in principle ...
The Minister for Health and Social Services:
You are only voting in principle for charges. You are not voting in principle for how those charges will be made until the second part comes back.
Deputy G.P. Southern :
Once the principles are there, you know and we both know ...
The Minister for Health and Social Services:
I do not think you would be very slow at challenging us if you thought, when we do get into the detail, what we put was not appropriate.
Deputy G.P. Southern :
But by then it will be too late.
The Minister for Health and Social Services: No, it will not.
Deputy G.P. Southern :
Yes, it will. You know that as well as I do.
The Minister for Health and Social Services: No, I do not.
Deputy G.P. Southern :
Okay, you have a different view to the way the system works than I do.
The Minister for Health and Social Services:
I think this is a pragmatic approach to a very busy situation.
Deputy G.P. Southern : To a very knotty problem.
The Minister for Health and Social Services: A knotty problem, yes, absolutely.
Deputy G.P. Southern :
Can I move on to not the hospital site itself but can you talk a little about the mechanism by which a decision is about to be arrived at?
The Minister for Health and Social Services: Yes, okay.
Deputy G.P. Southern :
For example, has there been delays unnecessarily. The throwing in of People's Park, when did that happen?
The Minister for Health and Social Services:
Okay, well People's Park originally was looked at and rejected as not big enough, way before I was Minister for Health. Because the work we are doing now, which is along the Canterbury model to some extent where you keep people out hospital and where you look at community services, where you develop primary care, and in changing those services, you know, we know that we need a slightly small hospital, bigger than the one we have got now but smaller than we might have done. Suddenly the hospital would fit, although they have rejected the People's Park before the hospital could fit on the People's Park. I know I have been referred to on Twitter and everything else as the peabrain that wanted the park but I think it is right to - with the biggest project the States has ever undertaken, with a project that is 4 times bigger than the Energy from Waste - push at the boundaries, challenge the norms, think outside the box and then consider all the facts for each site one against the other. Now, we are not going to consider, I think it is something like 50 sites have been looked at. I know of 23, 24 sites in my time and we have got it down to, as you know, Overdale the current site, waterfront and the People's Park. Now, I don't know until I get the reports which boxes these tick. Is there enough space?
Deputy G.P. Southern :
That is fine. What I am asking you is when was the People's Park put back in?
The Minister for Health and Social Services: Two months ago.
Deputy G.P. Southern :
Does that in itself putting that back in, did that cause a delay?
The Minister for Health and Social Services:
It delayed us by about a month because we might have only been evaluating Overdale current site and waterfront.
Deputy G.P. Southern :
Right. Who took the decision to put People's Park back into the pot?
The Minister for Health and Social Services: The Ministerial Oversight Group and I approve of it.
Deputy G.P. Southern :
Which consists of, just to remind us?
The Minister for Health and Social Services:
Oh now. Can you help remember all the Minister's ...
Deputy G.P. Southern :
It was not meant to be a trick question.
The Minister for Health and Social Services: No, no, it is not.
Chief Executive Officer:
The Chief Minister chairs the group and the Ministers for Health, Social Security and Treasury and Resources are members. The Assistant Ministers are invited to go to the meeting as well and obviously relevant officers support them at the meeting.
Deputy G.P. Southern : All right, okay.
The Deputy of St. Ouen :
What is the cost of re-engaging experts to examine all the sites?
The Minister for Health and Social Services:
I think - and I did ask but this was from memory - because most of the work had been done around the other sites, it could just be transferred over. I think it was about 10,000 ... would you know?
Director, Finance and Information:
I could not tell you off the top of my head.
The Minister for Health and Social Services:
No, we will come back to you rather than me take a guess at it. I think the extra, because a lot of the stuff was duplicated. You know, once you know what the footprint is you do not have to work that out again.
Chief Executive Officer:
It would be miniscule compared to making the wrong decision in terms of major capital expenditure. I think we do need to explore every legitimate option before reaching a conclusion.
The Deputy of St. Ouen :
Yes, there are the additional costs of adding a site in at a late stage, consultants cost but also the delay costs of deferring the decision a month or 2 or 3 because there must be costs building up as time goes on.
The Minister for Health and Social Services:
Absolutely, but the costs of getting it wrong on a £400 million project would be far greater than the little we have spent in just looking again.
The Deputy of St. Ouen :
Well, yes, I guess so. It is, but at the end of the day there has to be a shortlist ...
The Minister for Health and Social Services: This is a hospital for Jersey.
The Deputy of St. Ouen : ... and a decision made.
The Minister for Health and Social Services:
This is a hospital for Jersey, a safe, affordable, sustainable hospital for Jersey, and if I take a month longer to get the right decision, well I do not apologise for that, I think it is right.
The Deputy of St. Ouen :
Very well, Minister. The amount paid by the department to Family Nursing and Healthcare is to be reduced, am I correct?
The Minister for Health and Social Services: That is news to me.
The Deputy of St. Ouen :
Okay, then I am sorry. But we understand that Family Nursing and Healthcare are removing some of their services there, their domiciliary services.
The Minister for Health and Social Services:
Okay, I will let officers come in in detail in a minute but I would just like to set the context here. The change in service delivery was entirely ... I mean, I would have to say had they not done it I might have been talking to them about it but was entirely a decision of Family Nursing. It was their board and their management that saw that their skills were best used in delivering nursing care support in the community and not domestic care. They made that decision. They were not influenced by us. I have to say, I totally agree with it because I think that they are targeting the higher skilled end of the service. It is delivering more of that is the right way to go. Had they not made that decision I think I would have been talking to them. But they did it, they had no pressure from us to do it. It was a matter for their board and their management team. Now, if you want into this in a little bit more detail the officers will take you through it.
The Deputy of St. Ouen :
Is it accepted, Minister, that this domiciliary care is a low level of care for which your department is responsible?
Director, System Redesign and Delivery:
I think it is important to be clear what we are talking about, we are talking about domestic care services, so cleaning. We are not talking about the delivery of healthcare support to people in their own homes.
The Deputy of St. Ouen :
But this is delivered to people who have medical needs and issues and are often being treated in their home by a nurse who visits but cannot do their cleaning so that has been provided for them because it is part of a care package.
The Minister for Health and Social Services:
So, sorry, are you suggesting that a nurse should do the cleaning.
The Deputy of St. Ouen : No.
Director, System Redesign and Delivery:
Family Nursing and Home Care have taken the decision to stop providing cleaning services as part of the way that they are delivering and developing their services going forward so that they can focus their efforts on those individuals who have more complex and higher needs, and so that they can focus delivering care rather than providing cleaning services. There are a whole range of other organisations and companies that provide cleaning services in the Island and, of course, individuals are free to choose from any of those should they want or need their cleaning done. As part of the long-term care benefit, individuals do get assessed in terms of their needs and their indicative budget, their benefit levels set accordingly and they then work with the social workers to identify what services they want in their own homes to meet their needs against those assessed needs. But Family Nursing and Home Care have taken the decision to focus on providing care rather than cleaning services.
The Deputy of St. Ouen :
But the long-term care scheme will not apply to all. If an elderly person has fallen in their home and has broken a limb they will not be able to clean their home but previously they were supported by Family Nursing very often. Now, they are not eligible for long-term care, it is not a long-term condition, but while they are disabled or have mobility issues in that way perhaps they cannot clean their home.
The Minister for Health and Social Services:
Then they can purchase a service in from one of the other providers.
Deputy G.P. Southern :
I think what we have got here is the model on which you are basing the future, which is third party providers in the community wherever possible. It is magnificently illustrated by the relationship between your department and Family Nursing, and that is the model. That is an institution that people trust. Now, you have got, I think the figure is, 60 to 70 people who were having this service delivered by Family Nursing but who will now have to go out and seek another supplier for that. Overall, do you think that supply will come in as cheaper or more expensive that what Family Nursing ...
The Minister for Health and Social Services: Cheaper.
Deputy G.P. Southern : How do you work that out?
The Minister for Health and Social Services:
Well, it would be wrong for me to discuss the charges, that is commercial information that I have access to from Family Nursing but I can tell you it would be cheaper.
Deputy G.P. Southern :
That is not the opinion of the Chairman of Family Nursing.
The Minister for Health and Social Services:
Well, who made this decision, not us. Without any pressure or request from us. I have to say I would have been requesting it if he had not but he made this decision, not us.
Deputy G.P. Southern :
Okay. Do you think this will provider wider choice and cheaper domestic services?
The Minister for Health and Social Services:
I think it allows us to target the care where it is really needed or allows Family Nursing to support us in providing the nursing care where it is really needed and leave the less skilled stuff to people who are skilled in the less skilled stuff at an appropriate rate.
The Deputy of St. Ouen :
I believe you have a service agreement with Family Nursing and Home Care?
The Minister for Health and Social Services: Yes.
The Deputy of St. Ouen :
So is that being amended as a result of ...
The Minister for Health and Social Services: We are meeting to discuss that, certainly.
The Deputy of St. Ouen :
So will that mean that an element of the funding that has previously passed to Family Nursing will no longer pass over?
The Minister for Health and Social Services:
No, but we are meeting because what they are attempting to do, I believe, is to target the funding that they have in a more useful way, in a more productive way, in a slightly different way. But we are meeting to discuss this with them. They made that decision, I welcome that decision and now I am going to meet with them to discuss it in the near future.
[10:15]
The Deputy of St. Ouen :
But would it not be the case that where some of that funding was provided to allow Family Nursing to provide domiciliary care, now they will not be doing so then that cost is being passed on to members of public needing that service.
The Minister for Health and Social Services:
I think members of the public were paying for some of that anyway.
The Deputy of St. Ouen :
Perhaps not in the full commercial sense.
The Minister for Health and Social Services:
That is a question you will have to ask Family Nursing. They are an independent organisation. They made this decision independently. I totally agree with it, I support their decision, but it was them that made it.
Deputy G.P. Southern :
To what extent do you see the principle of third party in the community delivery of services extending to proper nursing care and proper caring for people in their homes?
The Minister for Health and Social Services:
We are doing proper nursing care. I am not an expert on it and, again, I will hand over to the officers, but the work I see being done around the rapid response, that is proper nursing care coming in and giving people I.V. (intravenous) antibiotics.
Deputy G.P. Southern :
Has that been open to other third party providers or is Family Nursing central to that initiative?
Director, Systems Redesign and Delivery:
There are a whole range of independent service providers that are on the approved provider framework to provide nursing and home care to individuals in their own home. But through the long-term care benefit individuals can choose any of those providers that are on the approved provider framework that have passed important quality standards and have then been independently inspected.
Deputy G.P. Southern :
What do those quality standards involve?
Director, Systems Redesign and Delivery:
I can send you a full list of the quality standards. They include things like ensuring safety, governance, safe recruitment practices, D.B.S. (Disclosure and Barring Service) for the staff that are employed there, training, ongoing support, supervision, delivery of care. There is a really comprehensive set of quality standards.
Deputy G.P. Southern :
Also levels of qualification in the staff?
The Minister for Health and Social Services: Yes, appropriate to the service being delivered, yes.
Director, Systems Redesign and Delivery:
We can send you the full documentation of all those quality standards.
The Minister for Health and Social Services: This will be regulated.
The Deputy of St. Ouen :
Thank you, yes, if you would. I would like to discuss with you, Minister, something perhaps a bit less controversial but it is an issue raised by one of the consultants recently on Jersey's record on issuing donor cards. I want to explore that a bit wider and ask about the whole system. Are we linked to the U.K. (United Kingdom) registers for the purposes of donors in Jersey and making that information available, exchange of information with the U.K.
The Minister for Health and Social Services:
I will let Helen pick up on this, but suffice to say that we know that we can do better, it is how we do better but I will let Helen speak about it.
Hospital Managing Director:
We are fully part of the U.K. blood and donor service so if we need ... if a patient in Jersey needs a transplant then we are highly likely getting that organ from the British donor system.
The Deputy of St. Ouen :
Okay, and the opposite, if there is a tragedy over here are organs available to the U.K.?
Hospital Managing Director:
Yes, doctors are fully connected to the donation system and we have donor nurses and donor doctors and then you get a team that come over to assist our doctors if that situation arises. So our intensive care doctors, Emergency Department doctors, know exactly what to do if that occasion arises. The organ goes to the person on the list who is most critical and that is a national list that is held, so obviously it has to match and then it has to be to the person who is in most need.
The Deputy of St. Ouen :
So Jersey residents are put on that national list, are they?
Hospital Managing Director: Yes.
The Deputy of St. Ouen : Okay, that is good to know.
The Minister for Health and Social Services:
Sorry, Chairman, I thought you were asking if we could do more to make organs available.
The Deputy of St. Ouen :
Well, in terms of cards, yes. That is all part of it. Do you have any ideas about that, Minister?
The Minister for Health and Social Services:
Yes, I think we can do better. That is about education. A driving licence initiative recently helped. When I say it is about education I think it is about getting people to speak to their family about what they would really like to happen in the event of. That is much less emotional done now rather than waiting until there is a big problem. I am watching, and as the Minister I have been getting advice from the officers, with interest what is happening in Wales, but I do not think you want 2 environments experimenting. We will watch with interest what is happening in Wales and see whether that works and then we will consider whether that is appropriate for here. But we are not going to go out on a limb. I understand the need to ...
The Deputy of St. Ouen :
Perhaps could I ask the Hospital Director, the consultants working in the Emergency Department is it part of their training that in the event of a tragedy and organs becoming available, do they ask the families involved?
Hospital Managing Director:
Yes, it is usually either the E.D. (Emergency Department) or the Intensive Care Department, and yes we have a trained team as is part of normal practice.
The Deputy of St. Ouen :
Okay, that is good to know. Because Jersey is a distance away from the U.K. are there disadvantages by being in Jersey, so the time factors ...
Hospital Managing Director:
There are some, yes, because usually a team has to come out to harvest the organ and that takes time. So it depends when it is, how available that team is, but we work with them very closely so we have all those conversations and we have workarounds so we know how to look after patients until they can get there.
The Deputy of St. Ouen :
Yes, so is it the case that perhaps wishing to be an organ donor I might not be as much use as somebody who lives in central London, say, close to some of the big hospitals?
Hospital Managing Director:
I would not want people to think that. Everybody that is remotely considering being an organ donor should and they should register themselves. We do not turn people down. If people really want to do this we try and do everything possible to make sure it happens. So I would not want to put anybody off.
The Deputy of St. Ouen :
Okay, so it is not a big factor, is it, being a small Island over the sea and time constraints?
Hospital Managing Director:
No. No, I mean it adds a logistical challenge but,no, it is not a big factor and it certainly should not put people off wanting to donate.
The Deputy of St. Ouen :
It is still worth doing, that is really good to know.
Deputy G.P. Southern :
Can I come in with some fresh air? We recently talked to the representative of the consultants at the hospital who revealed to us that morale, as far as he was concerned, was at an all time low and there seemed to be 2 issues there that were concerning his members. One was, he said, a 20 per cent reduction in equivalent levels of their salaries and also a serious issue with the insurance that consultants had to take out to work outside of the U.K. There is an issue around how the insurance is treated here as distinct from the U.K. Is there anything where you might make progress on their morale.
The Minister for Health and Social Services:
I will let my colleague the bean counter, as you called him last time, talk to you about the indemnity but it is not as was described in the Evening Post. We make ...
Deputy G.P. Southern :
I was there when he was talking about it and he was not that far off.
The Minister for Health and Social Services:
No, it was not as described like that from memory and Jason will correct me. No, it is probably best not to saying anything ...
Deputy G.P. Southern :
We can go through the transcript anyway.
The Minister for Health and Social Services:
Well, we are going to put you right. The Chairman has asked a question anyway for the next States sitting and we are going to put to you right, but I am going to hand over because what I do not want to do is accidentally identify the person's contribution so I will hand over to somebody who can perhaps be a bit vague about the people it might be.
Director, Finance and Information:
I will let Helen talk about this initially because she deals with the consultants and their insurance.
The Minister for Health and Social Services: But we do make a significant contribution. Helen.
Hospital Managing Director:
All doctors, whether they work here or in the N.H.S. (National Health Service) have to have medical indemnity insurance. In the U.K. most of the N.H.S. hospitals have joined a scheme called the N.H.S. Litigation Authority, which is a premium type scheme and that covers like a bit of a Crown indemnity. However, if they undertake private work in the U.K. they have to have their own insurance and that is nothing to do with the U.K. hospitals at all, that is a private matter for them. When they work in Jersey the same happens, every doctor has to have insurance, they insure themselves through medical defence unions, that is the normal route and that is the same in the U.K. or here, and they get given a premium. That premium will depend on the specialty that they work in and varies enormously by specialty, so that is based on risk. If the doctor earns less than 10 per cent of their current public salary in additional income from private work then we pay the whole of their premium so they are not paying anything. If they earn more than 10 per cent in addition to their public salary then we pay 50 per cent of their premium, so we are paying for the public part and they are paying for their own private work cover. That is the system that has been in place for a long while. The doctor that spoke to you had a 75 per cent rebate on his premium.
The Minister for Health and Social Services: So he does not pay 100 per cent as quoted.
Hospital Managing Director:
The reason he had 75 per cent was his job is split, he is partly a neo-natal doctor, which we would pay 100 per cent of all of that because it not private work, and partly paediatrics, so the paediatric bit is split. So he is an anomaly in that sense. We pay 100 per cent of one and 50 per cent of the other and then across the board worked out to 75 per cent.
The Deputy of St. Ouen : Okay.
Deputy G.P. Southern :
So you are saying there is not a problem?
The Minister for Health and Social Services: I think there is a problem.
Hospital Managing Director:
It is an accepted mechanism for Jersey before any consultant comes to work here I sit them down and have exactly this conversation. We might talk to them about how the Jersey system is different to the U.K. system, I have not had a single doctor say to me: "Oh, I do not like the sound of that, I am not coming to Jersey."
The Deputy of St. Ouen :
But is it the case that with the consultants we have their insurance premiums have risen dramatically over recent years?
The Minister for Health and Social Services: Everywhere.
Human Resources Director:
It is not just here, it is the U.K. as well.
The Deputy of St. Ouen :
But the U.K. system may be different, might it not?
The Minister for Health and Social Services:
Yes, the U.K. system, Helen put us right, when I have been briefed on this, the U.K. system, the N.H.S. carries a considerable amount of the risk under Crown indemnity.
Director, Finance and Information:
It is important to understand, as Helen has just explained, that the only cost burden that falls on the doctor is the cost burden of their private work. The burden relating to the public activity falls on the taxpayer. The costs have gone up, yes. We have a major insurance policy, apart from the insurance for consultants, so all the other staff that provide services, that is all middle grade doctors, junior doctors, the nurses, physiotherapists, everybody else that works within the services, is insured under a group policy. The cost of that insurance has gone up and up and up and it just reflects society and the cost of litigation and cost awards made by the courts. But it is important to understand that in terms of the consultants and the cost burden they are bearing their own insurance that relates to insuring their private activity not the public activity.
Deputy G.P. Southern :
It tends to be greater than would occur in the U.K. or not? That is the key question, I think.
Director, Finance and Information: More than what it would be in the U.K.
Human Resources Director:
I could add something there in terms of the Royal Colleges in the U.K. have issued guidance as recently as last year to consultants who are thinking of going into private practice for the first time, and they recommend them to set aside £20,000 for their personal insurance costs that will arise from engaging in private practice because the rise in the cost of insurance has gone up in the U.K. and Jersey, it has not just gone up in Jersey and affects Doctors in every jurisdiction. To support Helen's earlier point, my medical recruitment team who have been post for 7 or 8 years speak to or engage with every applicant and potential applicant for consultant vacancies and in all that time, they cannot recall a single example of a doctor withdrawing from a recruitment process or not accepting a job offer for any issue relating to insurance, ever.
The Deputy of St. Ouen :
I imagine private practice in some areas is lucrative but in other areas is not so lucrative. So is 50 per cent contribution the right way to go about it? Surely it should be a more calculated proportion.
The Minister for Health and Social Services: On private work? That is a choice for them surely.
Hospital Managing Director:
It is a choice for them, I do not have the figures of how much the doctors earn privately and I would not expect to. There is about a dozen doctors that have all their insurance paid in full and they do not do much private work at all, if any. The other doctors make that choice and they know how much that choice is going to cost them and if private practice is what they want then that is how they manage their private business.
The Minister for Health and Social Services:
You would not expect the public to indemnify me if I went off and did some consultancy work, would you?
The Deputy of St. Ouen :
No, of course not, I am not suggesting that, Minister.
The Minister for Health and Social Services: I thought that was what you were suggesting.
The Deputy of St. Ouen : I am not suggesting that.
Deputy G.P. Southern :
I think there is a response in there somewhere about the public and their votes. [Laughter] But never mind.
[10:30]
The Deputy of St. Ouen :
Why I am questioning it is if we receive evidence that the amount of insurance premium payable by consultants is a deterrent to them coming to Jersey ...
The Minister for Health and Social Services: It is not.
The Deputy of St. Ouen :
... and we know we have to recruit many more consultants ... well that is some evidence that we have received and that is why we are asking about it?
The Minister for Health and Social Services:
No, no, somebody saying something is not evidence. We can produce the evidence that it is not a deterrent.
The Deputy of St. Ouen :
Well, that is it, we will receive your evidence and then we will ... but it is evidence, Minister.
The Minister for Health and Social Services:
It is not evidence. The fact that they say it is raining out there, is not evidence. If I say it is raining out there, you would expect to look out and see rain, would you not, that is evidence.
Deputy G.P. Southern :
But surely you only give us gospel. Surely?
The Minister for Health and Social Services:
Absolutely, I only give you gospel but you have got hold of the wrong end of the stick on that one.
Deputy G.P. Southern :
Would you like to finish that sentence we trampled all over.
The Minister for Health and Social Services:
Helen covered it. In terms of the public indemnity it is not a problem but I know that some doctors, the more private work they do, the higher the cost goes up for them and the Medical Director was explaining that sometimes where that is going to fall next year they do not always know until they send their figures in. So it is a challenge for them. But that is a choice they make. Nobody makes them do private work.
Deputy G.P. Southern :
There is a second issue about the erosion of their salaries as they see it, compared to other professionals.
The Minister for Health and Social Services:
Well, I do not want to get in to discussing or negotiating salary here. They were part of a system to the U.K. They have always been linked to the U.K. and that has resulted in the outcome that we now have because they have always been linked to what ... if the N.H.S. gave the consultants a 2 per cent pay award, they got a 2 per cent pay award, even if people here got none or even if people here got 5. We have agreed to talk to them about a different negotiating body or way of doing it and we are in talks at the present time. But I am not going to go into detail.
Deputy G.P. Southern :
So the door is open, you are acting on that.
Human Resources Director:
We are having a negotiating meeting tomorrow morning.
Chief Executive Officer:
Do you want us to just touch on the issue of morale?
The Deputy of St. Ouen : Yes, indeed.
Chief Executive Officer:
I think when you spoke one to one to consultant colleagues that would say that morale is very low and that has been demonstrated through a survey. Just to be clear, that survey only had 5 questions and was purely about the pay claim and was not more general than that. I think there is a lot of dissatisfaction around the pay claim. In terms of morale generally, we are in different times, we have got challenges that we are all trying to face but I have a huge amount of engagement from the consultants helping us through these challenges. I have a whole raft of clinical directors that are actively looking at their services; they are working with the future hospital team to look at what the future requires, they are looking at the budgets, they are looking at how to make safe savings. So I would say engagement with the clinical teams here is probably better than I have ever known in any other hospitals I have worked. I do think this particular issue is causing them concern.
Deputy G.P. Southern : Thank you for that clarification.
The Deputy of St. Ouen :
The consultant we heard from explained how many consultants are due to retire in, say, the next 5 years. Is there a detailed plan in place to make sure we do recruit adequate consultants and can attract them here?
Hospital Managing Director:
We have got about 20 per cent, probably, of our consultants that could retire in the next 5 years. We have 2 that we know that are retiring soon. The plans are already written, we have new job descriptions, job plans, the Royal College has approved those job descriptions and we are going out to advert. So because they are retirements we usually know in good time when somebody is going to leave and we can make the appropriate plans. The difficulty or the difference we might have is consultants that work in Jersey are very much more generalists than consultants that tend to work in big hospitals in the U.K. where some specialisation has taken hold. So we are wanting to attract generalists because we do not have enough patients for everybody to be specialised. At the moment we have not had a problem attracting consultants and we will just see how the market is when we go out to these new posts. Since I have been in post, other than a respiratory consultant, which there was a national shortage, we have had applicants for all of our jobs.
The Deputy of St. Ouen :
But if you are seeking generalists and the thrust is to specialise in the profession then it is unlikely that we will get those or we will not get those who wish to be at the top of their field, is that correct?
Hospital Managing Director:
I think it depends on the individual doctor. The Royal College of Physicians produced a paper I think at the end of 2013 suggesting that specialisation had gone too far and they are now reversing that from a college point of view and expecting people to be keeping their generalist
skills going. So it has been recognised within U.K. by the colleges. Some of our latest recruits have been young consultants into their first jobs wanting to come to Jersey because it gives them the scope of practice. If you take some of our ophthalmology appointments or urology appointments, they see this as a really good place to work because they do not have to specialise and they can see the whole service for all of their patients. So I think it depends on the individual. So far we have had made some really good appointments.
The Deputy of St. Ouen : Okay.
Deputy G.P. Southern :
We have heard about our use of bank nursing and agency nurses from various witnesses. How are we doing on our use of locums in terms of doctors coming in? Is our use going up, down, is it static?
Hospital Managing Director:
It is static or down. I think it is down this year. We will always use locums because we have such a small workforce, if somebody goes on holiday and they are a single-handed specialist ... so for example our microbiologist, if he goes holiday there is nobody else on Island that can do that work so we agreed that we will use locums on a regular basis. We usually use the same people so it keeps the continuity for people that know the Island. If we have short-term sickness we usually cover among ourselves if that is possible. If that is not possible, it is another time we have to use locums. We do not have any vacancies at the moment, at the consultant level, that we cover by locums and so it is only when we have got the more planned leave.
Deputy G.P. Southern : Or at junior level?
Hospital Managing Director:
At junior level we have junior doctors come in on rotation from the Deanery and so they supply the individual as part of that rotation. If, for whatever reason, they cannot supply a doctor that we are expecting then we will get what we call a longer term locum into that post to hold the rotation. If there is short-term sickness we tend not to cover them with locums, they cover themselves or the person above them will come down and do their role for a couple of days. At middle grade level we have a couple of locums in place and that is deliberate because we are relooking at how those services are managing their care and we might want to do something different with that post. So, for example, do we want to appoint another consultant rather than a middle grade doctor. So we are keeping that post vacant until that decision is taken.
Deputy G.P. Southern :
Then that presumably ties in with the restructuring P.82 of the whole service?
The Minister for Health and Social Services: Yes.
The Deputy of St. Ouen :
Three months ago we asked you about waiting lists and what pressures there might be. In these last 3 months can I ask if there have been change in those pressures, any mitigation or any deterioration?
Hospital Managing Director:
It is not going be to an easy answer, I am afraid, because it varies by specialty. The summer is always a difficult time for us because we have got holidays. As I have just been explaining, if you have got small specialties with very few doctors in them they suffer when people go on holiday potentially. We also deliberately do theatre maintenance over August. So we close our theatres in pairs during August to do some maintenance. Having said that, our August position, our average waits were pretty comparable, in fact better in many specialties ... I cannot find my bit of paper to give you the detail. We have pressures ... thank you, that was not quite what I wanted but thank you.
The Deputy of St. Ouen : Take your time, that is okay.
Hospital Managing Director:
We have pressures in some specialties where demand has been going up. So trauma and orthopaedics continues to see increasing demand coming through.
The Deputy of St. Ouen :
Do we know what is the source of that increase?
Hospital Managing Director:
They are G.P. referrals but they are not inappropriate, they are just people on the Island needing to see an orthopaedic surgeon.
Deputy G.P. Southern : It is fluctuations for ...
The Minister for Health and Social Services:
I was going to say the ageing population will be a contributing factor. It may not be the only factor but it will be a contributing factor to that.
Chief Executive Officer: For orthopaedics it will, yes.
Hospital Managing Director:
In Ophthalmology now we have got a stable consultant team because we have appointed 2 ophthalmologists in the last year so their waits have now started to come down quite nicely. There are still people that are waiting too long, we know that and we are very keen obviously to keep bringing the rates down. From our outpatient point of view, the areas in August for average waits, hotspots were the dental service and in the acute service it was general surgery at 11 weeks to see a doctor, to see a consultant as an average wait.
The Deputy of St. Ouen :
Is that up or down on these figures?
Hospital Managing Director:
General surgery had gone up in August, it had been 8 weeks in July. All the dental services were coming down, although they are high and there are long waits, they are coming down. In terms of waiting for inpatient care. Our hotspot in August was ophthalmology, waiting 13 weeks to get a procedure and trauma and orthopaedics were waiting 19 weeks.
The Deputy of St. Ouen :
You mentioned in ophthalmology the waits were coming down because of appointments?
Hospital Managing Director:
They are but we still had a hotspot ... waiting times are coming down for appointments but as soon as you have seen more appointments you have got more on to the waiting list to go to theatre so then you have to move your capacity for operations. But the majority of these services where patients were coming in for their procedures, is about 6 weeks, 7 weeks. So we have some key specialties that we continue to have challenges with.
The Deputy of St. Ouen :
Okay, thank you. Could you let us have that chart if it is ...
Hospital Managing Director:
It is on gov.je. Every month we update it.
The Deputy of St. Ouen : That is right, yes. Thank you.
Deputy G.P. Southern :
Just one last thing if I may. You just mentioned dental services. I have a particular hobby horse with dental services. Dental fitness scheme to be precise. There has just been a review of dental services, which in my reading of it said you need some accountability, you need some extra management in there to work out what you are spending on what and basically park it. They have parked it. It will be at least 2 year before anything will happen. The dental fitness scheme has been atrophying for the last 10 years and needs an injection, needs updating. Are you prepared to do that in the short term?
The Minister for Health and Social Services:
First of all, let me say my interpretation of the dental report was slightly different to your own. It showed that our 5 year-olds were in a much better position than their counterparts in the U.K.
Deputy G.P. Southern :
With significant variations across schools, so the poor schools did worse.
The Minister for Health and Social Services:
But it showed that overall we were in a much better position than the U.K. and we put together a working party to develop a strategy now on how we are going to take the dental service forward. You will have noted - it went through fairly quickly - the change to the law recently that went through on the last sitting which I hope will help us with our waiting lists as well because it will release the dentists to do the real dental work and there are other therapists to assist with that. So things are moving in the right direction.
Deputy G.P. Southern : That is a good move, yes.
The Minister for Health and Social Services:
I think it will make it more portable as well. But maybe a year or so will tell us that, will it not, you know?
Deputy G.P. Southern : We will see.
The Minister for Health and Social Services:
Yes, we will see. But will create, I think, better competition.
Deputy G.P. Southern :
My worry is that if we leave the dental fitness scheme alone already dentists are looking at it saying: "It is just not worth my while" and that in 2 years' time when we come to replace it with something super and better, we will not have service.
The Minister for Health and Social Services: That is why we are reviewing it.
Hospital Managing Director:
It might just be worth clarifying that the Health Department and the hospital manage the under 11 year-olds and they are not in the dental fitness scheme. We see the under 11 year-olds. Once they are between 11 and 18 they have the opportunity to join the dental fitness scheme. The only part that we play in that is making sure they are dentally fit before they join the scheme, which we do, the rest of the scheme is administered purely through Social Security. So we do not really have the ability to do as you have just asked the Minister because it is not our scheme to manage, it sits with Social Security.
The Minister for Health and Social Services: But we do work together to look at it.
Deputy G.P. Southern :
All right, I will leave it there for the moment. We are under some time pressure. Cannot keep you from the Council of Ministers.
The Minister for Health and Social Services: You are so kind.
The Deputy of St. Ouen :
I think we will close there, Minister, and allow you to get to your next meeting.
The Minister for Health and Social Services: Thank you, that is appreciated.
The Deputy of St. Ouen :
Thank you for coming and giving your explanations robustly and assisting us.
The Minister for Health and Social Services:
Thank you, Chairman. I always look forward to these quarterly meetings.
The Deputy of St. Ouen :
You do not need to go that far. [Laughter]
Deputy G.P. Southern :
We will work on it. We will work on it.
[10:45]