Health and Social Security - Quarterly Hearing - Minister for Health and Social Services - 23 April 2015

Health and Social Security Scrutiny Panel THURSDAY, 23rd APRIL 2015

Panel:

Deputy R.J. Renouf of St. Ouen (Chairman) Deputy G.P. Southern of St. Helier (Vice-Chairman) Deputy T.A. McDonald of St. Saviour

Witnesses:

The Minister for Health and Social Services

Connétable J.M. Refault of St. Peter (Assistant Minister for Health and Social Services) Deputy P.D. McLinton of St. Saviour (Assistant Minister for Health and Social Services) Director of Finance and Information

Medical Officer of Health

Interim Head of Environmental Health

Director of Adult Services

[14:00]

Deputy R.J. Renouf of St Ouen (Chairman):

Can I just welcome everybody? This is a quarterly hearing with the Minister for Health and Social Services. As this meeting is being recorded, I would be grateful if we could do introductions. I am Deputy Richard Renouf and I am Chairman of the Health and Social Security Panel.

The Minister for Health and Social Services:

Chairman, can I start by giving apologies for the chief executive, who has another commitment and so we were fairly mob-handed as it was because the area of questioning is so wide. The chief executive is getting on with some of the very urgent business that we need to get on with, so her apologies.

The Deputy of St. Ouen : Of course, that is accepted.

The Minister for Health and Social Services: Thank you.

The Deputy of St. Ouen :

Thank you. Minister, we have had a week where we have had developments on the Strategic Plan and particularly the resources statement presented by the Minister for Treasury and Resources and I wonder if we could spend some time examining that with you and the part Health plays in the Strategic Plan. Specifically I would like to understand that we were told that Health was required to make 2 per cent savings in its budget and we spoke about that at our last quarterly hearing. Yet there is also a 2 per cent investment in service standards and healthcare inflation before additional items are included in the budget. Can you help me understand the difference between those?

The Minister for Health and Social Services:

I can give you the general principle, then if you want to drill down into particular detail while I do ...

The Deputy of St. Ouen :

Can I start with the general principle?

The Minister for Health and Social Services:

The general principle is that all States departments have to make a 2 per cent saving, a contribution towards reducing the increase in the growth of expenditure, not to be that they were reducing the level of expenditure overall. What we are doing is slowing the rate of growth. So every department had to make a 2 per cent saving. If you want to go into that we can. Health has been protected to some degree inasmuch as we have got a 2 per cent automatic increase which, if the Medium-Term Financial Plan comes, as we think it might, will be in there. That 2 per cent increase is to cover things like drugs particularly. If you wanted to look at one drug in particular, the drug for people with Hepatitis C; I cannot remember the exact figure; I am sure my director can. So it is to cover the increase in drugs that we know year on year, not only are there new drugs being developed and approved by N.I.C.E. (National Institute for Health and Care Excellence) because we would not authorise them otherwise, they also become more and more expensive. We have also got some new appointments to make around where consultants, particularly in the past have been specialists across all 3 areas. As they retire, that is no longer acceptable, not just not acceptable to us; the royal colleges do not allow it. So you very often end up bringing in more consultants who are specialised in each individual area and that is allowed for within there as well. There are other areas but those are the 2 that really struck me when we were looking at as the ministerial team. I do not know if

The Connétable of St. Peter :

Can I just one thing, Andrew? The Minister did say "a specialist over 3 areas". They are generalists over 3 areas.

The Minister for Health and Social Services: Sorry.

The Connétable of St. Peter :

The specialists are individual ones; just to make sure that is clear on the record.

The Minister for Health and Social Services: Yes, thank you.

The Deputy of St. Ouen :

Thank you, yes, I understand. But in relation to the 2 per cent departmental savings you have been required to make, where have those been made?

The Minister for Health and Social Services:

Well, again, I can remember some of them but not all of them but most of them are about efficiencies and then the one that you would particularly expect me to remember is reductions in waste in food being an area that I am particularly interested in. It is about efficiencies. I am sure the director will take us through the detail if you want us to.

Hospital Managing Director:

I can add a few more. We are looking at how we dispose of waste, how much waste we incinerate, and we are going to change the way we segregate waste so that we incinerate less and that will make a saving. We have looked at modernising the staff structures, particularly around pathology. That is delivering savings this year. We look at how we procure things like artificial hips and knees and we have done new contract deals with suppliers. That has made savings. We are looking at having better contracts in the U.K. (United Kingdom) for the providers that we use in the U.K. so that we are getting better unit cost per operational procedure in the U.K. So that is a series of things.

Deputy G.P. Southern :

Can you talk to briefly about changes to the pathology service because I distinctly remember pathology being reformed in structure in the last wave of the current term, certainly before you and me became a minister 8 years ago.

The Connétable of St. Peter :

No, it was just 2 years ago. It was part of the reforms that were instituted a couple of years ago and they have taken time for the new way to come into force. We are now seeing the positive impact. We saw a very small impact when it was first introduced. The financial impact is growing to our betterment and making some more savings when we want more efficient ways of working within pathology. Does that help, Helen?

Hospital Managing Director:

Yes, that is one element. The other element is that we have implemented more technology, so people are now doing e-referrals for their tests and so we have stopped printing all the results and they get things through electronic means and that has made a saving that is only just starting to be realised because as that is embedded. There have been quite a few bits in pathology. They are changing the way they configure the laboratories as well.

Deputy G.P. Southern :

You are talking about achieving then ... when you talk about value as a ...

The Minister for Health and Social Services:

I am pleased to say that the last report the ministerial team had showed that we are clearly on target and where we would expect to be in all those changes and reforms and efficiencies are at this stage.

Deputy G.P. Southern :

Okay. Can you put those in writing to us so we got them?

The Minister for Health and Social Services: I am certain that we can, yes.

The Deputy of St. Ouen :

Okay. So we learn from the resources statement that there is additional expenditure planned in addition to that 2 per cent annual increase in the Health budget. One part of that is the agreed pay parity provision for nurses. Can you elaborate on that?

The Minister for Health and Social Services:

Yes, just that S.E.B (States Employment Board) entered into negotiations with nurses last year, knowing that if you were to compare like with like that nurses were lower than they should be compared to their professional colleagues and we gave a commitment for that right. They had a pay rise last year plus a percentage extra and we had guaranteed that they would get a percentage extra, whatever the pay award might be for all other staff, that they would get a percentage extra this year, and we are holding through to that commitment. What we do not know and what we cannot anticipate is what the pay award is going to look like for everybody else.

The Deputy of St. Ouen :

But are they being brought into parity with the

The Minister for Health and Social Services: Yes, they are.

The Deputy of St. Ouen :

Is it over a period of time or are they are at parity now?

The Minister for Health and Social Services:

This is the second stage of bringing them up to that level, yes.

Deputy G.P. Southern :

That goes through to 2019, does it?

The Minister for Health and Social Services: 2018, I thought.

Hospital Managing Director:

Yes, I do not think it is quite so far as 2019.

The Minister for Health and Social Services:

No, no. But there is a commitment and we are sticking with that. What you cannot do is anticipate what happens round all the other staff rates.

No, I understand that. It is for negotiation. The additional expenditure is also the continuation of the investment in P.82. Can you detail some of what is proposed?

The Minister for Health and Social Services:

Yes. P.82 is about the reform of how we deliver services and indeed P.82 is an essential part of the development of the new hospital and planning for the new hospital. It is about delivering services that should be delivered outside the hospital, such as care of our aged population. We know that we need to deliver that service differently today and probably also know that we will need to do it for more people in the future, so P.82 is about that. We are already seeing the benefit of some of that P.82 investment in terms of people being able to access the services in a different way. Again, if you wish to go into detail, those are the ones that really struck me but if you really  want to go into other areas of service development, working with G.P.s (general practitioners) is another area that has got to be developed. We have got to start to do things differently within the hospital in order that if and when; it is not "if", it is when we build the new hospital, you cannot just lift the services that we have today and put them into the new one. That would be wholly inappropriate. So we need to modernise our practices, we need to modernise the way we support people in the community so that when we are ready to move, we are moving an already reformed appropriate service into the right environment. A lot of P.82 is about that.

Deputy G.P. Southern :

When you use the word "modernise", what were you thinking of as the difference?

The Minister for Health and Social Services:

We have got quite an old-fashioned model, and again the director can you take you through that if you wish but we have got quite an old-fashioned model where at the moment everything has to be done or a great majority of it has to be done in structure, in a building, in a hospital and we are heading towards a virtual hospital for some conditions, some treatments.

Hospital Managing Director:

One of the key areas is the way we manage emergency patients coming to the hospital. Currently they come in either through a G.P. or the Accident and Emergency Department. They get seen, they get transferred to our assessment ward, they get seen again and then they usually get admitted. What we are trying to do is say that you get the most senior persons in as early as possible in that process. You get all the diagnostics that you need as urgent diagnostics, you make a decision and you take them out of hospital as quickly as possible. You can only get them out of hospital if you have got the support in the community to pick up some immediate care needs. So the rapid response team that is in place is there to do that. We are starting to see the

benefits of that. But the way we are configured at the moment does not help with what we call ambulatory emergency care. So we want to move towards that before we get to the new hospital because, as the Minister rightly says, you cannot just go from one model of care now to a new hospital and expect people to work in a new model of care. So we have got to work our way towards that over the next few years. So they are the sorts of things that will modernise emergency care. Elective care, we currently have: you are either a day case patient where you come in, you have your surgery and you go home the same say, or you are an inpatient where you get admitted to one of the standard inpatient wards and you might stay a couple of days. What other centres do very successfully is have something called a 23-hour stay ward where you might come in in the afternoon and have your surgery in the afternoon, and, had you come in the morning, you would have gone home the same day. But these people will then stay overnight, get assessed first thing in the morning and go home in the morning. So they never stay a full 24 hours. By having a ward dedicated to that, the staff are in that mindset, everything is geared up to that mindset and you flow the people through the system much more effectively. So we want to introduce those sorts of concepts here as well. But that means a change, it means reconfiguring our wards and reconfiguring the staff.

The Deputy of St. Ouen :

Does that mean operating theatres and systems on a 24-hour basis or longer hours even?

Hospital Managing Director:

Operating theatres might go to longer hours. It is not advised internationally to operate into the evenings because of safety reasons. There is good evidence to show that if you operate on routine cases into the night then your efficiency, your effectiveness drops. So we will look at extending the day but it will not go overnight.

The Minister for Health and Social Services:

It does mean you could have a morning list and an afternoon list whereas currently you might only have a morning list or going into late morning.

Hospital Managing Director: Yes, it will sweep(?) the assets.

The Deputy of St. Ouen :

So they will make better you of what they have.

The Minister for Health and Social Services: Better use of resources, yes.

I think we can all see the need for change within the structure. But it needs additional expenditure, does it not? We have got the figure here: £47 million per annum of additional expenditure. What are the principal items of cost in that additional expenditure?

[14:15]

The Minister for Health and Social Services: Some are staff but

Hospital Managing Director:

I can name a few. I am sure Jason could elaborate. From my point of view we are looking at putting some additional beds into Samarès Ward , the rehabilitation ward, as part of the transition between now and the new hospital. That is an additional 6 beds. The works will start imminently. But we will need to staff those beds, so part of that is that staffing for those extra 6 beds into the future. You will have noticed the new build starting in the car park to put the 2 additional theatres in. Initially that is just to do their handling units in the existing theatres. But as and when that is completed, in order to then make use of the additional theatre capacity, we need additional staff to work in those. So some of it is about those staffing additional people. We are also looking at how we are going to manage the increase in demand from our patients coming in and we are looking particularly at the role of the specialist nurse. We have had some really good successes in cardiology where we have got some specialist nurses running, for example, arrhythmia clinics and they are seeing the totality of the patient from referral to discharge really successfully and have completely eliminated the waits. So rather than just assume that you need another doctor, we are looking at how different healthcare professionals can help us with that demand. So those are certainly in the bids I put forward for the M.T.F.P. (Medium-Term Financial Plan) I am sure Jason could elaborate on other areas.

Director of Finance and Information:

Some of the other areas, a lot of money over that time will be put into drugs, as new drugs will be developed and approved by N.I.C.E, as the Minister referred to. A good example of that is one new drug that was approved towards the end of 2014. Over the last few months of 2014 and into 2015, just on that one drug, there were a very few number of patients we have had to allocate £1 million. So one drug can cause significant budgetary pressure. So a lot of that money will end up on drugs one way or another. There is a whole range of other services that are described in the P.82 proposition that the Assembly approved that are within those figures that you have in the resource statement. A lot of investment in children's services, a lot of investment in mental health services, the impact of any changes in Mental Health Law, continued investment in the services

that the Hospital Managing Director has described about enabling people to stay out of hospital, preventing them from being admitted to hospital in the first place: Talking Therapies for children, a lot of work on health and lifestyles, particularly around weight management. Sexual health is getting the next stage of the investment. More investment around long-term conditions and how they are managed, particularly trying to keep people out of hospital again. That is probably enough flavour. But P.82 will list it in more detail. If you look back to P.82 the M.T.F.P. 2 that you are looking at within the resources statement, is described as phase 2 of the transformation. So the services I have just read out are phase 2.

The Deputy of St. Ouen :

Is what we would like to achieve with this additional cash coming into things.

Deputy T.A. McDonald:

Could I just ask before you move on, going back to the N.I.C.E. question? Obviously you have not named the actual drug involved but is it oncology related, that particularly expensive drug you were referring to?

Director of Finance and Information: No.

Deputy T.A. McDonald:

That is fine. Okay. Thank you.

The Deputy of St. Ouen :  

The figures for staff that are given in appendix A to the resources statement we have had show that Health are going to recruit 185 staff by 2019. Is that correct? And I am interested in the breakdown between 66 full-time staff work for the "continued investment in service standards," and 119 for the P.82 work. So I am guessing that is where much of the cost arises that we have spoken about.

The Minister for Health and Social Services:

These are all patient-facing staff, if I can put it that way.

The Deputy of St. Ouen :

Right, okay. All of them; are you satisfied on that?

The Minister for Health and Social Services: Yes, I am, yes.

The Deputy of St. Ouen :

Okay. That is good to hear. So it is the services in the community

The Minister for Health and Social Services: It is nurses, it is doctors, it is therapists, yes.

Director of Finance and Information:

If I could just add: it is the staffing behind the services that we have just talked about, so if I talk about Talking Therapies for children, it is the staff that will provide those services. The investment and maintaining standards and so on, the staff linked to that will be a range of staff: some will be doctors. The Minister just described where there is increasing specialisation, so while we have got the generalist at the moment, we have to appoint to specialists: one of those is an additional number of staff so he would be in that list. As standards for nursing ratios: the number of nurses to patients changes over time. Some of those staff would be within that 66 that you have described. It is worth just pointing out: those are our best estimates at the moment. We are looking out to 2019, so there is no guarantee around these things because we do not know what standards are going to change over time. So our best estimate is a standalone bit. It is in response to the services we have described and in terms of maintaining standards, it is to enable us to respond to those sub-specialisation issues, nursing ratios and other issues like that.

Deputy G.P. Southern :

Somewhere there is a list of who those people are.

The Minister for Health and Social Services: There is not a list of who they are. The type of post.

Medical Officer of Health:

Could I just make a comment to add a little to what has just been said? Doing nothing is still not an option. Much of the P.82 programme is based on if you do not get it right with early intervention across the piece in alternative ways of dealing with things, number one, the projected size of the new hospital is going to be far too small. So the projected size of the new hospital is absolutely founded on these things having to happen. The other thing that will happen, whatever we do, is that the size of the older population is growing rapidly, in the next 5 to 8 years particularly, because of the baby boomer generation becoming the older generation. So the existing pressures on the services are if you look back to the KPMG paper that was the basis of the 3 options and the Green Paper that were out for consultation, and then the White Paper, basically if you leave things the graph is sort of going upwards at a certain rate and it was projected to be around 2017 that the hospital would not be able to cope any longer, not just with the existing demand but the size of the demand projected to 2017. 2017 is not very far away. The platform that was burning 3 or 4 years ago is burning brighter now. I am quite concerned about getting on with all of these things even faster, perhaps, than it has been possible to do so far. So the case for change is even stronger than it was in the first place. That is absolutely fundamental. So I was concerned to hear that people are starting to question: "Well, is this all still necessary?" It surely is.

Deputy G.P. Southern :

We have an interim population policy, which I forget. But we have got one, which will take us through to 2017. What figures have you built into your estimate for 2018, 2019, beyond that? What is the going rate?

The Minister for Health and Social Services:

I cannot tell you the exact figure but yesterday I had a briefing on the number of beds that we might need for a hospital, based on a population of the projected size in line with the population policy but also in line with getting this work done. Dr. Turnbull is absolutely right. Doing nothing is not an option. We have to make these changes. This is not only about service redesign and therefore being able to predict the size of the new hospital. This is also about delivering the appropriate service that a community can legitimately expect to have. If we do not do that then we will have an old-fashioned model, longer waiting lists and people at risk because we will not have beds. So doing nothing is not an option. It is not all around the new hospital. We are not doing these things to keep the size of your hospital down. We are doing it to provide a legitimately appropriate-sized hospital, providing all the other services in the community that are right.

Deputy G.P. Southern :

That is based on what population growth?

The Connétable of St. Peter :

The interim policy was limited to 300 heads of households, was it not? That is for net inward migration.

Deputy G.P. Southern : So it is 300 people.

The Connétable of St. Peter :

Well, heads of household. But that could be more than that because that is just the head of household. If they bring a family, it could be 4 people, for example, husband, wife and 2 children.

Deputy G.P. Southern :

That is what the new figures were: they were actual people, not heads of household contacts. What we used to do in the past.

The Connétable of St. Peter :

Yes. The interim policy, I think, still says "heads of household". I may well be wrong but that was the last thing I heard. What we do know, even without immigration, that the local population is growing approximately by 300 to 400 over the amount of births over deaths per annum. So there is a growing population even if nobody else moved into Jersey.

The Deputy of St. Ouen :

And a growing ageing population.

Medical Officer of Health:

And a much higher proportion are older people within that.

Deputy G.P. Southern :

My question was: what figure are you putting at the objections beyond 2017?

Director of Finance and Information:

Deputy , could I help with that? The Chief Minister's Department, through the Statistics Unit, projects the population of the Island forward by age group well into the future, based on the current range of assumptions and policy that is in place. They provide the population projections which we and our advisers have used in the modelling that has been done to underpin the future size of the hospital. So it is the population projections produced by the Chief Minister's Department which are used for this purpose, along with lots of other purposes when they are looking at future population laws(?).

Deputy G.P. Southern :

Indeed, do you know if the future projections, are those done with current interim populations or a different figure?

Director of Finance and Information:

They will be based on that policy as far as it is relevant to base it into the future and then they will be applying assumptions after that. I am sure that we could forward the narrative behind how they have done those calculations to you. Because it is a matter

Deputy G.P. Southern :

I am familiar with the work of the Stats Department. I know how those projections work. I just want to know what the projection is.

The Deputy of St. Ouen :

In terms of delivery of services, Dr. Turnbull has expressed a wish that they could be delivered even more quickly. Have you got a timetable for the delivery of the initiatives set out in P.82 over the next 4 years?

The Minister for Health and Social Services:

Yes, we have. Some of that will depend on the Medium-Term Financial Plan 2 being approved by the Assembly, which is not the Assembly's fault; it is still being worked up. But providing that goes to plan, then we will be able to keep to our timetable, yes.

The Deputy of St. Ouen :

Okay. Is that set out in a business plan or could we have sight of it?

The Minister for Health and Social Services:

Yes, you can have a copy. It is part of our strategic overview and plans for the future. You can have a copy of that, certainly.

The Deputy of St. Ouen :

Yes, to know if there has been any variations.

The Minister for Health and Social Services:

We will update it and let you have a copy. It is not a problem.

The Deputy of St. Ouen :

Thank you. Okay. One of our questions, as you know, was about a business plan. Do you specifically have a business plan for what you are hoping to achieve?

The Minister for Health and Social Services:

We have a number of strategies which will form our business objectives. We are doing it slightly differently this time and particularly we have been working, certainly as a ministerial team of officers, been working very hard around the strategy for acute services and the strategy for children's services and the strategy for mental health services generally. So all of those will inform. We are not going to go for some flash glossy meaningless document. We will put these strategies together and when they are finally formed, because they are not finally formed yet, we will be able let you have a copy of them.

The Deputy of St. Ouen :

Okay. Thank you very much, yes.

Deputy G.P. Southern :

Excuse me if I ask this completely stupid question.

The Minister for Health and Social Services: You might get a stupid answer.

Deputy G.P. Southern :

I am used to doing that. The difference between a business plan and a strategy, to me, is a business plan contains the numbers and a strategy contains lots of words.

The Minister for Health and Social Services: We are having a combination of them both.

Deputy G.P. Southern :

So you were talking about getting strategies together to produce something with figures in the end in a business plan?

The Minister for Health and Social Services:

Yes, of course we have got to have figures. We have got to know what we are working to. Of course we have got to have figures. We have got to know what we are working to.

The Connétable of St. Peter

If I can be of assistance. Certainly there is no requirement for the department to produce their own individual business plan. We feed into the Central Government's business plan overall and that is being currently developed and consolidated in the departmental overall business plan, which is coming forward as part of the M.T.F.P. So it is the overall States business plan, so we feed into that, rather than have one of our own.

Deputy G.P. Southern :

As I understood it, once we have got the M.T.F.P. through, then what we are talking about - and I think I have seen it written down somewhere - is that then departments will produce their delivery plan, which will help ...

The Minister for Health and Social Services:

Yes, but that will be within the whole there will be a delivery plan for Health and Social Services. There will be a delivery plan for Social Services, all within one document. So we will have our pages.

[14:30]

The Deputy of St. Ouen :

Yes. Our reasons for asking are simply to enable us as a Scrutiny Panel to be able to do our job.

The Minister for Health and Social Services:

Do not worry. You will be able to hold us to account. But it will not be just Health's business plan.

Director of Adult Services:

Minister, if I may just comment on that. It may be helpful to know that within Health and Social Services, being such a large and eclectic range of services, that there are within discrete areas business plans to enable us to deliver for key business the objectives that we have within specific specialisms. So certainly within the community, I am aware that we will have our overarching Community and Social Services Plan. Within that I will have the Adult Services Plan, sitting in that to make that a part of the actual service plans for specific teams of service areas. So there is information, there is work around in terms of ensuring that there is, plans in place in order for us to deliver the outcomes of the business. Just for your comment.

The Deputy of St. Ouen :

Yes, I am sure that is right and as you comment, Mr. Dunn, it is just the remits of Ministers are so vast, just for me to try and gain an understanding of how you are keeping all these plates spinning, I suppose. It is a colloquialism. You are monitoring each and every area for which you are responsible.

The Minister for Health and Social Services:

Yes. We will be able to furnish perhaps I have been a bit pedantic on the play of words but we will be to furnish you with the objectives and what success looks like and all those sort of things for all of our departments. But we are not there yet.

Director of Finance and Information:

I think if I could perhaps add: perhaps the difference between this year and previous years is: historically there often been quite a glossy document being produced as a business pack for the department that looks quite nice and showy pages, and so on. We are not planning to do that this year. We have got the objectives, we have got the budgetary dedication as to the different parts of the business. The measures and performance indicators are there. We are literally just in the process of finalising that and it has taken a bit longer than it might otherwise have done because obviously the financial position changed later in the day in the 2015 budget. The current plan is that we will have a final draft of that consolidated document next week for the Senior Management Team of Clinicians to review before it gets presented to the ministerial team for final approval. I would hope, I am sure, by the time the panel next meets that we can furnish a copy of that.

The Minister for Health and Social Services: What is that document called?

Director of Finance and Information:

I think we will call it the business plan. It will be pieces of

The Deputy of St. Ouen :

Okay, we do not worry about glossy paper.

The Minister for Health and Social Services:

We are not going into the spin machine, okay? That is what I am trying to say.

The Deputy of St. Ouen :

It is just a working document that will

The Minister for Health and Social Services:

Yes, you are not going to have great big flashy things with little substance. We are going to have not flashy things but lots of substance. Yes, okay.

The Deputy of St. Ouen :

Okay. I wish you well in finalising that. We have spoken about needing to employ more consultants because of greater specialism. I know, Minister, you have had discussions with Guernsey and the Isle of Man in recent times. Is there any merit in us trying to share consultancy services, particularly with Guernsey?

The Minister for Health and Social Services:

We had a very good meeting, prior to the meeting, as you say, with the Isle of Man and with Guernsey and we have agreed to work together in a couple of areas. So this is just one area that we will be looking at. We already work with other colleagues in the mainland. We have visiting specialists as well, as you know, coming in. But we have agreed to look at that around particularly how we might procure those services jointly, so perhaps enter into a contract with a U.K. main hospital for Jersey/Guernsey in particular but the Isle of Man where appropriate. We also agreed to look at procurement generally as another area of work. So this is ongoing work. It was a very successful first meeting in terms of setting the scene and agreeing the culture. But there is nothing delivered yet. We have still got to have another meeting.

Hospital Managing Director:

Can I answer that? We have recently appointed a new ophthalmology consultant and a new urology consultant, both of whom have met with their counterparts in Guernsey and their skill set complement one another. So they are working, between them, to say which patient should I see in Jersey with my skill sets and which Jersey patients might be better seen by the person in Guernsey. We have not got any joint appointments and that could probably cause some difficulty because our terms and conditions and our employment mechanisms are very different between the 2 islands. But there is certainly a lot of desire, I think, and enthusiasm from the new consultants coming into work with colleagues so that we offer the best for our patients, even if we do not have joint appointments. There is nothing to say we cannot do that in the future but at the moment the 2 employment mechanisms are very different.

Deputy G.P. Southern :

Could you expand on the difference between the employment practices?

Hospital Managing Director:

Only at high level because I am not intimately involved with the Guernsey one. But my understanding is the majority of the consultants in Guernsey work as independent practitioners through chambers. So they are not employed by the States.

Deputy G.P. Southern : That is correct.

Hospital Managing Director:

They are brought in by the session to the States and that is a very difference concept to the one we have and their remuneration and their terms and conditions would be very different. So it is a completely different employment mechanism.

Deputy G.P. Southern :

What would you see going into the future as the way forward for both islands? Would you expect them to convert to closer to ours or would we consider converting closer to theirs?

Hospital Managing Director:

I know Guernsey, they had a contract with their consultants for a set period of time and I believe that they are reviewing that at the moment. I think it is coming to the end of the initial contract. I am not party to what they are thinking in terms of whether they want to change it. We have had some conversations with our consulting body around our consultant contract that we have here and whether or not it is time to start thinking about how that also goes to a modernisation and reform like we are with the nurses. We only had that conversation yesterday about: should we start to pursue that.

Deputy G.P. Southern :

And the pros and cons of each?

Hospital Managing Director:

Certainly, the U.K. are starting to look at the consultant contract more closely and we are aligned to the U.K. consultant contract. It is not exactly the same but it is more aligned to that. The U.K. have found some difficulties doing that and it has been a slower process than they had hoped. But at least we can learn from what they have looked at and what has or has not worked very well. The Guernsey it is difficult for me to say without knowing the figures but I think both have problems in terms of ... there are positives for both ways and there are negatives for both ways.

Deputy G.P. Southern :

But the overarching brain work is we have to conform, all right, to the U.K.'s otherwise

Hospital Managing Director:

We can have a Jersey version of that. We do attract most of our consultants from the U.K. system and they still have to be registered with the G.M.C. (General Medical Council). So we have got strong links with the U.K. The consultants I spoke to yesterday would not like us to go to the Guernsey model. It is not something that they would be pushing for.

Deputy G.P. Southern :

But it is something that you as a manager might ...

Hospital Managing Director: No, I do not think I would.

Deputy G.P. Southern : It does not have great ...

The Minister for Health and Social Services:

No. It is certainly not something I, as Minister, would want to see. There are too many disadvantages of the Guernsey system compared to not saying our system is perfect and as a direct segue, we are looking at tweaking it, indeed. But I would not wish to follow the Guernsey model.

Deputy T.A. McDonald of St. Saviour :

While we are talking obviously about other islands: Isle of Man and Guernsey and so on, health travel features an awful lot in the public's eye, public perception. Any real ideas brought back on that, any comparisons made, beneficial or otherwise?

Hospital Managing Director:

We are due to review our policy. It is up for review this year so we will do that. At the moment it is, as you know, some people get some support and others do not. I know that does differ from Guernsey and the Isle of Man, where I believe all travel is paid for by the States. When we review it I think we need to take all of that into consideration and in the consideration of the wider picture the States are in at the moment, the financial position.

The Minister for Health and Social Services:

It is worth remembering that we are spending ourselves half a million pounds a year on travel. That is not emergency flights. That is just on patient travel, half a million pounds a year.

The Connétable of St. Peter :

I think it is also worth to note that both the Guernsey and the Isle of Man model is predicated on sending a lot of their patients to other areas and not delivering some of the services which we already do here on Island in Jersey. So we avoid sending many of ours away to the U.K., whereas with Guernsey and Isle of Man tend to send more, with the more complex ones away to the U.K. rather than to do them on Island.

Deputy G.P. Southern :

Again, looking to the future, do you see likely changes in how much a proportion of work you do here and what portion of work you outsource?

Hospital Managing Director:

Our acute strategy is very clear: that we will do on Island what is safe and affordable to do so. Safety is the first criteria. There will be some things we should never do here. You should always send people to a specialist centre. But where it is safe to carry out the procedures here and we can make an affordable case for doing that, then it is our strategy to treat as many on Island as possible.

The Minister for Health and Social Services:

We are also looking at that in line with that strategy is whether you would bring the consultant over to see several people rather than send several people

Deputy G.P. Southern : Several people over there, yes.

The Deputy of St. Ouen :

Minister, may we ask you about the new hospital?

The Minister for Health and Social Services: You may.

The Deputy of St. Ouen :

When are the consultants to report and when are the working groups or Council of Ministers to make a decision.

The Minister for Health and Social Services:

We had a Ministerial Oversight Group meeting yesterday and I am advised that I should receive a very detailed informed report towards the beginning of May. So we will wait for that. They have looked at 4 sites, as you know, well, 4 options, because option 1 was a dual site: Overdale and the General. Option 2 and they are in no particular order, they are just as I remember them. Option 2 is redevelopment of the current site. Option 3 is the new development of Overdale only, and Option 4 is the development on the waterfront. Now, my questions around this was that I wanted to see the costs going forward, as much as you can project. Sixty years is reckoned to be the life of a hospital for major. You will always even 2 years after building you will be doing alterations and renovations as we are building because technology changes so quickly. But major life renovations and life of the hospital: 60 years. So, I have asked for the costs going forward for 60 years. I am told I am going to get a report something like this. I am told also that it is almost complete and that Ernst & Young are looking at some of the work just to make sure that all the figures are produced the way that they should be. Gleeds, who are very experienced and I have to say that I had not heard of them before but you have really got to look them up on the website. Gleeds are very experienced builders or advisers of buildings, Q.S.s (Quantity Surveyors) that sort of thing and so a huge amount of work has gone into this and we are close to having the information which will then allow us to make the appropriate decision.

The Deputy of St. Ouen :

So at the beginning of May you will receive this report and what then is due to happen.

The Minister for Health and Social Services:

The first week in May, I hope. Then of course I have to digest with the team. I have to read it and we are told it is thicker than the telephone book and I do not think that is done on purpose to put Ministers off reading it. There is a lot of information in there. When you are projecting forwards 6 years you have got to know the basis of that projection. You have got to know, for example, the one that I was particularly interested in is what it would cost to build a new unit, wherever, but also how does that compare to building a small unit at Overdale and renovating the General Hospital and then how quickly would you need to go back and do major renovation, if I can put it that way. I myself have renovated a home. If I had had more courage and put the bulldozer through it and rebuilt it, it would have been cheaper over 30 years. So those are the sorts of information I am asking for but over 60 years. Anything you want to add?

Hospital Managing Director:

I guess, based on the question, that you are planning to lodge.

The Minister for Health and Social Services:

Yes, sorry. I thought that was a given. Once we have selected that site then I intend to lodge a proposition to the States because the commitment that the Chief Minister gave, and I agree with, that the States would have the final say on the site. In fact, I do not think Standing Orders allows for it anyway. I am not going to give the States a choice because it is open to Members to amend it if they wish. But I will be naming the site based on that information and based on the advice of the Ministerial Oversight Group and the officers and all the technical people that we have employed. But at the same time I think States Members need to understand the journey. So you will be getting a similar report behind what is quite a simple proposition when it is produced but a big report behind it.

[14:45]

The Deputy of St. Ouen :

When do you hope to lodge that proposition?

The Minister for Health and Social Services:

I hope that we are able to lodge it before and debate, I hope, at the last sitting before the summer recess. That is my target. Of course I have only got to miss the lodging date by a day or so, unless States Members agree to bring it forward, it may have to wait for the first sitting. But I am hoping that we will debate it on the last sitting of this session.

The Deputy of St. Ouen :

I think we would encourage you to try and bring it forward as soon as you can before the summer break.

The Minister for Health and Social Services: You do not need to encourage me.

The Deputy of St. Ouen :

No, I shall not. But it would be good to have some of these decisions under the collective belt of the States so you can get on with your strategy.

The Minister for Health and Social Services:

That is said. It is important we do that because time is money. So it is important that we do that. But that said, we are not waiting for that. Already we are developing change in services we discussed in P.82.

The Deputy of St. Ouen :

I would go a stage further and say: bring it back a session from that because the last session, judging on history, will be a 4-week session. You do not want them making big sessions when you have got 49 tired people in there just thinking: "I need to be on a holiday".

The Minister for Health and Social Services: You may well be right.

The Deputy of St. Ouen :

That is how we paid for the incinerator in one go, £1 million out of that pocket because people were tired.

The Minister for Health and Social Services:

I make no comment about that one. But you may well be right but I may need to be in the hands of the Assembly to shorten the lodging period.

The Deputy of St. Ouen :

Okay. But meanwhile we have an existing hospital to maintain and I see the resources statement talks about backlog maintenance that needs to be caught up on. You put in a request to the M.T.F.P. for an additional £5 million expenditure on maintenance and that it additional to base budget, it seems.

The Minister for Health and Social Services: Yes.

The Deputy of St. Ouen :

Why is that figure not in the budget already?

The Minister for Health and Social Services:

Again the director will take you through detail. But if I could just discuss it. The States generally has had a very short term, I think, view of property maintenance and have not maintained their properties in order to perhaps even sometimes develop services. Clearly now it is payback time. We need a new hospital and we know that and that is why it is urgent that we get on with it. At the same time we have to provide a hospital that is safe. The current hospital, without that sort of investment, will not be safe. The director can take you through the areas that because I do not want to mislead you and I know the things we are working on. But some of them will come out of revenue, some will come out of capital. So I do not want to mislead you. But I think one of the ones that will come out of revenue, for example, is the updating of the fire alarm. We cannot leave that. It has to be done.

Deputy G.P. Southern :

I thought it had just been put off.

The Minister for Health and Social Services:

No, it is going to be funded in a different way. It is not being put off. It cannot be. I can list all the things. But I would muddle up the revenue and the capital. We have talked to them fairly.

The Deputy of St. Ouen :

I understand an additional £5 million has been requested as a capital cost.

The Minister for Health and Social Services: Yes.

The Deputy of St. Ouen :

Is this on our existing hospital when it might not exist in a few years' time?

The Minister for Health and Social Services: Yes, it is. Does that include the theatres?

Hospital Managing Director:

Theatres are a good example. The new theatre only looks at the 4 existing theatres having their handling units changed. We have our handling units in other theatres, in I.C.U. (Intensive Care Unit) and the renal unit and other places and they are very expensive things to change. What we have done is drawn up a huge spreadsheet - it has got at least 150 items on it - and looked at: what is the expected life of those items, where are we now, how old is it now, and do we think realistically it is going to get us to the new hospital or are we going to have to do some work on that before then? Wherever possible we have suggested that we will do a watch and wait for a lot of things. So we need to accept something might need replacing but we will not actively do that because hopefully we will be somewhere else. But there are issues. For example, the Maternity Department has not been upgraded or had any attention paid to it for about the last 30 years and that desperately needs some work doing on it, sanitary-ware and things like that. That will not wait another 8 years or more before we move.

The Deputy of St. Ouen :

But could not that have been planned for existing capital budgets because this is an extra £5 million on top of what

Hospital Managing Director:

I am sure Jason can help me here with something. I think this is a result of not having sufficient existing budgets: how to do these sorts of works.

Director of Finance and Information:

That is right. The need to do this work has been identified for some time now and of course the total quantum of it is dependent on when the new hospital facility is available and whether that new facility is based around the refurbishment of the existing site or a brand new site. So if the answer to the new facility was to start with a refurbishment of the current facility, then you would incorporate some of the issues that we are trying to address here very early in the programme to try and do 2 things at once. It is quite a complicated jigsaw to put together. But the need to make this investment has been identified for some time and to put some more clarification around it, it is not the place of the hospital to be going around saying: "We need to do this, this and this". This is a joint piece of work that we have done with Property Holdings and specialists that understand hospital facilities to go round and assess the building area by area and say: "This is what you would have to do to keep this safe and sustainable and operational over the coming period of time". The watch and wait policy that the director has described is a pragmatic view to try and avoid wherever possible spending money where we do not need to, to ensure that we are getting the best value for any pound that we do spend. Obviously we do not want to spend some money if we can avoid it, if we are going to be in a new facility in the future. But equally, if something needs to be replaced to keep the hospital operational, we cannot afford not to do it because if an operating theatre is unavailable because the air handling unit is not working, then that is an awful lot of operations that do not happen, which means waiting times will escalate.

The Deputy of St. Ouen :

Clearly it is a difficult balancing exercise. But you mentioned the maternity unit had not been upgraded for perhaps 30 years, so obviously very desirable to do so. But we have to remember it does come at the expense of other services the States are providing. So if it has existed for 30 years and we are planning perhaps at different maternity units on another site, is it essential to update, let us say that maternity unit, because it will cost somewhere else in some other provision the States are making.

Hospital Managing Director:

We accept that whatever we put into this hospital now needs to be absolutely essential. We are not going to be doing things just because they are nice. If we were to be assessed in terms of the use of maternity theatre, which we have already recognised and we have said publicly, it is not big enough, it is not the right size, it is not what you would expect to find in a modern hospital

The Minister for Health and Social Services: It is not safe.

Hospital Managing Director:

once those modern

The Deputy of St. Ouen : Safety is an issue.

Hospital Managing Director:

Yes, once those new theatres, the modular theatres are up and running, we will use one of them to replace the maternity theatre. So we are only going to be looking at things that are really seriously in need of changing.

The Connétable of St. Peter :

Yes. I think, Chairman, it would be useful for you to see the current maternity theatre. You will be appalled if you walked in there, quite frankly. You have an expectation in your mind of what a theatre should look like, and what you will see in maternity is nothing like what you will have in your mind today. That is why it has got to be done.

The Deputy of St. Ouen :

Okay. Could we take you up on that?

The Connétable of St. Peter : Yes.

Hospital Managing Director:

I would be delighted to give you a tour of the hospital.

The Deputy of St. Ouen : Thank you.

Director of Finance and Information:

It might also be worth just remembering that the assessment that has been done, what money would need to spent in, if you like, an ideal world, comes to more than £500 a year. So if we were to do the things that you would have to do if we were not planning to build a new hospital. It would not be £5 million a year, it would be more. So the £5 million does not get you everything off a list. It gets you the essentials.

The Minister for Health and Social Services:

Things like increasing dignity have not been included in most of that.

The Deputy of St. Ouen :

Yes, okay, thank you. I understand.

Deputy G.P. Southern :

Can I take you back to the area of the resources statement of the Strategic Plan?

The Deputy of St. Ouen : Yes.

Deputy G.P. Southern :

And ask you about the suggestion in there for a health charge to raise £35 million. Were you really thinking about the options? How do you think you are going to do that?

The Minister for Health and Social Services:

At the moment it is suggestion and at the moment we are working to see what that might look like. That is about all I can say at the present time.

Deputy G.P. Southern :

There is a suggestion that you must have been involved in the making.

The Minister for Health and Social Services:

Absolutely. And we are working on what that might look like now.

Deputy G.P. Southern :

And what are your thoughts, please?

The Minister for Health and Social Services: I am working on what it might look like.

Deputy G.P. Southern : Are you not prepared

The Deputy of St. Ouen : What options are there .

The Minister for Health and Social Services:

I am not going to discuss what the options are because we may not take some of those. What I am doing at the moment is looking at starting to formulate options and then we will come back with what we are going to do. I am not going to discuss it, though you are interested to know.

Deputy G.P. Southern :

Well, the public is interested because he has already announced it.

The Minister for Health and Social Services:

But it is policy in formulation at the moment and I am not in a position to discuss that at the present time. But you are right. We are ...

The Deputy of St. Ouen :

It seems to me you are being very guarded, Minister, about something that has been put into a public document.

The Minister for Health and Social Services:

I am not being very guarded. The principle is right. How we do it is up for discussion at the present time.

The Connétable of St. Peter :

I think if I can help in some way. You just mentioned earlier on about do we need to do some of these works to the hospital because of the costs involved and they will have an impact on other areas. We know, going forward, the impact on other areas is going to be greater. We know the health costs are only going in one direction and that is upwards. We know there will be a shortfall in funding to the hospital, coming from central reserves, if you wish. So we have to find other ways of finding the funds to deliver the essential services to people. One of those options may be to look at charges. It is up to us to look at them and decide whether they are appropriate or not. But we must look at them and make that decision.

Deputy G.P. Southern :

Can I preface this in a different way? The Treasurer of the States said at his talk when he outlined this particular point, that he personally would not like to see charges levelled at the point of delivery. Would you agree with that?

The Minister for Health and Social Services:

It is a view that I am prepared to consider. But I am not going to be drawn into agreeing with or disagreeing with any aspect at the moment. It is policy under formulation and we are still working on it. I am not trying to be difficult. I cannot tell you what I do not know at the present time. I can tell you we are looking at lots of options and working through it. But we are not ready to make that a public statement.

The Connétable of St. Peter :

To be fair, it is not gossip at the moment. It has only just come out. But there is no work been done on the concept. It is a pure pie in the sky concept at the moment.

Deputy G.P. Southern :

That is good to hear. This entire 23-page document is pie in the sky.

The Connétable of St. Peter :

No, come on Geoff. Let us be frank. We are talking about charges. Charges is an option which we are thinking about, that we have to do some work and consider. At the moment we still think it is in our charge.

Deputy G.P. Southern :

Politicians in charge of that simply have not thought about it. Is that what you are saying?

The Connétable of St. Peter :

No, we have. That is why it is in that document.

The Minister for Health and Social Services:

No, we are not saying that. What we are saying is that we have not yet formulated our final view.

The Connétable of St. Peter : Absolutely.

The Minister for Health and Social Services: And when we do, you

Deputy G.P. Southern :

So when might anybody hear your final view on that?

The Minister for Health and Social Services:

When we put together the Medium-Term Financial Plan.

Deputy G.P. Southern :

Now we are talking about pie in the sky.

The Deputy of St. Ouen :

No, well, we know some European jurisdictions have an insurance based health contribution. Is that going to be one of the items to consider?

The Minister for Health and Social Services: It could be.

The Connétable of St. Peter : Possibly.

Deputy G.P. Southern :

You are not going to get any further. This is policy in formulation. He will say no.

The Minister for Health and Social Services: I do not want to be unhelpful.

Deputy G.P. Southern :

You are being unhelpful. We are fellow professionals trying to examine what the options are and you are saying ...

The Minister for Health and Social Services:

We cannot examine what the options are until we determine what our options are and we have not done that yet.

The Deputy of St. Ouen :

You have not done that yet, okay.

The Connétable of St. Peter :

You have had a statement from the Minister for Treasury and Resources that Health have not considered what those options of charges might look like. That is work still to be done. That will also be predicated on whether we have a single site hospital or a double site hospital or a new hospital at all because all of that will have an impact on how we fund Health going forward. So there are a lot of other steps to go through before we can think about how we are going to charge, if we are going to charge at all, additional charges.

[15:00]

Deputy G.P. Southern :

Okay. Can I now try a different question but referring to the same resource statement? You said before that the 185 staff you were looking at as extra staff to employ were patient facing. Is there any work going on in reducing your non-patient facing staff at all? The most obvious thing that comes to my mind would be, say, outsourcing cleaners or that sort of thing, so as to reduce your actual head count in the Health Department. What thinking is going on there and what share are you going to take of the £6 million cuts to be made from staffing alone?

The Minister for Health and Social Services:

Yes, okay. Correct me if I am wrong, okay? When our efficiencies all come forward that we are going to make, there are some staff implications. Whether outsourcing it has not yet been considered but I will not rule it out because when we look at the new hospital in particular we will look at how they are doing that work. But it is not part of the plan at the present time. The way that we are going to tackle this generally is when a vacancy occurs then we will look at and this will apply to all vacancies but we know that with medical staff and those that we do need to keep the post but when a vacancy occurs, first of all, do you need to replace that post? Now the answer might be no, in which case, that is part of our contribution. If the answer is yes, it is: "Do you need to replace it in the current form?" The answer may be yes, the answer may be: no, the answer may be partly, and therefore you work up a different job description or whatever. The States generally is going to try and do as much of that change as it can by natural change, turnover and in some cases, in voluntary redundancy. But I will not rule it out. You tried to tie me down last time with: "Would there be compulsory redundancies?" I will not rule it out but there is not ...

Deputy G.P. Southern :

So that is one of the options you were thinking about?

The Minister for Health and Social Services:

No. The first option is natural turnover, the second option is voluntary redundancy and then we review it and I know you are itching to get in so ...

Hospital Managing Director:

Only just to give an example of what you have just been discussing in terms of how we review each vacancy. Only in the last couple of months, I have been reviewing vacancies from my senior team where somebody quite senior has left and we have not replaced on at least 3 occasions in just the last couple of months. So we have been able to share their work differently and look at the people in the structure beneath so for every vacancy we are doing that, and they are all not quite front facing people. I am talking places like catering and we have been able to do that and we are going to continue to do that with every single vacancy that comes up so we have already reduced the ...

The Minister for Health and Social Services: That is good management.

Deputy G.P. Southern :

That increases the workload on the rest of the staff.

The Minister for Health and Social Services:

Where appropriate. It might be the introduction of technology that does not increase the workload on anybody but delivers the same service in a more modern way so it is not always ...

Director of Finance and Information:

But I think it is important to remember because I am conscious these things happen, every decision we make around these things is underpinned by safe, sustainable and affordable. Nobody is going to make those decisions if they are not safe and it is not sustainable because it is no good making unsafe and unsustainable decisions so it is has got to be a sustainable answer and it has got to be safe.

The Minister for Health and Social Services: Absolutely.

Director of Finance and Information:

That is crucially important is all those decisions and I know that is always at the top of everyone's mind.

The Minister for Health and Social Services:

But regardless of the situation we find ourselves in today, you do your job properly as a manager and a vacancy occurs: "Do I need to replace this person?" That is standard good management. The answer might be, as I say, no. Fine. If the answer may be: "Not in this format", we might have a member of staff that is not patient facing and you want to convert that to a patient facing. There may be budgetary costs, i.e. the costs are slightly more but that is how you manage your staff. That is what good managers do all the time.

Director of Finance and Information:

But this is nothing new. The department has been doing this for some time.

Deputy G.P. Southern :

So the non-replacement policy is what exists at the moment effectively.

The Minister for Health and Social Services:

Yes, it is, except it is going to be managed across the States as a whole now as well rather than ... so you may lose a post in one area because it is no longer required and there may be a need in Health for another post. So the whole vacancy management is going to be managed across the States rather than in silence so we start to look at the ...

Deputy G.P. Southern :

As far as you are concerned, Minister, within the Health Department, there is no consideration being given to outsourcing any particular services.

The Minister for Health and Social Services:

Not at the present time but I will never rule it out. Never rule it out.

Deputy G.P. Southern :

If outsourcing were to become your policy, there would be obviously the T.O.P.S.E. (Transfer of Public Sector Employees) policy terms and conditions.

The Minister for Health and Social Services:

That is a hypothetical question because I am not looking at it at the present time.

Deputy G.P. Southern :

Back to you, Chairman, for the moment.

The Deputy of St. Ouen :

Thank you, Minister. In the Strategic Plan, you talk about introducing new legislation for public health, among other areas. Can you tell the panel what areas of public health might require new legislation?

The Minister for Health and Social Services:

Yes, again, I can give you the headlines and my colleague the Chief of Environmental Health - it may not be strictly the right title - will take us through it. We have got a number of pieces of legislation of the public health and we have got a number that are not. They are health but they are not public health ...

The Deputy of St. Ouen : Not public health, yes.

The Minister for Health and Social Services: ... in the true sense.

The Deputy of St. Ouen : Of the regulation.

The Minister for Health and Social Services:

For example, one more that is currently being drafted is the new Mental Health Law and the Capacity Law. They do not fall in this area but they are the adoption laws that we are ...

The Deputy of St. Ouen :

Your officers have kindly given us a briefing on that.

The Minister for Health and Social Services:

So the Public Health Law 1934 is to be updated to ensure that the infectious disease schedule reflects those used both in the U.K. and in Europe. Cremation Law (Jersey), I think the first one was maybe last updated in 1953. That is going to be updated to allow for other methods of safe and correct dignified disposal, if I can put it that way. It is not quite the words I would like to use when you are saying goodbye to a loved one but we are updating that law as well. We hope to have, before the year is out - and, again, the Director can take you through it - the Housing Rented Dwellings Law affectionately known before ... but it has been adapted as the "Snooper's Charter" but that has been adapted. I am quite keen because I see that as an extension of my role when I was Minister for Housing. I am quite keen to see that come in. That is being worked on at the moment. Another area that I have an interest in is the Food Safety Law. The last time it was significantly looked at is 1965 and things have moved on quite a bit now in terms of different bacteria and knowledge of the way that bacteria has reacted and the way that some of them have mutated. The Regulation of Care and Smoking in Vehicles which is to be lodged any day and it is going to be ...

Medical Officer of Health: It has been lodged, Andrew.

The Minister for Health and Social Services: It has been?

Medical Officer of Health: It is for debate on 12th May.

The Deputy of St. Ouen :

We have got a date of 12th May here.

The Minister for Health and Social Services:

I was just thinking in my brain for the date. 13th May if we run into the 13th but, if not, the sitting after, it will be debated and that is the one about no smoking with children under 18 in the car. So a huge amount of work coming in.

The Deputy of St. Ouen :

There does seem to be. With specific regard to the Food Safety Law, where are we deficient at the moment? What needs to be put into that revised law?

The Minister for Health and Social Services: I will ask my ...

Medical Officer of Health:

I will ask my Head of Environmental Health.

Interim Head of Environmental Health:

As is stands, it was written in 1965 with the regulations in 1966 and, since then, food safety technology has moved on. Even cooking technology has moved on with things like microwaves, all these techniques, none of which are controlled. We have no ability to serve an improvement notice on a restaurant so if a restaurant is deficient but not so grossly deficient as we have to have an emergency closure, we can send them a stiff letter and they can do what they like with that stiff letter and sometimes they suggest that we can do what we like with the same letter. What we want to do is ...

Deputy G.P. Southern :

As long as it is environmentally sustainable. [Laughter]

Interim Head of Environmental Health:

Indeed hygienic, yes. What we hope to do it to introduce measures that will back up what we have managed to do quite successfully with Eat Safe where we have used the commercial imperative to get people to realise that the back of the house is as important as the front of the house. The culture in Jersey is not for serving notices but there are times when you get somebody who is so keen on ignoring everything that we will need to serve an improvement notice to prevent people being made ill. We had the court case last year. Had we had the new proposed law in at that time, I do not think that those 86 people would have had salmonella, we would not have had 4 people in hospital and a threatened miscarriage.

Deputy G.P. Southern : Oh dear.

Interim Head of Environmental Health:

We certainly do not want to do anything that will upset our good relationship with the ... we have got 905 premises now on Eat Safe and some that are not needed to register but we just need to come up to date so that people who visit from the U.K. can expect the same standards of hygiene that you would get there or in Europe. But at the moment, we get them usually by persuasive compliance but we do not have the final method of persuading those who we cannot persuade, if you like.

The Deputy of St. Ouen : Yes, which I can understand.

The Minister for Health and Social Services:

Can I just add to that because I think you have been quite modest around the work you have done around Eat Safe? That is where you get the stars but has really generally been embraced by the industry and when they have got 3 stars, for example, which is an acceptable level, they strive to get 4 and 5. You have seen some significant movement, have you not?

Interim Head of Environmental Health:

Yes, we currently only have one with zero stars and we are working with him to improve but we have got far more with 5, some with 4 and some with 3. We do not give anybody stars under 3 because if, effectively, they are non-compliant with the law, but the law we have no enforcement measures over. What we have seen is significant competition between neighbouring Italian restaurants who notices his colleague has gone up to 4 and I suspect the food training business is doing quite well out of it. One of the regulations we would seek to put in here is that everybody will display their stars. We have a chain of supermarkets at the moment who have instructed their staff not to display their stars because they are not very good. That would not be allowed if our proposed regulations were accepted and passed through the States just so people have the choice to decide if they want to risk it.

The Deputy of St. Ouen :

I remember when that came in, some establishments said: "Well, I have been assessed on an inspection that was made some years ago." Is that the case? Were you able to ...

Interim Head of Environmental Health:

We were able to refute it fairly strongly I think in the J.E.P. (Jersey Evening Post) but though it was not the case, we are still inspecting to the same inspection regime and techniques that we have been doing since 1990. We were able to demonstrate through letters that we had written to them, the particular one, that they were deficient, where they were deficient, where they had been deficient in 2008, 2009, 2010 and 2011. I wrote a letter in 2010 asking him not to take his soiled bed linen into the restaurant kitchen. So those particular cases, we could refute and it is not for the enforcers, in my opinion, to inspect to make sure. It is not: "Well, you have not pulled me up

for speeding for the last 10 years. What are you playing at?" You should not have been speeding. If you are a professional caterer, you should understand the law. We are quite happy to advise people on it but in those 2 particular cases, there were deficiencies which they had been written to about. So fortunately, in those cases, it was a question that they had protested too much.

The Deputy of St. Ouen :

Yes, I understand, and now, does each establishment have an annual inspection?

Interim Head of Environmental Health:

It depends on the risk. If you are a Post Office merely selling Mars Bars and packaged sweets, the chances of causing a food poisoning outbreak are very slim, so we do not need to use resources to go there regularly. If, on the other hand, you are cooking higher risk foods or you are serving oysters, you will see us far more often, which is the way it is done throughout the world.

The Deputy of St. Ouen : Yes, of course.

The Minister for Health and Social Services:

Part of your risk assessment is the type of customer as well.

Interim Head of Environmental Health: It is, yes.

The Minister for Health and Social Services: So if it is a high risk customer; elderly patients.

Interim Head of Environmental Health: Yes, the hospital sees us fairly frequently.

Deputy G.P. Southern :

Can somebody tell me where you are with what you call the "Snooper's Charter"? Can you remind me what it is about?

The Minister for Health and Social Services:

Yes, Stewart can give you the dates. We are hoping to have it this year.

Interim Head of Environmental Health:

Certainly. A lot of the law drafting was already completed prior to our consultation. We have removed any reference to "owner occupation" from there.

Deputy G.P. Southern : Right.

Interim Head of Environmental Health:

By inserting the word "rented" into the title so it is "rented dwellings".

Deputy G.P. Southern : Okay.

Interim Head of Environmental Health:

We have removed anything from the first drafting which I believe was way back in 2008 to it coming forward. Other people such as ecoACTIVE have taken on a lot of the things that were causing concern about water usage, about energy and everything else. So subject to law drafting, we are hoping we are going to get it to the States before the recess in July. Most of our work has been done and we have done a lot of consultation with our colleagues in Housing.

Deputy G.P. Southern :

More or less, that is fit for habitation literally, is it?

Interim Head of Environmental Health:

Yes, it mirrors fairly closely on the regime that was introduced into the U.K. by the 2004 Housing Act. Instead of looking at a building as either being deficient or acceptable, it looks at the effect of that deficiency on health.

Deputy G.P. Southern : Right, okay.

[15:15]

Interim Head of Environmental Health:

So, for instance, you might have a mouldy shower room but we do not spend much time in there. The action of the shower takes the spores away from you so it might not be aesthetically pleasing but in terms of health, it is not a big risk. On the other hand, you might have only 2 square feet of mould within 6 inches of where a baby sleeps for 8 hours a day and that could be a huge health

risk. So we are assessing the health risk as opposed to doing what building inspections used to do 30, 40 or 50 years ago. The same if there is a slate missing. If that slate does not cause a leak or causes dampness, it is not really a problem.

The Minister for Health and Social Services: So it is being much more pragmatic.

Medical Officer of Health:

So that would bring the private sector in as well.

Interim Head of Environmental Health:

Yes, Andium Homes have already accepted the U.K. version of a Decent Home Standard. On the Decent Home Standard, the first line is that there will be no category 1 housing hazards in the Housing Health and Safety Law which is what we are proposed to adopt so it gives a level playing field. I will say that we must have hundreds, if not, thousands of really good landlords but we seldom come across them because they are doing their job well and nobody complains. It will still be complaint driven and we are also examining the possibility of having an accreditation scheme so we can celebrate good landlords as we celebrate good food premises.

The Minister for Health and Social Services:

So like restaurants get 5 stars, then a good landlord could have 5 stars.

Interim Head of Environmental Health:

Similarly managing agents because we have some good ones and some not quite so good ones.

The Deputy of St. Ouen : That is useful, is it not?

The Minister for Health and Social Services:

It is something that the officer is very passionate about but so am I because I want to see this as part of my previous life.

The Deputy of St. Ouen : Yes, I can see that.

The Connétable of St. Peter :

Again, if they are successful, less cost comes to Health because of their standards.

The Minister for Health and Social Services: Exactly.

The Deputy of St. Ouen : Of course.

Medical Officer of Health:

Preventing other ...

The Deputy of St. Ouen :

Coming back to the Food Safety Law, can I ask are residential care homes and nursing homes included in that regulation?

Interim Head of Environmental Health:

They are included in the inspection. The star rating is given. Currently they are not registered as a food premises because they are part of H.S.S.D. (Health and Social Services Department). When they are moved out into the separate commission, they will become registered. It is just at the moment, it is silly having dual registration but we were very clear. We are in the next office and we often do go and do inspections as is the prison.

The Deputy of St. Ouen : Of course there is the prison.

The Minister for Health and Social Services:

Chairman, were you thinking of private nursing homes as well or just these?

The Deputy of St. Ouen :

Yes, I was, and at one stage, there was a difference between States run and private run.

Interim Head of Environmental Health: Yes, they are.

The Minister for Health and Social Services: They are, yes.

Interim Head of Environmental Health: We inspect them all in terms of food safety.

The Deputy of St. Ouen : Yes, so that is happening.

Interim Head of Environmental Health: Yes.

The Deputy of St. Ouen : Yes, thank you.

Medical Officer of Health:

Just to clarify further on that, the Regulation of Care Law that was the new law that came through the States last year, sets of regulations are being developed and one of the first sets of regulations will be to apply similar standards that already apply under the old Nursing Residential Homes Law to the private nursing residential homes to the States provided nursing residential homes which currently do not apply and I think most people would be surprised that that was the case.

The Deputy of St. Ouen : That is right.

Medical Officer of Health:

The new regulations will bring a level playing field into that arena as well and that is already the case ...

The Deputy of St. Ouen :

But those regulations are not yet in force, are they?

Medical Officer of Health:

No, they are being developed and will hopefully be lodged this summer as well.

The Deputy of St. Ouen :

Yes, so you have got a lot bubbling away to be produced by the summer.

Medical Officer of Health: Yes, it is a busy time.

Interim Head of Environmental Health: Yes, a great deal.

Deputy G.P. Southern :

Can I take it on to another recent report which has come our way? The Optimus Foundation Report on early child development and I see that E.S.C. (Education, Sport and Culture) have picked up a bit of it where they talk about investment in the early years and provision for vulnerable children but I have not seen a reaction from your department.

The Minister for Health and Social Services:

Well, of course our department is involved and a taskforce has been formed and has indeed met. It is more than meetings so I know we need actions but the taskforce is ministerially the Minister for Education, Sport and Culture, myself and will include the Minister for Home Affairs as well. An officer has been appointed from within existing resources from Home Affairs to lead on this work so this is something that all the Ministers and the Health Department, Education Department and Home Affairs are all passionate about doing because, again, this is a bit like the prevention argument that you have in Health. The more you invest upfront, the less you have to invest later on. If you had asked me 6 years ago, I would have said that you needed to ensure that you need to have things properly in place for young people from age 7. If you had asked me that, that is what I would have said. I now realise it is at conception. I have been educated. It is not that it is irrecoverable, the current situation later on in life, but it is very much easier to prevent it from occurring in the first place by supporting families and young people. So this taskforce has been formed, we have had our first meeting and we have now got an officer dedicated to it. Some of the funding is going to come via a benefactor but I cannot say much more than that. You seem to be ...

Medical Officer of Health: No.

The Minister for Health and Social Services:

No? Okay, right. So that is where we are at the moment. I do not know ...

Deputy G.P. Southern :

When will we see some sort of reaction to that? Will there be something in the Medium-Term Financial Plan, for example?

The Minister for Health and Social Services:

1,001 days, which is the principle that we are working behind, is in the Strategic Plan and therefore must translate into it, yes.

Deputy G.P. Southern :

It is barely in the Strategic Plan.

The Minister for Health and Social Services:

No, it is there. It is there as amended. As amended, so, yes.

Deputy G.P. Southern :

As amended. I have not seen it as amended.

The Minister for Health and Social Services: As I remember, one a week, yes.

Deputy G.P. Southern : Okay.

The Minister for Health and Social Services:

So that just made it clearer, the amendment, that is all.

Deputy G.P. Southern : Okay.

The Minister for Health and Social Services:

So there is a huge commitment to this. This is really important to us.

The Deputy of St. Ouen :

Are additional resources going into the Health budget to match this commitment?

The Minister for Health and Social Services:

At the moment, we are doing it from within as we size the situation. We could take a good guess at it but we want to do it properly as we find out and size the situation as we develop our strategy and then my understanding is that somebody has come forward to assist us with funding. Whether we need to put anything else in, I do not know yet because the strategy has not been worked out but there is certainly funding there to get on with the work as it comes out. We know there is work to do though.

Deputy G.P. Southern :

Where do you envisage directing this funding, whether it is your funding or from a benefactor? Are we talking about midwifery? Are we talking maternity leave? Are we talking health visitors in a year?

The Minister for Health and Social Services:

All the things you mention there will be the things that we would be looking at in addition to supporting families - some stuff might be around Children's Services - who need to develop parenting skills better perhaps and it does not mean that we have to do it all. When we are setting up the strategy, we may be looking to partners in the charitable sector to work with us where it is appropriable to do so but it is something that the Chief Minister has taken a personal interest in so it is going to happen.

Deputy G.P. Southern :

What concrete is going to happen? Throughout the year, something is going to happen but it is rarely concrete so I welcome your assurances there.

The Minister for Health and Social Services: I think that is a bit unfair.

Deputy G.P. Southern : I am often unfair.

The Minister for Health and Social Services:

Well, good. A lot of concrete things happen. They may be a different mix of concrete to what you were told.

The Deputy of St. Ouen :

Well, it is encouraging to hear that the backing has been given to it and we hope that is going to result in a good outcome.

Deputy G.P. Southern :

Can I go on to the issue of recruitment and retention? We heard earlier that you were instituting the parity which could work for nurses.

The Minister for Health and Social Services: Yes.

Deputy G.P. Southern :

You did not say anything about the rest of the professionals and where their wage is or where their remuneration may be going. Have we got still areas where it is difficult to recruit and retain? What is the situation and where are they?

The Minister for Health and Social Services:

The very brief answer to that is yes, of course we have. The Director will take us through some of them. I would say that we have done quite a lot of work as a department around things like developing our own nurses. We have an excellent training school now where we have gone back to because they always did develop them when my mum trained as a nurse and then it stopped. That is back. We develop our own healthcare assistants and not just for us but for Jersey, so they can train there as well but there is lots of work going around recruitment and retention. That is the one I know most about so I will handover.

Hospital Managing Director:

Okay, starting with your first question which was about the pay of the professions and nurses, we are part of the lead in the Workforce Modernisation Reform that the States are embarking on so all of our staff, with the exception of doctors' jobs, have been evaluated and they are now working through to go on to this single spine pay modernisation programme. So everybody, whichever profession you are in, has all been evaluated and they will all be going on to a new spine so that is on its way. I am not entirely sure when that is due to happen. I think it is in the next 12 months or so to consider them.

The Minister for Health and Social Services: I am not sure there is a fixed date.

Hospital Managing Director:

There is not a date, right, but we certainly started that work and we have reviewed, like I say, everybody's job role as part of that work.

Deputy G.P. Southern :

That single spine has been agreed by the unions?

Hospital Managing Director:

I think that is the bit that is still ongoing with the unions, yes, but that is the work they signed up to. In terms of whether we have any hot spots for recruitment, there are a couple. We have some hotspots around specialist nurses so, for example, endoscopy where you have got specially trained nurses, we struggle to recruit into a vacancy there. Some adult mental health nurses, we have got some vacancies and theatre nurses, we have had some vacancies.

Deputy G.P. Southern :

Overall, are we below or above the 5 per cent vacancy rate?

Hospital Managing Director: You are going to test my maths.

Deputy G.P. Southern : Often seen as the critical one.

Hospital Managing Director:

This is for all staff in H.S.S.D. including ambulance, civil servants, everybody. We are around the 6 per cent. Nursing vacancies at the moment, we have got 61 nursing vacancies, 21 of those 61 have job offers so we have got people on the way so that is a better position.

Deputy G.P. Southern :

That is 40 out the total nursing.

Hospital Managing Director: Nursing, 1,091.

The Minister for Health and Social Services:

Specialist nurses, I know, are difficult to recruit. It is not that people do not want to come here. There is generally a shortage of them.

Hospital Managing Director:

We do have, as the Minister mentioned, the training on the Island. We have got 15 nurses due to qualify in the autumn so they would all be automatically put into the system and 2 nurses that have done the Return to Nursing Course so there are another 17 nurses in the system waiting to come on board.

Deputy T.A. McDonald:

Plus the H.C.A.s (healthcare assistants) obviously, yes.

Deputy G.P. Southern :

But that will not solve your experienced specialism.

Hospital Managing Director: No.

The Minister for Health and Social Services:

No, but you do need to have people always coming in as well and of course all of these are essentially qualified living in Jersey.

Deputy G.P. Southern :

Healthcare assistants, for example. Those essential building blocks of any system that is supporting people in a community particularly. Turnover rates?

Hospital Managing Director:

I have not got the turnover rate by individual staff group. The turnover rate as a whole is running at 9.6 which is slightly lower than it was but that is for all of the workforce.

Deputy G.P. Southern : Okay, it is still quite significant.

Hospital Managing Director:

9.6. Well, it is lower than it was and that is certainly lower than health systems in the U.K. They are usually about 11 or 12 per cent.

Deputy G.P. Southern :

Okay, and if I may just to round this bit off, other professionals would be equivalent to the parity of the nurses? Are there any particular areas there where it is difficult to recruit or retain?

Hospital Managing Director:

A couple of specialist social worker roles that they have had trouble with the C.A.M.H.S. (Child and Adolescent Mental Health Service) but other than that not that I have reported to me.

Deputy G.P. Southern : Okay.

Deputy T.A. McDonald:

I appreciate time is getting very close to half past. Could I just ask one question which I think is a very important one? Has the Prevention of Suicides Strategy now been finalised? I call Dr. Turnbull.

Medical Officer of Health: I will take that one.

Deputy T.A. McDonald: Yes.

Medical Officer of Health:

There are 2 major things going on. There is a major review of mental health services and that is due for release I believe in May but alongside that - and more urgently perhaps - is some work that has been going on since May 2014 but we have convened a Cross-Government and Multi-Agency Steering Group to look at prevention of suicide, particularly in the most vulnerable groups. One of the precipitants for that was a surge in suicides in a small number of young people in the Island within the last couple of years. The framework for the actions have already been put into place by the different agencies, particularly Education and the Youth Service and colleagues in the Police Service who obviously help on the front line.

[15:30]

That is already happening but we are going to release publicly the framework for action alongside the mental health strategy because they are obviously complementary. But one is about actions that are already underway and happening and the other is about the wider, bigger picture but they have been working alongside each other and work is already, as I say, being delivered.

Deputy T.A. McDonald:

I appreciate obviously that you were concerned that the current problems were only indicative of the size and scale and so on and literally the tip of an iceberg possibly.

Medical Officer of Health:

Well, I think you are talking about self-harm in terms of self-harm admissions to the hospital or something that was reported.

Deputy T.A. McDonald:

Yes, not applying to obviously escalating towards suicide.

Medical Officer of Health:

Not necessarily. It does not necessarily cause an effect, although if you look at completed suicides, there may be a history of self-harm but there is no predictability of necessarily self-harm predicting suicide. It is quite complicated.

Deputy T.A. McDonald: Oh, yes.

Medical Officer of Health:

But at the minute, obviously it is a concern. Linked to that is concerns from the schools health survey that we published recently looking at the question of low self-esteem among teenagers, particularly among the girls. We have been feeding results for individual schools back to individual schools so that they could take account of their own particular picture.

Deputy T.A. McDonald: Performance.

Medical Officer of Health:

But like everything else in public health, we like to sort of tackle everything at all levels and on all fronts so we are using the data we have got to inform the people who are best placed to use it.

Deputy T.A. McDonald: Yes, thank you very much.

Medical Officer of Health: Thanks.

Deputy T.A. McDonald: Chairman?

The Deputy of St. Ouen :

Thank you. Well, that brings us to the end of our time, Minister. Is there anything you feel you want to share with us?

The Minister for Health and Social Services: Not at this present time, thank you.

The Deputy of St. Ouen :

No? Okay, I just wanted to give you that opportunity.

The Minister for Health and Social Services:

Although I would extend the invite to come and have a look at the hospital and understand why ... as an outsider looking in, I would have great difficulty in understanding why we are spending money on a hospital we intend to vacate. I can understand that perception but we have to provide a safe facility and we would be happy to show you around.

The Deputy of St. Ouen :

Thank you. I am sure we would like to take you up on that.

The Minister for Health and Social Services: Thank you.

The Deputy of St. Ouen :

So I will leave our Scrutiny Officers to liaise with you.

The Minister for Health and Social Services: Thank you.

The Deputy of St. Ouen : Thank you all for coming.

The Minister for Health and Social Services: No, thank you.

The Deputy of St. Ouen :

It has been helpful to inform us of all your plans.

The Minister for Health and Social Services: It is a lot of work.

The Deputy of St. Ouen :

I can see that. We wish you well.

The Minister for Health and Social Services: Thank you.

[15:32]