Health and Social Security - Quarterly Hearing - Minister for Health and Social Services - 19 May 2016

Scrutiny Office

Health and Social Security Scrutiny Panel Quarterly Meeting with the Minister for Health and Social Services

THURSDAY, 19th MAY 2016

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 Assistant Minister for Health and Social Services Managing Director, Community and Social Services Service Director, Services for Older People Director, Children's Service

Director, System Redesign and Delivery

Director, Adult Services

Head of Health Improvement

Director, Finance and Information

[13:29]

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

Good afternoon, everybody. I would like to start. This is a public hearing with the Minister for Health and Social Services and today we are focusing particularly on community services. We are pleased to welcome the Minister and the Assistant Minister and all your team. As this meeting is being recorded we will, in the usual way, introduce ourselves as the panel. Minister, could I ask you to introduce yourself and the members of your team? So I am Deputy Richard Renouf and I am Chairman of the Health and Social Security Scrutiny Panel.

The Minister for Health and Social Services:

Chairman, before we start can I give apologies of the Chief Executive who is dealing with another urgent matter, and also welcome Francine because it is her first Scrutiny Panel meeting.

The Deputy of St. Ouen :

I thought we had not met Francine before, so welcome. We only have an hour today, Minister, so can we begin by asking you about the fostering and adoption service? We are aware that you wish to put more money into that budget and achieve improvements. Can you tell us what is planned for this year and how you are progressing with that programme?

The Minister for Health and Social Services:

First of all I would like to say that we had a really successful awards ceremony on Saturday night for foster parents, which marked their different achievements that the different foster parents had done. There is a whole list of awards but the important thing was that it came from the young people. That was very worthwhile and very emotional. Since January 2015 we have been able to appoint 11 new carers and 5 new foster parents.

The Deputy of St. Ouen : Eleven new carers?

The Minister for Health and Social Services:

Yes, and 5 new foster carers. Sorry, I will start again. Of the 11, 5 are what is known as foster carers and 6 are what is known as connected person carers. By "connected persons" there is a family relationship somewhere, grandmother or aunt or uncle or something like that. We have invested £5 million because the £5 million is about social services as a whole. So a significant amount going into social workers and others. But of the £5 million directly into fostering is about £300,000 at the present time.

The Deputy of St. Ouen :

So 11 have been appointed but how many losses have you had?

The Minister for Health and Social Services:

Three have been deregistered due to changes in family circumstances, not because they did anything wrong but because they were no longer able to complete the role.

The Deputy of St. Ouen :

The connected persons, family members perhaps, is that always a suitable way of dealing with cared for children or is it ...

The Minister for Health and Social Services:

You really need to speak to the experts on this one, but I can assure you that a connected person would not be selected to look after a vulnerable child unless it was felt that that was in the best interests of the child. But if you want to look into more detail ...

The Deputy of St. Ouen :

No, let us leave it perhaps for the moment. Is it the case that we still need foster parents?

The Minister for Health and Social Services:

Yes, we are still recruiting and to that end we are going to appoint somebody to ensure that we have very good publicity within that. I do not know whether that is a full-time job or part-time job, but there is a going to be a publicity officer to try and ensure that we get access to recruiting more people. I must say that we have the same challenges as the whole of the world really, but in particular if you compared us to the U.K. (United Kingdom), they have the same challenges in finding suitable people.

The Deputy of St. Ouen :

Are there particular challenges in the Jersey context? For example, do we have more of our adult population at work and not able to take on the foster role?

The Minister for Health and Social Services:

We do know that we have more adults that work but being a foster parent does not preclude you sometimes from working. It depends on the needs of that particular child.

Deputy G.P. Southern :

But supply and demand; in terms of supply and demand we still need some more?

The Minister for Health and Social Services:

We need more, yes. The lead-in time from us advertising and someone applying to being able to foster can be up to 9 months because of all the checks and training that needs to be done. We have an independent foster panel that ... if a person gets through the checks, the independent panel then interviews them and looks at their suitability.

The Deputy of St. Ouen :

Are we able to maintain these foster parents to act as foster parents over the long term or do we find that they encounter problems, whatever they might be? Do we assess that if they drop away?

The Minister for Health and Social Services:

I will let one of the officers answer that; either Susan or Francine. But what I would say is that at the awards ceremony the other night a significant number of people were rewarded for 20 years, 30 years, and one couple, in particular, 35 years' service.

The Deputy of St. Ouen :

I know, that is excellent. But could I ask: are there particular difficulties in retaining foster parents in the long term?

Managing Director, Community and Social Services:

I think there can be, Chair. Like other jurisdictions, the fostering task has changed over the years as children and young people that have been looked after in public care come with a much more complex range of needs and challenges. It is not always an easy ask for somebody to look after a child with a range of difficulties in their own home - throughout childhood perhaps. There is a number of emotional difficulties and behavioural challenges. It is a very tough ask and it is emotionally quite draining. The fostering task is not for everyone. So the assessment is absolutely critical because we would look at how we assess somebody's personal resilience and that is also sometimes about how long they may be able to do the task. There are a number of carers, as the Minister said, who have done the job - if I can call it "the job" - for a long time and have reaped the rewards of that and may have contact with those children well into adulthood. But for some people it is not the task that they thought it was when they first came in. Whether it is changed or their family circumstances change, there are always people going out of the system. Of course we have a responsibility to act when people are unable to keep to high standards and give a good sense of care to a child and help make up for their deficits that they may have experienced as young children. We have a responsibility to review that and perhaps sometimes to help people see that fostering is not for them. So the supports we put in place are very, very important. So the support of the supervising social worker, family support workers who can assist with some of the more practical tasks, and also some of the training that we give foster carers. Now some of that would not have happened years ago. It is a recognition of the complexity of the task. We also review on an annual basis how foster carers are doing; and that is to safeguard the children as well as the wellbeing of the carers. So it is a complex task. It is not for everyone. It is

demanding both on the carers themselves and their family who are living in the house and perhaps extended family. But for many people it works very well. But it is important ... that support is absolutely critical in the success of placements.

Deputy G.P. Southern :

Do we have anybody still in the U.K.?

The Minister for Health and Social Services: Yes.

Managing Director, Community and Social Services:

Yes, we do. We have 10 children just now in the U.K. foster placements.

Deputy G.P. Southern :

Would they be better suited to return to Jersey or not?

Managing Director, Community and Social Services:

I think we would always recognise that to remove a child from their local community, the local culture that is their culture, would not be a first choice. So it is a very serious decision to move any child. We do not always have the requisite types of placement when we need a placement for somebody with particularly complex needs, so we may have no alternative but to look to the U.K. and for a kind of care-planning scenario of how we support that, Chair, because generally it would be exceptional if we were not planning for them to return to Jersey so that they could take their places as an adult in this society.

Deputy G.P. Southern :

Are these then ... do they all have special needs, as it were?

Managing Director, Community and Social Services:

Yes, in the broadest sense of that term. I mean I think that there would be very few children who would be looked after who would not have some need ...

Deputy G.P. Southern : Some issues.

Managing Director, Community and Social Services:

... otherwise we would not be looking after them. I think it is ... in the last few years it has become very apparent, for instance, of the long-term impact of early neglect, for instance, which I think was not always recognised here or elsewhere in the U.K. about the very great impact of that longer term impact in terms of development. So somebody may not have a physical or an emotional disability, but they may have a range of very special or complex needs. I would like to assure the panel that the system of screening, if you like, to consider if a child leaves the Island often happens in the Royal Court. But before that it is considered in-house by the Director of Children's Services and then myself. So there are a number of gatekeeping arrangements that have to go through so, I would like to think, very careful consideration of those placements.

The Deputy of St. Ouen :

What are the costs of placing care for a child out of the Island?

Managing Director, Community and Social Services:

It is certainly quite expensive. It varies from provider to provider but you are probably talking an average of around £70,000 per annum. Now that does not include the cost of family visits or the child coming back or social worker visits to carry out statutory reviews, et cetera, but that is the kind of ballpark figure for foster care placement.

The Deputy of St. Ouen :

Is that usually paid to a local authority in the U.K.?

Managing Director, Community and Social Services:

It can be. More often than not these days there are a number of independent fostering agencies. That has been a boom part of the market over probably the last 10 years, I would say. In England I think people can make a slight profit. In other parts of the U.K. they cannot. But I think people see that as the reserve and things rather than profit. So generally we have independent agencies.

The Deputy of St. Ouen :

How do those agencies come to your attention and how do we assess them as being suitable to receive our children?

Managing Director, Community and Social Services:

We work very closely in Children's Services with our colleagues in commissioning, so a lot of the commissioning work is done by Andrew Heaven directly as the officer involved in that. So there is a whole contractual framework that we go through. The agencies are generally registered. They will be scrutinised at a U.K. level so there are safeguards around that. Often I have to say it is a case of seeing who does particular, if you like ... where the particular focus is, and some agencies are focused on different kinds of needs. So it is about that, narrowing it down, and then looking to see what the match is for the child with the care. Because it is not as straightforward as there is a placement there, here is a child. You need to put them together to match need with resource, , which is another instance where we may have to place off-Island. We might have a physical placement on Jersey but it is not one that is suitable for that child.

Deputy G.P. Southern :

David Cameron was recently committing himself to putting in some support for cared for children up to the age of 25, I think. How do we compare with that sort of target?

The Minister for Health and Social Services:

I think for some time we have accepted that up to 25 might need some support and help. My children are 37 and 35 and I am still helping them. There was at one time a cut off, was there not: "18 you are on your own, Jack." It is not like that now.

The Deputy of St. Ouen :

Okay, so what sort of help would we give beyond 18?

Managing Director, Community and Social Services:

It is the whole issue of throughcare and aftercare. There is very little legislation in Jersey, unlike some other jurisdictions where there are throughcare and aftercare duties on the local authority of course. But there are also powers up to 25. You are absolutely right, that has been a key area. I think in recognition of the thought that, if you like, children growing up in the mainstream with very little state intervention would struggle to leave home at 16 or 18 or 25. Why would we assume that looked after children with a range of difficulties can do that? It is an area that we would want to do more in, and we are doing some scoping work just now about it. We have done some work with Barnardo's and have been looking at accommodation. Some of that is about the emotional support more than anything, and we know that children who have been looked after can have much poorer outcomes than children who have not. I think it is incumbent on us and public bodies responsible for those children to try and change that.

Deputy T.A. McDonald:

Are you happy as a healthcare professional that this Island is doing the right thing at this moment in time?

[13:45]

What you are being presented with financially and homes and everything else, are you personally happy that it is working for us?

Managing Director, Community and Social Services:

I think we are going in the right direction. I think there is a way to go. Clearly there has been lots in the public arena around some of the difficulties there have been. Just to say that professionally I am a social worker rather than a healthcare worker, so maybe have a closer professional background to the social work stuff. I think we are going in the right direction. Change does not happen immediately. It is a long-term process. We are working under the auspices of the Improvement Board chaired by the Chief Minister, and I think that is very helpful in terms of the profile and the commitment that that brings. I think the investment that was mentioned earlier has been critical and it will be critical going forward.

The Minister for Health and Social Services:

Just picking up on the Improvement Board; the Improvement Board is looking at, where we are now, where we want to get to and the outcomes on the way.

The Deputy of St. Ouen :

Thank you, Minister. If we can move on to the area of mental health now.

Deputy T.A. McDonald:

Within the Mental Health Strategy it spoke to the next step is to begin a communication process with Islanders and key organisations before finalising that strategy in late June. How is the work progressing?

The Minister for Health and Social Services:

It is progressing well. In fact we had a Mental Health Day on Wednesday last week. I will hand over to Rachel to talk about the strategy, which is progressing in the right direction. I am pleased with the work that we have achieved so far. I particularly want to see the stigma side of mental health changing. I believe it is, but there is still more to do because people would rather tell you they have been in hospital and had their appendix out or had a broken leg. Very few people will tell you that they have had a mental health challenge and have had treatment for that. We need to change that because 1 in 4 of us has problems at one time or another to some level. We all know the earlier we intervene, the earlier we ask for help, the earlier and more successful ... the earlier we do that the more successful the outcome. But if you want to talk about the strategy particularly I will hand over to Rachel, and then we can maybe talk about the Mental Health Law.

Deputy T.A. McDonald: Indeed. Thank you.

Director, System Redesign and Delivery:

The Mental Health Strategy was launched last November, having been approved by the Council of Ministers. As part of that launch there was a communications exercise through various media routes. The big thing about the Mental Health Strategy is that it was done in conjunction with a whole range of people. So people who were users of the service, carers, the general public, those who work in mental health services, and those who work in associated areas. You will probably remember that the strategy was not a Health and Social Services Department strategy. It was a strategy for Jersey. So we had input from Home Affairs, Criminal Justice, the police, the prison, Education, and the theme of that co-production, working with people and listening to people's views was really, really important. Since the strategy was launched last year we have continued on those themes. So we still have the citizens' panels running and they are really important and it's really valuable to keep listening to what service users think and want. As the Minister said, we had an engagement day just last week, and we had over 100 people there, of which there were a goodly proportion of people who were still involved in the citizens' panel and people from across Health and Social Services, Education, Criminal Justice, et cetera. We are progressing well with the plans in terms of how we turn the strategy into action. We have got a set of workstreams with owners of those workstreams properly project managed, exactly as you would expect, with milestones and goals all along the way. That is overseen by an Implementation Board that has representation across the piece.

The Deputy of St. Ouen :

Can you give us anything concrete?

Director, System Redesign and Delivery:

Yes, I am just getting on to that. So we are really well progressed with our plans on the Recovery College, and that has been led by the Jersey Employment Trust. So the Recovery College will be produced and led by the voluntary sector and people who use services. That should be up and running by the end of this year. The planning has really well progressed on that. As I say, we have got a key voluntary sector organisation helping with us on that.

Deputy G.P. Southern : Where is the funding for that?

Director, System Redesign and Delivery:

It is from P.82, from the White Paper funding. All the Mental Health Strategy funding is from the White Paper funding. We have the 2016 money and then subject to the debate later on this year we hopefully will get the money going forward.

I.e. the Medium Term Financial Plan.

Director, System Redesign and Delivery:

Part 2. Older adults mental health is really well progressed. We are doing it in a different way, so we have held some development centres and really started kind of ground up, talking about values and the way that we provide services and some quite robust feedback from service users and people who work in the service. Those older adults mental health services, those dementia services, are well in train now in terms of their planning and posts are starting to be recruited too. Pathways are well in development on that as well. All the services will be fully live by the end of this year but they are coming onstream throughout this year. Mental health awareness is really important and so we are focusing on increasing awareness. There will be some questions in the Annual Social Survey this year around mental health awareness. The Mental Health Awareness Week is this week. So there is some awareness raising around that. 10 September is suicide prevention and October is Mental Health Day. Then in February we have got Time to Change. Prevention and early intervention for young people, we are working very closely with the Education Department around getting more counsellors in schools and working with the Yes project around how we can support younger people with things like Talking Therapies, which is, you will remember, been really successful for the adult population and was part of phase one investment from P.82. Urgent mental health assessment: so we have been doing some work on the Place for Safety and looking at where people should be looked after when they are having an exacerbation of a mental health issue with a set of key principles being developed between mental health services and the police. We are also looking at outcomes and standards across the system. So we have now signed into a benchmarking club which will give us some really rich information about how our services compare with other services and identify other areas where we can progress and improve even further. So that is a very long answer. There is a huge amount going on but a really important part of it is we are doing what we said we would do and we keep on listening to people and we are involving them in the planning.

The Minister for Health and Social Services:

Chairman, I do not know if we invited you - we should have done if I we did not - to have a look at the 2 new places of safety we have on Robin Ward . Did we invite you to come and have a look at those?

The Deputy of St. Ouen : No, I do not think so.

The Minister for Health and Social Services: Well we ought to do that some time.

The Deputy of St. Ouen :

Okay, thank you. That would be worthwhile.

The Minister for Health and Social Services: I am sure my assistant will follow it up now.

The Deputy of St. Ouen :

If you did and I have forgotten I apologise.

The Minister for Health and Social Services: No, I cannot remember if I did, so leave it at that.

The Deputy of St. Ouen :

We will take you up on that, I am sure.

Deputy T.A. McDonald:

Sounds like an awful lot of achievable aims and a lot are being achieved. I can tell just by the enthusiasm. You are obviously more than happy that you are ... you have reached where you want to be at this stage?

Director, System Redesign and Delivery:

We are where we planned to be on that journey to implementing the Mental Health Strategy.

Deputy T.A. McDonald:

Absolutely excellent. That is good news.

The Deputy of St. Ouen :

There has been some concern expressed about the waiting times for Talking Therapies. I think it has been said that it is desirable that they be improved. How can we improve them?

Director, System Redesign and Delivery:

It is always desirable to improve any waiting time down to zero but not possible unfortunately. I think with Talking Therapies it is kind of a victim of its own success in a way. The more that people have understood what it is and how useful and valuable it is the more the demand has gone up. We are keeping that under review, and if you want to talk about the detail around that.

Managing Director, Community and Social Services:

There was some impact because of staffing vacancies at one point. We are kind of coming out of the wood with that. But I think Rachel is right. It is a bit of a success story. I think as we move forward we are wanting to do, in line with the Mental Health Strategy, just how we are organised in community and social services around mental health and wellbeing, and that whole kind of spectrum to try and get some of that early intervention of preventative work that Rachel talked about in an earlier stage to stop people progressing and becoming ill. So trying to do some work on that.

Deputy G.P. Southern :

You said you are out of the woods with particular staffing issues.

Managing Director, Community and Social Services: We are getting out of the words.

Deputy G.P. Southern :

You are getting out of the woods?

Managing Director, Community and Social Services:

I think we have appointed but not got bodies in place yet.

The Deputy of St. Ouen :

So, Rachel, towards the end of what you have just told us, I think you remarked that you were benchmarking our standards. So will that include waiting lists for these therapies? Do we measure them against ... against what sort of benchmark?

Director, System Redesign and Delivery:

There are a whole range of benchmarks that we will be able to access. We have just signed up to the benchmarking club. So there will be things like bed numbers, staffing profiles. I think waiting times is part of that. But if you are interested I could get you a whole list of the factors that will be benchmarked.

The Deputy of St. Ouen :

Yes, can we ask for that? Anything else, Terry?

Deputy T.A. McDonald:

Obviously I would like to ask about the current state of play with obviously the new Mental Health Law and Mental Capacity Law. Have we got a timeline for completion on that one?

The Minister for Health and Social Services:

Yes, I will let Ian go into detail in a minute, but what I can tell you, if you want to know some detail on the law, I can tell you that C.O.M. (Council of Ministers) approved the law yesterday, so that is the Mental Health Law and the Capacity of Self-Determination Law were approved by C.O.M. Now normally we would then go straight down the road and lodge it. Not quite ready to do that yet but we are very close. The only reason we are not, there is not going to be any change in the law unless Members bring amendments and they are discussed in the normal way. We just need to finalise that all the money is in place for the different departments outside of Health that are affected by the extra work that we are giving them with the new Mental Health Law. For example, appeals that will be independent of Health. That is just being sorted out in the next week or 2.

The Deputy of St. Ouen : When might it be lodged?

The Minister for Health and Social Services:

I am hoping that it will be in the next week or 2. I do not know if you have had a draft copy.

The Deputy of St. Ouen :

Yes, we have as a Scrutiny Panel been given a briefing.

Service Director, Services for Older People:

Chairman, the copy you had was probably one of the first of the copies. It was the consultation copy that we circulated. So we have come to the final draft copy that was presented to the Council of Ministers yesterday and, as the Minister said, approved by the Council of Ministers pending the ... making sure we got the right resources in the right departments to make it work in 2018 when it comes into being. There are 2 pieces of legislation, 2 substantial pieces of legislation. There is the new Mental Health Law and there is a brand new Capacity and Self-Determination Law. The work on both these pieces of legislation started in April 2014, when we got the resource required to do the piece of work. So we have moved quite swiftly to the point of getting to lodging both pieces of legislation for them to lodge. Hopefully by the end of this month, early next month, probably early June now we would be looking to lodge. We have identified and put in some time that is going to be required for yourselves as a Scrutiny Panel to look at both pieces of legislation before it goes into States debate and then on to Privy Council. There is a significant amount of work once it is lodged. Obviously the secondary legislation and the policy that we need to move forward on quite swiftly to make sure that it is all there when we acquire it, when it is ready to come forward. But I think the work and the joined-up work between department, law officers and also law drafting has been a good piece of work. Hopefully the laws themselves reflect modern practice, particularly in relation to the European Convention of Human Rights, and changes that are happening regularly through the Supreme Court testing and retesting, deprivation and liberty safeguards for people who are deprived of their liberty.

The Deputy of St. Ouen :

Yes, too long awaited pieces of legislation and will be very welcome.

Deputy T.A. McDonald:

Before we leave mental health, what is the long-term plan for accommodating the mental health services?

The Minister for Health and Social Services: That is currently under review.

Service Director, Services for Older People:

It is a workstream that sits with the Mental Health Strategy that Rachel took us through but I have got lead responsibility for that. That is the States plan for mental health, the estate strategy. Myself and my colleague, Chris, were at a meeting before this one with Jersey Property Holdings and with commissioning looking at developing that workstream. The intention is to ensure that we have got an estate strategy for mental health ready to be put into the 2020 Medium Term Financial Plan.

[14:00]

So there is a significant piece of work to do between now and then. There is however a piece of work with a colleague I am working on at the moment, which is what I am describing as phase 1, phase 2 being the ultimate strategy. But phase 1 is looking at our current estate, including the estate of C.A.M.H.S. (Child and Adolescent Mental Health Services) and J.T.T. (Jersey Talking Therapies) and psychological therapies to see how best to support and house them They cannot wait until the middle of 2020 to have appropriate accommodation. Similarly with our colleagues in Orchard House Unit, so we have agreed a feasibility study for the Orchard House work, which is commencing as we speak. It is starting now and we have been moving that forward. So there are a number of pieces of work that have been done sort of in tandem but one is looking at the short term, the immediacy and the other is the planned longer term estate strategy.

Deputy T.A. McDonald:

But work has to continue, does it not? Thank you very much.

The Deputy of St. Ouen :

In relation to C.A.M.H.S., Minister, I am aware that we had a briefing from you over a year ago and we discussed the short-term plans at that stage. But I think I would like to write to you, if I may, and request your written response to some detailed questions about the implementation of medium and longer-term plans within C.A.M.H.S., but could you take this opportunity perhaps just to give us a general update on the work of C.A.M.H.S.?

The Minister for Health and Social Services:

I notice in the advice you gave us beforehand you wanted some progress reports on recommendations, which I will hand over to an officer to take us through in a minute, but we do look at that fairly regularly. It is interesting that we were talking about the estate on the last question and that is one of the ... I have to be upfront and say that is one of the frustrations for me, that the accommodation for C.A.M.H.S. is unacceptable and embarrassing. If I was a young person coming into that facility ... I know good care can be provided by good people in tin huts but if you are a person who has got other challenges and you come into that facility you would think: "Well, nobody cares about me."

The Deputy of St. Ouen : Specifically in what respect?

The Minister for Health and Social Services:

Well, it is just completely run down. When it rains water comes through it. I am pushing very hard and, as Ian said, we may well have a solution in the near future to get better accommodation for the start but primarily better and more suitable accommodation for young people, adolescents with mental health problems. So where we are at the moment is just not acceptable. That said, I know that the work down there has moved on. But I will let officers take you through that.

Director, Children's Services:

In relation to the recommendations that are outlined in the Minister's questions, they related to the care pathways, to closer working relationships between C.A.M.H.S. and other agencies and partners, to the skill base and the training of the team as well to make sure that was right, and early identification and intervention. So work has been ongoing to achieve these aims. There has been significant progress in developing joint working processes. C.A.M.H.S. have joined with the Early Help and the M.A.S.T. (Multi-Agency Screening Team) meetings, which gives them that opportunity to contribute to that joined-up working and identify at an early stage any issues that they think they can support families with. A joint pathway: I think the recommendation talks specifically about eating disorders so a joint pathway has been developed for eating disorders to include C.A.M.H.S., paediatrics and dietetics. Pathways for neuro developmental disorders have

also been developed. For preschool children with suspected Autistic Spectrum Disorders, the child development service provides assessment. For those children of school age there is a multi- agency joint assessment clinic for autism and social communication disorders. Those were the ones that are particularly mentioned in the recommendation and work has been ongoing to confirm those pathways. With regards to the skills and the training for staff within C.A.M.H.S. we did a training-needs analysis and we reviewed the staffing establishment, and there have been a small number of new posts agreed since Scrutiny. We have 2 new duty roles and they respond to the urgent referrals. The behaviour therapist, a family therapist, and 2 primary mental health workers, those have not all been filled as yet but recruitment is imminent. So we have been able to do that. But with regards the professional development of the staff, we have got 3 senior clinical staff nearing completion of the cognitive analytical training, which supports those young people with eating disorders and those with complex psychological issues. We have got 2 further staff members are nearing completion of the family therapy training and the whole team have received risk assessment training as well. With regard to again the early intervention joining the M.A.S.T. and the Early Help it enables early identification from universal and targeted services. C.A.M.H.S. have also started offering a consultation process as well for other agencies to ring up. I think one of the recommendations, number 31, is about ... let me just check before I say that. For those undiagnosed, those individuals who are undiagnosed, there is support available within schools via the school counsellors and were being co-ordinated, and also the Yes project provides support for the younger people over 14. C.A.M.H.S. have regular consultations with those groups as well. With regard to the priority of children's mental health, as previously mentioned I think children's mental health has been incorporated into the priorities outlined in the Mental Health Strategy for Jersey in 2015, and there is also a recommendation with regard to the family therapy. We currently have a locum registered family therapist within the C.A.M.H.S. team. A further member of staff will also qualify as a family therapist in the autumn, and the service is currently able to offer a range of family interventions to support some of the more complex cases. So certainly the skill base and the training is improving.

The Deputy of St. Ouen :

So there has been a lot of progress made. Are these permanents posts that have been recruited?

Director, Children's Services: Yes.

The Deputy of St. Ouen :

That is good to see C.A.M.H.S. is making great progress in that way. Thank you for that. Moving on, Minister, unless there are any other questions on C.A.M.H.S. Minister, can I ask you about liquor licensing because there has been a public consultation on licensing and how we should do that in Jersey. But from a public health point of view how has your department responded to that consultation and what are your views?

The Minister for Health and Social Services:  

Okay, funnily enough it is the meeting after the next meeting. We are going to meet to discuss the consultation, [Interruption] ... all jokes aside, we have known for some time, I think we all know and not surprised, that alcohol consumption in Jersey is high when compared to other countries. Although there has been a reduction here in Jersey we are still among the highest in the world. That concerns me. We know that there are health implications to excessive alcohol consumption but it also impacts on the community in the way of lost working days, in the way of ... there is a link between excessive alcohol and crime, albeit that some might say at a lower level. It is estimated that that cost is between £45 million and £70 million a year to Jersey. Research does show that consumption is related to the price and, as you know, we were in consultation about whether there should be at least ... whether there should not be promotions of buy one, get one free sort of thing. As I say, we are going to a meeting after next to discuss this. I think you asked in your question, before I hand over to officers to give you the detail, about extended licensing hours as well. The evidence is ... I am advised, from the work that has been done in the U.K., extended licensing hours does not have the desired effect that one would like to see, i.e. that people drink less because they have got longer time before closing time. That they come out of the clubs at different times and therefore do not congregate to make a nuisance of themselves in town. The evidence suggests alcohol consumption increases even further, and we understand the problems that go with that. For that reason, I know I have been known as a killjoy when we are discussing, for example, the licensing extension for the Queen's birthday party, I shall be consistent, as I was with her Diamond Jubilee, and vote against extending it. I do not think it is good for us or good for the people that live in town. I will hand you over to Martin if you have got any detailed questions.

The Deputy of St. Ouen :

Martin, there has been quite a public outcry at the thought that we might fix a minimum price for alcohol, is that the best way to describe it? We have heard about the petition that retailers have organised. If I can provoke a question: why should we not buy what we wish to buy at the cheapest possible price?

Head of Health Improvement:

In the first instance, the policy I think that was being proposed was specifically about trying to restrict the actual promotion of price. It was not about implementing any restrictions on the trade around their own pricing policies. It was specifically around highlighting to the customer about these prices. A consultation summary I believe is due to be released from the Shadow Alcohol Licensing and Policy Group in the near future. What we do know is that the price and availability of alcohol are the 2 strongest drivers to alcohol consumption and therefore are very strongly linked onwardly to kind of harm from increased drinking. Accessibility specifically around licensing areas we know can be impacted by opening hours, can be impacted by age, purchasing age, and also by the density of the provision of licensees that are available. So they will be things that, as part of a Shadow Alcohol and Licensing Policy Group or the actual Alcohol and Licensing Policy Group when the law is passed that the Minister for Health will have a view on it and move forward with that. I think effectively we know that the impact of availability through increasing alcohol licensing has been linked with increasing harm through systematic reviews of the evidence. So it is something that would concern us to move forward on. We do know specifically that the World Health Organisation released an action plan in 2012 to go through to 2020 and that specifically states that we should be looking to curtail the availability of alcohol and curtailing licensing hours. They go on to say specifically where a community appears to suffer more significant harm from alcohol that licensing hours and availability should be considered for being reduced rather than anything otherwise. Jersey, with its very high per capita consumption and higher than average known harms, it is something that might want to be considered.

The Deputy of St. Ouen :

Are you pressing for that? Is that the control that you would like to see introduced as a department?

Head of Health Improvement:

I think it is something that we would be looking to support, looking for advice on. I think it is something specifically that the Alcohol and Licensing Policy Group together needs to take a view on and it is something that is cross-government and led by Chief Ministers. But from a public health perspective, the 2 most significant drivers, as I have said, around price and availability are the things that I think we need to make ... they are difficult decisions. As we have heard, you know, the public were ... there was some level of concern around the issues that related to price promotions. I would add that quite often we are unsure if the public to the consultation were responding specifically to the issues raised in the consultation or to the trades' representation of that policy. But it is very much something that difficult decisions around price and availability will need to be considered if we are to have a really good effect in reducing the harm that alcohol currently causes on the population of the Island, so yes.

The Deputy of St. Ouen :

But just how can we square that circle because I imagine there are some people saying we need to encourage people to the Island, we need to encourage the economy by allowing people to spend in the bars and hotels and you are saying: "No, we need to reduce alcohol intake." How do you square that circle?

The Minister for Health and Social Services:

If people were ... and I am not an educationalist in this, but quite clearly if people were to drink sensibly and proportionately there would not be a problem, but we know that does not happen.

[14:15]

We have got, as I say, one of the highest levels of consumption of alcohol in the world per head of capita. That makes me wonder sometimes because I know quite a lot of people that do not drink at all, so it means others are drinking even more. It causes problems. It causes many, many health problems. It is absolutely disruptive on the family. We know that a great deal of domestic violence is fuelled by the consumption of alcohol and the misery it causes on occasions. Drunk in proportionate amounts it is fine. It is part of our social infrastructure. I do not drink myself but I understand that. But we know the misery and the harm that it does do when it gets out of hand, and the evidence that we have in front of us is quite clear. I am not an expert on it but the evidence I have seen that it is linked to price.

Deputy G.P. Southern :

But you will be aiming for a joint approach to this led by the Chief Minister?

The Minister for Health and Social Services:

We have a dilemma here, do we not, inasmuch as you outlined it. I do not want to put words in the mouth of the Economic Development organisation but the Economic people want to attract people ... want to keep prices really low, want a vibrant economy but a vibrant economy based on the sale of alcohol is not one that I want and I do not think they do either, to be fair. So there is getting that balancing act.

The Deputy of St. Ouen :

It is very much a difficult balancing act, I guess.

Deputy G.P. Southern :

Can I take you on to the long-term care scheme?

The Minister for Health and Social Services: Yes, certainly.

Deputy G.P. Southern :

We have had some problems, I think, about there being delays in gaining people and the process for it. Is that solving itself, do you know?

The Minister for Health and Social Services:

It is not completely solved. It is much better than it was. Again, if you want to go into detail we will get one of the officers to speak to it, but I think it is fair to say that initially we were overwhelmed by a number of assessments that needed to be done. But we worked our way through that. I have got here that there have been 900-plus assessments completed, 40 short-break assessments, 30 day-service assessments and 80 low-level care assessments. So it is much better than it was. If you want the detail then I will hand over to Chris Dunne.

Director, Adult Services:

Forgive me, because in the slight change of seats I missed the question, so I did not want to make an assumption I knew the question. Would you mind?

Deputy G.P. Southern :

I asked if the long-term carer scheme is bedding in.

The Minister for Health and Social Services:

Your specific question though initially was there have been delays in assessment.

Director, Adult Services:

We have been working really hard and in particular in partnership with our colleagues in Social Security. We still have both joint operational group meetings and joint strategic group meetings to try and keep on top of this. Forgive me, I think I reported last time because we have had some additional investment support from our colleagues in Social Security, so we have been able to increase some of our resource to try and break the back of the anticipated increase in activity and the Minister is correct, that as well as business as usual, which would be our normal flow of referrals coming through from July 2014 through to December 2015, there was something like 900-plus additional referrals that we have processed through. The majority of that being in older adult services. Subsequently from the beginning of this year we have been targeting the next cohorts and again the Minister is correct that that was around people in existing services for not new business but assessments that we need to be on top of, ensuring that people are getting access to the right benefits under the new system. So that, in the main, included our short-break services, which includes our day services. We are in the throes of a cohort, which is a whole host of people. There are about 80 people in total who have historically received fairly low levels of support. We anticipate that many of those might not tip into the long-term care benefit threshold but we do not know until we have done the assessments. The additional resource we have comes to an end at the end of June so our push is to have completed all of these assessments by the end of June.

Deputy G.P. Southern :

When you say "additional resource", are you talking about people?

Director, Adult Services:

Yes, we had funding from Social Security for 3 additional posts in the team to assist with the assessments. Originally it was targeting 2 additional social workers. We elected to have 3 social work assistants working within the team, because that gave us more efficiency with some of the lower level work that we needed to do. That has certainly helped us over the last 18 months, coming for 2 years obviously in July, to break the back of what was an anticipated fairly substantial increase in the workload that we had.

Deputy G.P. Southern :

There was an issue around the computer programs. Are those out yet? Can you talk to Social?

Director, Adult Services:

Yes, we can. It has all gone like ... last October we went live with the cloud-based system that is referred to as "Carepath". We have rolled that out across all of our older adult services, so we all use a single assessment process that is integrated, that speaks to Social Security to the N.E.S.S.I.E. (New Employment Social Security Information Exchange) system, through what is referred to as the resource allocation system. So what happens today is we do the assessment, we do what is referred to as the needs assessment out of that. That gets pinged across to the Social Security, it is all electronic. That produces an indicative budget and then the final outcome is we produce ... it automatically produces a personal support plan based on the assessment that allows us then to know what the needs are, what the outcomes we want for people and how much money we have got to spend on a care package. That allows us then to go out and commission a package of care, whether that is within a nursing care, residential care or a package of care at home.

Deputy G.P. Southern :

Have there been any problems with transition from ... I think it is the cohort you are talking about, people previously on some form of impairment through into the long-term care? Have there been any issues around that? Has that been smooth or ...?

Director, Adult udit Services:

Nothing goes smoothly. We work really hard to make it as smooth as possible. I think in the main for most people it has gone smoothly. From a service point of view there have been real challenges, and I think the biggest issue is in regards to where a number of people access income support benefits and transition to long-term care benefits because the systems are different. We are having to work through with families individually to help understand and manage the decision making in that post less.

Deputy G.P. Southern :

But people have not been left stranded? Out of one but not yet in the other at all?

Director, Audit Services: No.

Deputy G.P. Southern :

You have got some work to do then. While on this subject of long-term care and in particular our attention has been drawn to domiciliary resistance and have care in the home. Have you any plans, Minister, to cease ... what plans do you have to cease, reduce or outsource services that currently are delivered by the department in the context of the Medium Term Financial Plan?

The Deputy of St. Ouen : Community services, yes.

The Minister for Health and Social Services:

Yes, because I got a question from you about that and I do not have any plans at the present time to outsource. That is what you asked me. I cannot say that we do not have plans to do things differently in different areas, we are always looking at when somebody leaves whether you should do it differently, whether you should have 2 assistants rather than a leader or something like that. We are always looking at things like that. We have no plans at the present time to outsource. But you always then ask me: "Well, will you guarantee me that you will not outsource?" and I will not do that.

Deputy G.P. Southern :

I will follow that up with: are there any services that you are considering ceasing or reducing? Which is the 3 arms that all Ministers ...

The Minister for Health and Social Services:

Across the whole of Health, not just in the area that we are questioning about?

Deputy G.P. Southern : Take it as wide as you like.

The Minister for Health and Social Services:

There are some areas that we are looking at doing differently around primary care, working with our colleagues in primary care because, as you know, that some of the things that we do in the hospital we need to get where they should be in the community. We are still going to be doing them but doing them differently. So we are looking at that at the present time. We have got a couple of suggestions because we are working with our colleagues who have come forward with pilot schemes and primary care that we are looking at doing, but I think Rachel can take you into that, if you wanted to talk about.

Deputy G.P. Southern :

But there would be no reduction or cessation of services so it will be delivered in some means or other?

The Minister for Health and Social Services: It will be delivered in some way or another, yes.

Service Director, Services for Older People:

Minister, it might be helpful if I gave an example with the community mental health services, which is we are changing the model of service provision there where traditionally we provided a community mental health team which, to be honest, has provided an element of primary care service within that because our primary care services currently do not have sort of nurses, mental health nurses and such like, working within them. So traditionally what happens in Jersey, which would be slightly different to our colleagues in England or Wales and such like, would be that our secondary care mental health services, which normally would look for complex and in-patient services, also have to pick up some of the secondary care services because we do not have them currently within our primary care G.P. (General Practitioner) services. The way we are addressing that with the investment we got from the P.82 is a complete model change in the way we are providing services. We are looking at 4 specifications. One of them is a primary care service and what we will be looking and what we are in the process of doing is developing teams of nurses, primary care support workers, which are non-registered staff, and occupational therapists working within the primary care, working with G.P. practices directly, which will take the load away from the community mental health team to concentrate on the complex mental health issues for older people. That then means that there is a - coming back to your point, Deputy - change in the way we provide our community mental health support service. At the moment we have community mental healthcare assistants working to nurses within the complex community mental health team. Those will then change to community mental health primary care support workers. Rather than just being a healthcare assistant or nursing assistant - and I do not mean "just" - but other than being a nursing assistant-type role there will be partly nursing assistant, partly social work

assistant, partly occupational therapy assistant. Because when you are working with people in their own homes they need part of any one of those areas. So we are changing the way we provide services. It means there is going to be an increase in the staff numbers, but a change in the staff role. I think that is probably an example where the way we are changing and remodelling services will have an impact on particular roles where you could say the 6 healthcare assistants that are working now within my service will no longer be there but they will be either healthcare assistants somewhere else within Health and Social Services or be part of the primary care support team.

Deputy G.P. Southern : I think I followed that.

Service Director, Services for Older People: It is complex, Deputy .

The Deputy of St. Ouen : Change is always with us.

The Minister for Health and Social Services: Yes.

Service Director, Services for Older People:

It is something we have been developing for a while.

The Deputy of St. Ouen :

Minister, we have come to the end of our time. We had a couple more questions we might have liked to ask but if we may put those in writing to you we would be very grateful. But thank you to you, the Assistant Minister and your team for helping us today. It has been informative.

The Minister for Health and Social Services:

Thank you, and I have one apology, I should apologise for Constable Refault, my other Assistant Minister, who could not be here today.

The Deputy of St. Ouen :

Okay, and we have an apology too from Deputy Jackie Hilton, who is out of the Island.

[14:29]