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Scrutiny Office
STATES OF JERSEY
Health and Social Services
Quarterly Hearing with the HSS Minister
THURSDAY 19th OCTOBER 2017
Attendees:
Deputy Richard John Renouf of St. Ouen
Deputy Jacqueline Ann Hilton of St. Helier
Deputy Terence Alexander McDonald of St. Saviour Deputy Geoffrey Peter Southern of St. Helier
Kellie Boydens – Scrutiny Officer
The Minister for Health and Social Services Assistant Minister
Director of System Redesign and Delivery
Chief Executive Officer
Medical Officer of Health
Managing Director, Community and Social Services Deputy Chief Executive
HR Director
[10:00]
Deputy R.J. Renouf of St. Ouen :
This is a public quarterly hearing with the Health and Social Services Minister and his team. In the usual way we will announce ourselves for the transcript, and I shall ask the Minister to do the same and introduce his team. So, I am Deputy Richard Renouf , Chairman of the Panel.
Deputy J.A. Hilton of St. Helier :
I am Deputy Jackie Hilton, panel member.
Deputy G.P. Southern of St. Helier : Geoff Southern , Vice-Chair.
Deputy T.A. McDonald of St. Saviour : Deputy Terry McDonald, panel member.
The Minister for Health and Social Services:
Senator Andrew Green, Minister for Health and Social Services.
Assistant Minister:
Deputy Peter McLinton, Assistant Minister, Health and Social Services.
Chief Executive Officer:
Julie Garbutt, Chief Executive Officer.
Medical Officer of Health:
Dr. Susan Turnbull, Medical Officer of Health.
Managing Director, Community and Social Services:
Susan Devlin, Managing Director of Community and Social Services.
Deputy Chief Executive:
Jason Turner, Deputy Chief Executive.
Director of System Redesign and Delivery:
Rachel Williams, Director of System Redesign and Delivery.
HR Director:
Tony Riley, HR Director.
The Deputy of St. Ouen :
We are joined by Kellie Boydens as our Scrutiny Officer and I want to give apologies for Senator Sarah Ferguson, but she will be coming in to the meeting as soon as her prior commitment has ended. Now, I will ask this fine Deputy next to me to put the question on HR.
Deputy T.A. McDonald. Terry.
The Deputy of St. Ouen :
Terry. We all have senior moments.
Deputy T.A. McDonald.
Sorry, HR. It gets confusing, does it not? Too early in the day.
The Deputy of St. Ouen : We are doing that first.
Deputy T.A. McDonald.
We are? That is fine. Has a programme to eliminate bullying within the work place been put in place?
The Minister for Health and Social Services
I shall just introduce that then hand over to the man at the coal face, our HR Director, Tony. Clearly, at HSS, we take bullying and harassment really seriously. We not only apply the States of Jersey policies but we also have support mechanisms in place for staff. My officers are heavily involved in improving policies and support mechanisms, learning lessons from the past and other jurisdictions, and we are piloting, on behalf of the States, a new approach designed to improve behaviours and relationships at work. This has been launched only in the last fortnight or so. It is known as "Our Values, Our Actions", and I shall ask to Tony to go over it. Although, as Health Minister, I am Chairman of the States Employment Board, I guess I can talk about S.E.B. It has also commissioned an external, independent, expert review of bullying in the States. Over to you, Tony.
HR Director:
I will say a little more about the points that the Minister referenced there. The SOJ policies associated with bullying and harassment and grievances have gone through a very recent review and overhaul, and I have been heavily involved in that. I was invited to contribute because of my extensive experience in the U.K. Those documents have all been recast. They are with the law officer's department at the moment, just to check for legal compliance, and they will be launched and promoted to the staff in the workplace in the very near future. Support mechanisms that the Minister referenced that we have in place include access to an independent employee helpline. We use on-Island professional mediation and resilience services to come in and work with teams and with staff, and in Health and Social Services we have our own psychology department, obviously, and we had one of the psychologists do some sessions and surgeries with staff to support them. We monitor statistics and data relating to bullying and while the figures in recent years could be considered statistically encouraging we are certainly not complacent; it is regularly a big-ticket item on Julie and the senior team's meetings. In 2016 there were 14 recorded cases of bullying and harassment that were processed and in 2017 so far there have been a further 7. With a work force of over 3,000 that is statistically relatively encouraging. We are not complacent and we do continue to monitor this very carefully. The innovative and new approach that the Minister referenced, "Our Values, Our Actions", is a piece of work that Julie launched just two weeks ago to hundreds of staff at various focus groups and presentations. It is a programme that we developed based on feedback from a large number of focus groups and workshops we have had with our frontline staff. That was followed up with a series of meetings with senior officers from Unite and Prospect and the Royal College of Nursing and the J.N.A. Julie attended some of those; my team and I attended all of them. The most common agreement among that group was that we should look at something that other organisations and jurisdictions call a staff compact. We are not calling it that here because a lot of our staff did not like that brand, but that concept was then taken forward by a staff partnership forum. That is a standing meeting where Julie and all of her senior executives meet regularly with the senior lay officials of all of the trade unions and professional bodies. That group embraced this idea of a compact, commissioned a project team made up of the Royal College of Nursing, Unite and Prospect to go away and research some good examples. They found some good examples and those representatives, assisted by one of my team then worked through them in a series of workshops and case study meetings with shop floor workers from across Health and Social Services throughout the spring and summer of this year. They spent a lot of time on this and they have produced a version for Health and Social Services. I have some copies here to show you. In essence, this document and that piece of work translate the values of the States of Jersey into a statement of values and behaviours for Health and Social Services. The most important and most powerful bit is that it is supported by a detailed behavioural framework. We are about to support this with a handbook, a tool kit and training for all 3,000 staff, with extra intensive training for a cohort of what we are calling champions. At the end of this process we hope and we aim that all staff will be better equipped to challenge and respond to inappropriate and unacceptable behaviour, including bullying, and where necessary they will be supported by a champion in doing that. I will leave you a copy to look at.
The Deputy of St. Ouen : Thank you.
HR Director:
It has been enthusiastically welcomed by the staff partnership forum, by our CEMEX group, which is the senior managers and senior clinicians, and by Julie and the executive team, so we hope that the launch a couple of weeks ago will kick on and really make a difference. My last point is on the S.E.B. review that the Minister mentioned. The S.E.B. has commissioned and procured an organisation called HR Lounge.
Deputy G.P. Southern : Sorry, again?
HR Director:
They are called The HR Lounge. It is a U.K. organisation. They are going to undertake this review. It will be led by a guy called Martin Tiplady. He was the chap who led a very high profile review of bullying in the Metropolitan Police a year or two ago. The whole project is going to be overseen by the S.E.B.'s external adviser. They are going to be working across all States departments over the next few weeks, including Health and Social Services, and they will be interviewing me and my team, senior managers, trade union reps and some shop floor staff and they will report back to S.E.B., I think early in the new year, with some recommendations, no doubt, about how we can continue to improve how we respond to bullying in the workplace.
Deputy T.A. McDonald:
Can I just ask about that cohort of champions? Where were they drawn from?
HR Director:
Volunteers at the moment. Julie did a recruitment call from the stage and we already have about 25 volunteers. Most of the staff partnership forum are volunteering to become members, those trade union officers and representatives. The executive directors have all expressed an interest in being trained as champions and we have commissioned some quite interesting, I think, and innovative training to put in place early next year for the champion cohort. And they will function as coaches, trainers, supporters, interveners if necessary to help the staff deal with difficult and challenging behaviours. So much of what becomes a bullying issue can often be found to have at its root a personality clash, a team friction, so the earlier we get in with trained champions and with mediators the more likely we can keep staff away from the bullying laws and just deal with it at an early stage.
Deputy T.A. McDonald: Early intervention?
HR Director: Yes.
The Deputy of St. Ouen :
That is fine. Did you say you were going to -
HR Director:
Yes. Shall I leave some.
The Deputy of St. Ouen : Yes, please do.
HR Director:
There should be enough copies there.
Deputy T.A. McDonald.
That is lovely. That is fine. I am happy, unless anybody else -
Deputy J.A. Hilton:
Yes. A slightly different subject, but still on HR. The independent Jersey Care Enquiry heard evidence that difficulty had been experienced over many years in recruiting and retaining suitably qualified and experienced staff. One of the recommendations was that a dedicated specialist HR resource be set up. Could you tell us where you are with that recommendation?
HR Director:
Susan maybe can add something to this but my understanding of the position at the moment, which Susan can probably clarify and correct if necessary, is that there is a committee looking at all of the recommendations. Funding is being provided to deal with those recommendations and a business case and a paper for the appointment, securing of this HR person is one of the things on that list.
Managing Director, Community and Social Services:
Yes. I prepared a business case for a senior HR business partner and an HR assistant. That is part of the paper that will come to the States Assembly from the Council of Ministers. We really want to crack on with that. We know that will make a significant difference to how we manage recruitment and will assist managers in that regard.
Deputy J.A. Hilton:
So, when are you expecting to have that person in post?
Managing Director, Community and Social Services:
In my business case, it is before the end of the year so we are looking for a general nod about the finance that has gone in, I think, in principle. I do not want to stamp over any processes but that is very positive. It is a very clear recommendation in the Care Enquiry so I think that we will be able to crack on with that. We have a job description that is very similar to the business partner role, in a sense.
The Minister for Health and Social Services:
I think, to be totally realistic, though, we will have the green light by the end of the year because, with the best of all will, the sort of person you are looking for will probably already be in employment so they will have to give notice. The process has started.
HR Director:
In the mean time, I do have someone on a short, fixed-term contract who is putting as much time as possible into supporting Children's Services and I am rejigging the portfolios of all my team to make sure Susan gets as much support as possible until we get the dedicated person in place.
Deputy J.A. Hilton:
What other barriers do you think there are to employing those social workers that you desperately need to provide the services for children?
HR Director:
Barriers? It is a white hot labour market. Every council, every city, every county in England is chasing the same pool of people so it is a very competitive labour market. We always have our own Island challenges to U.K. recruitment: we are asking people to give up their home, for their spouse or partner to give up their job, for their children to leave schools and friends. It is a big ask. It is one thing to move from Derby to Leicester for a job; you can still stay in touch with your family and friends and everything, but coming to Jersey has its own challenges. Our salaries are competitive on the surface but it is an expensive place to come and live.
Deputy J.A. Hilton:
So, what do you think we in the States of Jersey need to do to attract those quality candidates? What do we need to change?
HR Director:
We need to understand the labour market in the U.K. better, because we have seen the emergence there in recent months of new strategies and tactics that we are not deploying here yet and we would probably need S.E.B. to approve some of these. People are getting into the golden handshake market.
[10:15]
Deputy J.A. Hilton:
Is the States Employment Board aware of what you have just said about understanding the market better?
The Minister for Health and Social Services: Yes.
HR Director:
And the Children's Improvement Board, which the Chief Minister chairs, gets it very regularly as well.
Deputy J.A. Hilton:
Can I ask the Health Minister a question on recruiting new social workers and essential health staff? We know housing is a massive issue. How confident are you that the key worker policy – opening up the market to essential workers – will be in place soon?
The Minister for Health and Social Services:
It has to be in place soon. It has been talked about long enough and it is not just about social workers, it is about nurses and other key workers as well and there is a commitment from this group that has been set up to tackle the issue, because it is also about partnership working. We know that HAWAG (Housing and Work Advisory Group) is creative about helping with that but we do not really want that. We want people to come here knowing that they can get the right accommodation and that their partners can work.
Deputy J.A. Hilton:
As you said, Minister, it is something that we have been talking about as States members for a very long time and at this moment it does not seem to me that we are anywhere nearer having a policy that, for instance, the Children's Service can present to potential candidates. We understand that we are looking for 18 new social workers. I should have thought that it was vital at this stage in recruitment to have a firmed-up policy to offer those new recruits.
The Minister for Health and Social Services:
And I am hoping that we will have that soon. There is a great emphasis behind this, led by the Chief Minister, to sort this out as soon as possible. The key worker accommodation in relation to junior doctors has been sorted but we need to sort out the key worker accommodation for social workers and for nurses, to be honest.
Deputy J.A. Hilton:
Okay. And so the Council of Ministers is also on to the fact that sometimes partners, husbands and wives of key health staff need to be treated differently?
HR Director:
The Population Office is very supportive.
The Minister for Health and Social Services:
Yes, and they always have been, but it should be up front as a right rather than something that is worked out when they get here and that is being worked on now.
Deputy J.A. Hilton:
Yes. So, can you give us any sort of time scale that you would like to see for those policies to be firmly in place?
The Minister for Health and Social Services:
I should like to see it as soon as possible. It is not in my gift but it is something that I am pushing for all the time. To be fair to H.A.W.A.G. (Housing and Work Advisory Group), whenever we have raised a particular issue it has been dealt with fairly quickly but we should not have to raise it. It should be there -
Deputy J.A. Hilton:
As you said, it should be a policy.
The Minister for Health and Social Services: Yes.
The Deputy of St. Ouen :
But is the plan to have those measures in place before the 18 social workers are recruited?
The Minister for Health and Social Services:
I do not know whether they will be in place before the 18 are recruited.
The Deputy of St. Ouen :
So, we are still hamstrung in our recruitment?
The Minister for Health and Social Services: That is not the only issue.
Deputy J.A. Hilton:
It is a big issue, though, is it not? It is a massive issue because –
The Minister for Health and Social Services:
One of the other big issues, I believe - some people tell me that I am wrong - is that now that we have the care enquiry behind us, in that it is published and there is a commitment to do something about it, we have become more attractive. Whereas, before, people did not really know, when looking in – this was a failing service if looking from outside – a lot of work has been done over the last 3 years to improve it a great deal. However, someone looking from outside would just see that there is a big enquiry going on. The enquiry has happened and been published and there has been a huge Government commitment to sorting this out. If you were thinking of coming to Jersey you would see that, yes, the authority is now committed to sorting things out. So, that has to happen.
Deputy J.A. Hilton:
Let us just hope that they do not know how slow we are at sorting things out.
The Minister for Health and Social Services:
I think they probably would if they worked in local authorities in the U.K. While we are still talking about recruitment, it is longer term, but I am really pleased with the work that is going on in terms of our working towards training our own social workers in September/October next year. I hope that the first cohort will be going through with work in the Island and study at university. That has worked really successfully in Probation and Susan has done a lot of work on this.
Deputy J.A. Hilton:
Yes, I agree that it is a huge plus because if we can train our own social workers that will go some way to addressing the issue.
The Minister for Health and Social Services:
It also opens up the recruitment possibilities to people who, for whatever reason, cannot leave the Island but have all the right skills to do the job. They will have to go away for some of the training but not leave the Island permanently for years.
Deputy G.P. Southern :
You mentioned bullying cases before and you pointed out that that is relatively low. That is in the context of how many grievance procedures go through the system.
HR Director:
It is formal complaints lodged under bullying and harassment policy, yes.
Deputy G.P. Southern : Sorry?
HR Director:
Sorry, it is formal complaints that have been dealt with formally using the policy. Those are the cases that are on the database.
Deputy G.P. Southern :
Okay. In terms of making the Island attractive so that we can recruit these extra either nurses or social workers, is it not time that we lifted the cap on salary? Are there any issues around that?
The Minister for Health and Social Services:
You know that it is not as simple as that and you know that the work going on means staff should be treated fairly and with equal value for equal work. We do have to have an eye on the market but it is not as simple as that because staff need to be rewarded appropriately and fairly within all the different disciplines right across the States.
Deputy G.P. Southern :
How far are you to solving that equal treatment issue?
The Minister for Health and Social Services: That is an S.E.B. question. We are working on it.
Deputy G.P. Southern : Well, you mentioned S.E.B.
The Minister for Health and Social Services: We are working on it, yes.
Deputy G.P. Southern : You are working on it?
The Minister for Health and Social Services:
Yes. I am not going to enter into negotiation on pay here.
Deputy G.P. Southern :
I am not authorised to engage with you on pay. I am authorised to point out that that is a fundamental question and that it might give you time to review that.
The Minister for Health and Social Services:
If you listen to the experts – I do believe that pay is important, but it is not the most important factor when people are considering whether or not to apply for a job.
Deputy G.P. Southern :
No, the terms and conditions are.
Deputy T.A. McDonald:
Before we move off the subject, a lot of these are very stressful jobs, high profile and so on and certainly, for the people that I have spoken to, financial remuneration is very important. However, a good example, when we were trying to recruit nurses, was that we were offering less holiday to nurses than they were getting in the U.K. One thing that is important, and it applies to all civil servants, not just medical professionals, is that their time off is vital to them. They need to get away and so on. Is that being looked at as well?
The Minister for Health and Social Services:
It is one of the things that is being looked at in the terms and conditions for all staff members, yes.
Chief Executive Officer:
It is generally true that our levels of annual leave are lower. We can all tell you tales of the many days of annual leave that we lost when we came here. My 24-year-old daughter has a higher annual leave entitlement than I do, which is rather galling.
Deputy T.A. McDonald:
Yes, I can understand. Say no more. I just wanted to bring that up because, talking to people every day, that means so much. It is getting away from the job.
The Deputy of St. Ouen :
That is fine. Thank you. Okay, if we have no more questions for Tony – Tony, thank you for coming to explain those new initiatives which we shall read and question in the future.
HR Director:
Thank you very much.
The Deputy of St. Ouen :
Minister, I shall pass over to Deputy Hilton, who will begin by asking questions about the Fostering and Adoption service.
Deputy J.A. Hilton:
Going back to the care enquiry again, evidence was heard that there was considerable dissatisfaction among the Island's foster carers, who felt that they were not viewed as being part of the team. The enquiry heard from the Chief Executive of the fostering network that in his opinion Jersey was at the very lower end of what he would hear from foster carers in terms of practice. One of the recommendations was a thorough review of fostering in the Island. I wonder if you could talk to us about the review and when it is going to happen.
The Minister for Health and Social Services:
Yes, I will answer your question in a minute but I should not like you to think that for the last couple of years we have done nothing to improve it. One of the little examples that I know of, which Susan has done with her team, has been to make it much easier when a foster parent has a child who needs to go to the doctor. They used to have to get permission. They do not have to do that now; they have an arrangement and the person, as they would with their own child, if they think the child needs to go to the doctor they just take them. That is work that Susan has already put in place. However, there is to be a review. That is not only to look at current foster parents but to consider how we might get more, including people who might be excluded at the moment but who may be suitable. Something that I am keen on, but which needs to be looked at to see whether it will work here, is the use of professional foster carers. From my point of view, that is more, probably, about keeping young people out of remand. If, at the moment, they could be remanded into custody, I would rather see them with a professional foster parent as a way of improving their lives. However, there is a review to be done. I have a personal view, but there is a review to be done and that work is going to start in the new year.
The Deputy of St. Ouen : Who will conduct the review?
The Minister for Health and Social Services:
We have not got that far. It needs to be somebody who understands; it cannot just be someone who is interested in it. It needs to be a professional who has worked in the said field before, to support Susan with a proper report.
Deputy J.A. Hilton:
So, you are expecting that to happen in the new year?
The Minister for Health and Social Services: Yes.
Deputy J.A. Hilton:
And is that going to be a professional from outside of the Island?
The Minister for Health and Social Services: It will have to be.
Managing Director, Community and Social Services:
It is important that it is a subject expert, so we will look for somebody who has possibly worked for something like the British Agency for Adoption and Fostering, so that we have that technical know- how, but also somebody who has looked at the development of services on different models. Fostering has changed immensely over the last 20 years and the Minister has talked about remand fostering and so-called professional fostering. Those are things that we need to get into because they can be direct alternatives to residential care, to custody and, we hope, to children being placed on remand.
Deputy J.A. Hilton:
Going back to Williamson, do you think, in hindsight, that it was a mistake to follow the recommendations to reduce the number of residential beds to 15 in 2008 with the idea that Jersey was, somehow, going to provide all these foster carers to look after the children? I understand that we currently have 21 children being cared for off-Island.
The Minister for Health and Social Services:
Susan can talk, not specifically, about the 21. I would always start by saying that this is where we need to get in much earlier, I would suggest. Some of those children are off-Island because, with the best will in the world, given the damage that has been done to them, they need that specialist care that we could never provide here. There are not many that are off-island receiving services that we could be providing here, but Susan can talk about that in more detail. It was a mistake. I think the philosophy behind Williamson was probably right.
Deputy J.A. Hilton: But the reality -
The Minister for Health and Social Services:
But the whole thing was not followed through in terms of reducing the number of residential beds. Moving away from big residential homes to more family-type is absolutely right, but there was an assumption that we would have fewer people coming through because of other interventions that had taken place and we still have quite a high number of cases where we need to intervene. Susan can give you more details.
Deputy J.A. Hilton:
On Monday, when we attended the safeguarding conference, Susan talked about a specialist therapeutic unit possibly looking at that. We recently had two brothers placed off-Island because there were not foster carers here to look after them. Can you expand a little bit more on that comment that you made on Monday?
Managing Director, Community and Social Services:
Yes, sure. The comment was about the fact that we should consider whether we could, and whether it was appropriate for us to have a small therapeutic specialist residential unit. And that is with the understanding that we are seeing children in Jersey who have very complex needs because of, for instance, sexual abuse or the cumulative impact of long-term neglect. So, we are seeing children with a range of needs, who sometimes come with very challenging behaviours, and we need carers, whether they are foster carers or carers in residential units, who are able to cope with that and be very resilient. It can be very emotionally draining and they can be targeted, if I can use that term. It is important for us to consider whether that is something we could have on-Island; it would be a 2- or 3-bedded unit. We would have to consider whether we could staff such a unit in terms of skills. We would want to have a multi-disciplinary team around those children, so we would want to make sure we had, for instance, CAMHS (Child and Adolescent Mental Health Services) support, plus psychological support and play therapists.
[10:30]
So, when I made that comment, that indicated an intent to look at: Do we need it? Would we definitely use it as much as we think we can ever say that? And could we do it to try and retain children on-Island? I think one of the other comments I made on Monday was that for some children it was absolutely appropriate that they be placed off-Island, because for some of them it is only when they have gone off-Island and had the pressure removed of Jersey and all that Jersey has meant to them in terms of abuse, that they have been able to start to talk more about their experiences and the receipt of therapeutic help has been quite important.
Deputy J.A. Hilton:
I understand that in Children's Services you are currently holding pop-up recruitment events for potential foster carers. You held your first one on the 14th?
Managing Director, Community and Social Services: We are. It was on Saturday at St. Martin 's –
Deputy J.A. Hilton:
Could you tell us how that went?
Managing Director, Community and Social Services:
It was relatively good. I have 12 or 16 enquiries in my head; I think it was 12 – let me just err on the side of caution. We had 12 enquiries so we have set in place a much quicker process to deal with those enquiries and we have set out a new standard for trying to get from the point of enquiry through to presentation at panel. So we are saying initial assessment would take 4 months. I have not heard how we are getting on with that. All sorts of people make enquiries. They sometimes do not go anywhere. People are just interested – but if we have enquiries we can follow them up and we do that very actively.
Deputy J.A. Hilton:
So, from the time a person makes their first enquiry, it takes 4 months to go through an assessment process?
Managing Director, Community and Social Services:
That is a new time scale. That is not what it has taken to date.
Deputy J.A. Hilton:
It has been 6 months to date.
Managing Director, Community and Social Services:
It varies. It is important to say that fostering assessments can be very intense. People are being asked to talk about their relationship, how they will manage a child, their own experience of childhood, what that means for them about managing difficult behaviour, all that kind of thing so, often, there will be people who drop out or who say, "We will just hang on a bit." So, it can be quite a long process. We are now saying that we need to try to make sure that we keep the pace up with that, both to keep people's interest and for our service in terms of placements. However, that process can feel quite intrusive.
Deputy J.A. Hilton:
Are there any barriers that keep coming up and stopping people from potentially being foster carers?
Managing Director, Community and Social Services:
Some people talk about the reward – allowances, fees and so on – and the notion of professional foster carers, who are then getting into more of an employee status with a salary and the terms and conditions that go with that. The care enquiry also talked about accommodation. Those are issues that we will have to grapple with if we want more people to come forward. We would also want carers to reflect our community and the children that we work with, so much more of an ethnic mix. We have employed a part-time publicity officer, who is doing a lot more using different methods to try to get people in. Sometimes people exclude themselves because they are not married or they are L.G.B.T. (Lesbian, Gay, Bisexual and Transgender) and think, "Oh, I cannot foster," and it is about trying to get rid of some of those myths.
The Deputy of St. Ouen :
How are foster carers rewarded in financial terms? Is what is paid to them meant to meet their expenses of having an extra person in the household or is it a real reward for doing a job that is needed?
Managing Director, Community and Social Services:
All over the U.K. people would tell you it is not a sufficient allowance or reward. It is usually based on the age of the child. There is a fee structure depending on how people are assessed as foster carers: do they do more or less complex placements, shorter term, or do they do long-term? There is a level of fee attached to a carer and then there is an allowance paid per child depending on age. If there is particular complexity we would look at enhancing that allowance. Where what is usually described as professional foster caring is concerned, there is a much more salaried approach because the children that such people would be looking after would need somebody at home; somebody who could go in if there were difficulties at school; or, if the child were struggling to go to school, to do the necessary cajoling and encouraging. Having a different job does not sit well with that. So, we have a lot of cases in Jersey, as you will know, where two people are working because of money, etc., so if we are to develop a professional scheme we will have to get to a point where we can pay a reasonable market rate so that somebody can receive a salary and the things that go with that, and be able to give up working at another job.
The Deputy of St. Ouen :
Yes, but is that money not already within the system? It might be being spent on placements in the U.K.
Managing Director, Community and Social Services:
We cannot stop one thing. We sometimes have to run a double system and I guess that goes back to what Deputy Hilton said about reducing the number of residential placements. Of course the hope with that is that we reduce the number of placements and increase the number of alternative family placements. In Jersey we have recruited people but we have also lost people at the same time, so the net numbers have not really increased, against the backdrop of significantly increasing numbers of looked-after children, across the board, the U.K. and Jersey as well. I do not know whether you saw the headline news last week: 90 children are taken into care every day in the U.K. That is a staggering figure.
The Deputy of St. Ouen : Not in Jersey.
Managing Director, Community and Social Services: No, we sit at about 90 looked-after children.
Deputy T.A. McDonald:
Could I just say, before we move on, a personal thank you to everybody involved in that day at the hotel? It was one of the best days that I have attended. Deputy Hilton and I went to look at sub- groups, as you know, and foster carers was certainly one of ours. That gave us a chance to see and hear for ourselves. So, all in all, from me and, I am sure, from Jackie, thank you.
The Minister for Health and Social Services:
I made a point of attending that one as well, but I went to the second workshop.
The Deputy of St. Ouen :
I would echo those remarks. Can I ask Deputy Southern , if you could move on to –
Deputy G.P. Southern :
Yes, can I take us on to broader terms? We are some time down the road from P.82. and I wonder what we have achieved. What services, for example, are now being provided in the community, and how, that used to be provided in hospital? Where are we on progressing?
The Minister for Health and Social Services:
We have achieved a great deal and we are exactly where we would hope to be. Rachel will take us through that.
Deputy G.P. Southern : Marvellous.
The Minister for Health and Social Services: I thought you would say that. Thank you.
Deputy G.P. Southern : I rarely say that.
Director of System Redesign and Delivery:
In terms of the services within phase 1, which was 2013 to 2015, we have implemented all of the ones we had planned to. You will remember that we have a brightly coloured diagram. I can give you the latest version of that.
Deputy G.P. Southern :
There is always a brightly coloured diagram.
Director of System Redesign and Delivery:
And it is a sea of green, as we turn things green when we bring them on-stream. Let me give you some examples. The main purpose of P.82. investment in the first three years was in community services, in order to relieve pressure on the hospital, with services for those people who did not need to be in hospital. However, at that time there was not really the range of community services for them to be cared for at home, which is where they told us they wanted to be cared for. Some examples of that would be rapid response and re-ablement, which is run by F.N.H.C. (Family Nursing and Home Care) and the step-up, step-down beds, which are for people who are not quite well enough to go home with rapid response and re-ablement; they still need to be in a unit, but they are not quite ill enough to be in hospital. That is run at Silver Springs. Other examples might be the work the hospice has been doing with us around the gold standards framework, which is having a real impact on quality of care and the range of services for people with life-limiting conditions and end-of-life care. Hospice also opened up their doors to all life-limiting conditions, where previously it was cancer and motor neurone disease. There are services for people who have respiratory conditions, there are community respiratory services, community oxygen services, rapid access heart failure. These are for individuals who have those physical health conditions, often more than one condition together, who previously might have been looked after in hospital but now can be looked after in their own homes, staying safe and well and independent for even longer. Of course, the long-term care benefit also has a role to play in this because it has given people choice. So where, previously, they might have struggled at home, now we have a range of over 20 providers of home-care services who can go into people's homes that they can pay for out of the long-term care benefit to look after them at home. As you will probably remember from previous scrutiny panels, I employ a quality assurance officer to make sure that they are all up to the correct standard to give Islanders assurance about that. About a month ago, the stats unit published a really interesting report on the prevalence of long-term conditions, looking at what is going to happen in coming years in respect of diabetes, heart disease, lung disease and that really shored up our strong belief, back from 2012, that that was where we needed to put the main investment money in that first period, which is what we did. Other services that we have enhanced or brought on board as part of P.82. in that first period are services for children. For example, sustained home visiting, which is also run by Family Nursing and Home Care, mellow parenting and continuing to support organisations such as Brighter Futures and N.S.P.C.C. (National Society for the Prevention of Cruelty to Children), which do really good work for us.
Deputy G.P. Southern :
Is that because they are likely to be opened up to the market along with general care?
Director of System Redesign and Delivery:
As I have just said, Family Nursing and Home Care provide a sustained home visiting service. Obviously, they are not Health and Social Services, so it is already out there in the market.
Chief Executive Officer:
And it was awarded on the back of a tendering process, so other children's organisations could have put forward proposals to provide it.
Deputy G.P. Southern : But, so far, have not.
Chief Executive Officer:
There was some interest at the time but I think because F.N.H.C. has that universal health visiting option, that is what it offers, it was perhaps simple for it to build on that and produce the enhanced service, which, of course, goes into every home universally and then gets targeted to the people who really would value the extra support.
Deputy G.P. Southern :
Looking longer-term is it envisaged that competition will be encouraged in this area?
Director of System Redesign and Delivery:
Yes. A good example on children's services would be the community short breaks, where we ran a tendering exercise and we had 4 organisations on the framework that is now offering children and parents choice where previously there was no choice. Now, if they need a short break they can choose from 4. We need to refresh that tendering exercise as awareness starts to rise and as people start to realise that they, too, might like to provide some of these short breaks. So, we need to look to do another tender exercise, particularly for short breaks, so that we can offer even more choice.
Chief Executive Officer:
If I understand the question that you are asking, Deputy , when we talk about opening up to the market and encouraging, we are talking about working with our third sector, the voluntary sector, the independent sector that is in the Island. We are not thinking of the grand contracting opportunities for Virgin Care or somebody to come into the Island and take over ranges of services. This is about stimulating our own.
The Deputy of St. Ouen :
But not all of the providers are voluntary or charitable sector, are they? They are commercial operations.
Chief Executive Officer:
Some of them are commercial but they are Island-based commercial operations. What we are not saying is, "Let us put a big call to tender in the European Journal and have these very large multi- national organisations that you see in the U.K." That is not where our policy is going. Our policy is about stimulating and supporting within the Island.
Deputy G.P. Southern :
You have a policy to discourage the arrival of these big -
Chief Executive Officer:
I would not say that we have a policy to discourage, but it is not something that we are seeking to encourage, because we have enough interest in the Island, of very well placed organisations that understand our culture and our system and want to work in an integrated way with us. This is all about the Health Department working with its partners, and we will talk more about that in the second session.
[10:45]
It is about growing those relationships within the Island, not constantly adding more and more new players from everywhere else. That just leads to fragmentation.
Deputy G.P. Southern :
But the evidence elsewhere in the U.K. and probably worldwide is that these large conglomerations are tendering and are delivering, successfully or otherwise, the services that we are talking about.
Chief Executive Officer:
Some do and some do not. There are spectacular stories of success and there are equally spectacular stories of major failures of entry into the health system by external companies. Our view is that it is the best story in Jersey because we have such a vibrant sector of both voluntary organisations and already well located and based commercial organisations within the Island. For us, it is always driven by, "How can we secure the best service for Islanders against the specifications that we work on together and develop? This is what we want for Jersey people. Who is best placed to deliver it?" Sometimes, we would look at a service and say, "It does not make sense to put it into any market because it is very clear that there is only, really, one sensible provider for that type of service." However, where there are people who would say, legitimately, to us, "We could provide a good service for you," then we have to have some opportunity to allow them to put their wares on the table and take a judgment on it.
Director of System Redesign and Delivery:
What is really important is how we work in partnership with these organisations. It would be quite difficult to work in partnership to develop strategy and investment proposals and then the services with organisations that are not physically here. The alcohol pathway is a really good example. We work really closely with Silkworth Lodge and we have seen the development and the benefits of working closely with that client group: for community detox, for alcohol liaison. That has partly been possible because of the type of people that they [Silkworth Lodge] are, and because they want to work in partnership but also a big part of it is that they are physically here so it is easy to go out for a coffee and talk through the plans.
The Deputy of St. Ouen :
I think that we have explored that. Can we now ask what services are planned to be delivered in the community in the next year or 2 or 3?
Director of System Redesign and Delivery:
The focus for the P.82. investment in this phase is predominantly acute services, as we start to change those services, ready for future hospital and further investment in children's services. We are also continuing to invest in and develop a range of mental health services. The mental health strategy was agreed at the end of 2015. We are looking at things such as criminal justice, older adults' mental health services working much, much more closely with G.P.s and with the primary care teams and starting to build up better multi-disciplinary teams wrapping around a G.P. practice, which is where people with the lower-level conditions need to be going. So, the policy thrust of this is that if somebody should not be cared for in hospital, they should not be cared for in hospital. We need to build up the services in the community, in people's own homes and in G.P. practices so that they can be cared for in those areas, and that is exactly what we are doing.
The Deputy of St. Ouen :
So, specifically, which services are planned?
Director of System Redesign and Delivery:
Older adults' mental health is a good example. More care will happen with and in the G.P. practice. Jersey Talking Therapies was a good example: rather than people coming into a mental health facility a lot of them go to their G.P. practice to get their talking therapies. More investment and development is needed for those long-term conditions, which is backed up by the stats unit report. We know that we are going to have more people with those long-term conditions, we know that those individuals in the less acute phase of their conditions should not really be seen by specialists in the hospital. They need their G.P.s, their primary care teams, their practice nurses and community nurses and pharmacists looking after them.
Chief Executive Officer:
A good example of that, because I think you would like an explicit example, would be to talk about the diabetes pilot. That is a hospital-based service and we are testing how that can be brought out into primary care through the pilot that has just launched. The other thing, before Rachel talks about that, concerns how we implement the acute services strategy. We have briefed you about that before, and it has been published. I do not know whether everybody is aware of it. We did a lot of work across all the stakeholders to ask what types of service must be in the hospital, what types of service must be primary community care? Then there is a raft of what you might call services in the middle that could be in either. We are now starting to look at those services in the middle and go through a logical and sensible piece of work involving all the people who are
interested to say, "Where will we put it, then? Going forward, is it part of the future hospital or is it going to be part of primary care and how do we move from one to the other?" Quite legitimately, some can genuinely be either. So, it might make sense that something that is done in primary care in another jurisdiction remains in our hospital because it is good value for money being
placed there. It may be the case that we would bring something out of our hospital because it makes sense to do it in primary care, that, perhaps, in other jurisdictions would stay in the hospital. It is about making sure that it is appropriate for us, and that piece of work has been launched.
The Deputy of St. Ouen :
So, to help us understand how things are changing, can we talk for a few minutes about the diabetes service? In an article in the Evening Post, the consultant was saying that we are not following best practice, we need dieticians and a foot specialist, because I cannot say podiatrist, but those will be hospital appointments. Is that right?
Director of System Redesign and Delivery:
Within the sustainable primary care strategy there are two pilots in particular that are relevant, one for diabetes and the other for C.O.P.D. (Chronic Obstructive Pulmonary Disease), lung disease. The diabetes pilot is being run with Cleveland and Health Plus and this is identifying those people who really do not need to be in hospital; they do not need to be seen by a specialist, they really should be seen by their primary care team, offering them a series of appointments within their G.P. practice, where they have their practice nurse and, for now, a specialist nurse from the diabetes centre up-skilling the practice nurse and helping the G.P., so that individuals do not have to go to the diabetic centre for all their appointments; they can go to their G.P. practices.
Deputy G.P. Southern :
And how is that service being funded?
Director of System Redesign and Delivery:
Partly through the sustainable primary care strategy and partly by the patients. However, because the cost is no different from the cost that they were already paying for their G.P. appointments, they are getting more appointments and the services for the money that they were already paying, but it is being part-funded –
Deputy G.P. Southern :
The money they were already paying?
Director of System Redesign and Delivery: To see their G.P.s.
Deputy G.P. Southern : To see their G.P.s?
Director of System Redesign and Delivery:
Yes. They are getting more appointments and more services, and they are also getting services from diabetic nurses in their G.P. practices.
Deputy G.P. Southern :
So, we are delivering a service in the community that has a cost attached?
Director of System Redesign and Delivery:
Yes, because that is how G.P. services are funded at the moment.
Deputy G.P. Southern :
Yes, but from a hospital service that was not chargeable.
Director of System Redesign and Delivery:
Yes, but a lot of these individuals were already seeing their G.P.s and paying for it.
The Deputy of St. Ouen :
But, equally, were not a lot attending the diabetes clinic for their needs?
Director of System Redesign and Delivery:
So, rather than go to two places, they now go to one. It is much simpler and easier.
Deputy G.P. Southern : And paying for it.
Director of System Redesign and Delivery:
Paying the same amount that they were paying anyway. With C.O.P.D., on the other hand, we are testing a different way of working for lung disease, and that is with the Co-op. So, through the money that we have put into the pilot, they have employed a care manager, whose services are free for patients, so individuals are now getting a care manager who is looking after all of their care and making sure that they are linked into the right services and they are not paying for that. We have to pilot, to test out, how acceptable these services are for patients. If we find that it is not acceptable, then we need to think again, but we have to try it out.
The Minister for Health and Social Services:
I think we need to go back one step to how those two services came into play. That is because we invited partners to come to us with schemes that fitted around P.82., that could be done either working with us or independently providing services for us. Those are the two schemes that came forward that were accepted as worthy of trial and they are going on at the moment and they seem to be working very well, from what I hear.
Director of System Redesign and Delivery:
On the C.O.P.D. scheme, for example, they launched it on a Friday a couple of weeks ago. When they came in to work on the Monday morning, their answering machine was full. They had no capacity on the answerphone because they had been inundated with calls from people interested in enrolling.
The Deputy of St. Ouen :
But is it not the case that the management of a long-term condition such as diabetes, which was previously managed through the hospital service is now being moved to a service where, over a lifetime, the client will need to pay fees to G.Ps?
Chief Executive Officer:
We have to differentiate between the complexity of individual diabetics. If we simply have a service based in a hospital, lots of people who have very well controlled diabetes – and I am one of them; I have type 2 diabetes. It is well controlled. I do not go and see Peter because I have my services from my G.P. and my practice happens to be very good at managing diabetics, and that is one of the issues because across the patch lots of our G.P.s are already providing levels of service and care to people with diabetes or people with C.O.P.D. or people with heart failure. However, a lot of people have been sucked into the system of going up once or twice or even 3 or 4 times a year to have a level of maintenance given to them that could be done in their G.P. practices. Therefore, the pressures arise that Dr. Bates feels in relation to trying to give services to people who have complex, uncontrolled types of diabetes that get squeezed. We need to have the right people going to the right places so that if my diabetes becomes unstable or becomes more complex to manage I would want to know that I could get access very quickly and that I would get access to the range of services that I need because we would not be struggling with people who did not need to be there because they would be getting the right service for them. I think your point is that issues arise from our policies regarding which parts of the services are free at the point of delivery and which parts are paid for at the point of delivery. That is a whole new debate that we could have, and it will need to be had.
Deputy G.P. Southern :
It is not a new debate.
Chief Executive Officer:
But it will need to be debated if we want to move these things forward.
Deputy G.P. Southern :
So, effectively, in certain areas, and we can probably do with a list of those areas, the funding issue has been transferred from the hospital, from the central budget, to individuals paying for that service.
Chief Executive Officer: That is a potential risk.
Deputy G.P. Southern : It is happening.
The Minister for Health and Social Services: No, it is not.
Chief Executive Officer:
But the pilot has got a money value to it.
The Minister for Health and Social Services: They are already going to their G.P.s.
Chief Executive Officer: Yes.
The Minister for Health and Social Services:
They are already going to their G.P.s but they are getting a more rounded service whilst they are there.
Director of System Redesign and Delivery:
It means that they do not have to go to their G.P.s and the diabetes centre.
The Deputy of St. Ouen :
Well, I think we can understand the answers that have been given to us.
The Minister for Health and Social Services:
This is part of the evaluation to see if what we think is going to happen is happening or has happened. That is part of the evaluation.
Deputy G.P. Southern :
Where are you with assessing your pilots? We are now some time down the line but what sort of assessments have been done? Is there anything that we can lay our hands on yet?
Chief Executive Officer:
If you mean the whole range of services that have been developed for P.82. there is a lot of evaluative material. The pilots that we have just been talking about have only just started but there is evaluation built into them so that we will be able to look after a period of time and see exactly where the benefits are and, if there are dis-benefits, where they are and how we might be able to do something differently.
Director of System Redesign and Delivery:
And an important part of that is what do patients think?
The Deputy of St. Ouen :
Just moving on to the healthy lifestyles programme, with some money allocated within the budget, Minister. What is that programme, what will we be seeing?
The Minister for Health and Social Services: Susan, do you want to answer that?
Medical Officer of Health:
This is connected with the repositioning of myself and the small strategic public health unit out of Health and Social Services and into the centre. So, we are now positioned where we have a different reach to work more closely with other aspects of government that affect determinants of health. It is in line with what is happening in most of the western world, recognising that health services alone are just a small aspect of what protects life and prevents early death. It is prevention of disease further upstream that makes a difference, and having a public health team embedded in a social services delivery department is not the best place for it to wield its small and mighty power as it should do. It also gives it more independence to be more separate from health and social services so this is the first scrutiny panel meeting that I have been to where I am not part of health and social services. I am a separate, more independent entity, who still works closely with the Minister. I also work closely with other ministers, such as the Chief Minister and Home Affairs Minister, and on housing policy areas –
The Deputy of St. Ouen :
So, what additional services are you going to be offering as a result of this injection of money?
Medical Officer of Health:
It is moving the healthy lifestyles work stream, the reducing preventable disease work stream, which is part of P.82., into a different place, so that the money that comes with that – we have already had the programmes, some of which Rachel has mentioned. There was the alcohol pathway and the extended reach smoking cessation was among the first set of programmes in the first phase of P.82. We now have the food and nutrition strategy, which you may remember being released this summer. It comes with a range of programmes which need investment to make them happen. They are already happening to a small extent this year, but it is building up on programmes such as the school food scheme, supporting little children in nurseries to have healthier starts. There is a range. I could list them all. I have a paper that lists them, if that would be helpful for you to have.
[11:00]
The Deputy of St. Ouen :
Perhaps you could let us our officers have that.
Medical Officer of Health:
Yes. It is connected with the food and nutrition strategy, the next phase of investment. That is not all. As part of what we do we already work across government with things such as our development strategy. If you look at the report that came out at the end of last week on preventable disease, the biggest single cause of death in the Island is still lung cancer. So we still need to keep up with real energy on reducing the impact of – so the tobacco strategy was published last November but that was very much a cross-governmental strategy. A little bit of it is about health services delivery, smoking cessation, but a lot more of it is about excise and customs and the economy and the wider-reaching tobacco strategy. Alcohol strategy is similar. The health services pick up when everything has gone wrong, people need care for their cirrhosis of the liver and their liver cancer and managing their early end-of-life care. This is about working in concert and food nutrition is another example of the same type of thing. So, really, the money is coming to the C.C.A. instead of Health and Social Services because that is where we are now in strategic public health, so it does not make sense for it to have to be diverted through Jason [Finance Director, HSSD] in order to be sent to me and my team. That is the simple answer. The other answer is getting more upstream about preventing what is estimated, in terms of the cost to our society of preventable disease at the moment, at £114 million, not just health care costs; costs in loss of productivity and need for extra welfare. There are lots of different aspects
The Deputy of St. Ouen : Is it £140 million a year?
Medical Officer of Health: £114 million.
The Deputy of St. Ouen : £114 million a year, is that?
Medical Officer of Health:
A year. That is the cost of preventable disease at the moment. That is why Rachel mentioned the disease projections report. We know that just based on the population structure now and what the population structure will look like in 10 and 20 years' time, there are going to be a lot more older people. It is us baby boomers who are going to be becoming the older –
Deputy G.P. Southern :
You mentioned where the money is going. I understand that it is always good to look at where the money is coming from. So, effectively, instead of competing with the massive leviathan that is health and its budget, as a small cog, a little bit of that, you are now competing with the police service as that dominates home affairs, as used to be, whatever it is called now. So, you have a different fight for the funding to deliver what you have to do.
Medical Officer of Health:
So far it is not feeling like a fight. We feel like a very valued small strategic team and I think that we have become more likelihood of securing the investment bits in the coming year.
Deputy G.P. Southern :
We shall see whether you are saying the same thing after you have had your first round table budget fight.
Deputy Chief Executive:
If I may, perhaps, help you out, in terms of the money that has been agreed in the Medium Term Financial Plan (M.T.F.P.) up to 2019, the money that is allocated to P.82. for healthy lifestyles, for example, cannot be spent on anything else. So Dr. Turnbull cannot lose an argument with the Chief of Police over where the money goes. It has to go to that activity of P.82. There will be lots
of discussions to be had on the M.T.F.P. but as it stands at the moment the money that is earmarked for that work stream is for that work stream and even if Dr. Turnbull wants to spend it on something else, she cannot.
Deputy G.P. Southern : Jolly good.
The Deputy of St. Ouen :
Right. Deputies Southern , McDonald, I propose to finish there unless you have got some burning question that you want to ask.
Deputy G.P. Southern :
Can I ask the burning one that is mentioned by my wife? Is there any transferability in the long term care fund for someone who wants to take their care away from the Island?
The Minister for Health and Social Services:
That is not a question for health. That is a question for social security.
Deputy G.P. Southern :
I will put it in the pending tray.
The Deputy of St. Ouen :
Okay, so, Minister, thank you and thanks to members of your team. We had some other questions but we have not got to all of them, so apologies but we can either put them in writing or reserve them for next time.
The Minister for Health and Social Services: Whatever suits you. We will be as helpful as we can.
The Deputy of St. Ouen :
Yes. I think I would have loved to ask the Assistant Minister if he had any update on the mental health estate. Perhaps he can tell.
The Minister for Health and Social Services: We had that in the States the other day.
The Deputy of St. Ouen :
An update from then, because it looked as though it were so imminent. Thank you for coming and we will see you again in an hour. Thank you, Minister.
[11:05]