Health and Social Security - Quarterly Hearing - Minister for Health and Social Services - Transcript - 15 November 2018

Health and Social Security Scrutiny Panel Quarterly Hearing

Witness: The Minister for Health and Social Services

Thursday, 15th November 2018

Panel:

Deputy M.R. Le Hegarat of St. Helier (Chairman) Deputy K.G. Pamplin of St. Saviour (Vice-Chairman) Deputy C.S. Alves of St. Helier

Deputy T. Pointon of St. John

Witnesses:

Deputy Richard Renouf , Minister for Health and Social Services

Deputy Hugh Raymond, Assistant Minister for Health and Social Services

Rob Sainsbury, Group Managing Director, Health and Community Services Derek Law, Interim Director for Community Services and Adult Services

Darren Skinner, Interim Human Resources Director, Health and Social Services

[14:00]

Deputy M.R. Le Hegarat of St. Helier (Chairman):

Good afternoon, and welcome to the first Health and Social Security Panel meeting with the Minister for Health and Social Services. Before we start, I would like for us to take a moment's reflection on the sad loss today of our colleague and friend, Deputy Richard Rondel, and our thoughts are with his family today. [Silence] Thank you. Thank you all for coming. It might be helpful just for everybody to introduce themselves in order that those that are looking at the livestreaming will be aware of who is here today. I am Deputy Mary Le Hegarat of St. Helier , and I am the chairman of this panel.

Deputy T. Pointon of St. John :

I am Trevor Pointon, and I am a member of the panel.

Deputy K.G. Pamplin of St. Saviour (Vice-Chairman):

I am Deputy Kevin Pamplin and I am vice-chairman of the panel.

Deputy C.S. Alves of St. Helier :

I am Deputy Carina Alves . I am a member of the panel.

The Minister for Health and Social Services:

I am Deputy Richard Renouf , Minister for Health and Social Services. If I could introduce my team, beginning on my right.

Group Managing Director, Health and Community Services:

I am Rob Sainsbury, the Group Managing Director for the Department of Health and Community Services.

Assistant Minister for Health and Social Services:

I am Deputy Hugh Raymond, Assistant Minister for Health and Social Services.

Interim Director for Community Services and Adult Services:

I am Derek Law, the Interim Director of Community and Adult Services.

Interim Human Resources Director, Health and Social Services:

Good afternoon. My name is Darren Skinner, Interim H.R. (Human Resources) Director for Health and Community Services.

Deputy M.R. Le Hegarat :

Thank you. Today we are going to start off by asking the Minister for Health and Social Services some questions in relation to the report that was released yesterday. Obviously, this is something that has just come into the public domain. Therefore we thought it was appropriate to ask a number of questions. I will be asking Deputy Kevin Pamplin to start with those questions.

Deputy K.G. Pamplin:

Last night, this report was released. I stayed up last night to read it and have gone through it. Very curious to hear the Minister's response. I know this morning to certain parts of the media you have declined to go into further detail but we just felt, given today's public hearing, giving you the opportunity, as Minister for Health and Social Services, and because of the public interest, to start by asking you for your view and your comments, especially because you seem to reject the majority of this report's finding. We would just like to start to ask you why you came to that conclusion?

The Minister for Health and Social Services:

Thank you for your question but this has been a group that was set up to advise the Council of Ministers. It has given its report to the Council of Ministers but the Council of Ministers has not yet discussed the contents of the report. I believe that those discussions should proceed - they obviously did not proceed yesterday - before we have any further discussion in a public arena. I do not wish to disclose now because I do not think that is good government, and it is not good procedurally. This is a government project and policy, which, if there are doubts about it, they first need to be discussed and threshed out at Government level. Then the Chief Minister said he will submit a further decision for the States. But I do not think it is helpful for me now to perhaps adding fuel to the fire, when the Council of Ministers has not yet had an opportunity to discuss this.

Deputy K.G. Pamplin:

I appreciate that. I feel though because you were part of the panel you could provide our panel some insight to that because you are the Minister for Health and Social Services. It is interesting in the report because it refers to the Comptroller and Auditor General's findings of both our reports into the governance of healthcare, which we have discussed in the States Assembly. That one of her major issues she had, you could call it that, was the clinical lead was the driving force of this big project, which was one of the big political decision failings of the previous decision. You are therefore now, of course, the Minister for Health and Social Services and therefore the responsibility of the clinical lead of the delivery of the hospital, and you have been on this panel for the last 4 months. While I think we all agree that you are quite right with the approach to the Council of Ministers but given your position in the panel, and reading some of the minutes, you did have a position that is in the public record. I just want to ask more of your ... as a member of the panel, and as the Minister for Health and Social Services with responsibility, where do you see this and your role in it? Was it helpful? Did you feel that you were listened to?

The Minister for Health and Social Services:

You are very tenacious, Deputy . You are right. There is stuff out there that is public and my position is known, so that is not a secret. You will know that. There are 2 members of this panel that can communicate that to you because they were on the board. That also provides ... there is a complexity here, is there not, because you are asking me to respond to Constable Taylor 's report in a Scrutiny hearing. So you are conducting scrutiny of the issue but how can you offer independent scrutiny when 2 of your members, themselves, were on Constable Taylor 's board?

Deputy K.G. Pamplin:

That is why we are trying to focus on you, as the Minister for Health and Social Services, because they were just - like this panel - panel members. They were panel members of that but you are the Minister for Health and Social Services, the driving force of both the health strategy and the hospital deliverable. Were you conflicted of being on this panel? Was there any point of you being on this panel at all if you have seemingly, as you go through the report, do not agree with all their findings?

The Minister for Health and Social Services:

I went on to the panel because it was the Chief Minister who asked me to do so. I will always try and be of assistance, and I want to get a new hospital built for the people of this Island.

Deputy K.G. Pamplin:

But it is very clear, in all the recommendations, you disagreed with all of them. That is what you ...

The Minister for Health and Social Services:

No, not all of them. But it is fair to say perhaps the most significant.

Deputy K.G. Pamplin:

Yes. So why did you reach that conclusion? You have commented and you have responded so it is just trying to find out why you made those decisions?

The Minister for Health and Social Services:

Yes, but I have to say I think it is unfair for me to give my explanation to you today when I have not yet had an opportunity to give it to the Council of Ministers, whose project it is.

Deputy M.R. Le Hegarat :

Can I just make a point as well? In relation to the Scrutiny Panel, we thought it was appropriate that we ask the question because this is live information which came out recently. I think the public would expect us to make some form of comment about it. You are right, this panel has 2 members who were also on that panel but let us make this quite clear, that the panel, which Deputy Kevin Pamplin is the chairman of, which is the Future Hospital Scrutiny Panel, those 2 people are not part of. The reason they are not part of is because they were on this development board panel. Part of the Hospital Scrutiny Panel, it is only myself, Deputy Pamplin and also the Constable of Grouville , John Le Maistre. There is only the 3 of us who will be, if you like, scrutinising it. But we felt that because this has come out into the public domain it was appropriate for us, as a panel, to bring it up. The question I would ask though was: in your view therefore, do you think it would have been more prudent for the Chief Minister to have brought this report to the Council of Ministers for them to comment on before it was released into the public domain?

The Minister for Health and Social Services:

In answer to that last question: yes, there is a strong case for saying that. But I am not criticising the decision that was taken. There are all sorts of things to weigh in the balance because there is clearly great public interest, and I can understand that is why you feel you need to ask me that question, and I fully appreciate why you want to try and push me on this. I hope you can appreciate my position. I will say that should you wish to invite me to the Future Hospital Review Panel at any time, of course I will respond and co-operate.

Deputy K.G. Pamplin:

If we may turn to you, because you provided some evidence in this report that was released yesterday. Just for the panel's sake, and for the people watching, could you outline some of the detail you went into of the concerns of not providing the hospital, as you clearly outlined in the evidence you provided to the panel?

Group Managing Director, Health and Community Services:

Yes, I was asked to provide some evidence in relation to our strategic delivery of the White Paper in the P.82 strategy. I was also asked to submit some evidence on my view in relation to not delivering the Future Hospital. In the first part, around the strategy, I outlined to the board that there had been some significant achievement of core parts of the strategy. There are some bits that were in train, and there were some bits that had not been achieved at the required pace. I did not think that any of those components were irretrievable. Healthcare is a very changing domain and the strategies need to be amended to meet those changes at many, many points. There was not anything there that I felt was of significance that would cause doubt on the actual Future Hospital programme. In relation to the latter point, around the risk of non-delivery of the Future Hospital, it is a view of me as the managing director and the management executive committee of the Department of Health that the case for change is still as relevant now as it was at the beginning of this programme. There are significant risks in not having a new hospital. That is environmental. That is around patient care. That is around multiple issues that are very well-documented within the report that I provided. Rates of infection risk, it relates to a stat- related risk, it relates to end-of-life care because of insufficient capacity with cubicles and multiple many issues that have been very well highlighted in the 6-facet report and within our own risk register as a department.

Deputy K.G. Pamplin:

In your opinion, is there anything in this report, if you have had a chance to read it, that changes your opinion or makes your point even more urgent? Is there anything that you have seen in this report that you feel we need to push on or we need to step back? Is there anything you can pull out of it from your point of view, from what you are picking on here? You mention infection prevention control, the quality of water, all these issues. Is there anything that you have read in the report?

Group Managing Director, Health and Community Services:

Not in relation to those points. I think that the case for change is accepted as a fact and I think that the report highlights that there is a definitive need for a new hospital. I support that stance. The one component that I of course would take note of, and would want to address, is around better and broader staff engagement, which we are very much working on, and which we have had some success with. That is a key point for me.

Deputy K.G. Pamplin:

The delay of delivering a hospital and a health strategy. What is the urgency of this? For those who are listening and watching today, the public appetite, this has been going on, I appreciate, before your time, but this has been going on for a long time. What are the risks if another terrible political decision is made, and we go back to square one? What is the urgency? This is clear that this should be led by the clinical demand for a health strategy in a hospital so how do you see this playing out?

Group Managing Director, Health and Community Services:

I have been really clear that the demographic pressures within this Island context for health and care are consistent with patterns across the world and that we are going to see increasing pressures within our acute system in the hospital and within the community system.

[14:15]

We are already seeing that. We see much more prevalence of older persons, in particular, who are needing more care and are needing to have hospital intervention at the right point in time, as well as community support. In my view, the consequence of not having any new hospital for the future will mean that we will not have the sufficient estate to meet that demand. We will not have the right level of capacity that will impact significantly on the ability to have planned care, whether it is in operation because we will be using a lot of that capacity for emergency capacity. It will place greater pressure on our clinicians and our workforce, who are already dealing with demographic demand. It will also lead to detrimental patient care and experience. There are too many complaint letters and too many patient stories that I hear where we have not been able to afford the kind of care that should be required when you are needing to have a quiet room, if you are approaching the end of life, for you and your loved ones, and where you need to be properly isolated from infection risk. We simply do not have a layout of a hospital that is able to meet the modern demands of health and care.

Deputy K.G. Pamplin:

What you are saying is we cannot afford a delay?

Group Managing Director, Health and Community Services:

We cannot afford a delay, in my view, and in our executive committee view and in the clinical consensus view, I am confident to say.

Deputy K.G. Pamplin:

So a time period of 6 months, would you say that is too long?

Group Managing Director, Health and Community Services:

What I would say is that we need to deliver a hospital within the timeframe that was set within the original proposal for this outline business case and for the Future Hospital. Any further delay increases the risk.

Deputy K.G. Pamplin:

That leads me to you again, Minister for Health and Social Services, and this is the final time, because hearing what has just been said there, that is clearly arguably your position from this report as well. That you will be sitting around the Council of Ministers arguing the clinical lead that we cannot afford to delay. Is that your position?

The Minister for Health and Social Services:

I can say that is my position. I have said that previously.

Deputy K.G. Pamplin:

Do you feel you are going to be successful in that, when seemingly a large majority are pushing for the other? Do you feel that you have a battle on your hands?

The Minister for Health and Social Services:

There is a battle. I feel we just have to put the evidence for the new hospital, the need for the new hospital, and the sufficiency of the current site out there.

Deputy K.G. Pamplin:

Has that report done that? Has this new report, in your opinion, done that?

The Minister for Health and Social Services: No, it has not.

Deputy K.G. Pamplin:

Therefore your position ... you were chosen by the Assembly, you were voted by the Assembly, you were not the Chief Minister's choice for Minister for Health and Social Services, which is accurate, so therefore do you feel that you have consensus, do you have the support needed to see through your position as Minister for Health and Social Services?

The Minister for Health and Social Services:

I am not thinking about my position as Minister for Health and Social Services. I am thinking about what I know to be a vital need for the Island and how we can best deliver that.

Deputy K.G. Pamplin:

But you could argue that, as you have just said, there is a battle on. What happens if you do not win that battle on behalf ... and we have a delay, as the director has just been talking about?

The Minister for Health and Social Services:

That is very likely we will have the consequences that the managing director has spoken about.

Deputy K.G. Pamplin: Thank you.

The Deputy of St. John :

In relation P.82, if you look at the Draft Budget Statement for this year, point of order of course, but it is linked. I wanted to go on with this though to the Draft Budget Statement, which we are debating in the near future. In that statement it suggests that the P.82 programme is behind schedule and underspent against the available budget. The programme is under review, I gather, with no new money to be allocated. It is not clear if any new measures will be implemented to support P.82 to get it back on track, if it resumes.

The Minister for Health and Social Services: Would you like me to comment?

The Deputy of St. John :

No, that is the foundation for my subsequent questions. In the Draft Budget Statement, which I have read to you, why are the reforms behind schedule and still under review?

The Minister for Health and Social Services:

It is true to say that we are not in a place where we would have hoped to be. That is a fact. I do not think anyone is disputing that, but the health service now, in 2018, is very different from what it was when P.82 was debated in 2012. There are services being delivered in the community, very successfully. Care is being given to Islanders in the right place, in their homes, or in community settings or at G.P. (general practitioner) level. Why? A variety of reasons, and perhaps officers can also contribute, but we must realise that it is not just government that provides healthcare in this Island. There are other sources. There are obviously the G.P.s as independent businesses. We need to work and engage with the primary care sector to co-ordinate our efforts, to deliver all our P.82 ambitions. Then there are the charitable sectors, such as Family Nursing and Jersey Hospice we work well with also.

The Deputy of St. John :

If I may stop you there, Minister. I am specifically relating to the budgetary constraint that is suggested will be part of our financial picture going forward. What action is being taken to try and free up funds for something that is an essential to the Island?

The Minister for Health and Social Services:

Yes, I will pass in just a minute to Mr. Sainsbury, but I have just said this is the budget for the single year coming up, and then of course there are detailed plans being considered for the government plan, the 4-year project. There is this issue about last year but I will pass over to Mr. Sainsbury.

Group Managing Director, Health and Community Services:

The approach that we had over the summer is we have undertaken a strategy refresh for P.82. So we have looked at the points that have been delivered, we have looked at the points that are in train. We have looked at what we believe are the future priorities, and we have tried to focus that very much into high impact changes that are really needed. An example of that would be intermediate care, where you can see that there had been previous funding through P.82 to develop community- based care closer to home. What we now understand is that we need to bring that up to a broader scale where it is able to have more capacity and is able to deliver higher volumes of care for people in the right setting, and then have the right level of interface within the hospital and within the broader voluntary and community sector. For next year, in terms of budgetary position, I must highlight that we are not in a definitive position whereby we have been told we will not be able to use P.82 funding and that we would not have funding for our innovations and changes needed. We are working through what those will be now. The 2 bigger schemes relate to the acute services strategy, which has always been an intention of the P.82 strategy, and the team have worked very hard to pull together what they call the acute floor model, which is very much needed to connect the hospital services to community and the patients requiring admission. Then the other component will also relate to mental health and crisis prevention and crisis intervention, which we know is going to be a big priority. We are confident that through our budgetary position going forward in 2019 there will be a potential ask for increased investment but there will also be an expectation that we seek opportunity where possible by making best value and best use of resources we have. Some of that

will require refocus of resources. I do not think it is as easy as saying we require all new investment. Our delivery of the strategy going forward needs to be in the context of how we manage our budget generally and where we do and do not need money. I do not know if you want to add to that, Derek.

Interim Director for Community Services and Adult Services:

Yes, and in terms of the focus on the community aspect, for example. There was money set aside in P.82 for what I call preventative initiatives and we are re-engaging very thoroughly in that regard, working with the Parishes and the voluntary sector in the wider community and charitable sectors. That will bring forward, as the managing director said, proposals that will probably refocus some of our attention on that very important agenda around well-being and prevention.

The Deputy of St. John :

You are assuring us that developments of P.82 are going forward but there has recently been a problem with the Regulation of Care legislation that is coming forward. Not with the legislation itself but with one of the organisations or companies that provides care in the Island, albeit a company that is registered in the U.K. (United Kingdom) and provides care 24 hours in people's homes have hitherto been able to operate here but with the new care regulations will not be able to operate unless certain conditions are met. I gather that they support a significant number of families. Is this a concern for you?

The Minister for Health and Social Services:

Would you like to say something because I have asked my Assistant Minister to take responsibility for this?

Assistant Minister for Health and Social Services:

As you know, Deputy , we had a few issues with the company in particular, and I think at the present time we are talking about 19 families. There were 21 and I think we are now down to 19. What we have said to them, and our team have spoken to them at length, saying that with the Regulation of Care Law coming in on 1st January that if they put these requests into position then they can continue working here. The issue was based on the fact that they were a U.K. company based in the U.K., they had no office here and there was nobody to relate to. The other thing is, which I find from my own previous background, nothing to do with health, they were all self-employed. So we were concerned about the problems of checking their ability. I gather from the discussions that I had, that we were going back to 2015/2016, when they were last checked and everything else. It was us doing almost a safeguarding situation with regards to this company by saying: "Look, all we are asking for is some sort of procedure and everything that comes through with the Regulation of Care Law and we will be quite happy to see you here in 2019." That is where we are at the present time. They have had discussions with our team. The have been told where they stand and that we

would look to seeing them on 1st January. But they must adhere to the regulations as set down. The most important one being is that the people that they ask to come over here have been checked and we have the ability to make sure that they are okay, and also it would be beneficial if they had an office or an individual here that was looking after those people that were working here for them.

The Deputy of St. John :

So the soonest you will get to know what the results of these negotiations are will be after 1st January, presumably?

Assistant Minister for Health and Social Services:

No, we are in the process now. I have just been given a piece this morning, is that we are just waiting to hear back from them. They have had a discussion. They are talking with our staff and I would like to think that we would probably come back to hopefully say that they will be here on 1st January. I think the worrying bit was that the letter that was sent to the individual families, and I know that you, Sir, had had a couple of requests about them, and from my perspective I did as well. I think we just have to keep the pedal on the accelerator and that we make sure that these people do come back. But I will hasten to add there were a few problems with certain individuals that had come over and that was what created the problem for us to discuss the present situation.

The Minister for Health and Social Services:

The caveat of course is that the States have still to pass the regulations and the States, a sovereign in this, if there should be any wish of the Assembly to change what is proposed then that is what will happen.

Deputy M.R. Le Hegarat :

Thank you very much for the contribution so far. Moving away from P.82 and the Future Hospital. Minister, would you like to provide us ... what are your personal priorities for the next 4 years?

The Minister for Health and Social Services:

Although I served in your position, and had learned such a lot about our health services and social services, really when I move across the table, I realise just the breadth and depth of services that we try to offer. As I said before, we are not the only organisation because there are the primary care and all sorts of charitable sector.

[14:30]

It really is a very vibrant sector but we are trying to do so much for people who have sometimes very serious needs. I am very conscious of that. It leads me on to think that so many of the problems that we see coming into the service could have been addressed at earlier stages. Health promotion and preventative measures must really take such a high priority now so that from a young age we try to educate children in keeping themselves well and active, and that at older ages we encourage our elderly population and people like myself to keep active, to try and keep well, to avoid those sorts of challenges and complications that impact on our health later on. So promoting good health, the Active Jersey programme I would want to give good support to and make sure we develop that as an Island, and ensure that we do our best with preventative medicine or screening matters. Just making sure that we keep people who we know have long-term conditions, that we try and manage those when they are perhaps at a low level. So we pick up those people and not allow the conditions to escalate to a serious situation, that we start managing people at a lower level and helping them to self-care and preventing that impact on the health service for their sake but also for the Island's sake. Otherwise the health service will just become overwhelmed with demand and will require so many more resources in terms of financial input and staff, both of which are problematic. Another priority must be mental health and I am astonished at some of the things I am hearing about the issues some people have about their mental health and how this has grown so much, which in part is a good thing, that people are not just putting up with difficulties but they are being more and more ready to talk about their mental health and they are seeking out help. So we have to praise and be thankful for that. But it has meant a huge call on the health service and, clearly, it has been letting people down as much as the people providing the service are dedicated and passionate. They have often been overwhelmed with the demand and we have to try to put that right. I know, and I thank you for conducting a Scrutiny review into mental health provision. I am sure that is going to help and inform our services going forward. I am no longer based in Peter Crill House, but when I was I occupied an office, which directly overlooked the entrance to the Gwyneth Huelin Wing. I used to just see such activity, just people pouring in and out and cars driving up and not being able to manoeuvre, it just highlighted to me how we have a hospital that drags people in. I do not feel we need to do all of that. I feel we need to take healthcare out to where people are and be able to provide so much more for people in their own homes or in community settings, Parish Hall s perhaps, or community centres, or specified centres in different parts of the Island, or in G.P. surgeries because I believe that the G.P.s across primary care, we could be doing so much. Really that is what people want. People do not want to have to come into a hospital clinic, which they might have to wait weeks or months for, and it is difficult to get there and you wait a long time and you spend 10 minutes with your consultant. That has been the model of care which seems to have been delivered around ... it is no criticism of the people working in the hospital but it suited the hospital and the staff within it, bringing people in when they have needs. But we should be thinking differently that we take our services out to people, where appropriate of course, and I think that is a view that is shared not only among management but among many of the clinical staff and they would want to move towards that sort of working. I am really looking forward to plans that would see that working out.

Deputy M.R. Le Hegarat :

You made comment on the mental health. What is your view of the facility at Orchard House?

The Minister for Health and Social Services:

It is very, very poor. I am astonished that we could have ever let such a situation arise that we take people in there who are in a serious condition. That is no criticism of the staff. It is a criticism of past politicians and Executive perhaps. I do not know how far they flagged this up but the situation has to be addressed. It is highly regrettable that we are having to address it by having to spend money on Orchard House now when we know people should not be in it. But that is the fact. We have got to spend money to bring it up to a minimal standard and then we have got to spend more money on where we want to move to - we hope in about 18 months or so - which is across the road. Even that might not be the longer-term answer because there is the thinking that we might need another site for mental health. You asked me my opinion, I think everyone shares that. I thank you for going to see the premises too, and I know you have been moving around lots of health premises, so thank you for the interest you are taking and your willingness to understand.

Deputy M.R. Le Hegarat :

We can only make proper judgment if we look at it properly. What priorities do you think will require legislative changes to achieve, if any?

The Minister for Health and Social Services:

That is interesting. I am just trying to think if we are thinking of any new legislation. At the moment I see most of the changes being to our structures and our strategies. Can anyone at the table think about legislation where we think might be needed?

Group Managing Director, Health and Community Services:

Not at this moment. We might need to depending on the Brexit outcome in relation to medicine over a longer term, but at the moment we do not believe we need to do any legislative change in that department.

Deputy M.R. Le Hegarat :

How will you measure and monitor any progress that you make in relation to achieving of your priorities? How will you know when you get there?

The Minister for Health and Social Services:

That is an excellent question. Because perhaps we have not been good enough at measuring in the past. We have been good at producing plans but not measuring what we do. I hope that I will be able to improve on that. I will answer at a very high level and then perhaps if I may pass it on to officers. But at a high level you will know that in our response to the C. and A.G. (Comptroller and Auditor General) report we proposed the board, which will consist of the management executive, the Minister and Assistant Ministers. I want that to be a board that will hold this service to account and ensure that measurements are being taken and that we get regular reports of how we are performing. There will be a clear accountability so that we know that if we are not performing well who or what section takes responsibility and what needs to be done. That will be a responsibility of that board, of everyone who serves on it. I want to improve that transparency and accountability. At the moment what I see is good work being undertaken in refreshing a lot of the strategies that we have and bringing forward improvement plans, which are being worked on. We are not yet quite in a position where we can announce those, with all their metrics and deliverables it seems to me, but they are being worked on. I cannot say that I have seen them to a great extent as yet, but if at this stage I can pass over to Mr. Sainsbury.

Group Managing Director, Health and Community Services:

We recognise that there needs to be greater transparency in relation to describing what we do. One of the first ministerial directives that we had was around republishing our waiting times by the Minister. Being able to demonstrate that we provide good access for services is a key component to measure whether or not we are meeting the needs and demands of our citizens on the Island. I have to say, in many respects, we do very well and we provide very quick pathways for diagnostics, for cancer services. We have some exceptionally talented staff and a very, very dedicated work force. I think what I would really like to see is how you demonstrate and how we can describe everything that they do and the outcomes that they deliver. I think that will also require much greater emphasis on patient experience, and we are committed to ensure that patient voice is a core part of our decision making and that we are being scrutinised by patients as well in terms of the services that we deliver. They are providing us, they are informing us, and they are helping us to understand whether or not our services are delivering what they should be. So we are keen to ensure that better patient experience metrics are incorporated. If we look at what we are doing within nursing, we have introduced some very exceptionally high standards of quality audit across our clinical and community environment that are quite exceptional. We really need to start describing these in much more prominent reporting. I think we have a journey to go on in terms of how we demonstrate what we are good at but also highlight what we need to improve with. We know that we have got some areas of improvement required.

Deputy M.R. Le Hegarat :

Just following on from that, the questions I am going to ask are looking at the changes to the Health and Community Services. What progress has been made in reorganising the Department of Health and Social Services as part of the wider One Government changes?

The Minister for Health and Social Services:

As part of the wider, perhaps, Rob, could you talk about what is proposed for the next few months?

Group Managing Director, Health and Community Services:

And Derek can shore that as well. We have been working along with all of the newly formed departments to develop our target operating model. That is based on the priorities that we have set out. So for us there is a clear requirement to connect our services better and to ensure that they are joined up for our citizens and they are not having to tell their story multiple times to multiple professionals. So with that mindset, we are looking at our care groupings and how we can start to integrate our services in a more prominent way. We know that primary care and community facing services require greater connectivity to the hospital, and we are going to look at a key care group that starts to push that forward. We know that there is probably something within the hospital that we need to do to make it a bit simpler. There are lots of departments, lots of directorates, lots of business units, it is quite complex for a small hospital. We want clinical leadership and professional leadership to operate in a much simpler environment where your ward sisters are people who are making the decisions and your consultants are leading their agenda in the way that they should. So we are looking to change the hospital way of working.

[14:45]

We have a standard that we want to set that there is no health without mental health and that we have parity of esteem between physical and mental health. So across all of the care groupings there will be mental health throughout. We serve all ages from cradle to grave and beyond. We want to ensure the quality and safety and safeguarding is a key component throughout the structure, and we know that from a social care perspective and a community perspective, there is much more we need to do about connecting our services to our Parish-based system, to our voluntary sector, and we need much more focus on collaborative arrangements with those partners. There are a lot of them and they provide an awful lot for this Island. We need to start really utilising the contribution that they can give in a much more prominent way. We are getting good relationships formed with those partners. Derek, I am not sure if you wanted to add anything?

Interim Director for Community Services and Adult Services:

I think that captured it very well but there is also the opportunity in the community of bringing community-facing staff of all professions together working in teams so that they can represent each other in walking down the garden path, because that is very much achieved elsewhere; so that is a real ambition. There are also interdepartmental opportunities, so at the moment we are talking about the long-term care staff in Social Security coming to work and co-locate themselves with our

assessment staff, because we are effectively working with the same people in the community. Sometimes they do have discussions that are at odds with each other; we think there is a real opportunity in bringing them together to be aware of each other's roles and responsibilities and sharing information about the same people. That should be a better outcome for people out in the community frankly.

The Deputy of St. John :

Have you any examples of real progress toward achieving your goals in this sense? How far have we extended that contact with the Parishes, for example, and the examples of what work has been done?

The Minister for Health and Social Services:

It does not relate to the Parishes but perhaps I can give one example. Deputy Raymond and I went to the child development centre at William Knott some weeks ago and we were both very impressed with how they have transformed their services. So previously children with difficulties would attend to see a speech therapist and then they would go away again, and then they would attend another time to see a physiotherapist or something like that. But they have transformed the way they work and they have had a refurbishment of their premises - they are really attractive - but it is the transformation into their teams that is impressive, that they have now centred care around each child. So they take the child and they assess that child's needs and they allocate a speech therapist, physiotherapist, child development officer, whatever is needed ...

The Deputy of St. John :

It is good to hear of good practice and we are very much aware that we are working within a frame in which children come first, so it is very good to hear that those developments are evident in that particular frame. We do know that other developments within the Children's Services are going forward. The area that we are really concerned with in relation to development of services, or keeping them out of hospital, is care of the elderly. Where are we in relation to developments for care of the elderly?

Group Managing Director, Health and Community Services:

If I pick up on the hospital part and Derek can pick up on the community part. We have looked hard at the patient groups that are coming into hospital and the older person demographic is becoming very, very prominent. Then when they were in hospital, we found that they were staying for very extended long periods of time. Prior to the summer we started an initiative with our community provider, with Family Nursing and Home Care and our wider community partners and our acute hospital team, to come together to start to look at how we can start to change the pathway and to stop patients staying in hospital for such a long period of time. We have made huge progress in that area  and  our  number of  patients that  we  would  call  delayed  transfers  of  care  has  reduced significantly. The number of patients staying for more than 7 days has reduced significantly, and that is helping to release some of our capacity pressures. So it is a good example of whereby our hospital teams have a better interface with the community staff, in particular with the rapid response team, to be able to get patients home quicker but also to try and stop them coming in as well, which is the work that you have probably been more focused on really, Derek.

Interim Director for Community Services and Adult Services:

Yes, it is. You heard the Minister earlier on talking about well-being and closer to home services. We have got a small team that have been working with all 12 Parishes, so they started off by meeting the Comité des Connétable s and so we worked initially with them as a group and it is fair to say there were some historical challenges that were arising at that time. But then when we committed ourselves to go out and meet each of the Parishes with each of the local politicians there, that was met with quite a lot of enthusiasm. So working together with the Parishes, together with the voluntary sector, together with the charitable organisations within that community, there was a real sense of growth and enthusiasm about: "This is the right thing to do. We should be developing services, sometimes in our own Parish Hall s or close to." St. Brelade is a real example because they are really picking up and running with it and we are looking to develop services that will work out of Communicare, which is very local within that area. I think that once we get examples of good practice and real good outcomes starting to shape and show themselves it will catch on.

The Deputy of St. John :

Where are the funds coming from to encourage the development of such services?

Interim Director for Community Services and Adult Services:

First of all they are there, and I think it is a question of co-ordinating them and working out how we all collate our efforts and probably rearrange the way that we undertake things. So we will put a bit of staffing in there to support and help because it is invest to save, because if you can prevent people from getting into the system that is going to cost an awful lot more later down the line then you are saving money in that respect. You heard us earlier on about reconfiguring some of the P.82 money. Now there might again be ways in which we can reconfigure P.82 to offer some support to those that really, really do take off and where they need a bit of investment to make it work really effectively.

The Minister for Health and Social Services:

Can I say that I also feel strongly that it is not just government's role to offer well-being and support to vulnerable members of the community; we all, as members of the community, have a role to support each other.

The Deputy of St. John :

I appreciate the sentiment but we have not got those people in front of us to question them.

The Minister for Health and Social Services:

Well you might have because I feel very privileged to have been ...

Deputy M.R. Le Hegarat :

They are all part of the community.

The Minister for Health and Social Services:

Yes, we are. One of my greatest joys as Deputy that has really grounded me is being involved in the community support team in my Parish and to see the capabilities of that. Part of our job has been to be giving lifts to people to go into the hospital clinics, in and out, in and out; I would love to change that. But the best part of that job is going to sit with somebody for an hour who lives alone, or offering respite to the person who is acting as a carer or a spouse who might be acting as a carer. So we have been doing that but also I know lots of people do that throughout the community, not necessarily to their own family but just to people that they know or have met. So people are supporting each other but as communities we can be a bit more organised and make sure that people do not slip through the net. But let us not put everything on to the heads of government, let us try and ensure that we ourselves are challenged to provide the sort of care that we would love to have or we would love to have for our parents when we are vulnerable. It can be done; it does not need extensive hospital services or management organisation, it seems to me.

Deputy C.S. Alves :

So, kind of going back to what we were discussing before, are you satisfied with the pace of the organisational change within the department then? What is happening at the moment sounds very good; do you think it is gaining momentum or things have not been as quick as you would like them? Are you satisfied with the pace currently?

The Minister for Health and Social Services: Is that a question for me?

Deputy C.S. Alves :

I think it is to all of you because you have all kind of contributed.

The Minister for Health and Social Services:

I am very satisfied with what I am seeing coming forward from management. I am absolutely confident we have got an excellent team who are building services and, in answer to your question, yes.

Group Managing Director, Health and Community Services:

I think we are doing really well. I think the next steps for us really are implementing our target operating model and the structure and the teams to be able to deliver it. For me that requires a bit of a shift because it requires a lot of professional and clinical leadership being in place, and we are looking to our clinicians and our care professionals, our nurses, our therapists, our pharmacists, to really step forward to start to drive that change, supported by good management and business support. But they have really got to be the people who are delivering the change within this Island, and we believe that is where greater focus and pace will be needed, is our assessment.

Deputy C.S. Alves :

Following on from what you are saying then, what impact have the changes had on the department's ability to carry out its core responsibilities and role? So like you are saying there, it needs to be handed over to the staff, but what do they need to be able to do their day to day as well efficiently? So what kind of impact do you think the changes are having?

Group Managing Director, Health and Community Services:

We have not fully implemented all of the change needed really. I think in implementing any change it needs to be well-managed and we need to do it in a way that staff feel they are contributing to the change needed and that they are driving it. So we are listening to them now and getting input from the professional clinical fraternity and taking their feedback about what they think needs to be done. We have got to make sure that the change does not disrupt the business as usual, and that is difficult because we have got some staffing difficulties in key areas and releasing people is often not easy. But I think we are doing quite well at the moment in terms of having a case for change and a narrative that I think our staff will look at and think: "We support that; that is the right thing to do." We have listened to them and we are continuing to listen to them about the changes that are needed.

Deputy C.S. Alves :

So do you think it is more ... sorry, did you want to ...

Interim Director for Community Services and Adult Services:

I was going to add to that. As you have mentioned, I will probably be gone before I learn the language, but there as an outsider coming in, I think the way in which the department have engaged with staff, the outcome of that I think will be a lot of staff will be very, very engaged once they recognise what it is that they have contributed to. So we have workshops where we have been developing the model of care together with them; obviously influencing it by talking about the Minister's priorities, but it has been something that the great majority of staff have embraced and really welcomed. I think it has lifted their enthusiasm, so that sort of motivation helps them with business as usual because it is a challenge. There is no getting away from that; it is a constant challenge making sure that people are able to do their job that they are there to do, at the same time as contributing to change. But if you can enthuse them in the way that I think the department has in a number of ways, then you have got a lot better chance of getting there and getting a good outcome.

Group Managing Director, Health and Community Services:

We do need to be realistic about our challenges, so we had some very pressurised areas in key specialties with workforce difficulties; you are very well aware of the pay position, and so there are issues that make change difficult at times. But I agree with Derek; I think we have had true input from our workforce in the changes that we need, we have just got some wicked issues at the same time that we are trying to deal with.

The Deputy of St. John :

It really is the elephant in the room, is it not, at this moment in time. Do you think things are going to get worse in terms of the relationship if Mr. Parker imposes a settlement, as he is saying he will?

[15:00]

The Minister for Health and Social Services:

I am not really sighted on all the ins and outs of the pay negotiations to express a view of whether that might be worse or not. It is a very regrettable situation. The States Employment Board are making a statement on Tuesday so we will look forward and I really hope that might be something that can move the whole problem forward and out of the mire we are in at the moment and the beginnings of a settlement.

The Deputy of St. John :

But if there were an imposition do you think it would be detrimental to the relationship that we have and move things back rather than forward?

The Minister for Health and Social Services:

I suppose an imposition is a last resort and it means a failure of talks, does it not? But, as I said, I am not really sighted ... not being a member of the States Employment Board I cannot really comment on the implications of your question, really, and it might be seen ...

I ask the question because these staff - and I use the term very loosely - belong to you in the sense that they are employed by Health and by the States to work in Health.

The Minister for Health and Social Services:

Yes, and we would obviously want to reach agreement with them and have a workforce that at least satisfied with what they feel they have contributed to. An imposition is something they have not contributed to.

Deputy K.G. Pamplin:

I want to come back on to a couple of points that you have picked up. The aspiration of what we are talking about, care in the community, working with the volunteer sector; it is music to somebody's ears like myself who has worked in the voluntary sector at Headway Jersey and the Brain Tumour Charity. But these things have been going on for many years. They have been saying this, they have been delivering it; in fact Headway created the Brain Injury Referral Department in Overdale; so it is good to hear those things. But the key to a lot of people's healthcare pathway is the G.P. and for a lot of people ... when I care for my grandmother, for example, she wants to go through her G.P. Now, a lot of people get sick in the evenings, it is fair to say the elderly get weaker in the day, people with children - like myself who has got young children - you have a choice to make, you have to pay money to make that first clinical step. The evidence is growing that the blockage to some of these aspirations is this issue of our healthcare strategy in Jersey where we have public healthcare, charitable healthcare run by volunteering and fundraising which is limited and stretched, but then we have paid G.P.s. But if people are stopping getting an early diagnosis because they do not want to pay a fee, they then present later in life at a hospital, late at night, when you cannot reach 24- hour healthcare for the elderly, you cannot reach a mental health service because it is not there. So where do they go: the hospital. So if we are going to achieve this aspiration, and I am really keen to hear about this, how do you feel that we achieve P.82? Is it deliverable if we still have this model of healthcare that you have to pay for your step of medical help?

The Minister for Health and Social Services:

I will happily take that. Personally I do not feel that we could deliver P.82 satisfactorily if we just retain business as usual, the same model we have. We have to find innovative ways of delivering healthcare at a G.P. level, and at the moment it is right. G.P.s collect a fee when somebody comes to see them and they come to see them only when the problem has got serious enough. G.P.s should, I believe, be managing their patients. So the hospital has developed a diabetes service over years because it was recognised perhaps - I do not know really the history of it - but it was recognised that there is a set of patients there who need some constant monitoring and perhaps it might have cost them too much to be always going to their doctor so we put that in place. But why? It is just

because of the model we have with the G.P.s that we had to do that. If we could change the model, that G.P.s were able to monitor their diabetic patients, do all that is needed and, as you say, patients prefer going to their G.P. It is a relationship and we can deliver good care in that context. I hope we can really start moving towards that. I know there have been discussions, I have been present at some of them, but there have been discussions particularly with the director general and G.P.s - and I am sure these gentlemen have been present at some of them - as to how the model could change. But that is in the melting pot; it is difficult because they are commercial businesses, they need to cover their overheads and make their profit, but does it have to be every time somebody passes through their door that payment comes or do we say: "You have 1,000 patients on your books that means we can agree a contract price with you." There are perhaps different models but we need to change.

Deputy K.G. Pamplin:

I was going to say, for the impact to the hospital - which you highlighted at the very beginning of all of this - is you see that straight away. They come to A. and E. (Accident and Emergency), people come to the hospital, if somebody falls over late at night your instinct is to phone the ambulance service and get people in. But we are hearing they are stretched and we see the red lights go up, you close the doors at the hospital; surely that cannot continue, can it?

Group Managing Director, Health and Community Services:

I agree with the Minister, I think we have to change the current system. I would say that the primary care G.P. system here could be the jewel in the crown of the Island. I have left a very distressed U.K. health system where G.P.s are very difficult to get, and we have good G.P.s and lots of G.P.s. There is common ground around our shared priorities and I think if you look at long-term care - diabetes is a long-term condition - there is a fundamental question that we need to answer about whether or not it is in our interest to re-provide those services within primary care in a way where money will follow. I think that is a key question we need to answer. For older persons, we know that their care is better within their home environment if it is right, and G.P.s play a critical part in that. But I agree with the Minister; I am not sure an episodic approach to that is the only and the right solution. I think there is something about how do we manage populations and groups of people in a more whole system way; how do you get better specialist advice and guidance direct from the G.P. to the hospital without needing to make a referral.

Deputy K.G. Pamplin:

Yes, the pathway, it is connecting up digitally as well.

Group Managing Director, Health and Community Services:

Connecting the pathway effectively, and is there a way of making sure that that can be resourced properly in a win-win way so you are not taking money out of one system and just giving it to another; you are trying to connect it so that money is better spent between the systems of care. We are looking at all of that now and I do think we have got a unique opportunity.

Deputy C.S. Alves :

Can I just pick up on a couple of things? Sorry, that is the second time I have interrupted you. You said the diabetes centre, for example, was developed through a need that G.P.s could not necessarily cater for?

The Minister for Health and Social Services:

Well I am not putting that forward as fact, I am just ...

Deputy C.S. Alves :

Okay, well basically my question was going to be are there constraints on G.P.s on what they can do at the moment? Because I know from a personal level also, and hearing from other people, that there are patients who would like care from their G.P.s and the G.P.s would like to administer things like certain blood tests, which they are not authorised to do, and would have to be seen by a consultant, which just seems like a massive amount of duplication, if you like, and probably a waste of money a little bit. Is that a constraint that is not currently in place, and is that something that would require ... because we mentioned legislation earlier, so is it something that would require legislative change, or is it just a kind of policy that is in place at the moment?

Group Managing Director, Health and Community Services:

I am not sure it would require a legislative change. Some of the prescribing component may, but I am not certain. I think it is a policy change that would be required. The diabetes is a perfect example; so it is difficult for G.P.s to manage diabetes if they have not been managing diabetes. What you see in other jurisdictions is that you have a blend of expertise from specialists to the G.P.s so that the G.P.s feel confident about managing a long-term condition. For something like diabetes, that is absolutely a normalised condition, that would ordinarily be managed by a G.P. So they need the right level of support around them so that they can call on a specialist when needed for certain cases, and those that involve endocrinology and where you may need other specialist nurses or support to be provided. But I think that is about how you connect the systems, and the strength that we have to do that is in the personal relationships within the Island. I think that is where we need clinicians to come together to think about how they are able to support each other, whether they are in the hospital or the G.P. surgery, in a much more informal way that does not involve older persons having to go into hospital for blood tests or for outpatient appointments where they could be done virtually or where the G.P. can do that on their behalf. I think that is where we need to be pragmatic and that will require a change in the way we work. We are at the beginning of that journey. We have made some progress; diabetes is one of the areas we are doing really well with that.

Interim Director for Community Services and Adult Services:

I am going one step back again into prevention. I have met with a number of G.P.s now and they are certainly up for this. They are an incredibly rich source of information, are they not, because who is it that gets to know that somebody is isolated for the first time? Quite often the G.P. Who is lonely, who is depressed because they have lost a loved one, who are those that are beginning to sort of trip over a little bit at home but not quite to the point where they have lost their mobility and they are falling over? So sharing that information with G.P.s, which will not cost a lot if anything because some G.P.s said: "This is information that we should be sharing with you anyway" will enable us to get those people connected to the Parish, the voluntary sector, the services that are out there in the community already. It alerts us to the fact that people like that might need a bit of assistive technology when we get that in place, which we are working on, so that we can get in there, early intervention before ever they get to a point where they have gone so far into the system because we have not heard about them, we have not got to know them, and suddenly we are intervening at a point where it is hospital.

Deputy K.G. Pamplin:

But to get those people into their G.P.s - which you are quite right has all those records, it should be joined up, that is what we are all talking about - if they are not going because they do not want to pay their fee, they are going to say: "I feel not great but is it worth me paying £50?" when that could be the start of something very serious. If we remove that barrier and got more and more people through that door creating the pathway; is this what we are hearing, that we have to relook at that?

Interim Director for Community Services and Adult Services:

I think we have to relook at that but I think that information is still there. G.P.s, from what they tell me, pick up quite a lot of intelligence about the people that they know and the families that they know, and I guess this is where Parishes come in as well. Parishes will probably know who those people are that do not connect with the local village and are a little bit isolated, and somebody might have a view about them being depressed. I just think that information is out there and the G.P. is one of those ...

Deputy C.S. Alves :

So what are the barriers that are stopping that from being shared?

Assistant Minister for Health and Social Services

Can I just come from the other side, if I may? You are going down the same route as me. One of the biggest problems is legislation. G.D.P.R. (General Data Protection Regulation) has caused a lot of problems with the Parishes, and it is not just the clinicians, it is not just you across the other side of the table. You know from my own experience, I get frustrated by a doctor who cannot really say there is a problem with a patient because the person he is telling it to has not been checked out by the Parish. We have got to get our act together across both sides to make this work, and I totally agree with everything that is being said, but the problem is we have got frightened by legislation: "Has he gone on a safeguarding course? Has he done a C.R.B. (Criminal Records Bureau) check?" You know what it is like; and the system is not only affecting you, it is affecting everybody. The volunteer sector is now coming to the stage of saying: "Hang on a minute, do I want to take on that responsibility?" It is the old story: "I am quite happy to look after my child, I do not want to look after somebody else's child just in case something goes wrong." We have all got to look at this. It is not just the hospital, it is everybody in that sector because, I tell you what, we could do so much more for the general public of the Island than just ... it is great that we are talking about it and I am sorry I interrupted, Minister, but I think ...

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

Assistant Minister for Health and Social Services ... we are all there on the same hymn sheet.

[15:15]

The Minister for Health and Social Services: It is another facet to be resolved, is it not?

Deputy C.S. Alves :

So that could be something that would require legislative change then?

Assistant Minister for Health and Social Services

I mean, as Derek has said, we have got a great connection through - and again the Deputy will know - we have got the Comité des Connétable s, we have got the Constables themselves, they all want to help with care in the community. Believe it or not, they have got a lot of people there that would like to help but they are worried as to the responsibilities they take.

Deputy K.G. Pamplin:

Very quickly, can we just go on to the response to the C. and A.G.'s report on health governance. What are the key changes that will be made in the department as a result of that? Could you just pick on a few because it was quite widespread; but what are the key issues or key changes you are going to pick out from that report and focus on first?

The Minister for Health and Social Services:

For my part, I see a greater clarity about the roles in the department, that those working in the department at all levels will know exactly which teams they belong to, who is their line manager and who they are accountable to, and all the way up to the highest management that roles will be much clearer. That means there will be accountability and transparency and we will be reviewing all of that at quarterly hearings in public just to keep a check on ourselves and invite scrutiny. We will have input at that top level from outside sources, the patient voice we have spoken about, we want G.P.s to be able to contribute, and the voluntary sector also.

Deputy K.G. Pamplin:

A big part was the whistle-blower; I think you touched upon it earlier. How are the proposals to that to reform this problem? We know it is a States-wide issue of speaking out, feeling confident that they can ... not just the public but staff members. So just to go into some of that detail about how we are going to change this epidemic about speaking out and fear of doing so?

The Minister for Health and Social Services:

Yes, and it must, and I do not want anybody in the department to feel that they cannot speak their mind, say when they think something has gone wrong, or say if they feel they are being harassed or bullied. We all want to ensure that nobody is put in that position. There are existing policies in place but as for the detail and what might change, can I ask, Mr. Sainsbury, if you might help us?

Group Managing Director, Health and Community Services:

Yes, I think for us there is a delicate balance whistle-blowing and what we see ordinarily through our reporting of risk and clinical concern, professional concern. One of the key differences for me, following the Auditor General Report, is that we are establishing a revised quality and safety forum, which will be led by the medical director and the chief nurse, and incorporate a lot of clinical audit. The intention of that is so that you can have a greater connectivity between those senior corporate professionals and then your clinical services. So from ward to the board you have got a much cleaner, easier way for staff to raise concerns, to look at risks, to look at incidents where they do not feel they need to whistle-blow, they do not feel they need to take a different route; they feel they can escalate a concern. I think when it comes to individual concerns around the way staff are treated and their own personal circumstances, we need to make more effort in the way we listen to people, and greater connectivity between the executive, the managerial layers and frontline staff. Whether

that is being visible in areas, having open forums where staff can talk to you, having the ability for staff to provide constant feedback and where staff feel they are seeing an output of escalation so their concern is being listened to and something changes I think are all the acts that we need to start to build upon to get more confidence from our staff that they are being listened to. The Auditor General Report has prompted the requirement for the department to operate good governance, and the approach that we want to take is that every member of staff understands what good governance is and their role of good governance and what they should hold us to account to in terms of good governance as well. So we would have a handbook for everybody. We are spending a lot of time on how we educate people around what they should expect and what they need to do and what they need to ask other people to do; I think we have made good steps in terms of how we are going to approach that.

Deputy M.R. Le Hegarat :

Thank you. Back to the Minister. In early 2018, the States approved the new system of organ donation. When can we expect an Appointed Day to be lodged in the States to implement this new law?

The Minister for Health and Social Services:

I think we are currently envisaging 1st July, subject to States approval of course, but that is the present plan. Before that time we want to embark upon a campaign to ensure people are aware of what is happening. So I know my ministerial support officer is in touch with the N.H.S. (National Health Service) Blood and Transplant Service to discuss how they are helping us with that. We have had one meeting with Mr. MacLachlan, who is the consultant who is passionate about this. We are going to ask Connétable Shenton-Stone if she wants to assist us because she has taken an interest, and I hope she will. We are thinking about publicity and an education programme, and asking people to make a choice; we are not promoting a particular choice but just trying to make people aware that they should choose either not to consent, if that is their wish, or to register on the register to give their consent - both choices can be recorded on the organ donation register - and then to tell their family or next of kin, because that is most important. So that is underway.

Deputy M.R. Le Hegarat :

Do you think that there has been information so far provided to the public about what opting in and opting out means?

The Minister for Health and Social Services:

When the States were debating it there was some discussion at the time, and a Scrutiny review, as you might know. But at the moment it has disappeared, it is not in the public consciousness, so it is our role to bring it back to public consciousness. I feel I would like to walk up and down King Street with the leaflets that people might need to fill in, although it is far better to do it online, and perhaps some States Members will join me to just encourage the local population to do something that is so easy, just go online, sign up - I have done it myself, it takes just a couple of minutes - and that has the potential perhaps to save a life.

Deputy M.R. Le Hegarat : When will your campaign start?

The Minister for Health and Social Services:

It will be in due time. I cannot give a specific date as yet but we had the first meeting of a group, if you like, about 10 days ago that tasked people to go off and speak to the N.H.S. and the like, and we must meet again, probably before Christmas with some concrete ideas to start that in the New Year.

Deputy M.R. Le Hegarat :

Is there sufficient funding for it?

The Minister for Health and Social Services:

We, as a Scrutiny Panel, were concerned about the £20,000 that had been allocated, it did not seem a lot to us.

Deputy K.G. Pamplin:

I have got that in front of me because this is one of those serious hybrid moments where you were the chairman of the Scrutiny Report and you responded as Minister for Health and Social Services to your report, which was highly interesting. But in it one of your recommendations to the Minister was: "The Minister should consider increasing the budget in light of the experience of Wales and the fact that Jersey is not able to sign up people to the N.H.S. organ donor register via the driver licence application process." So that was your recommendation and now you are that Minister for Health and Social Services, so do you agree with yourself?

The Minister for Health and Social Services:

I think we might need to spend more than £20,000, not because we will be profligate but because I think it is important to get the message out. Wales of course were the leaders; it was not in the national consciousness until Wales introduced it. It is now in the national consciousness, it has been talked about in the U.K., it appears on current affairs programmes; so I hope there will be something in people's minds that will connect. That might mean we do not need to overcome that first hurdle. Therefore, we might not need to spend as much as Wales might have spent. But I think it is money well spent and I am going to do my utmost to make sure that we engage people.

Deputy M.R. Le Hegarat :

Will there be any other changes, either sort of clinical or administrative, that will need to be done as a result to the changes of the law? So is there anything from the clinical/administrative ...

The Minister for Health and Social Services:

I do not believe so, no. The practice will not change essentially, it is a presumption that is changing, but at the end of the day next of kin will always be able to say what should happen and their wishes will be respected.

The Deputy of St. John :

The change thus far is administrative, is it not, in that the driving licence application form is no longer used.

The Minister for Health and Social Services: That is right.

The Deputy of St. John :

Has the date been transferred to the register by the Connétable s as yet; do you know?

The Minister for Health and Social Services:

I have regularly asked and I think the current position is that the data is with N.H.S.B.T. (National Health Service Blood and Transplant) and they have yet to give us a confirmation that all those names have been transferred on to the register. That is as far as I can say at the moment.

The Deputy of St. John :

Because it would seem an opportunity lost if we are not to have them.

The Minister for Health and Social Services:

I agree, and I hope before we begin our campaign, we can know the answer to that because then we can answer that question.

Deputy K.G. Pamplin:

I just want to talk about workforce morale but before I do that, where are you based now because you said you have moved office?

The Minister for Health and Social Services:

I am based now at Cyril Le Marquand House on the sixth floor.

Deputy M.R. Le Hegarat :

I want to ask a question. Is that a good idea or not?

The Minister for Health and Social Services: It is a new way of working, is it not?

Deputy K.G. Pamplin:

Was it your choice? Did you have any say so?

The Minister for Health and Social Services:

Yes, I was invited to go across. I dilly-dallied a bit because I was comfortable having a dedicated desk, but at the end of the day it was going to happen so I decided, well, go for it. I think those of us who lived through the last Assembly saw ... sorry, am I getting this right. Yes, sometimes Ministers getting deep into their departments and not working together enough as Ministers at a strategic level. That is simply because they came together at Council of Ministers meetings and Council of Ministers were busy agendas and there was not enough time just to talk through important issues. Then all Ministers disappeared into their departments and got involved. I loved being in the department next to the director general and next to the managing director, and you heard all that was going on in the department but I can see how I might get so immersed in that culture that I am just dealing with Health. A Council of Ministers needs to think strategically I think, and trust these guys to deliver the services that we need. So hopefully, if we are together as Ministers, hot-desking, then we are going to talk to more.

The Deputy of St. John :

It is part of a Minister's role to oversee, is it not? How do you oversee from a distance?

The Minister for Health and Social Services:

I mean, there is still going to be extensive meetings, I meet daily with one or more of these officers, and twice a week I have meetings with the director general, and other times as necessary. But there is a political responsibility so it is a case of balancing the duties.

[15:30]

Deputy K.G. Pamplin:

I am conscious of time but I think this is really important and I hope you will allow a few minutes extra. You alluded to our review into mental health services, which we are engaging a lot of people. We are also as part of this panel looking at a wide range of topics. It is fair to say we have received

several letters now from health staff which show that workforce morale in the healthcare system is not good. You could argue it is low, it could be improving as we are hearing. So for those listening, and for us as well, what plans do you have, how can you right here right now tell us what the plan is to try and improve workforce morale and combat these conditions? Because the biggest thing that we need is staff and they need to be appreciated and they need to be heard and they need to be listened to, and I think we have skimmed around the edges but right here to end it: what is the plan and how are you going to measure that success?

The Minister for Health and Social Services:

I will ask Mr. Sainsbury to deal with the plan, but it does concern me that there does seem to be such low morale. However ...

Deputy K.G. Pamplin:

I must say, it is not just the hospital, this is widespread from all areas ...

The Minister for Health and Social Services: Widespread, yes.

Deputy K.G. Pamplin:

... and as I alluded to with our mental health review, we are hearing some very desperate voices, and I am sure you are in your roles as well.

The Minister for Health and Social Services:

Remember, health itself has a workforce of about 2,500 full-time posts, but I think there are more in the service because many work part-time, and inevitably some people are not going to be pleased with the conditions they are in. But I do not want to solely reinforce a negative picture because I think our staff go above and beyond the call of duty often. I mean, they work tremendously hard and are dedicated and are passionate. It is really wonderful. I meet such passionate staff members who are really keen to serve the Island, to do what they do well to the best of their ability; I think across the service they are doing that. We have got good staff who want to work to the best of their ability and to be led well. So if they have a low morale it is not - I would like to assure the public and yourselves - I do not feel as a general rule it is being reflected in the service they give.

Deputy K.G. Pamplin:

No, I think what we are seeing and what we are alluding to is they are very dedicated because anybody who has been in that environment, they will go that extra mile. The problem is that going that extra mile and feeling like they are having to continue going the extra mile; when do they have to stop going the extra mile and just provide a service that is supported, that people can feel comfortable that they can go home and have some sleep or feel like they have been listened to and feel like ...

The Minister for Health and Social Services:

Yes, and perhaps we have neglected in past years the sort of measures that looked after our staff, but I see there are plans now to change that, the sort of "Team Jersey" concept. But as to the detail of that plan or department plans, could I pass over to Mr. Sainsbury?

Group Managing Director, Health and Community Services:

I think there are multiple issues that are causing that low morale and I think we have got to deal with them in turn really. Some of those are strategic and some of them are operational and tactical. I think we have to come to a solution in terms of the pay position. We need to work with our trade union partners in getting to a good position because it feels that it is a dark cloud that is stopping everybody going forward. As part of that we know, because we hear from our staff, that there are wider components of living within Jersey that can be difficult; whether it is accommodation, whether it is childcare, whether it is parking, and I think we have got some change that we need to make to support particularly those in lower-paid employment in our services to support them in their environment of work. I think we are clearly seeing that for some key workforces they are working at a level of intensity that is not sustainable. So there are too many periods of time when they are on call, and they are working in teams where there are too many vacancies and there is too much reliance on temporary staffing. I think some of that we can do something about and we have had some good return on recruitment, particularly in the hospital in key areas. We have just recently recruited 2 paediatricians, which will hugely support the intensity and workload of our doctors caring for children, but for some areas that is difficult and mental health unfortunately is one of those areas where it is just not very easy to get registered mental health nurses and key professionals. I think we are going to have to do something different around that; whether it is different therapists, whether it is support workers, whether it is general nurses who are able to have modules or experience and learning about mental health in a different way. We are going to have to adapt in a different way because we are not going to have an army of nurses that we can recruit from over in the U.K. or within the E.U. (European Union), in all honesty.

Deputy K.G. Pamplin:

We have almost gone full circle then, P.82 and the new hospital; is this something in your opinion that is still deliverable and still workable? Or as part of your structure in going forward, all the things you have openly talked about today, mean in essence we have to go back and find something that comes from the healthcare staff who provide our services and that we have to create a new healthcare strategy, which will make these things happen?

Group Managing Director, Health and Community Services:

I do not believe we need a new healthcare strategy. I believe if you look at the objectives with the P.82 strategy it would be consistent with any health jurisdiction; it is the right things that we are trying to do and I think the Future Hospital strategy is also consistent and the right thing to do. Delivering it through a workforce that is sustainable and recruitable is the challenge, however, we are uniquely placed in Jersey where we can be more bespoke, we could look at different solutions with internal training, education, our own schools of education and nursing, our own approach as to how we get the future clinicians, professional social workers to sustain those services. But we do need to act now to start to develop that.

Deputy M.R. Le Hegarat :

You have probably almost answered my question. We used to in Jersey train our own nurses. Now, I was going to ask you this question because this is something I think a lot of us talked about during the election campaign, that not only in nursing and health but there is an awful lot of other police, fire, ambulance, et cetera, education that we should be looking to train within Island. Because you have got more chance of retaining somebody if you have ... and I know that there are costs to that but is that a cost probably worth taking?

Group Managing Director, Health and Community Services:

I believe it is. I believe it is, and we are starting to see that. If we think about the ambulance service working closely with police and fire, there is a real opportunity there about how workforce expertise and skills can be shared, and we could do something different. We do not have to be tied to a U.K. system that is separate in the way it delivers public service. We have a one-service opportunity that we could start to develop.

Interim Director for Community Services and Adult Services:

There are ways, particularly in social care as it lends itself to this, where you can review the skill base and there might be ... because of the way that our referrals are usually spread, which is the great majority of them, are quite straightforward assessments and maybe 20 per cent are very, very complex. Our workforce is probably the other way around where 80 per cent of our staff are very well-trained and professional, the other 20 per cent are not. We know that when we go out to advertise for a care assistant or someone that is a social work assistant perhaps that can undertake a straightforward assessment; we get 30 or 40 applications from people that live here on the Island. So there are ways in which I think we can capitalise on that rich availability by growing our own and having our own training arrangements; so it is there. I agree with Rob; it is now we need to start doing that and the opportunity is at the top because we have got the opportunity of shaping that when we configure the services beyond the structures that we are now looking at.

How many people have you got coming up to retirement?

Interim Human Resources Director, Health and Social Services: Far too many.

The Deputy of St. John : I mean ...

Interim Human Resources Director, Health and Social Services:

Although obviously with the legislation they do not have to retire so we are seeing more people choosing to work on beyond the retirement age.

The Deputy of St. John :

What is their reason for working on?

Interim Human Resources Director, Health and Social Services:

They do not really give a reason but anecdotally I think they enjoy the work, and probably because they need the money.

The Deputy of St. John :

So there are one or 2 people who take that choice, but there is a significant number who are going to take the retirement?

Interim Human Resources Director, Health and Social Services: They could if they wanted to, yes.

The Deputy of St. John :

Yes, proportionality, many of them will I imagine. I know I did. The fact is you cannot train enough people to replace them or replace the experience you are losing. So where are you going to bring the experience from and what are you going to do to facilitate their well-being in the Island?

The Minister for Health and Social Services:

It is not just a case of somebody retires and you bring someone new to replace them, it is a progression. It would normally be, so that somebody would move through the health service and gain experience and gain qualifications to be able to step into the retiree's post. At the lower level you might bring in somebody new and give them the training. It is a flow, I would think; that is how you would try to manage it.

The Deputy of St. John :

It takes 3 to 4 years to train a nurse.

The Minister for Health and Social Services:

Yes, I am sure, and we do that, do we not, in our education programme. There is a problem about training mental health nurses because of the requirements that are imposed by the professional bodies, quite rightly; it is about expertise and knowledge and qualifications needed. We are a small place; we do not have the capacity to offer that. There are always going to be challenges and I cannot imagine the health service will ever reach a steady state.

The Deputy of St. John :

Do you think you are on top of the challenges?

The Minister for Health and Social Services:

I think that would be brave to say. We are attempting ...

Deputy K.G. Pamplin:

Well that is what we are here for.

Deputy M.R. Le Hegarat :

I am very conscious of the time and that it is now past 3.40 p.m. Thank you very much for coming this afternoon, and thank you for those of the public that also have attended. We look forward to the ...

The Minister for Health and Social Services:

Thank you for receiving us. Can I just say I should have at the beginning offered apologies from Anthony McKee ver, our director general, who would have wanted to come and contribute, but he is off-Island on department business.

[15:42]