Transcript - Quarterly Hearing with the Minister for Health and Community Services- 26 April 2019

Health and Social Security Panel Quarterly Hearing: Governance Arrangements for Health and Social Care

Witness: The Minister for Health and Community Services

Friday, 26th April 2019

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 R.J. Renouf of St. Ouen , The Minister for Health and Community Services Deputy H.C. Raymond of Trinity , Assistant Minister for Health and Community Services Ms. C. Landon, Director General, Health and Community Services

Ms. R. Naylor, Chief Nurse

[14:02]

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

Good afternoon, everybody. This is the Health and Social Security Scrutiny Panel meeting in public with the Minister for Health and other colleagues. Firstly we will introduce ourselves. I am Deputy Mary Le Hegarat of St. Helier District 3 and 4 and I am the Chair of this panel.

Deputy C.S. Alves of St. Helier :

I am Deputy Carina Alves of St. Helier District 2 and I am a member of the panel.

Deputy K.G. Pamplin of St. Saviour (Vice-Chairman): Deputy Kevin Pamplin and I am Vice-Chairman of this panel.

Deputy T. Pointon of St. John :

I am Deputy Trevor Pointon. I represent St. John and I am a member of the panel.

The Minister for Health and Community Services:

I am Deputy Richard Renouf , Minister for Health and Community Services.

Director General, Health and Community Services:

I am Caroline Landon. I am the Director General for Health and Community Services.

Chief Nurse:

I am Rose Naylor, Chief Nurse.

The Minister for Health and Community Services:

May we record that Deputy Hugh Raymond is also part of our team and is willing to answer questions as well?

Deputy M.R. Le Hegarat :

Primarily this meeting is to do with the Comptroller and Auditor General's governance arrangements for health and social care, which came out in September 2018, so we are therefore going to ask questions in relation to this documentation and obviously the responses that are being provided by the Health Department. Firstly, the question I would like to ask you, Minister, is how is work progressing with rolling out the new target operating model within your department?

The Minister for Health and Community Services:

I believe our department is well-advanced and we are progressing through the tiers now. I know work is advancing and interviews are being held to appoint to the lower tiers.

Deputy M.R. Le Hegarat :

Are you able to tell me what tier you are on at the moment?

The Minister for Health and Community Services: Can I ask the Director General to clarify that?

Director General, Health and Community Services:

Thank you, Minister. So we are currently on tiers 3 and 4, Deputy .

Deputy M.R. Le Hegarat :

Okay, so how many have we got left to go then?

Director General, Health and Community Services:

May I ask Rose, who has been working closely with the T.O.M. (target operating model) just to comment on that?

Chief Nurse:

Yes. We launched phase 2 of the consultation on Wednesday and those in scope are the tier 3s and 4s. I think there are about 45 staff involved in that. That consultation runs for 30 plus 2 days, which takes account of the bank holidays, and that really gives those individuals an opportunity to attend one-to-ones, have conversations about the particular impact for them and also feed back. At the end of that consultation we will compile the feedback and produce a response in the beginning of June. We will then start to appoint to those posts. We have already appointed to the Associate Medical Director posts, which these are the new care group leads, and those interviews were held on Tuesday this week and we have appointed to all of those posts as well, so we will be announcing those this week. Then the next phase of the consultation will start in summer once we have got the care group leads in place, to start to shape up what we need within those care groups, so that will go down to tiers 5 and 6.

Deputy M.R. Le Hegarat :

When do you anticipate that the department will have completed their whole structure? Bearing in mind that this started in January of 2018 - or in fact before that, because obviously there were people brought in on interim posts before our new Chief Executive arrived - when can we anticipate the staff at the bottom of those tiers are going to find out whether they have got a job or not?

Chief Nurse:

The plans around our T.O.M. are not going to disrupt the clinical hierarchy, so it is not going to go into clinical services that directly deliver patient care. For those staff, so for nurses, for social workers, physios, the restructure will not go into those parts of our department. The next tiers of the T.O.M. that will be reviewed in terms of the new structure will be really around the care groups that are going to deliver the services in the future, so that will be some of those support services, the essential services that we need to run our business. I think the next phase of the process will probably take us until the end of the year before it is completely fully implemented because of time for consultation at the next level.

Deputy M.R. Le Hegarat :

Therefore one can anticipate by the end of 2019 that all staff employed by Health will know where they are in relation to their employment?

Chief Nurse: Yes.

Deputy C.S. Alves :

So structural change is necessary, but not sufficient for real change. What have you done or are you doing to change the culture within the department to help promote learning and encourage constructive challenge?

The Minister for Health and Community Services:

I have seen good work being done and I am hearing encouraging reports that there has been a change in culture and people recognise that and are feeling it, as it were, so there is a greater assurance that they are able to bring concerns and to raise concerns and to escalate them and better working together, a better relationship, I think, across the whole department. As to the measuring of what I have just said, perhaps can I ask Rose if she can detail that?

Chief Nurse:

Yes. One of the things we talked about, particularly this morning in a group of staff on maternity, was around the important roles that we have got in our new structure around clinical and professional leadership. The crucial nature of those appointments means we have to appoint people who are going to be in leadership positions who have the right values, who have the right cultures and right behaviours and that we start to build the trust within the organisation and the confidence that enables people to feel safe to raise concerns and bring things forward. I am very confident from the calibre of individuals we interviewed earlier this week that we have got really good people in those posts. Part of it is around who we have put in those posts within the structure and then there are other key components and elements around that. So how we work as an executive, myself with the Medical Director and the group Managing Director as a triumvirate, so we have got clinical leadership sitting alongside operational leadership along with Caroline, it really sets the tone as to how that is going to work throughout the organisation. That is going to be sitting in a structure supported by Team Jersey, supported by a new performance and appraisal system that is going to be rolled out next year, which really promotes behaviours, values and the culture. So there are a lot of things that we are absolutely committed to doing to change the culture and I think some of the things we have already started to do, as the Minister said. The feedback we are having from staff has been really positive, that they are starting to feel there is a different tone in the organisation.

Deputy C.S. Alves :

Now, you mentioned there feedback, so is that part of your evidence that you will be providing to show that learning and change has happened?

Chief Nurse:

Yes. I mean, there is a variety of ways in which we can get feedback from staff. There are lots of different mechanisms that we already have in place, as well as structures and policies: "If it does not feel right, speak out", all of those things that have been relatively recently lodged. But there is also much more dialogue with the executive than there has been previously. Our new D.G. (Director General) does a weekly blog to staff, which has been very well-received. We have executive briefings on a Friday lunchtime, which anybody can come to. We are doing more and more to improve communication and a 2-way process with our staff. We are also going to be introducing departmental visits, where the executive will go and spend some time in the departments. While we are all individually visible and quite busy around the place, it is about creating some space for people who have got time to come and talk to us, as opposed to going through a department and chatting to staff. This is more of a reflective formal opportunity for them to do that.

Director General, Health and Community Services:

I think the key is very much in that phrase "working as an executive", so the decision-making is not seen as being very much top-down, led by the D.G. and coming from the D.G.'s desk, but it is an executive team working together, accepting ultimately that I am the accountable officer, but us working as a triumvirate and cascading that down and bringing it back up so that we are getting that learning. Absolutely appreciating what you are saying about structures, but some of our structures have been quite exclusive, so with our M.E.X. (Management Executive Committee) structure, which is just in effect the executive team and a few chosen people, that is now going to go across our entire tier 3 leadership level. So it is going to be a room of 16 and it is going to be lively, but everyone's voice is going to be heard and that is very much the message that we want to give out, about we want to listen.

Deputy M.R. Le Hegarat :

Can I just ask, because you have mentioned about the calibre and the people that you interviewed this week, where have those candidates come from?

Chief Nurse:

They were all internal appointments.

Deputy M.R. Le Hegarat :

They were all internal?

Chief Nurse:

Yes, they are all from our existing workforce.

Deputy M.R. Le Hegarat :

Because obviously it is just really to know which level we are at and whether we have been able to obviously recruit locally as well.

Chief Nurse:

No, we are delighted that we have been able to fill all the posts. As I said, the calibre was really good as well.

The Minister for Health and Community Services:

I think the appointment of Professor McInerney as Clinical Director and the enhancement of that role from tier 3 to tier 2 has been so well-received and he is well-respected as a clinician, but he is now bringing those skills and that knowledge into the management executive and devoting himself to so much. His background is really helpful and you have seen that in meetings with him and in addressing issues as they arise.

The Deputy of St. John :

Minister, you mentioned this earlier, the Health and Community Services Board, and maybe we are going to integrate your presentation in relation to agenda, but clearly you are quite a way down the line. Can you describe to us how things are going?

The Minister for Health and Community Services:

Yes. We are moving down the line. We still have work to do, so as we have said before, we will be establishing a public board, which will consist of the Minister and Assistant Ministers and the management team. What principally the D.G. has been working on more recently is the level beneath, which will consist of various committees which will do the detailed examination of issues, so there will be 4 committees. One is the Quality and Performance Committee, which deals with patient issues and the delivery of care, the safety of that, the standards of that. Finance and modernisation, around keeping value for money and our initiatives around digital and such things.

[14:15]

People and organisational development, which is about staff and recruitment, and a Risk Committee, which is critically to measure or to embed assurance that we are dealing with risk and addressing it and addressing it at the right stages, making sure minor risks are dealt with at an operational level, but other risks that come up to that committee, more serious risks, are flagged and would come to the H.C.S. (Health and Community Services) Board. Those 4 committees would seem to be the sort of powerhouses and they would bringing reports to the H.C.S. Board about what they have been doing and outstanding concerns and the board has that oversight to ensure that all these functions are progressing well, working well, and receiving assurances that they are, or if we are not satisfied, then we will be directing what can be done.

The Deputy of St. John :

Do you as yet have terms of reference agreed for the board?

The Minister for Health and Community Services:

There are in draft form. We cannot share them as yet, but we are working on them, because it is something that Jersey has not done before and it is not just a case of taking something off the shelf from the N.H.S. (National Health Service) because we are not an N.H.S. here and there is the political responsibilities to take account of. So this board will not be a decision-maker, because we cannot alter the fact that the D.G. ... you would not want to alter the fact that the D.G. has responsibilities in law, as an accountable officer, and I have political responsibilities to the States Assembly and ultimately the States Assembly is the legislator and discusses and decides on the big policy areas and strategy areas. That does not change. It is just the board to assist us in a transparent way to implement those strategies and to assure the whole organisation and the public that we are working safely and with the patient at the heart of all that we do.

The Deputy of St. John :

It is worth considering formalising in law the relationship between the D.G. and the exec board, given that in the future we may not have such a lovely person - and I do not mean that, I mean a nice, amenable, insightful individual - heading the show, who may become in conflict with the board.

The Minister for Health and Community Services: Equally a Minister perhaps.

The Deputy of St. John : Yes.

The Minister for Health and Community Services:

I think it would need to evolve. I would not want to do that straight away and that will take too long, because it would need legislation. I am not sure we would know exactly what is required. I think there would be opposition in the Assembly if we legislated to give a board formal powers.

The Deputy of St. John :

It is not unique in the sense that the police have a board managing their affairs, for example.

The Minister for Health and Community Services:

Yes, but then politicians do like to get involved in operational aspects of health it seems, do they not? I hear what you are saying. I think it is something that would need to evolve. People would need to be happy first with the board, as we are envisaging it, and then we can see how it can be improved. We would willingly receive input from Scrutiny and all interested parties on that. We will be inviting to the board third sector providers as well, so they will be bringing their input into it.

Deputy K.G. Pamplin:

I just want to refer back to the action plan and I know - and I think we are all aware - that some changes have already taken place since the publication. Could you just go into some detail as to what they are, what other changes have been made?

The Minister for Health and Community Services: To the action plan?

Deputy K.G. Pamplin:

Yes. There has already been changes to the plan since the publication of the executive response already, so some things that were mentioned that have changed already, so just to give us an update on what they are since the initial response.

The Minister for Health and Community Services:

By the action plan, do you mean the response to the recommendations?

Deputy K.G. Pamplin:

Yes. For example, high level governance arrangements, that sort of thing.

The Minister for Health and Community Services:

This is more ... I am not aware of any strategic change, anything that is significantly different to the recommendations. I suppose the 4 committees I have outlined to the Deputy of St. John were not in sight at the time of the response to the C. & A.G. (Comptroller and Auditor General), but as to more detailed change, could I ask the D.G. to elaborate?

Director General, Health and Community Services:

I might have to ask Rose, because I am not sure of any significant changes we have made since the publication, apart from the changes that we have made around our governance framework, which will impact upon this, but we have continued to manage this via our Mental Health Improvement Board. Rose, are you aware of any significant changes we have made?

Chief Nurse:

Only in so much that we obviously put some assurance committees in place last year, so we changed our internal governance arrangements. They have been further strengthened since Caroline's arrival and we have looked at how we strengthen those, so those groups and committees set up last year, so we established them fairly quickly. Most of the things that were in the plan we have been working towards. As I say, we have probably strengthened it further than the original recommendations. I do not know if that covers it. Is that the sort of answer you were ...

Deputy K.G. Pamplin:

Yes, because where I am basically heading with this is some elements of the detailed response are not specific as to time of delivery, for example, descriptions of works such as "ongoing", "early 2019", "summer 2019". In my humble opinion, effective monitoring should be facilitated by specific dates and targets for the completion and to implement the recommendations and see them through. Also, where are the timetables? If it is going to take time, it is not a surprise out of the blue, that can be shared in advance, say: "We are now using foresight and we can predict it will be ..." and share that, instead of what could happen, you say: "Oh look, it is not happening" and people go: "Oh, why? That is ..." so transparency comes into play. That is pretty much where I am heading with this and just what your response to that is really.

Director General, Health and Community Services:

I completely acknowledge that, Deputy Pamplin, and apologies, I should have been closer to this. You are right, those proposed timescales are too nebulous and what we need to have is defined timescales with trajectories of delivery and milestones in there. I think that is something that I can take back and work with the team around firming up.

Deputy K.G. Pamplin:

I think that is a cultural thing. I know you might have been here a few weeks in, but I think that gets to the heart of this, while there are all these structural changes and the Government changes, there is a culture change that goes right to the heart of this. It is this sort of thing has got to be rooted out. It is simply not good enough to say: "Yes, this is terrible and in spring 2019 something will happen." What is that happening? How is it going to happen and where is the transparency, so everybody, from the very bottom to the very top, so everyday folk out there can go: "Oh, I see that and I understand that"? That is where trust and respect comes in.

Director General, Health and Community Services: Absolutely agree with you.

The Minister for Health and Community Services:

At the time of writing the response, which is within 6 weeks I think is the required period ...

Deputy K.G. Pamplin: Of course.

The Minister for Health and Community Services: ... we might not have been able to do that.

Deputy K.G. Pamplin:

But we would be able to understand why that is, because at the moment you say that, but we go: "But why? We cannot see it anywhere and we have to take it at face value." That is part of our role, to bring that out. Of course I get that, but ...

The Minister for Health and Community Services:

But in the short timescale of 6 weeks, it might not have been - I do not think it was - possible to deliver a detailed timetable because you have got a lot of preliminary work to do, and taking a stab in the dark perhaps is less helpful than saying "early 2019" but ...

Deputy K.G. Pamplin:

But you could create a culture for future, that is in the future when you do seek to report, you go: "We have created a new structure in place so that does not become an issue" because you say: "Look, we have changed things for the future, in 20 years' time ..." what you have just described, you want to break that and sort of ...

The Minister for Health and Community Services: The new structure is all about better planning, certainly.

Deputy M.R. Le Hegarat :

The thing is as well, I think we have all seen that quite often there are particularly C. & A.G. reports that come out and they give recommendations and the departments have not acted on them or nobody has checked that those things have been done. Of course if you have a specific ... we all know about S.M.A.R.T. (Specific, Measurable, Achievable, Realistic, and Timely) and if you have got specific timescales for something to have to have been done or if you have not done it then you have got to have a reason why you have not done it. I think that is the thing, is it not? We can sort of observe, all of us here, I think, that in the past we have been told that things are not working well and we say: "Oh yes, we know it is not working well and we are going to do something better" but we do not really do anything better or we do not tell people we have done anything better. Of course what you have here is 4 new politicians who think: "Hold up a minute, this is not really acceptable, to be saying we are going to do something and then not do so" or at least say: "Well, we said we would do this, but we cannot" and then give the justification for not doing it. I think that is what we all ... yes, I think it is about following up about what we are all saying we are going to be doing.

Deputy K.G. Pamplin:

Yes, because I think every level-headed person, when they see a genuine reason why something has not come out and it is transparent will go: "Okay, we accept that, but we see you working at it and we see and we will move on" but when that does not happen, that is where people start to feel disconnected, under-trusted, undervalued and all those sort of things.

The Minister for Health and Community Services:

I agree. In many cases in the past, it has not been acceptable and it has brought the States into disrepute, but I think our Quality and Performance Committee would be checking on that sort of thing, so we would have various work streams and targets that they are monitoring and they will be asking the questions and drilling down into the organisation to find out why, so it is about systems management.

Deputy M.R. Le Hegarat :

This is about being able to manage our staff, their responsibilities, and when you look at the appraisal of your staff, you have to have targets, you have to ... the word "target" is probably not ... people have to be given what their expectations of their delivery is. If you do not have that and people do not know that by a certain time and a certain date they have to have done something, then how can you then appraise that individual? It is not only about the department as a whole, but it is about from your perspective as the D.G. in 12 months' time, you will be able to sit there and say: "Right, this is what I have achieved in the last 12 months" because otherwise how can we possibly know whether you are achieving the objectives that you have as an individual, let alone as a department?

The Minister for Health and Community Services: Yes, indeed.

Deputy K.G. Pamplin:

Putting that into the framework of what I have just experienced in the last 24 hours in the hospital, one of the many things that came really clear to me is the high level of governance that a serious health practitioner has got to go through in order to deliver the care they are doing. If it is to save a life or to perform a procedure, an operation, there are many strict guidelines in Health to make sure the best possible care is delivered and the reasoning before that and the checks that go in and what the staff have to do with the systems and the note-checking, double-checking. I have seen that first- hand, so when the staff on the ground are doing that, then they look up and see that is not being replicated at the top, but then the top come down and say: "Right, we are doing this" and you think: "Well, hang on a second, we have to do that because if we do not, then we are in trouble." I am coming with that perspective, from those sort of things.

Director General, Health and Community Services: Absolutely.

Deputy K.G. Pamplin:

That clearly should be the motivation, so that the staff feel valued and they see: "Well, we are doing that and we understand you are our bosses, so you have got to change" but the respect comes back. Am I making sense?

The Minister for Health and Community Services:

Yes. I think if the staff can see - and they will see - that we are more streamlined and organised and planning our work and strategy at a high level, they will respond, I am sure of that, because they will be clearer, it will be more transparent about what we are trying to achieve and it can be accessible.

Deputy K.G. Pamplin:

Then it makes it harder when tough decisions have got to be made for budgetary reasons or space reasons and you have got to move somebody and that will upset them.

The Minister for Health and Community Services: They see how is being worked through.

Deputy K.G. Pamplin:

Yes, and then it can see your work before and it is easier to explain if it means that it is going to change their daily routine, their office, their experiences working with colleagues. It is easier then, because ... that is my view, anyway. Good, I am glad I made that clear. I am a bit tired.

The Deputy of St. John :

I think Kevin should be reassured that what we heard prior to this is that there is consultation going on and people's ideas, views and opinions are being sought, listened to and responded to. I think that is very important. I am not so greatly concerned about the nuclear facilities in Health and the people in the nuclear facilities.

The Minister for Health and Community Services: Sorry, what do you mean by "nuclear", Deputy ?

The Deputy of St. John :

The main body of Health, which is the people who you have a responsibility for, an accepted responsibility for. I am a bit concerned about a couple of elements of provision of healthcare that seem to have been moved outside your area of responsibility.

[14:30]

I have in your response to the C. & A.G.'s report, this is page 9: "Responsibility for services related to children's health is moving to the new Department for Children, Young People, Education and Skills and the management of the Ambulance Service has transferred to the Department for Justice and Home Affairs." There is a whole spectrum of issues in relation to governance for those 2 services that this morning we were unable to establish answers for with Justice and Home Affairs. Now, are the Ambulance Services going to be launched off to Justice and Home Affairs without any clinical governance?

The Minister for Health and Community Services: Not at all, no.

The Deputy of St. John :

But you, in this response, have said that they have gone, you no longer have any responsibility for them.

The Minister for Health and Community Services:

I am unsure. I have not prepared for questions on the Ambulance Service, Deputy , I am afraid. I cannot remember the precise date, but perhaps you can, Caroline, but there has been a transfer, but there is still close working with H.C.S. and a transition plan is in place. I am assured that there is that governance around and the clinical governance is there. We must not get too hung up on the fact that it is one department and there is another department and think that things are not going to work merely because they moved from one part of the administration to another. The important thing is to ensure that the Ambulance Service continues to provide the excellent service it does, the staff are properly provided for and have a route for good clinical governance. I am sure that happens.

The Deputy of St. John :

The same question applies of course to C.A.M.H.S. (Child and Adolescent Mental Health Service) who, in our discussions with them, feel quite isolated in the situation that they are. Their relationship seemingly has been ... they seem to be not considered to be - or they do not think they are considered to be - a clinical psychiatric service, because psychiatry is one thing and they are another thing over here under a Children's Service. Are we to include children's paediatric inpatient services under Children's Services?

The Minister for Health and Community Services: No.

The Deputy of St. John :

Are we to include community paediatric nursing services?

The Minister for Health and Community Services: No.

The Deputy of St. John :

Are we to include health visiting services under Children's Services?

The Minister for Health and Community Services:

No. It is about looking at where the service is best-placed for the service users, for the children, and we are approaching it from one end of the telescope, which is all about the departments we have some involvement with, but we can also look at it from the other end of the telescope, which is what is best for the children. I agree, this has rather worried me at some stages because it is sometimes a medical service, is it not, that prescribes medication, intervenes clinically and the like, and you could say that: "Surely that should stay with the health service" but I do not think there is a right or wrong answer here. There are advantages to moving it to a service that concentrates on children and families, because very often it is about families and working with the families, because children do not have an independence, do not have a choice very often.

The Deputy of St. John :

But health visitors work with children and families.

The Minister for Health and Community Services:

Yes, but in C.A.M.H.S. very often the remedy has to lie with the family, because children do not always have the choice about what actions they can take and the like. As I said, I do not think there is a right or wrong place to put it. The important thing is to make sure that children can receive the services they need and for the staff ... yes, I accept the staff are maybe feeling: "Why is this happening? Are we going to lose those links?" but there is going to be intensive work with them before the transition happens. I know there is a transition plan and I have seen and discussed all sorts of measures that are in place to make sure there remains good clinical governance and proper professional links with the Health Department.

The Deputy of St. John :

You are certainly offering some reassurance, but the fact stood out that these people would go, these departments were off elsewhere and there is no further reference to them or their clinical governance, which is the important bit. It is a very important side of it.

Director General, Health and Community Services:

When I came into post, the Minister was very clear with me that he wanted me to examine this as part of our executive portfolio and that it is very clearly not a management decision or a political decision, but a clinical decision based on the patient at the centre and clinical outcomes and what is best for our patients in Jersey. So I asked our Medical Director to do a risk assessment, a comprehensive risk assessment around the transfer of C.A.M.H.S. to C.Y.P.E.S. (Children, Young People, Education and Skills) and to work with his opposite clinical number around that. He did a comprehensive risk assessment, which we have shared across the whole piece with nursing colleagues, A.H.P.s (Allied Health Professionals) and clinicians and his findings out of that assessment was indeed that moving into the children's environment would provide more beneficial outcomes for the children that we serve. So that is how ... the decision was not originally based on that, but that is how we have stood by that decision. Now, some of the caveats that our Medical Director has put in place to ensure we deliver that outcome-based care is that we have an umbrella board that sits over C.Y.P.E.S. and H.C.S. which focuses on C.A.M.H.S. and the deliverables from C.A.M.H.S. As a team, we have a feed-through to all of our governance committees around our commitment to put children first. So I am assured from the work that he has produced for us and which we have presented to the Minister that the right clinical decision has been made and ratified by our Medical Director. Similarly, with the Ambulance Service, there has been a lot of concern expressed about that. If you look at the metrics, the performance standards delivered have not changed, response times have not deteriorated. There has been some dissatisfaction among staff and that can impact significantly on delivery of care, but the arrangements that we are currently putting in place for the Ambulance Service is to have a joint liaison officer that sits across H.C.S. and Home Affairs and we have had a clear conversation with Home Affairs that all clinical governance for the Ambulance Service, which is hands-on care, comes through H.C.S. and is supported by our Medical Director. I do not think we have cast them out. I think they are an integral part of the care we are trying to deliver, but just sitting separately. But I recognise that this document is perhaps not up-to-date.

The Minister for Health and Community Services:

It was not a document which was intended to go into detail about the governance around those services, was it?

Deputy M.R. Le Hegarat :

I will ask a radical question here then. What is the purpose of moving the ambulance away from Health then? What is the purpose of it? Why move it? What was the purpose of moving it?

The Minister for Health and Community Services:

There was seen to be synergy in putting all blue light services together.

Deputy M.R. Le Hegarat :

But they are all different services, so I am just asking the question, why would you move ambulance away from Health?

The Deputy of St. John :

I was going to say, was that the only reason, that an ambulance has a blue light on top?

The Minister for Health and Community Services:

As I said before, I have come prepared for sort of a governance discussion rather than something which has already happened around a particular service, but no doubt there were good reasons put forward and we have to ask ourselves, at the end of the day, it is making the service work for people. Does it really matter which section of Government administration it sits in? We have to make sure the systems work rather than being precious about whether it is Health or Justice and Home Affairs. If we can show it works - and it has happened - do I need to really say ... is it something I need to be worried about it now and try and get it back into Health?

Deputy M.R. Le Hegarat :

That is not necessarily what we are saying, but what I think is fundamental is that you have the services overseeing the services which are relevant to their departmental business, so the fact that they are a blue light service really does not make any sense to me as an individual whatsoever, because they are a health service, they are people that go out and deliver medical care, so why would you put them, as the Deputy of St. John says, under Home Affairs purely because they have got a blue light on the roof of their ambulance? Because in actual fact, your transport is not a blue light at all. Patient transport does not go ... so fundamentally, I do not disagree with what you are saying from the point of view of it does not matter, but to me it does matter. That is the whole point. You put services and the supervision of services under the umbrella to the service that they provide.

That to me is commonsense, but maybe it is me that does not understand, but I cannot see how something that delivers a health service is put under something that does not. Fundamentally, I think all 4 of us probably think the same thing. We do not understand why this has been moved. I do not think anybody has answered the question as to why it was moved. Fundamentally, that is maybe what the question is, that we may need to bring in a question to the States and maybe one of us will do that and say: "Fundamentally, why did we move them?" Maybe that is what we need to do.

The Minister for Health and Community Services: I think the D.G. can add something.

Director General, Health and Community Services:

I can give you my perspective on the separation of service, but I am sorry, I cannot answer that question because it was before my time, which sounds like a bit of a copout.

Deputy M.R. Le Hegarat : No, that is fair enough.

Director General, Health and Community Services:

It is that I absolutely agree with you, that they provide on hands-on patient care, but I think it is a different model of care to what we provide as an acute provider and a community provider, so I can see the rationale of separating out those 2 care models, because in some respects it keeps the cleanliness of that line, because as we change our model in H.C.S., it would be very useful for me if I am looking system-wide to use those paramedics differently and it may be slightly beneficial for me not to offload those vans so quickly and not to take those calls in because of what is happening across H.C.S. So I think it helps us to maintain that probity of service for the Ambulance Service in that there is a really clear service line, as long as we maintain the governance. I think the key thing is governance, ensuring patient safety, and that they have to sit still underneath our M.D.'s (Managing Director) umbrella and they have to come through Q. and P. (quality and performance) and they have to be on our performance report so that we can absolutely see the response times, but also some of the wellbeing standards which we are asking to be put in there, so we are able to determine that staff are getting the training they need and that they are able to have the linkages through, because you are right, it is one health system. But I can see some rationale around why they may have made that decision.

The Deputy of St. John :

It beggars belief, really. There is not another organisation in the United Kingdom that behaves in that way. Dublin is a place that runs a joint Fire and Ambulance Service, but every one of their personnel is a qualified paramedic, very expensive, but nevertheless an effective system. They are not happy with that. But these are issues that ...

The Minister for Health and Community Services:

Yes. I find myself in some difficulty. I would have liked to have given you fuller answers. If I can just say, if you had had in your question plan questions about the Ambulance Service, perhaps you could have let me know and I would have tried to beef up on this.

Deputy M.R. Le Hegarat : I think that may be more ...

Deputy C.S. Alves : Cross-government.

Deputy M.R. Le Hegarat :

Yes, I think it was about the working of cross-government, as Carina said, in relation to that and obviously sometimes you sit here with a distinct plan, if you like, but there will always be occasions when you think ... because I asked you questions that were not on the plan because I think the thing is sometimes something will come to you ...

The Minister for Health and Community Services: I understand.

Deputy M.R. Le Hegarat :

... either just before the meeting or somebody comes in and says: "Oh, I would like to ask this" so there will always be a bit off piste, but I think ...

The Deputy of St. John :

It came to me at the site of Loch Lothian.

The Minister for Health and Community Services:

Is that where you have been? A lovely part of the world.

Deputy K.G. Pamplin:

Can I just bring us back to the subject of C.A.M.H.S. that the Deputy talked to us about and what you mentioned about doing what is right for the patient and refer to our infamous mental health report, where we had discussions with C.A.M.H.S.? I just want to read you a statement that C.A.M.H.S. themselves submitted to us. This is obviously all public domain: "Parents have fed back to us that they are concerned that they are now in the same building as the Children's Service. We need an independent identity for a small Island service. We have little choice in where they go for support, as we do live in an Island. The families have thought of entering a building full of social workers leaves them feeling anxious, and for those who struggle with trust, ask us if we are independent."

[14:45]

That is then echoed by the Children's Commissioner, who of course at the moment is working in the Shadow Forum, and says: "Through the words of a child, one of the things that children have said to me quite clearly is that the colocation of children's social workers is something they are finding extremely difficult, because they do not trust the system at the moment." So if we are taking the information, that we are listening to the patients and the families and the service users, well, there it is. If we are serious when we say things like that, how do we feed that in? If that is what the users, children, are saying, that this colocation of putting it together and where does it fall under is confusing the families and making them feel unease, then no matter what you do and how much you shine a building up, the actual proper service and the impact to the users should be paramount. If they are saying ... is that not what we are talking about, governance and making sure what we are all talking about here?

The Minister for Health and Community Services: That was about colocation, was it not?

Deputy K.G. Pamplin:

Colocation, putting it in the same building. They talk a bit before about the independence of the structure and it was not clear of where they fall under, but I think that is what we are alluding to with this transitioning of governance and how it works, but feeding it back through the users, the patients, that there are concerns: are they being listened to going up the ladder or are they not?

The Minister for Health and Community Services:

There are a number of questions there, I think. I was at C.A.M.H.S. on Monday talking to staff and, yes, some users are concerned about the colocation with Children's Services, but for most users I understand it has not been an issue that been raised or seen to give concern. Obviously people are all different. Some might have a concern, but for others it will not be relevant. So perhaps the location is a factor. That will have to be something assessed as the service moves forward, I think, and that is something that could be changed. The States has many premises and C.A.M.H.S. could move somewhere else if that were felt to be the right thing to do for the children and the families.

Deputy K.G. Pamplin:

Because it does, we are talking about the governance arrangements and the moving of C.A.M.H.S. to the Children's Department, the Minister's department, but that is what are saying, there are concerns under that model being expressed.

The Minister for Health and Community Services:

But do we think the concerns lie with the families of children that need help? Does it matter to them whether it sits in Health or whether it sits in C.Y.P.E.S.? The important thing is that they get the service they need.

Deputy K.G. Pamplin:

Agreed, but that is the whole point of governance, is it not, it is the checks and balances: is it working; are service users clear and are they happy? Also that the people like C.A.M.H.S., the actual people who are on the ground doing the work, are being listened to and say: "We do not know. We do not feel sure." Is the governance in place to make sure that ...

The Minister for Health and Community Services: Yes.

Director General, Health and Community Services:

It is. I think that is what our Medical Director is putting in place. In fact, it may already be in place, I am not sure. It is an overarching board that is going to sit across C.Y.P.E.S. and H.C.S. and that governance framework will ensure that we are listening to staff and to users to hear any colocation concerns.

Deputy K.G. Pamplin:

I think what you just said there is really key: "putting in place." What I think we would love to hear is: "It has been in place for the last year and here are our findings."

Director General, Health and Community Services:

Yes, I agree, but I literally only asked the Medical Director when I came into post to do it. We are absolutely acting on his recommendations and we will make sure that we have a trajectory for delivery.

The Minister for Health and Community Services:

You see, these plans are being laid at a certain higher level at this stage, but I am told that in the months ahead - it will be next month, because I think the transition is due from June ...

Director General, Health and Community Services: It is.

The Minister for Health and Community Services:

... so next month there will be heavy engagement with staff to address their concerns, to explain what is happening, to explain about the governance arrangements for them and for the organisation generally and to provide that reassurance. But we could not have done that from the very inception of an idea to move it across. You have got to make the plans first and then embed it with the staff, which will be happening. I do not know if you can add anything, Rose.

Chief Nurse:

No. I mean, John and I have met and gone through the transition plan arrangements. We are very clear around the professional lines of sight, that they remain the same. The medical staff will stay under John's direct management as well, so it is about making sure now that we start to embed the checks and balances.

Deputy K.G. Pamplin:

We will hold that to account.

Chief Nurse:

That is okay. Please do.

Deputy K.G. Pamplin:

That is what we are here to do.

The Minister for Health and Community Services: Yes.

Deputy K.G. Pamplin:

You know we will. All right, that moves me very neatly on to our new D.G. for Health and Social Services. Now, obviously, as we know, the report was pretty much driven by the Interim Director and obviously now you are here, so I think the first question is how do you take something that was written by an Interim Director and make it yours? Maybe just guide us and we will start there.

Director General, Health and Community Services:

I think I have recognised from the inception of my employment that we are challenged on governance and risk across H.C.S. and I completely echo what you have said, Deputy Pamplin, around ensuring that you have that golden thread from top to bottom and bottom to top, which we have not. I think

the work that I have been focusing on for the past 3 weeks and before that with my team, because it has been very much across the executive team and ministerial colleagues, is around putting in place a structure that will ensure that all of this happens. That is not just having a board, but committees for assurance and the board to report through to, but having operational groups below that which are very clear around how risk is managed and escalated across the organisation so that we start, as an organisation, to make decisions based on risk, what has the greatest impact on patient outcomes and patient care, and the delivery of that care is impacted accordingly. I am confident that once we have embedded the structure of governance across the organisation, it will be an infrequent event when we sit in front of you with incidents that have happened across our organisation that we are unaware of or are surprised by and that our governance processes and structure will make staff feel safer, more listened to and will ensure that the care that we deliver for our patients is measurable so that when we do sit in front of you we will have tangible evidence to give you around delivery. So while I think this is a great initial response and I commend my predecessor's efforts and the team, I think there is a lot more we have got to do - absolutely agreeing with you - to ensure that the structure we put in place makes this more than words.

Deputy K.G. Pamplin:

What has surprised you the most since you have been here, given your wealth of knowledge and your experience elsewhere? You know, you have come into the position and gone: "Oh my God, what has been going on?" What can you highlight with that thought process? Also, what do you see the real challenge is really from what you have seen in your short period of time?

Director General, Health and Community Services:

I think we have a health economy that is people - as I have said to you when we met - who are the most passionate health providers I have had the good fortune to meet, and who I think because of the geography here are absolutely committed to delivering patient care. I think they perhaps have felt that their voice has not always been heard or it has not been heard through the appropriate framework in place for them to not only feel it is heard, but see the actions that have been taken from what they have said. I think I have been surprised that perhaps we have not been as robust in our communications with our staff, who are our precious resource, particularly when delivering care, which is the most intimate delivery. So I think some of the work we are talking about and which we have already kicked off with our blogs, our executive visits, we are going to start doing a lot more around open door. We have changed the way that we have laid out the executive floor, so I have moved out of my large office and we are working much more as a team together and having very much a policy for staff that they do not need to make an appointment to see the executive team, they can pick up the phone, they can email. We are about to put boxes around the organisation. Then we would like to cascade that out to the people that we work for that provide a service for us across the community and in the wider health economy. So yes, there is lots to do, but I am fortunate to have a fantastic team around me.

Deputy K.G. Pamplin:

I certainly echo that, from what I have been through in the last 24 hours. I think what was really apparent to me during that time was what you have just described there and what I have witnessed in the last 24 hours is you are right, in delivering care in an acute hospital environment or any environment really it is about the patient, so that is saving a life, it is about delivering a life or dignifying for a family and the person as a life comes an end. But to do that in the environment currently, they are doing it under an extreme way of working due to insufficient governance, insufficient funding, buildings and infrastructure that makes their job difficult, so to deliver that care, they have to do it even harder to ensure that care.

Director General, Health and Community Services: Yes.

Deputy K.G. Pamplin:

I guess when they are tired and they have worked 8 hours and they have not had a break and they get: "Oh, we have got to do a governance check, we have got to do all these things" to take the journey through that process to ensure that they feel it and value it, not just words and sayings and diagrams and smiley stickers and all that, so how do you think the challenge of that is going to be overcome?

Director General, Health and Community Services:

I think it is going to be immense. The work that we have been doing to put the framework in place, which will enable us to assure our patients, colleagues and you that we deliver safe, responsive, patient-centred care is just the very beginning and it is the work plan that I have been discussing with colleagues around how we will make that real. Part of us making that real is again going back to the structures we have put in place around executive reviews. We have board, committee, operational groups, M.E.X. in the middle, which will be all of our senior leaders, so everybody has a voice at operational decision-making, not just 4 people. Underneath that, we will be having an executive review framework, whereby every month the service lines will come to the executive team and we will start to have a very adult to adult assurance and holding to account process, whereby we are very clear around what those deliverables are and what is happening. But in order to do that, we are going to have to support them to learn. So we are looking at how we can utilise the resource we have in order to be able to roll out this framework to staff. My experience is - and I am sure yours is the same - that when staff we are working within a framework which is clear, responsive and patient-centred, then they are freed up not to have to worry about ticking the box, dotting the i's, crossing the t's, because that is absolutely what we do not want our most expensive resource doing. We want them delivering hands-on care, but in order to ensure that is safe, we have got a bit of the pain of making this happen.

Deputy K.G. Pamplin:

Also I think it is the communication of that, so if you are going to phone up somebody who has just done an 8-hour shift and tell them: "Right, your department is moving" and if you just simply say: "That is what you are doing, get used to it" obviously for somebody who delivers care in such a way, surely they should be told in a similar way. How do we break down that? It is just a historical thing? Is it just that is the way it has been done and we have to change it, break it and retrain people in the art of how to engage with staff at that level?

Director General, Health and Community Services:

I think we recognise that and that is why we are in the early days of our engagement profiling, which is ... and I will not bore you again with the current stuff that we are starting, but what we are hoping to do, we went out to the teams and did not say: "We are going to come and do an executive visit." We went out and said: "Do you want us to come?" and we have had 55 areas come back to us. So it is the people who want us that we are going to first and I am hoping that message will spread, but what we have then come back and said is: "What is it you want to talk about?" We are not going out going: "Here is the governance and risk framework, it is real exciting" we are saying: "What is it you want to ask us about? What is it you feel that works well? What is really inhibiting you?" and a lot of the things you have said: "What is it you want us to do about them? What is it that we, as an exec team, are doing that is not adding any value? What do you want us to stop doing? What do you want us to do more of?" and starting to try and have that much more informal engagement and breaking down that slightly hierarchical culture that we have. So it is very much, as we describing it, a journey. We are working with Louise, our comms person, and Darren, our H.R. (Human Resources) Director to have a workforce engagement plan that we can cascade out to the organisation and get feedback on, because there is no point us sitting in a room and saying: "This is how we engage" and asking staff exactly what it is they want from us.

Deputy K.G. Pamplin:

Yes, and how it is done though, because interestingly, you are dealing with people who then, if a tragic moment happens, they have got to sit down with the family and tell something very heart- breaking to. So they know what that is like in the worst possible way, so when somebody comes down, they know what they should be hearing and how they should be taken through the process. That means: "By the way, you are losing some money" or: "By the way, you are working here now" because I have just told a family some terrible heart-breaking news and I am trained to deliver it in such a way that it guides me through, but when I come out doing that and I do not get that back from my managers ... do you see what I am getting at ...

Director General, Health and Community Services: Absolutely.

Deputy K.G. Pamplin:

... with how that shift needs to change?

Chief Nurse:

Yes. One of the things I just wanted to add , in terms of the new care group leads, the Associate Medical Directors, they were all asked the question around development into the role, because we recognise these are senior clinicians who are coming into quite a different role, so they have all identified some development needs. I have to say, we had already put a plan together so that they will be supported into that role, but in the same way that I am working with Rob and John, they will be working with lead nurses, the lead A.H.P.s, supported by a general manager. So again, the cultural shift and the cultural change will be coming through clinical professionals who know exactly what you are describing. I know exactly what you are describing, because I have been there. So they will be working together in order to help us deliver the changes. It is about us all doing it together.

[15:00]

Having been in the organisation for a long time, I have to say this is the most significant shift and the most exciting time I think we have in our department in the time I have been here. Even this morning, someone from A. and E. (Accident and Emergency) came down to the department and said how pleased they are to see the green shoots and they can feel a difference already. We really are at the very beginning, but it is a real positive start, I think.

The Minister for Health and Community Services:

It seems to me that is the most significant change I see, that clinicians are being involved at the highest levels, so it becomes a clinically-based service and not management-led.

Deputy K.G. Pamplin:

I guess the final part of it before I shut up - and I am trying not to fall asleep, I keep apologising - but not to be complacent.

Chief Nurse:

No, no.

Deputy K.G. Pamplin:

Because historically in Jersey, these sort of things start up this way, then something happens and it does not happen and then something distracts us, so I think it is really important that complacency does not set in, that in 4 years' time we go: "Well, that was a nice idea."

The Minister for Health and Community Services:

We will be exposing ourselves in a public board. We will be setting our standards there and people can hold us to account because we will be doing so publicly.

Deputy K.G. Pamplin:

Yes, that is good. Okay, thank you.

Deputy C.S. Alves :

Okay, so just drawing on recommendation 9 here, which you said a draft would be available in December 2018, so just has a new performance report been developed in response to the C. & A.G.'s concerns about performance reporting and inaccurate information?

Director General, Health and Community Services:

Yes, it has. We are just awaiting sign-off from our Minister, but it is our integrated performance report. What we have been very clear, working as an executive team and alluding to Rose's reference to a clinically-led organisation, is we have changed it so that we are looking right outside from primary care all the way through the acute services and then out into the services that we commission. It is right from the beginning to the end of what we manage and it is qualitative, it is performance. It is around care standards and it is around ensuring that our workforce standards and performance standards around the times that patients have to wait to access our services are all in one integrated performance report. Then each of those groups sits under the steermanship of an Executive Director and that Executive Director is held to account. That quality and performance report, which we are calling it, goes to the Q.P. Committee, but it also will be going through our risk committee. We should be able to share that with you imminently. Rose, you were very involved in that, so I do not know if you want to talk more about your clinical indicators.

Chief Nurse:

Absolutely. Yes, so I have been working hard to make sure all of the key indicators, particularly in relation to nursing, are captured in that report. Again, we will be able to see through your golden thread detailed information on a ward-based level right up to a broader position in the organisation. The report will be centred around the care groupings. The care groups will be responsible for oversight and monitoring of their own key performance indicators, but we will have oversight of the whole picture right across the organisation.

Deputy C.S. Alves :

You mentioned primary care then. How would that work with the primary care? Because you do not have direct oversight with them, so how does that tie in?

Director General, Health and Community Services:

As part of our governance framework, on the board we are inviting colleagues and partner organisations to join us. We have included primary care in our integrated performance report, although we are not able to currently access that data, because that is a dialogue that we wish to enter into with colleagues, and indeed has already been entered into around the sharing of that data, because of the impact it has upon the delivery of care. So we are going to be quite clear, open and transparent about our data and R.A.G. (red, amber, green) rate it accordingly. What we want to be able to do is to escalate to our Minister any of our ambers and reds with clear action plans around how we are going to get the ambers to green, the reds, why they have got to red and why they have got to go on his desk and the plans we have got to get them to amber. If we cannot get them to go to amber, they will have gone through our governance process and go to our board. So very clearly we would like our partners to be involved in that so that we can measure the whole patient experience. This is not about any kind of performance management of colleagues external to us, but it is about just ensuring that what we deliver is what our patients need.

Deputy C.S. Alves :

You touched on there sharing of data. Historically there has always been a problem with software and computer services with sharing that data, because there is not an integrated service between G.P.s (general practitioners) and the hospital. Is there anything that is being investigated with regard to that? Because I think that is quite a crucial link there that is missing, especially when patients have got to repeat themselves quite a lot or there is information that is held with a G.P. that is not necessarily held with the hospital. So are there things in place that are looking into that to ...

Director General, Health and Community Services:

So we had EMIS in this week and the digital team have been having conversations with EMIS and we have been talking with our primary care colleagues around how we can start to access that one EMIS system. Again, it is going to be a journey, but I think we are absolutely on the same page as primary care and acute and community providers, exactly what you said. We do not want the patient to keep having to repeat their message.

Deputy C.S. Alves :

Absolutely.

Director General, Health and Community Services:

It is traumatic enough to be presenting unwell without having to say the same thing over and over and over again. So it is absolutely high on our work schedule and I hope that next time we appear in front of you we are able to give you more definitive evidence of how we are progressing on that, but it is absolutely our aspiration.

Deputy C.S. Alves : Brilliant, thank you.

Deputy M.R. Le Hegarat :

In the report that was provided, you advised that a revised whistle-blowing policy would be launched following a programme of training in order to ensure its effective and consistent application throughout the States. Has training begun? If so, have you received any feedback on that training?

The Minister for Health and Community Services:

I think Rose would be the person most suited to answer that.

Chief Nurse:

Yes, so there was a new whistle-blowing launch last year across one government and I was involved in the launch, so it was not just for our department, but it was across all departments. Every member of staff was invited to the launch of that, so people had direct feedback on how that new policy is going to work, which also includes a line that people can ring if they want to talk to somebody on an anonymous basis. So that was widely circulated, that information. I know it is all around the organisation. Deputy Pamplin might have seen some information about it yesterday when he was in the building. Yes, so that happened last year.

Deputy M.R. Le Hegarat :

Has there been an increase in people using that facility that you are aware of?

Chief Nurse:

Not necessarily that I am aware of, because it would not come to me directly. However, what I would say is again, through the change in the organisation, there is definitely more dialogue and people raising concerns. Sometimes people do not necessarily say: "I want to raise through whistle- blowing." Just the fact that they are talking to us about things that are worrying them is the most important thing. I cannot answer that question, honestly, in terms of numbers.

Deputy M.R. Le Hegarat :

But you are quite content that the policy will encourage a culture of people feeling that they can whistle-blow if they need to?

Chief Nurse: Absolutely, yes.

Director General, Health and Community Services: Is it okay for me to speak?

The Minister for Health and Community Services: Please.

Director General, Health and Community Services:

Absolutely, but I think it is much more than a policy. I think it is much more about what we talked about earlier about the way we change our culture. I am used to seeing a report where you do see those numbers, absolutely anonymised and you do not see what people are talking about, but you do start to see people accessing the service, because you can have the most great whistle-blowing service, but if people do not trust it and do not speak to it, it is in name only. For me it is about getting our staff to ... well, hopefully that they are not in a culture where they are forced to whistle- blow.

Deputy M.R. Le Hegarat : They have to.

Director General, Health and Community Services:

But first of all being able to understand by measuring if that service is working. That is something we were talking about last week, was it not, and talking to our staff about: "If you whistle-blow, we are failing."

Deputy M.R. Le Hegarat : Yes, exactly.

Director General, Health and Community Services: So I think it is a very big piece of work for us.

Deputy C.S. Alves :

Which follows on to my next question, which is how will you ensure that complaints made at the bottom end of the structure are recorded and recognised at the top end?

The Minister for Health and Community Services: Staff complaints or staff concerns?

Deputy C.S. Alves : Yes, so it follows on.

The Minister for Health and Community Services:

Yes, I think through all the structures we have been talking about, access to clinicians who are involved with management decisions and the like and reporting upwards and the R.A.G. rating of concerns and the like, it is organised, it is planned and it something that is comprehensible to staff, I think they can see a pathway that will be followed.

The Deputy of St. John :

I have a final question, but I think in actual fact the question has been answered, because it was a question about improving transparency and you are working towards improving transparency, that is quite clear. What it might be an opportune time to address is your presentation.

The Minister for Health and Community Services:

Yes, pleased to do that. So if I can ask the D.G. to go through it. Please add to the details. So we recognise the importance of managing risks and being aware of problems that might be bubbling away and not letting them develop so that they become a real crisis, but we also have to recognise that we are in a human situation and emergencies happen and so there are risks involved around the service that we offer. Everyone is different and presents their own individual difficulties. So we have set out our risk appetite and declared lowest tolerance of risk to be those associated with patient safety. That has to be the key, everything that drives us must be around patient safety. As we have been speaking about it, risk management is about changing our culture, ensuring we have effective systems and that we are all adhering or behaving in a way that respects those. It is a journey and it is a continuing journey; it will probably never end. You could never say: "I am sure we have reached a stage where everything is just right." It is constant renewal and checking to ensure that we are improving. Yes, on the next page we are always trying to evolve and improve. We are renewing our strategy and procedures and our oversight. We are establishing the Risk Management Committee and we are taking advantage of good practice elsewhere, so looking at the work of the Institute of Risk Management, its best practice standards and using those to assess our risk management. We will audit ourselves to measure our awareness and compliance with risk management strategy policy and procedures. Risk is defined by where it sits. Is that what it means?

Director General, Health and Community Services: Absolutely, absolutely.

The Minister for Health and Community Services:

Yes, so the issues around safety, health and safety, quality work and all those bullet points. We assess it by looking at its consequences, when the event happens, but also the likelihood of it happening. We begin to go into quite a bit of management detail. Can I ask the D.G. to take over, because I think she will be clearer?

Director General, Health and Community Services:

I will not go through it word for word, because you can see it, but I think it is just fairly standard risk management process, using a standard risk matrix around likelihood and consequences, but also being really clear about what that escalation process is, so staff are aware that when they put something into Datix it is not just going to sit there, but we are going to take out what comes out the other end, we are going to risk assess that and we are going to have a very clear escalation process through our operational groups, our management executive group, which is the layer with all of our clinical leaders, through our committees, through to our board.

The Deputy of St. John :

I wonder if you could explain for our public what the Datix is.

Director General, Health and Community Services:

Sorry, so Datix is where we encourage staff to report any incident that may occur that causes any concern to staff, whether it is staff wellbeing or around a patient's wellbeing, or indeed any form of harm, and that is entered into the Datix system. The best system you can have is when you have got as much entered on there as possible, because it is much better to have much more recording than to have too little. The way you get to that is staff start to trust that when they put something on there, there will be a response at the other end. That is what we have got to get much better at.

Chief Nurse:

Datix is just the name of an electronic web-based reporting system.

Director General, Health and Community Services:

Yes, sorry. Rose is much more eloquent than me. That is how you start to build up that trust and transparency across there. Again, looking at the consequence and likelihood and using the standard risk matrix, whereby at the Risk Committee and at Q. and P. all risks that are 8 to 12 will come through to that committee to be assessed.

[15:15]

So we will stop any surprises, hopefully. Of course there is always going to be something that comes out of the blue in an organisation as large and complex as ours , but it should not be a common occurrence if you are managing properly through risk, because you know what is bubbling away under the surface, you are getting it reported through to you. If we cannot mitigate the risk, as previously said, then that risk will go through to the board. All risks that are a 15 will go across to the Minister and the ministerial team's desk via our Quality Committees and through to the board if we cannot mitigate the risk. Or if the risk has gone to committee, there is a mitigation plan and the committee has said: "I do not think that the mitigation plan is going to work. I want further assurance" then it will automatically go to board for the Minister to seek further assurance. So it starts to give us some confidence about how we are doing our decision-making. Again, just explaining around the controls, around what are we going to do, what we are working towards, if you have got a risk of 12, what is your target risk? So at the moment we have a risk of 12, you can say: "I am going to go away and mitigate it." Well, what are you mitigating it to? Because I am expecting it to be mitigated to 8, and then when is it going to get mitigated to 6, so if it is not going to get mitigated from 8 to 6, then it needs to stay on the committee work plan until it does. So we have always got that line of sight across the organisation of what our potential risks are. Then we have tried to just put in place a kind of easy to see chart, although it is not as simple as what we would like it to be, around our governance structure, which I think I have talked through ad infinitum, so I do not want to bore you. Then at the end is our integrated governance framework, which is trying to cover all of the boxes, really. So we have got our first line of assurance, which is our operational groups, so they are the teams that are performing the activity, delivering hands-on care. Then we have got organisational oversight, which is our assurance committees, and then we have got our third line, independence assurance, which is our board, which the Minister has described, which consists of H.C.S. and partner organisations and is chaired by our Minister, following all of these principles of Government priorities, local priorities and good practice and tying into what we hope to have, admittedly it is very embryonic, which is a piece of work around our values and behaviours. What we would like to do is - and again, I think that it is something that is probably going to take us probably the next 12 months - engage our staff in deciding what our values are and what our behaviours should be to deliver those values, but also engaging our patients. One of the key things we are doing in this framework is having patient representatives on each of our committees and at our board, so we start to hear that patient voice coming through, so it is not just ... although we wish to be clinically-led and health-driven, it is about every single one of us is here because of patients. So it is very much a document that will be continually evolving, because I think that is what risk and governance is about, but I think we are fairly content that it is an improvement on what we have previously had.

Deputy K.G. Pamplin:

I guess then the proof is in the pudding, is it not, because then when you can use this on a situation ... and I found a few of my own in the last 24 hours in the hospital. I am no expert, but what I saw and I talked to staff and I see this will produce a case and say: "We need to replace this because this is making an impact on how we deliver our work." Right now I could say that and you could say that and we could sit here and go: "Oh yes, but the money" and dah dah dah, but once you have this and the staff saying: "We have to have this for us to deliver a better service" then we get the changes I think we all want.

Director General, Health and Community Services:

It is a business tool for us, so the money we spend, the decisions we make, the clinical priorities and work plans we make will be determined by risk to our patients and to our patients' outcomes.

Deputy K.G. Pamplin: Yes, absolutely.

Director General, Health and Community Services:

Because that is how we should be spending that Jersey Health pound. For me and for my team, I think it is very much about having that in place, so it is transparent to staff that this is why the decisions are being made, because it has come up through that framework. So we might make a decision around a care pathway that has come up because you entered something on Datix. But again, we are on a journey and we have got a lot of work to do.

Deputy M.R. Le Hegarat :

It will be a never-ending journey.

Director General, Health and Community Services: Yes.

Deputy K.G. Pamplin: That is right.

Deputy M.R. Le Hegarat :

Anything further from anybody? Okay, thank you very much. That is us done, I think, unless you have got any questions of us, of course.

The Minister for Health and Community Services:

I do not think so. Can I ask my Assistant Minister if he wishes to say anything?

Assistant Minister for Health and Community Services: I have been fascinated.

The Minister for Health and Community Services: Do you wish to say anything?

Assistant Minister for Health and Community Services:

I would like to say something. It is quite interesting. Very much like the 4 people in front of me, I am new to the States as well and I think I have spent the last 10 months just finding out about Health. I knew nothing about it and I have known Trevor for some time and Trevor has been very much involved in Health and we have always had discussions. The case about the ambulance, because I was on the board the other side, talking about ambulance joining with police and fire and all that sort of thing.

Deputy K.G. Pamplin:

I should have got you to answer that question.

Assistant Minister for Health and Community Services:

But the other thing which I have been fascinated with, we have gone, I think, to every property that is used by the Health service and it is quite interesting to see the standards in some and the standards in others. Sitting with my other hat on as Assistant Minister for Infrastructure, it has been quite fascinating to see that some of the properties.

Deputy K.G. Pamplin:

I was going to say, do not get me going.

Assistant Minister for Health and Community Services:

I know you will support me to the hilt, and that is that we have underfunded for so long, and I think the problem now, it is catch-up time. Having the likes of the colleagues on board now that are coming from the same direction, it is absolutely great to see. We are not going to achieve everything overnight, without any doubt at all, just purely on buildings, but the actual talking to clinicians, to dentists, to doctors has opened my eyes completely how important it is we must look after our general public and I think that has come through from all of us. It has been a fascinating journey, Richard, has it not?

The Minister for Health and Community Services: Yes.

Assistant Minister for Health and Community Services:

Like you again, Kevin, we spent Christmas Eve in A. and E. If you go there, you suddenly realise what life is all about, especially with somebody with no background in medical care at all, but it is important that we get on with Scrutiny in the sense that you are important to us to keep us on our toes as to where we move forward. Sitting in the back and listening, I think it was absolutely fascinating and it is good that we are all coming hopefully from the same hymn sheet and that we can only move forward and you have held us to account, which is what we are here for.

Deputy K.G. Pamplin:

Yes, and I think it is very clear and I think we always say for the public listening that Scrutiny is the third voice of the Assembly. This is not opposition. I think that is an issue that we, as States Members, continually have to work with the public to make them understand that it is not opposition. We do not work that way. But in response to the point you make about the infrastructure and buildings - and I know we are off subject slightly - I think the time is more severe than that, to be honest. I think we have got to act a lot quicker and sooner. You are right, but my case is - and that is my side of aisle in terms of Scrutiny - it has got to be more urgent, because the time is way past. We have a building ...

Assistant Minister for Health and Community Services:

In personal terms, I know a lot about property. It is. We have got to ... but we also look at property in a different way. Have we got so much property that we could condense our property to do up the property to make sure it is worthwhile for everybody? We seem to be dotted all over the place and we have bits here.

Deputy K.G. Pamplin:

That is what the C. & A.G.'s report and our own report suggests, that Health is so complex and fragmented and bits all over the place that we have to bring it together. But secondly, for me, yes, of course you are right in terms of looking at the infrastructure of buildings and how we replace, it takes time and stuff. What I am more concerned about is what we can do in that interim period ...

Assistant Minister for Health and Community Services: Yes, I agree.

Deputy K.G. Pamplin:

... right now. I will put my head on as a charity, when I was at Headway, we could not shut down the centre, but we had to work around it to make approachable and warm and safe and secure, knowing that there is going to be some infrastructure. So what are the quick wins? How can we still make it appealing?

Assistant Minister for Health and Community Services:

Because there are 2 situations here, not only the people that are in there, but the people that are running it as well.

Deputy K.G. Pamplin: Yes, the staff.

Assistant Minister for Health and Community Services:

If you look at some of the buildings that we have, which are absolutely excellent, and without mentioning names because you do not want to compare them, but there are some properties you would not mind getting up in the morning and going to work there. There are some properties that some of our staff are in that really do need looking at. It is silly not to say so. I think in the past we have tended to hide it, but for goodness sake, we have got to look at it. I totally agree with what you have been saying.

Deputy K.G. Pamplin: Yes, good.

The Deputy of St. John :

Just one of my own unrelated questions, clearly there is an interest, going back to ambulance, there is a relationship between Health and Justice and Home Affairs. I was wondering if there would be any benefit in this being a process of breaking down silos. Would there be any benefit in Scrutiny breaking down the silos and having a joint Home Affairs/Health Scrutiny session at which both Ministers attend?

The Minister for Health and Community Services:

There may well be. I would certainly be willing to participate in that, but perhaps give the new arrangements some time to bed in and then examine whether they are working well and then everyone can have a feel of where we might be able to adjust and improve things. Soon might be a bit too early, I would venture a guess.

Assistant Minister for Health and Community Services: That is where you and I do not go, is that right, Mary?

Deputy M.R. Le Hegarat : Sorry?

That is the debate where you and I do not go.

Deputy M.R. Le Hegarat :

Yes. I think it is time for us to close now. Thank you very much.

[15:25]