States Assembly | Transcript - Quarterly Hearing with the Minister for Health and Social Services

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Health and Social Security Scrutiny Panel Quarterly Hearing

Witness: The Minister for Health and Social Services

Thursday, 19th September 2024

Panel:

Deputy L.M.C. Doublet of St. Saviour (Chair)

Deputy J. Renouf of St. Brelade (Vice-Chair)

Deputy P.M. Bailhache of St. Clement

Deputy L.K.F. Stephenson of St. Mary , St. Ouen and St. Peter

Witnesses:

Deputy T. Binet of St. Saviour , The Minister for Health and Social Services

Deputy A. Howell of St. John , St. Lawrence and Trinity , Assistant Minister for Health and Social Services

Ms. R. Johnson , Director, Health Policy

Mr. A. Weir, Director, Mental Health, Social Care and Community Services

Mr. M. Querée, Deputy Head, Finance Business Partnering for Health

Mr. C. Bown, Chief Officer

[14:03]

Deputy L.M.C. Doublet of St. Saviour (Chair):

Welcome, everybody. This is a quarterly public hearing with the Minister for Health and Social Services. We are the Health and Social Security Scrutiny Panel. I am the chair of the panel, Deputy Louise Doublet of St. Saviour . I will let my other panellists introduce themselves.

Deputy J. Renouf of St. Brelade (Vice-Chair):

Deputy Jonathan Renouf . I am the vice-chair of the panel.

Deputy L.K.F. Stephenson of St. Mary , St. Ouen and St. Peter : Deputy Lucy Stephenson , panel member.

Deputy P.M. Bailhache of St. Clement : Deputy Philip Bailhache , member of the panel.

Deputy L.M.C. Doublet :

Minister, if you could introduce yourself and your officers, please.

The Minister for Health and Social Services:

Deputy Tom Binet , Minister for Health and Social Services.

Assistant Minister for Health and Social Services:

Deputy Andy Howell , Assistant Minister for Health and Social Services.

Director, Health Policy:

Ruth Johnston, Director of Health Policy.

Director, Mental Health, Social Care and Community Services:

I am Andy Weir. I am the Director of Mental Health, Social Care and Community Services.

Deputy Head, Finance Business Partnering for Health:

Mark Querée, Deputy Head of Finance Business Partnering for Health.

Deputy L.M.C. Doublet : And online.

Chief Officer:

Chris Bown, Chief Officer.

Deputy L.M.C. Doublet :

Thank you for joining us. I am pleased we managed to get the technical issues sorted.

Chief Officer:

I do apologise for not being with you today, but it has been unavoidable, I am sorry.

Deputy L.M.C. Doublet :

We understand. Thank you. We have several members of the public viewing today. Thank you for attending. If you could also make sure your devices are switched off and that silence is maintained at all times. Thank you. We are using this hearing as our quarterly public hearing, but we also have some questions around our Budget review. We have compiled the 2 to make best use of the time. That does mean that we have a lot to get through today, so it is very important that answers are kept succinct and if we need more information we will ask for more. Minister, we are going to open with an item about the Jersey Recovery College which was highlighted in the media recently. Could you clarify whether the closure of Jersey Recovery College ... before the closure, whether they approached you and asked for any additional support before that decision was made?

The Minister for Health and Social Services:

Yes, the first approach came during January, before my appointment. I first became actively involved with discussions on 8th March, if my memory serves me correctly. So there have been ongoing discussions since the beginning of the year.

Deputy L.M.C. Doublet :

What support did you offer to them?

The Minister for Health and Social Services:

The detail of that I will leave to Andy, because he will have a better memory of the exact ... of the precise figures involved.

Director, Mental Health, Social Care and Community Services:

To begin with, we met with them on a couple of occasions to talk about sustainability and how we might work with them to make them sustainable. There was a concern in January that they would probably fold. We did a number of things. Their contract was due to expire with us in June, anyway, at the end of June. We talked about a different contract for a year that would give them additional financial support.

Deputy L.M.C. Doublet :

This was in March, did you say?

Director, Mental Health, Social Care and Community Services:

This was in March; from March onwards. We agreed with them that we would significantly reduce our demand for activity but maintain the same level of financial investment. The amount that we were paying for activity remained the same, but the activity was significantly reduced. We supported them through our commissioning arm to work with the Jersey Charities Fund to get some support from them. It is important just to contextualise that the Jersey Recovery College, half of their work was funded by H.C.S. (Health and Community Services) and half of it was not. It was other work that was funded in different ways. We had already started a conversation with them about a different model of delivery for H.C.S. and we worked with them to agree that we could deliver that from the end of June onwards. We continued to fund their summer school in order to allow that to run, even though we were not sure where we were going to go. We agreed that we would provide some H.C.S. staff, some mental health staff, to help them deliver the groups that they were going to be delivering in this new arrangement. We did all of those things. Those things were just starting to get up and running at the point at which the announcement was made that they were unfortunately not able to sustain.

Deputy L.M.C. Doublet :

Was there any thought given, Minister, to giving the charity more certainty rather than just a one- year solution? I know that other charities have raised this repeatedly and it is a common issue. Is that something you considered?

The Minister for Health and Social Services:

I would like to think we looked over the course of those months at just about every option that we could. But I think when a point comes where you can see something is not working out, you have to allow that situation to develop.

Deputy L.M.C. Doublet :

What specifically was not working out from your point of view?

The Minister for Health and Social Services:

You have already heard that we were arranging to having a consistent amount of money for a reduced service. There are a number of factors that sit behind this that have led to the situation that we have got.

Deputy L.M.C. Doublet : What are those factors?

The Minister for Health and Social Services:

It is a little bit difficult. The way that the charity was structured, it was not going to deliver going forward the sort of service that was required for the money that was available, if I can put it in those terms.

Deputy L.M.C. Doublet :

What service were you asking the charity to deliver?

The Minister for Health and Social Services:

I will hand back to Andy for the points of detail on the service.

Deputy L.M.C. Doublet :

I would just like to hear a bit more from you on the points that you have raised.

The Minister for Health and Social Services:

I think it is safe to say, without going into too much detail because there are people involved, that working with the team over a period of 6 months we did everything we could and, at the end of it, we took the decision that what happened had to happen. Does that make sense?

Deputy L.M.C. Doublet :

Were there any solutions that the Recovery College team suggested to you that you declined to pursue?

The Minister for Health and Social Services:

No, they made a series of suggestions and we ran with that, and those suggestions did not really come properly to fruition in a way that was required for it to be sustainable. Bearing in mind that we have budget deficits and we have got to be ... it is very, very easy to be critical of not saving everything and everybody, but we, as you know, have considerable financial pressure and have to be extremely careful about the way we spend money.

Deputy L.M.C. Doublet :

Can I just clarify your answer there? Were there any potential solutions that were proposed by Recovery College that you decided not to pursue?

The Minister for Health and Social Services:

Offhand, I cannot recall anything that looked vaguely workable.

Director, Mental Health, Social Care and Community Services:

So I can help with this. In relation to the first part of the question, we sought legal advice as to the duration of the contract because we originally had planned to move to a 3-year contract. But actually because it became known to us in January that there was a financial sustainability issue, we were having to put special measures into the contract for them at the start of 2024, the legal advice was that we could not do anything other than a one-year contract because it was a sustainability proposal for a year to see if we could make it work. They proposed that they should novate the contract that they had with H.C.S. to another charitable organisation. The legal advice was that you cannot do that. You cannot, as a provider, simply novate your contract to another charity. So they did propose that early doors in the discussions, but it was ruled out as an option.

Deputy L.M.C. Doublet : Because of legal advice?

Director, Mental Health, Social Care and Community Services:

The advice we were given was that you simply cannot novate a contract in that way to another provider.

Deputy L.M.C. Doublet :

Could you just give some detail on what that legal advice, what the basis of it ...?

Director, Mental Health, Social Care and Community Services: Not from the top of my head, I would need to go back and look at that.

Deputy L.M.C. Doublet :

If that could be provided to the panel that would help us understand, thank you.

Deputy J. Renouf :

Minister, when you were considering that situation over those months, you would have been considering presumably the service that was provided and the value for money of that service and alternatives that would have to be put in place somehow to provide that service. Was it in your mind that keeping this organisation ... doing this would be a simpler and more effective way than trying to create a new service?

The Minister for Health and Social Services:

I think common sense dictates that when you have got an up-and-running charity you do everything you can that is practical to maintain the existence of that charity. But I will make the point again that when you reach a point where you have to take a judgment, that judgment was made, and I am guided by a team of professional people, and the decision was made that that was where it should end.

Deputy J. Renouf :

Had you had time to put in place measures to pick up the services that would be lost?

The Minister for Health and Social Services:

Not on a back-to-back basis, but once again I need to hand over to Andy for the details of what is actually happening now, going forward, to replace the service.

Director, Mental Health, Social Care and Community Services:

During the last term, 79.5 hours of courses were provided over 4 months. That is the equivalent of 4 hours a week of activity. We are in a place now where we are able to deliver more than that from within H.C.S. within October. What we have done is, because we had already started the work with the Recovery College around a future model, and a future model particularly that potentially involved partnerships between mental health staff in H.C.S. and the Recovery College, we have just been able to accelerate that and build upon it. We have got a plan from October to deliver more than that in terms of groups, but we are going to grow that incrementally. So tomorrow afternoon there is a workshop involving people who use services, some of our partners and people from within H.C.S. to look at how do we want to do this, particularly focusing on the parts of the work that were commissioned by H.C.S. for H.C.S.. The particular change that we were talking to the Recovery College about was having more of a focus on serious mental illness and a focus on groups and activities particularly for people who use secondary mental health systems who were not hugely represented in a lot of this activity. The other half of the activity was very much about education around mental illness, reduction in stigma and workplace mental health, that type of stuff, so health promotion, health awareness in the form of mental health. We have not taken much of that on at the moment but in the end we will work with other partners to think about how do we replicate that.

Deputy L.M.C. Doublet :

The other partners that you have mentioned, Mind Jersey, if there was not a legal way to simply transfer the contract, why was another option not explored? If that charity was willing to take over, why was another way to do that not found?

The Minister for Health and Social Services:

As I say, you have got to bear in mind that I think the legal advice actually predated my involvement, so, as I say, Andy has explained that he has had legal advice and I was not aware that there was another way of getting around the problem. If you have got any suggestions, I am sure we would be pleased to hear them, but Andy is fairly comprehensive in the way he deals with things and I do have to trust professional people.

Deputy L.M.C. Doublet :

Would you like a glass of water, Minister?

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

Deputy J. Renouf :

If I understood you correctly, some of the services have been taken in-house, effectively. Those would be the ones that were provided for the Government. So you are now going to provide those in-house. But presumably that leaves still to be picked up the services that were provided not for Government, is that correct?

Director, Mental Health, Social Care and Community Services:

Part of the problem, I think, is that those services were services that were commissioned often by individual people. For example, there were mental health workplace courses that the Recovery College sought to sell to business and to the finance sector, et cetera. Whether or not people want to buy that currently is a different issue. We need to work out what we want to re-provide in terms of the overarching health promotion, mental well-being, reduction of stigma around mental illness- type activities that were run by the Recovery College.

[14:15]

Absolutely crucially to all of this, we have done through the Mental Health Partnership Board, which is a strategic board with all partners on, including the Recovery College, we have done a superb piece of joint work looking at developing a framework for how we co-produce and co-deliver mental health services. That is going to be integral to the work that we do now, moving forward in the replacement of the Recovery College, because that must not get lost in the long-term in all of this, I think.

Deputy L.M.C. Doublet : Thank you.

Deputy P.M. Bailhache :

Can I broaden the questioning slightly to third-sector organisations generally, rather than the Recovery College, and ask the Minister whether he agrees, first of all, that third-sector organisations play a really important part in the provision of health services?

The Minister for Health and Social Services:

I am happy to answer that and say yes, very, very much so.

Deputy P.M. Bailhache :

Sometimes indeed they do it better than the Health Department itself might do.

The Minister for Health and Social Services:

Very often charities are manned by people who have personal experience of the areas of work that they are dealing with and I think they do, by and large, deliver great service.

Deputy P.M. Bailhache :

Do you think that H.C.S., generally speaking, has a sufficient understanding of the way in which third-sector organisations work?

The Minister for Health and Social Services:

In the main yes, but I think in this particular instance, given the options that were available, we could end up having a better service now than we would have had under the previous circumstances. It does not change the fact that at some point in time, as things develop, that activity might go back out to a charity at some point. We are going to keep an eye on how this provision works, and if at some point the decision is taken that that might be better provided by a charity, then that is something we would consider. The work that is going on at the moment is work to make sure that we fill the gap.

Deputy P.M. Bailhache :

I asked the previous question really following up a question from the chair as to the period of time for which contracts are given. Would you agree that it is really quite difficult sometimes for charities to operate on the basis of 12-month contracts?

The Minister for Health and Social Services:

It certainly is, and I think one has to also bear in mind the fact that behind the scenes with the economy having changed, with the Ukraine war, with COVID, all of these things have brought about a situation where the money that used to be donated to charities has dried up significantly. I think all charitable sectors are finding that private funding is drying up and increasingly charities are coming under pressure. It may be the case that we are going to see some charitable consolidation, which I think would be no bad thing, which reduces costs and reduces unit costs. That is a possibility going forward. I think that will be a natural progression.

Deputy L.K.F. Stephenson :

Can we just confirm that the political decisions that were taken around this, did you take them as Minister?

The Minister for Health and Social Services:

We took them collectively; we discussed it on a number of different occasions.

When you say "we", is that you and C.O.M. (Council of Ministers) or you and ... politically, not officers?

The Minister for Health and Social Services:

Politically, that is how ... we have got a political team but those decisions are obviously taken in conjunction with the professionals that are providing the background service.

Deputy L.K.F. Stephenson :

At any point was a conflict of interest or potential conflict of interest raised around your ...?

The Minister for Health and Social Services: Which conflict of interest?

Deputy L.K.F. Stephenson :

... your involvement with a mental health charity.

The Minister for Health and Social Services:

Everybody seems obsessed that I support a mental health charity. No. I have said time and again there are no conflicts of interest. I have been to the commissioner and I have had the commissioner write to me to confirm that he is very happy about the way things are done. I know everybody seems obsessed ... every time I come here I get asked questions about conflict of interest. There are not any.

Deputy L.K.F. Stephenson :

It is an important thing and there are also perceived conflicts of interest.

The Minister for Health and Social Services:

As long as I tell everybody every time the question is asked, there are no conflicts of interest.

Deputy L.K.F. Stephenson :

So for the record there was non-declared in the decision-making process ... you did not declare a conflict or potential conflict of interest.

The Minister for Health and Social Services:

I do not need to declare a conflict of interest because everybody that I deal with knows full well and we are frequently reminded.

Just in terms of conflict of interest, the code of conduct is quite clear that even perception of a conflict of interest, something that might be perceived as a conflict by a reasonable member of the public, should be declared and that is best practice. So I would hope that you take that on board.

The Minister for Health and Social Services:

I thank you for the reminder but I have been to see the commissioner and had it confirmed back ... I can forward the letter to you, if you wish.

Deputy L.M.C. Doublet :

Please do, yes, thank you. Thank you for your answers. We are going to move on to the dementia strategy and implementation plan. I believe that you are here to assist with the answers, Andy. The implementation plan for the dementia strategy states that funding would be required to deliver and develop a proposal for a "brain health island plan" by March 2025. Has sufficient funding, Minister, been allocated to meet this target date of delivery?

The Minister for Health and Social Services:

Well, the budget for next year has not actually been defined yet, so that is a process that is taking place between now and Christmas. That will be defined at Christmas when we will know where we are at.

Deputy L.M.C. Doublet :

So if the Budget, as it is in draft form, if that is approved ... with all of your bids that made it into the Budget, if that is approved, is that sufficient funding to meet that target date of March next year?

The Minister for Health and Social Services:

Like I say, those decisions have not been made in detail. They are being made over the course of the next 12 weeks, 14 weeks, so we will know what that budget is when there is a breakdown at Christmas.

Deputy L.M.C. Doublet :

Okay, I will just ask that again. So if the Budget is approved, does it contain sufficient funding to meet the target date of March 2025?

The Minister for Health and Social Services:

And I will repeat my answer. If we are going to have a budget of X amount of money, the division of that money takes place between now and Christmas and at Christmas we will be in position to let you know as best as to what there will be available and what that is going to achieve. I am hopeful.

Deputy L.M.C. Doublet :

So when you go through the process of allocating growth bids in the Council of Ministers, you have obviously made growth bids, one of those is around the dementia strategy, is that correct?

The Minister for Health and Social Services:

It forms a part of quite a complex budget process, yes.

Deputy L.M.C. Doublet :

If that is approved by States Members, are you confident that that is sufficient funding to deliver the dementia strategy by March next year?

The Minister for Health and Social Services: Insofar as we have committed to it, I am hopeful.

Deputy L.M.C. Doublet : Is that a yes or a no?

The Minister for Health and Social Services: It is a hopeful.

Deputy L.M.C. Doublet :

I would like a yes or a no, please.

The Minister for Health and Social Services:

I am hopeful that we can deliver that. I mean in answer to the question ... I really do not know how to answer your questions. I am hopeful that we are going to get that situation. That is as far as I am prepared to go.

Deputy J. Renouf :

The memory assessment service does not rely on money being allocated in the Budget because there is a target to get to 6 weeks' waiting time by October this year; are you on target to get that waiting list down?

The Minister for Health and Social Services:

To the best of my knowledge, I think that has been exceeded. I will pass you on to Andy for details.

Director, Mental Health, Social Care and Community Services:

The team have done a superb job. We did a piece of work in the early part of the year where we looked at a trajectory for delivery against this objective. We have put in a small amount of additional resource and crucially the team have worked differently in order to achieve the target. We are now at the end of August and we have gone from ... in December we had 171 people waiting and they were waiting for 124 days, at the end of August we have got 66 people waiting and they are waiting for 53 days. So we have achieved that in advance of October and I am confident we will sustain that delivery.

Deputy J. Renouf :

Thank you, that is great news.

Deputy L.M.C. Doublet :

Could you give your view, Andy, on the March 2025 delivery date? Do you think that is achievable with the funding that is being bid for?

Director, Mental Health, Social Care and Community Services:

I think that the implementation plan sets out against each of the 20 actions where money is either available now and things can be done within resource or where additional resource is going to be required. The biggest one actually is one of the ones that you picked, which is the delivery of the whole brain health service, which is far bigger than anything that we have got now. My understanding of the plan is that we would develop the model by the end of March, and then we will need to cost that and understand what does that look like. So I think realistically, because of the way that things work, we would probably start to plan for an implementation date of next year for that service. Also, there are other tricky factors like staffing it, and all of that other stuff that comes with new services. But I think for each of these actions, some of them can just be done, like the reduction in the waiting list, that we do not need additional resource. Some of them we are going to need to plan that resource over the implementation period of the strategy.

Deputy L.M.C. Doublet :

I know that you have spoken recently about the increase in demand for these services. How much of an understanding does the department have in terms of what that increase in demand will look like? How able are you to plan for that in advance?

Director, Mental Health, Social Care and Community Services:

We have got figures - our colleagues in planning did some good work as part of the strategy - giving us what we think the dementia trajectory looks like. What we really need to start to unpick now, and include it in the strategy, is what does the workforce plan look like in association with that? In 20 years' time, if the number of people with dementia on the Island has doubled ... we are creaking now

in terms of particularly social care workforce. How are we going to make that work in 20 years' time? That is the type of work I think that goes beyond the timeframe of this strategy, but is so important in terms of delivering moving forward.

Deputy L.M.C. Doublet :

One of the things that I am interested in is family carers, and the training was due to begin last month, I believe. How is that going?

Director, Mental Health, Social Care and Community Services:

I do not know actually and I will find out and let you know. Some of the stuff that is delivered in this strategy is delivered by partners. It is not everything by H.C.S. clearly. I will get a specific answer for you on the training. I spoke to the chief executive of Dementia Jersey recently and she was talking to me about they have got a new training offered, but I cannot be confident as to exactly where it is at.

Deputy L.M.C. Doublet : Okay.

Deputy J. Renouf :

Can you provide an update on the development of the new integrated model for the Dementia Health and Social Care Service and, in particular, whether you have funding for it?

Director, Mental Health, Social Care and Community Services:

We have only just started that piece of work. To contextualise this, there is a programme lead who is employed specifically to deliver those 20 things in the scope of the implementation plan. She has been obviously prioritising the work and trying to get things up and running, particularly with partners, and there is an overarching steering group that looks after this, but we have only just started the work on the model. We have got funding now because we deliver dementia services now, so we have bespoke dementia services, we have dementia services delivered from within the community mental health team for older people particularly, we have funding for some charitable work. So there is money in the pot. What the new model will look like and whether that is entirely funded by what is available today, we do not know until we have done the work. But I think it is the thing, particularly the carers that were involved in the development of the dementia strategy, that they most talked about really. The model in terms of how we divide up services and deliver them currently does not really work for carers and they particularly push us - very correctly, I think, in the Steering Group - to talk about how can we do this in a more co-ordinated way.

Deputy J. Renouf :

What is your timetable if that work has only just begun?

Director, Mental Health, Social Care and Community Services:

Let us have a look and see what is in the plan. Could you point me to it? Okay, so it is by May 2025. The model says that we will develop a new integrated model across health and social care that embeds continuity support for people - that is a helpful point to make - by May of next year. That continuity of support is particularly the thing that people most spoke about.

Deputy J. Renouf :

Are you on track for that?

Director, Mental Health, Social Care and Community Services:

We have started the work. I am sure that we can have a model developed by May next year.

Deputy L.M.C. Doublet :

In terms of the organisations that will partner with Government, you have just mentioned, Andy, that they would be critical. Minister, what work can you do now, maybe taking some learning from the Recovery College, to make sure that those organisations have all the support they need to deliver, in partnership with Government, some of these services?

The Minister for Health and Social Services: Are you talking the general charitable services?

Deputy L.M.C. Doublet : Dementia organisations.

The Minister for Health and Social Services:

As I say, I do not think we have got a similar situation with the dementia charity in any event. Not to my knowledge, I think that is all very secure.

Deputy L.M.C. Doublet :

I am talking more prevention of a similar ...

The Minister for Health and Social Services:

Well, I do not consider there is any particular problem to address at this point in time.

Deputy L.K.F. Stephenson :

So, Jersey Recovery College, if I understand correctly, it was created off the back of a government strategy and piece of work, and I think, if I am getting it right, the question is more what lessons can we learn from that process going forward with things like the dementia strategy to ensure we do not set up an organisation that then fails again a few years later.

The Minister for Health and Social Services:

I am obviously not able to answer your questions correctly. If we have a dementia charity that seems to be very stable and doing good work at the moment, I think we have got other things to do other than to worry about what may or may not happen in the future. It seems quite sound to me. We are under a lot of pressure in a lot of other areas, so it is not ... I have to say, perhaps I am wrong, but it is not an area of focus for me at this point.

Deputy L.M.C. Doublet :

So you have not identified anything that you ...

The Minister for Health and Social Services: No, I have not.

Deputy L.M.C. Doublet : ... can learn from this?

The Minister for Health and Social Services: No.

Deputy J. Renouf :

You were going to, I think, submit a bid from Digital Jersey for assistive technology. I just wondered whether that had been done and what stage that bid had reached in terms of being successful or not.

Director, Mental Health, Social Care and Community Services:

I am sorry to say I cannot answer that off the top of my head, so I need to go and check. That was being done jointly with Dementia Jersey, so I need to go and check what happened.

Deputy L.M.C. Doublet :

Okay, thank you. We do have some more questions on dementia, but we will send them to you because we need to save the time in the hearing. I would like to ask some questions about the recent announcements you made, Minister, about the restructuring of Jersey's healthcare system. Could you advise about the manner in which they were announced? Why were the plans not announced to the States Assembly and Scrutiny, in the first instance.

The Minister for Health and Social Services:

I thought I had mentioned in the Assembly that they were not really in a fit state to be announced and I confirmed that once they were then they would be announced through the formal processes. They go to Council of Ministers, they come to you, then they go to the Assembly, then they will be made public.

Deputy J. Renouf :

I am interested in the process that you have gone through there. Could you talk us through the process you are going through in relation to those restructuring proposals? There must be a series of steps.

The Minister for Health and Social Services:

There are a series of steps. I have been in office for 8 months. Over the course of time, I have made some observations. Those observations are built up over the course of time.

[14:30]

They have started to build a picture. Once I got the bones of the picture as to what I thought was right, I started to have discussions with my policy officer, Ruth, and we have been, in conjunction with the Assistant Ministers, developing them ever since, and that is where we are at the moment. We are in further stages of development.

Deputy J. Renouf :

Is there something that can be written down and seen in a set of proposals?

The Minister for Health and Social Services:

It is taking shape. You do not wake up one morning and suddenly have a ready-to-go strategy, do you? No, it would be nice if we did; it would make life a lot easier. This is an evolving process, and when you are trying to reshuffle these to make them more efficient, what you find quite quickly is that this element might not work or this element is going to create a problem, then you have got to deal with that, you have got to go and talk to the people that may or may not be affected by it, you have got to work out what the consequences are. As you know, I have shared my views as I have gone along, when people have said to me at any point in time: "What are your current views?" I am quite happy to sit and talk about the direction of travel. As you know, I was asked to do that at a conference in the Town Hall and I gave a series of observations and, at that point in time, I said at this point this is what it is starting to look like. I think for me that is good open politics, is it not?

Deputy J. Renouf :

You said in the Assembly that you were undertaking a consultation, that you are now consulting around these proposals. Can you describe what form that consultation is taking?

The Minister for Health and Social Services:

At the moment it is basically talking to the senior leadership team at H.C.S. We started talking to G.P.s (general practitioners), we will talk to 2 or 3 people in the larger charities to start with and say it is not a formal process, this is basically ironing out the areas that we think are of concern so that we can come up with something that when we do start a formal process we have got something that is credible.

Deputy J. Renouf :

So what is being consulted on? Is there a written set of proposals that are being consulted on?

The Minister for Health and Social Services:

Yes, we have got a small set of slides that indicate the direction of travel.

Deputy J. Renouf :

Would it be possible to share those with the ...?

The Minister for Health and Social Services: I thought we had a briefing organised.

Director, Health Policy:

We do have a briefing in diaries with the Scrutiny Panel. I believe it is on 4th October. It might just help to understand that what we have is we have a very small - I think it is 3 slides - which are an initial concept. What the Minister has been doing is testing that initial concept with a very small group of key stakeholders and once that initial concept has been tested then we will be moving to wider consultation with other providers, with staff in the department and obviously with Council of Ministers and informing Scrutiny, and that is the reason why there is a date in the diary to come talk to you on 4th October, because we are confident at that stage we will have gone through that initial concept testing.

The Minister for Health and Social Services:

It will not be the finished product but it will be hopefully fairly close; it will be the bones of it.

Deputy L.M.C. Doublet :

How do your proposals sit with the announcement by the Assistant Chief Minister in the Assembly about cutting management posts?

The Minister for Health and Social Services:

To be honest with you, until we have got it finalised we will not be able to analyse that properly but that will be a process that we will go through when the time comes.

Deputy L.M.C. Doublet :

Do you believe that there is scope to do so within Health?

The Minister for Health and Social Services:

I think there has to be really. We will have to make a good case for it. I think that what we are planning on should actually make things a little bit more representative, a little bit more efficient over the course of time. One of the meetings recently I said to the people we are talking to: "If you are designing a health service would you design the one that we have got now?" and the answer I think unanimously was no. I think that leaves us to suggest that it might be time for a review.

Deputy L.M.C. Doublet :

Are there any particular roles that you have identified as the Minister at the moment that you think you would be considering for changing?

The Minister for Health and Social Services:

I think the overarching difference at the moment is that what I would like to see is somebody as a chief executive of an entire health service rather than just H.C.S. Their terms of reference would be to provide a holistic single, seamless, integrated health service.

Deputy L.M.C. Doublet :

So this would be a new role?

The Minister for Health and Social Services: Yes.

Deputy L.M.C. Doublet :

Could you compare how it differs from the current structure?

The Minister for Health and Social Services:

As I say, we are not really quite decided as to the exact role models, whether the person at the moment that would run H.C.S. moves up. We just have that board still reporting through to that or to introduce an additional ... not a different tier, but somebody who also works as a co-ordinator at that level. That is the sort of analysis that we are doing at the moment. But I think the important thing to say is that the overall difference is that I want to put a representative body or board together, which reflects the composition of health in terms of public health, charitable sector, primary care, and H.C.S. with somebody charged. Some of it may have to become statutory in order for it to be workable.

Deputy L.M.C. Doublet :

Sure, and how would the interim chief nurse fit in with that?

The Minister for Health and Social Services:

That is still to be decided as to whether there would be an overall Island chief nurse or we would stick with the model we have got. These are the discussions that are happening now. You can appreciate that they are quite important issues to get right before we go public with any model.

Deputy J. Renouf :

Could you be clear about the future of the Health Board? We currently have an advisory board, it is up for review. What you are suggesting is, it seems to me, a new role in that; a new chief officer role, and a new legal institution.

The Minister for Health and Social Services:

It is a shame we have not got the slides, if we had done briefing first we could have discussed it. No, the advisory board remains the advisory board. At this point in time they are an advisory board to H.C.S. There is no plan to change that.

Deputy J. Renouf : So it is a new board?

The Minister for Health and Social Services:

This is more like an operations board. This is basically the team level with H.C.S., working with primary care, charitable sector and public health.

Deputy J. Renouf : And care services?

The Minister for Health and Social Services:

Yes, the whole thing. Like I say, we really want to try and have a more integrated health service.

Deputy L.K.F. Stephenson :

Appreciating that it is early days and things you have explained about the process so far, could you give us a bit of insight into the evidence base that you are using to move forward from and how the key stakeholders, the small group of stakeholders that you are going to engage with first, how they have been chosen?

The Minister for Health and Social Services:

Right, what are the motivations? I keep quoting the same sorts of things but at the moment the interaction between the various parties is sometimes a bit fractured and sometimes a bit fractious. I think we all witnessed G.P.s' primary care not having an uplift in their subsidy from the state over a 10-year period, and I think that was detrimental. I think that we ended up with a situation 18 months ago where the cost of going to a GP, I think, was £70. I think people with limited means probably would avoid going to the doctor. If you avoid going to the doctor and you are not well and things get worse, people end up in secondary care and costing an awful lot more to put right than they would have done if they had have gone to the doctor, as they can at the moment, for £10. But that issue took 10 years to resolve. We do not want to be in a position where that happens again. Similarly, I do not mind saying when I came to office, the idea was family nursing was going to go out to ... their service was going to go out to tender in the U.K. to see if we could get better value. On an Island of 100,000 people that made no sense to me at all. I thought it was destabilising. That is just a political view and it may not be shared by everybody, but it seemed to me to be a little bit pointless and I think we can do commissioning better.

Deputy L.K.F. Stephenson :

So they are some of your stakeholders?

The Minister for Health and Social Services:

Those are the sort of things that led me ... and I am looking at Public Health, and I am going to say I have only been in post 8 months but I am led to believe that Public Health does tend to shrink and grow at various times and it has not really got a stable role in things. I would like that to be stabilised, I would like their budget to be, I would like to see what they do to be recognised and continuous and stable. Those are the sort of things I am trying to achieve.

Deputy L.K.F. Stephenson :

So there is no kind of formal evidence-based data that you are using to move on from; it is listening, learning, talking to people?

As a layperson, and I am afraid I am a layperson, I can only go with what I see, and as a politician that is what I think you are supposed to do, is it not? Look and recognise what you are dealing with and do your best to put the bits together and try and take as much guidance as you can from the people.

Deputy L.K.F. Stephenson :

With the support of your officers who have lots of data.

The Minister for Health and Social Services:

Absolutely. We have discussed this with the officers and, like I say, I have made it very, very plain to people nothing is cast in tablets of stone, so if anybody has got any concerns, they can put their ideas in.

Deputy L.M.C. Doublet :

What has been the advice from your officers about all of these ideas that you have?

The Minister for Health and Social Services:

I think in principle, I think the principle is welcome. A number of people have pointed and said: "You have got this to think about, you have got that to think about", and that is the whole purpose of going to the people at the most senior level at this point in time, because they are the ones that have got the longest perspective on things.

Deputy L.M.C. Doublet :

What has been raised in terms of those things, can you give us some examples?

The Minister for Health and Social Services:

Yes, for example, introducing ... taking somebody to run the whole issue starts to create potential problems in H.S.C. about people's grades and levels, and that could be a complication. So we have to find a way around that, because we do not want to demote anybody and we do not want to offend anybody. That would be very, very counterproductive at the beginning of the process. Those are the awkward things that we are wrestling with.

Deputy J. Renouf :

Can I just confirm, you said that you were listening to these consultation opinions and so on. If there was a strong view expressed the significant part of that proposal that you had come up with needed to change, you would be prepared to change it?

Yes, I think we have already got ... I think it is safe to say that we have already ... I think we modify something virtually every time we talk to somebody.

Director, Health Policy:

We have developed an initial concept. That concept is based on evidence. From a policy perspective, we have looked at other jurisdictions and what models of good and effective change look like in other jurisdictions. We have looked at what a proposed new structure for the system looks like. We have put that on a piece of paper. We have tested that with a very small group of people. So executive leaders of the department and the 5 G.P.s who make up the Primary Care Board. It has not gone beyond that at the moment. They have given us feedback. We have made some significant changes to the model based on that feedback. Once we have gone through that initial concept testing, we will be rolling out to a wider consultation. As ever, we do listen to what people say and reflect that back.

The Minister for Health and Social Services:

We have also spoken to Public Health at some length as well. They have had their input.

Director, Health Policy:

Yes, so the executive leadership teams of the teams that Tom is responsible for, so Health, Public Health, and de facto health policy.

Deputy J. Renouf :

So that will be a formal consultation?

Director, Health Policy:

There will be a formal consultation, yes. At the moment we are testing a concept before moving to formal consultation.

The Minister for Health and Social Services:

We are going as quickly as we can because ... Ruth is under a lot of pressure, as you probably know, because we would like to get this done, if we can, and implemented within this parliamentary period.

Deputy L.M.C. Doublet :

Minister, you mentioned things being perhaps delicate and having a sensitivity around that. I wanted to ask you about the cultural issues and governance challenges. How are you managing those and ensuring that there is improvement and change there while this restructuring is happening?

On the day-to-day side of things, I am comfortable that those issues are in the process of being dealt with. Some of them are quite long-standing and I think they will take quite a long time to move, but they are moving in the right direction. I sometimes think when you bring about structural organisational change, that is a good stimulus. It is a good point at which you can get some of those things to come together because, as I say, you are sort of moving the furniture around a little bit. I think it just makes people feel that they can move in a different direction.

Deputy L.M.C. Doublet :

Do you have any experts in this area advising you? Aside from your officers of course, any additional experts?

The Minister for Health and Social Services:

I am comfortable that we have got a good collection of people. We have been lucky, we have now got a new deputy medical director who is - I do not mind saying - proving very effective as well. It is a very, very good addition to an already good team.

Assistant Minister for Health and Social Services:

Can I just say, I think the advisory board are also very helpful? We are listening to what they say as well.

The Minister for Health and Social Services:

We have got a session booked with them tomorrow, I think. We have got a team session with them tomorrow to go through the details. We are being quite thorough. I think you can appreciate that there is a need to be thorough before we start going and standing on a mat and broadcasting what we are doing. It is a pretty serious set of changes if they happen.

Deputy J. Renouf :

I have in mind the reforms in the U.K., which Chris will be very familiar with. In 2012, the Lansley reforms, which are still being quoted only earlier this month, as a disastrous example of health service reorganisation.

The Minister for Health and Social Services: Nice of you to choose something negative.

Deputy J. Renouf :

The potential for politically-inspired reforms to go wrong is certainly there. I am sure Chris has seen the effects of that, so I think it feels appropriate that this should be subjected to pretty searching analysis.

The Minister for Health and Social Services:

That is why we are taking our time. It is a great shame you could not have picked a successful alternative to bring up, but there you go. Such is life.

Deputy L.M.C. Doublet :

We wish you success, of course.

The Minister for Health and Social Services: Thank you.

Deputy L.M.C. Doublet :

In terms of the costs in the short term, my understanding is that you are hoping to achieve savings in the long term with this restructuring, am I correct?

The Minister for Health and Social Services:

No, I do not think we would go as far as to say that. What I am hopeful is in the long term it will help with efficiency. The extent to which those efficiencies can deliver savings is yet to be seen, but you would hope that it might. What you really want, even if you do not get savings, is you would like to think that it would eventually deliver perhaps a yet more effective service than we have at the moment. It is a combination of goals. If you can make it cheaper and more efficient, fine. But if nothing else, if it just helps to speed things up, reduce waiting lists, make things more efficient and more balanced, so we do not get these imbalances that we have seen in the past that I think have been quite dangerous and quite damaging.

Deputy L.M.C. Doublet :

Thank you for outlining your vision to us for the long term.

[14:45]

But in the short term, what will the costs be of implementing this restructure?

The Minister for Health and Social Services:

To be fair, I do not think we have identified anything particularly at this point in time. We are doing all of this within the resources. Sometimes people stay late after work to have discussions with us,

so we have put in a lot of overtime. We are actually trying to do it within the resources that we have got. Once we have got a final model, we can look at it and say: "Well, this may be plus or minus."

Deputy L.M.C. Doublet :

Are you able to advise us if there will be a cost?

Director, Health Policy:

Where we are at this point in the process, we have not done a full costing because we do not have a settled proposal against which to cost. But obviously we will do a forecasting at the point at which we have got a settled proposal that we wish to go out to consultation on. As things stand at the moment, the additional costs associated with the concept we have at the moment, which might not be the one that goes forward, they are relatively minimal. Those costs would arise with regard to some potential changes to a very small number of senior roles. There would be some additionality within that, some additional roles. Also, as Tom has said, one of the things that the concept hinges on at the moment is the development of a partnership board so that other partners have a say in decision-making around healthcare strategy and the services that are required. There is a recognition that those partners would need to be remunerated for their contribution. So there will be a cost associated with that as well. But at the point at which we have a firm concept that we wish to roll out, we will also have the costs alongside that as well.

Deputy L.M.C. Doublet :

Does someone want to ask a final question in that section? Fine. Assistant Minister, I believe you were trying to say something earlier. Would you like to say something?

Assistant Minister for Health and Social Services:

No, I think we were just also trying to make the healthcare on the Island seamless, so that there is better communication between primary care and secondary care, and everybody is working together.

The Minister for Health and Social Services:

One final point is I think we need to step up our efforts in the digital area. I think we need more money because I think the more I look at it, the more important it seems to me that everything is interconnected. So we will be looking for more money for digital work.

Deputy L.M.C. Doublet :

Yes, we might come back to that. Thank you. Related is the Health Board announcement that you have appointed a new member of the Health Board. Could you explain why that appointment has taken place when previously you expressed that the board was perhaps not necessary?

The Minister for Health and Social Services:

No, that is not correct. I seem to remember making the point at the time when the board was first mooted that it was early days to be putting a board in place but since its implementation I have not said that it is unnecessary. I found it very useful, to be honest with you. I think, because the finances had found themselves in a bit of a muddle and a significant amount of work has been done to make sure we have clarity on the finances, it made sense to appoint somebody who was more specialised in finance on that board. That was the reason for ... the place existed. We were supposed to have somebody there that is centred on finance, so we thought we would go ahead and include.

Deputy J. Renouf :

I have in mind that in April, I think it was, you said when the chair of the board left, that you would not appoint a replacement because there was not time, because the future of the board was going to be replaced, and that person still has not been replaced.

The Minister for Health and Social Services: That is the chair.

Deputy J. Renouf :

But you feel that there is enough ... there is a time to replace the members of the board.

The Minister for Health and Social Services:

I think the job of the chair is perhaps slightly different. It is more onerous, more time consuming and more of a commitment, so it seemed to make sense to do that.

Deputy J. Renouf :

So you still have no intention to appoint a chair?

The Minister for Health and Social Services:

I think the review comes up fairly soon on the board and at that point in time probably will.

Deputy L.M.C. Doublet :

Minister, you said that you do value the board. Are you engaging with them and how is that engagement happening?

The Minister for Health and Social Services:

We engage with them as much as we can. You have got to bear in mind in an ideal scenario they would not ... at this point in time because ... we are not in a position of turbulence but there is an awful lot going on at H.C.S. I think in the longer term as things are a bit more settled they probably have less involvement. At the moment there is quite a lot of day-to-day comings and goings with the board which they are probably finding unexpected. I do not think they find Jersey is a typical board situation for them.

Deputy L.M.C. Doublet : Can you give an example?

The Minister for Health and Social Services:

I think Jersey is quite different to the U.K. in it is 100,000 people. People get more involved. I think people ... most members of the public have sort of direct contact and I do not think they are used to the extent and level of involvement they have found themselves in. Hopefully that is going to stabilise over the course of time. But coming back to your question, we have phone calls, occasional Teams meetings, and meetings away from the board when they come over.

Deputy L.M.C. Doublet :

Can you give an example of something that the board has advised that you have actioned recently?

The Minister for Health and Social Services:

If you had asked me before ... off the top of my head, I am trying to think it through, probably not. But I can tell you there have been a number of different things where they have either phoned me and said: "What about this?" Or I have phoned them and asked for a bit of advice on a number of things. Without quoting off the top of my head, there have been a number of times when I have been very pleased to be able to reference them.

Deputy L.M.C. Doublet :

Would the officers recall any of those instances?

Director, Health Policy:

Not off the top of my head but I can certainly provide you some information. I think if it would be useful, as you know, it was always intended that there would be a review of the board ahead of a States Assembly decision as to whether or not they should continue. The States will be making that decision in April, May time next year. One of the things that we are working for now is the board evaluation process in order to be able to demonstrate value to the States Assembly to inform their decision-making. That is being worked up at the moment. When it is ready, we certainly share that with the panel.

Deputy L.M.C. Doublet :

Yes, please do. Thank you. Any more questions on the board?

The Minister for Health and Social Services:

I am just wondering, given that we have got Chris here, if you would like to speak to Chris about the useful ...

Chief Officer:

About the usefulness of the H.C.S. board?

Deputy L.M.C. Doublet :

Briefly, if you can. I am just noting the time.

Chief Officer:

To put it briefly, I think it is essential. It is an essential mechanism for holding the organisation to account. It also enables us to bring skills into the debate that otherwise we probably would not be able to attract, which would be typical of a benefit that you would see in N.H.S. (National Health Service) boards. But I think the fact that it holds people to account, that we hold our meetings in public, has given some great benefit to that and provides a discipline of accountability that would not otherwise be there.

Assistant Minister for Health and Social Services:

Can I just add that we really appreciate the expertise of the advisory board and we are extremely lucky to have them? We have to thank them very much.

Deputy L.M.C. Doublet :

Thank you, I am sure they will be pleased to hear that from you, Ministers. We are going to move on to some questions around the proposed Budget now. Minister, please could you talk us through how the budget allocations for the various expenditure and service levels within H.C.S. were determined by yourself and your team.

The Minister for Health and Social Services:

To be honest with you, I would like to hand that because I ...

Deputy L.M.C. Doublet :

If you could start with an overview and then, sure, we can hand over.

The Minister for Health and Social Services:

I have to say that the finances are complex. There is still some degree of uncertainty about certain elements of them and I have just taken the advice that I have taken from the team; that is Obi, as you know, the turnaround manager and the remainder of the team. I have not been involved in intimate breakdowns of those budgets, to be quite honest with you.

Deputy L.M.C. Doublet :

In terms of your political vision, you have outlined your long-term political vision - that is becoming clearer - what do you see as the main priorities for H.C.S. that are within the budget?

The Minister for Health and Social Services: In terms of the functions?

Deputy J. Renouf :

Which bits do you feel are the priority ... your vision needs funding. You have put in for extra funding. To what extent are you matching the vision to the funding?

The Minister for Health and Social Services:

The extra funding and, as I say, I will draw on the professionals for this, is to actually fund the work that is being done that would have been committed to beforehand. There is nothing extra that is going to be put into place this year or next with the budget that we have got. The budget that we have actually asked for will barely cover the expenditure that we have got. We are still finding expenditures that were not accounted for, or some accounting processes that were not perhaps as sharp as they should have been, which are putting us under pressure. From my point of view, what I was hoping we were going to do, and I am fairly comfortable with what we have done, is provide a baseline where instead of coming back for lots of money every year, we actually understand what it needs to run in 2024 and 2025, and that becomes our baseline funding going forward, bearing in mind that health inflation is constantly outstripping standard inflation. We have got the added difficulty coping with initiatives that come in, not that they are wrong, but I.V.F. (in-vitro fertilisation) funding brings in another requirement to suddenly find another three-quarters of a million. Assisted dying brings in another layer of expense, as do expensive drugs, as Catria(?), I think, is one. I think it is £120,000 a person. There are now going to be 3 people, that is another third of a million pounds. You have got all of those additional stresses on top of the fact that health inflation generally is running in advance of ordinary inflation.

Deputy L.M.C. Doublet :

When you say "health inflation", do you mean the fact that there is more need among the public?

The Minister for Health and Social Services:

It is a number of different factors, not least of which is the cost of drugs are going up beyond the cost of inflation. I am sure Chris can come in on this, the cost of care in the U.K., health services are in short supply, and people providing health services are in a position to put their rates up. It would be useful to hand over to Chris, who has got a little bit more intimate knowledge. But I think some costs have gone up between 20 per cent and 40 per cent. These are very, very difficult to cope with. As I say, if we can establish a base budget and we can articulate what is happening over and above that, we can then come to the Assembly and say: "This is the reality of the situation." I am not looking to shuffle around the work that is being ... the work that is being done I think is fine. Those are the areas of work that we will carry on doing. What I am trying to do is get stability into the situation and a point where we know what we are doing with the finances and what is going to be required in the future because we may have to look at different funding models over the course of time.

Assistant Minister for Health and Social Services:

We are literally having to pay for all this wonderful staff who are doing their jobs to look after the patients and all that goes with it, physical health and mental health.

The Minister for Health and Social Services:

And we have got an ageing population and the balance between working and non-working people. We are going to have a higher instance of dementia. These are all things that are going to play havoc with having a stable, balanced budget. In answer to your original question, I was not trying to be facetious. I do not get involved in trying to chop things around or having to move things in different directions. So I accept that the work that we are doing is good and what is currently being delivered is going to be delivered. We can sharpen up on any of those things, fine, but we are really trying to find balance and clarity going forward. It is worth, I think, handing over to Chris to articulate some of those things.

Deputy J. Renouf :

I will be very interested to hearing Chris on some of those details but just at the political level, in a way you are the big winner in the Budget. You have got a lot more money than anybody else. The baseline that you keep talking about, the extra funding you requested crept up during the year. Are you confident that you now have that baseline and that when you come back to the Assembly it will be for those incremental increases due to inflation and demand? Not that there is some big black hole.

The Minister for Health and Social Services:

I think any black holes, 95 per cent of them will be found. I have to say, since I stood up in the Assembly and made that statement, Obi has come back with another couple of problems that he has found, because this whole time he is dredging through every area of the finances . However, what he has said and what we are going to endeavour to do is to make sure that even those anomalies are dealt with within the budget that we have asked for, that is going to take a lot of fine- tuning. Believe me there is an awful lot of work going on to cut corners everywhere we can. So the intention is to try and stabilise that money that has been asked for because, as you say, people run out of tolerance. When you say we have been the beneficiaries in this Budget, this is true, but I like to think it is the Island that has been the beneficiary of that because the health service is for everybody.

Deputy L.M.C. Doublet :

I would like to understand how this would look for service delivery. What will the public see? You mentioned that the bids that are currently in, if they are approved by the Assembly, will still only barely cover the expenses of your department. What does that look like in terms of service delivery and quality of service?

The Minister for Health and Social Services:

You have got a team of people that are ... we have had the turnaround team now for quite some time, that has been embedded. Some of those changes are going to, over the course of time, hopefully result in things being a little bit clearer and a little bit more efficient. Hopefully over the course of time waiting lists will come down and the service will become more efficient because of the constant effort that has been made by the senior team and all the people that work with them.

Assistant Minister for Health and Social Services:

But there have perhaps been on occasions in the past when money was taken for the H.I.F. (Health Insurance Fund) but it was not actually used to pay for what they said it was going to be paid for.

[15:00]

It has paid for salaries, for example. So there has been a great deal of work for Obi to try to work it out. I think a lot of it had gone back centrally, the finances, and it has been really hard to unpick.

Deputy L.M.C. Doublet :

Minister, would you like Chris to add some?

The Minister for Health and Social Services: I think Chris could add some useful comments.

Chief Officer:

Mark can give you some of the numbers because he has got them in front of him, but I think if you look at 2025, so the Government Plan for 2025, as you say we are looking at a situation where those costs or that budget will cover the existing service. The only additional funding we have is for I.V.F., and so the process of there was no government planning process as such in the past that you ... I think, Chair, you alluded to the submission of business cases. That process did not exist this year for next. So the funding that we have got, which covers pay increases, some inflation and various other things, and Mark can talk about what those numbers are, but this will only enable us to continue to deliver what we are delivering this year; so no great change next year. This year we were looking to deliver a deficit of some £24 million. The month 7 results, we felt that there was a risk to that and if we did not put in place further mitigating saving actions we could be at £29 million. This is largely due to, and the Minister has alluded to this as well, seeing some increase in drugs but also packages of care where it is exceeding even our pessimistic forecast. We are looking this year to maintain a deficit of £24 million, we are looking in addition to the original financial recovery plan of some £8 million; I think that is right, is it not, Mark?

Deputy Head, Finance Business Partnering for Health: Yes.

Chief Officer:

We are looking for another £5 million so we can keep at that £24 million. We are not going to see significant change. It was mentioned about management costs. We have included in the 2025 plan a reduction of just over £500,000 in management costs. We agreed that as a senior leadership team recently. But as regards to service change and development, all developments will have to be done within the existing resources that we have. I think, again, that the Minister mentioned that, and Obi Hasan and I have often said that of course the financial recovery plan and efficiencies alone will not be sufficient to close the ever-increasing gap between the costs of healthcare. I was going to say in Jersey, but across the world. It is a global challenge, is it not? There will have to be, in my view, a conversation and debate - a political one - about how healthcare is funded in Jersey over the coming years. It is a debate, obviously, that the U.K. and other jurisdictions are having as well, but it is while we can continue to make savings that there will be a limit to that. The financial recovery plan is delivering, actually we are expecting to over-deliver this year on our financial recovery plan savings but, as I say, the costs that we are seeing, which are not uncommon across other jurisdictions are causing significant pressures. I do not know, Mark, if you want to add to that?

Deputy L.M.C. Doublet :

Can I just say, thank you, that was really interesting and helpful? What I would like to understand, the £24 million deficit that was just quoted - and perhaps Mark actually might be the person to help me understand this - it is my understanding that the budget had to be balanced, so how is it that there can be a deficit within the Public Finances Law?

Deputy Head, Finance Business Partnering for Health:

You are correct, in terms of the Public Finances Law does state that government departments have to manage within their allocated budget. It is a fact that within the Government that within year it is possible to allocate from central reserves or move allocations between heads of expenditure. Those discussions are ongoing with the Treasury around how the £24 million deficit will be managed within the year. In terms of the 2025 allocation, just to give some context, the 2025 Budget allocation for the department is set at £322 million per the Government Plan, which includes an allocation of deficit funding of just under £30 million. That is actually less than we are projecting to spend this year, so the deficit position this year of £24 million is a spend of £329 million. We start 2025 with a lower budget than the actual out-turn for 2024. 2024 was a similar situation, in that the Government Plan had already allocated the 2024 budget ... so the decision-making processes over the course of 2023, yet we had to rely on an allocation from central reserves to balance the Health budget in 2023 as well.

Deputy L.M.C. Doublet :

Okay. Thank you. Minister, I see you nodding when talking about sustainable health funding. It must not be an easy solution, must it?

The Minister for Health and Social Services: I wish it were.

Deputy L.M.C. Doublet :

But do you see any solutions on the horizon for this deficit, in terms of how we fund our health system?

The Minister for Health and Social Services:

As I say, we are going through a period of stabilisation at the moment and gaining more clarity, and I am sure that probably 6 months from now we should have total clarity and know exactly where we are, so that everything that goes forward can be analysed and assessed. Hopefully, we can then start to predict more accurately from our new baseline. When we can have a proper trajectory from then on, we need to start talking about ways to fund that. One area that may be of interest is illness prevention; I think that is an area that we need to focus on. I think a lot of places - when I look at the news and read articles - people are saying that we should invest more in upfront healthcare. When we look at comparisons I think Jersey is particularly bad at it. I think we spend more on secondary care here than on primary and preventative work than other places. I think we need to

find a way ... I am not quite sure yet how we are going to do it, but I think we need to change that balance, which is going to need more upfront funding over a period of time so that we can actually start to invest in preventative measures.

Deputy L.M.C. Doublet :

Is that something that the current Council of Ministers will be able to make significant headway with in this term, do you think?

The Minister for Health and Social Services:

That is something that is under discussion. The problem has been recognised ... or the solution has been recognised. I think the need for this is common everywhere; everybody in Health seems to be having the same discussion about trying to get in front of the job rather than tail behind it. But it does require an upfront injection of money in addition to what you need to keep the ship afloat while you are doing it. I think that is why the can has been kicked down the road, as it were, because nobody has really come up with a chunk of money to start doing the job properly. But the worry about not doing that is if you leave everything until the last minute, then the costs of dealing with it increase.

Deputy L.M.C. Doublet :

Where do you think that extra funding should come from? Would it be savings from other departments or do we need to raise more?

The Minister for Health and Social Services:

A few ideas, but I do not think this is the time to sort of ...

Deputy L.M.C. Doublet : Give us one.

The Minister for Health and Social Services:

... make it public. Well, there are not many sources of income, are there? That is it. Increased taxation, savings that we may have, borrowing; that is 3. I think we might be in receipt for some other money as well, but I am sure that has been already pencilled in for other purposes. There is no easy way around this, and that is the decision that we have got to take, and that is the decision that hopefully will come back to the Assembly in the not-too-distant future to make that decision: do we want to put some money up front? If we do, where are we going to get it from, and do people think that is a good way to be spending your money? On a personal level, I think that is where we should be.

Deputy J. Renouf :

Can I just clarify on the deficit question? Is it the case that we have been running deficits and bailing them out from the central reserves - central consolidated funds, basically - but the new budget for next year incorporates those deficits so that in future there will not be a call on those transfers because we have re-based the budget to include that level of funding? Is that the current situation in the budget that has been proposed?

Deputy Head, Finance Business Partnering for Health:

From Treasury's perspective, an assumption that the current deficit will not further increase is included in that piece of work. So identifying that in 2023 and 2024, the department has been underfunded. What is not built into this, other than allocation for maintaining healthcare standards funding of 2 per cent and non-pay inflation, those are really the only year-on-year growth items within this. I think there is an element of uncertainty around some of the cost pressures on the department, such as in the social care sector where people's needs are assessed and Health are required to fund any element of people's long-term care that is over and above the benefit-funded level. That is a pressure that falls on the department that is not fully controllable and the department would have to meet the needs as they are assessed for an individual. So there are elements of expenditure falling on the department that I do not think we could say with any degree of certainty that there will not be further budget pressures in future years. So from Treasury's perspective, this has brought the funding to a realistic level based on what we see in 2023 and 2024, but it is not future-proofed around any further pressures there may be.

The Minister for Health and Social Services:

Could I go one step further and say I think we can guarantee that it is not future-proofed. I think the point to make here is that we are hoping we have got it stable for 2024 and 2025 and that it is the right sum of money, but during the course of that time what we are going to have to try and do is look further down the line and make a real estimate on where we need to go for the next 5 and 10 years. Some of those figures might look quite disturbing. But I think the sooner we can come up with those figures and make them plain, rather than hiding away and then coming up at the end of every year and saying: "We need another chunk of money", I think we need to be on the front foot going forward and saying: "Well for 2026, 2027, if we want to do X, Y and Z, these are the realities and these are the reasons for those realities."

Deputy L.M.C. Doublet :

Would you say this is an urgent priority for you?

The Minister for Health and Social Services:

It is, absolutely. There is a lot of work that has been done. The whole team have been working hard on this for quite some time; they continue to, and we are going to keep the team together for at least another 6 to 9 months, if all goes well. That is what we are looking to try and do to make sure we get right to the bottom of this.

Deputy L.M.C. Doublet :

That level of urgency and the understanding of the problem, is that shared among the Council of Ministers?

The Minister for Health and Social Services:

To the extent that they have all got their own work to do, but we do update periodically and yes, I think that is known.

Assistant Minister for Health and Social Services:

It is just, unfortunately, the environment needs money for climate change and every department. Infrastructure needs it for the drains.

The Minister for Health and Social Services:

Rightly said. We are viewed as the lucky recipients of extra money.

Assistant Minister for Health and Social Services: Yes, we are the lucky ones, but they are envious.

Deputy P.M. Bailhache :

Listening to your officials, Minister, I do get the impression that what the H.C.S. is doing is essentially firefighting, trying to balance the books against enormous pressures.

The Minister for Health and Social Services: Yes.

Deputy P.M. Bailhache :

What always comes back to my mind is the comment of Chris Bown, which he has made on more than one occasion, which is that if we go on in the way in which we are going, the whole of the States budget will ultimately be consumed by Health. That is clearly completely unacceptable and a situation which cannot be allowed to emerge.

The Minister for Health and Social Services: No, absolutely right.

Deputy P.M. Bailhache :

But who is doing the thinking about the strategic stance that the Island ought to be taking to limit the amount of expenditure on Health within the demands of the system? Who is doing the strategic thinking, Minister? Is anybody doing the strategic thinking?

The Minister for Health and Social Services:

I would like to think that we are all doing that strategic thinking; it is an ongoing situation. The reorganisation of the structure itself is part and parcel of that work. The truth of the matter is people want better and better services. Science delivers better treatment for people all the time; that treatment is expensive. We are facing a demographic challenge here where more and more people are falling into the older age bracket. As you say, dementia is going to increase simply because there are going to be more older people getting dementia. These are all of the realities that have to be put into the pot and analysed and then we have to make a decision as an Island as to how we are going to cope with them. Are we going to have to raise taxes, are we going to have a health ... These are all the questions that have to be asked and we have to face up to them. But all I am saying is, what I am comfortable with is that an awful lot of work has been done by the team to sort the finances out. From the stuff that has been explained to me, there was quite a lot of confusion about where money was and where money was not. I think that, running into the new year, we are going to get a fully clear picture, and from that point onwards we can have clarity about where we are going. We can make better estimates of what is required, be open about them, and bring them forward for discussion. When you talk about strategic development, I think one of the things that we need to do, as I said before, is health prevention. I spoke to a cardiologist here and he was explaining to me that if you can stop people having a stroke, you save the Exchequer between a quarter of a million and half a million pounds; the same with heart attacks. These things, when they happen, are extremely ...

Deputy L.M.C. Doublet : Per person?

The Minister for Health and Social Services:

Yes. Extremely expensive. If somebody has a stroke and they live for another 20 years, that is very miserable for them and it is very expensive. If somebody can have a pacemaker fitted and avoid having a stroke, then I think your money is well spent. But you have got to have that money up front so you can be able to monitor people, so you pick up the problems in the first place. Strategically, yes, I think we need to put a lot of focus on prevention because that is the only thing that is going to reduce the rate of increase as we go forward. That is quite a bold move and that is going to require quite a lot of money.

[15:15]

Deputy L.K.F. Stephenson :

Was there not supposed to be a political group working at a strategic level to look at that big question stuff? And then it was supported by an officer group? Is that right?

The Minister for Health and Social Services: Help.

Deputy L.K.F. Stephenson : Ruth is nodding.

Director, Health Policy: Yes, there was.

The Minister for Health and Social Services: Rescue me, Ruth.

Director, Health Policy:

There was a political group - it was called the Health Funding Reform Group - and that was the previous Government, and we did some work around understanding the funding - not in H.C.S. - across our healthcare system. What we were spending money on, what we were not spending money on, and looking at how that differs to other jurisdictions. That is how, as the Minister has just said, we know that we are quite unique in Jersey in that we spend a lot more on secondary care as a portion of our total budget than we do on primary or prevention. Also, part of that work was we cast forward future healthcare spending; so we said: "If we continue as we are at the moment and do not create efficiencies, what does this look like in 20 years' time?" What it looked like in 20 years' time is a very significant gap between expenditure and income. A gap that is of the extent that, while efficiency and improvements are very important, they will never close the gap. In terms of taking that work forward, it is difficult and complex work to take forward, partly because it has got a really horrible, sticky question in the middle of it which is, if you strip away everything else, it is either we do less or people pay more. One of the pieces of thinking that the Minister is looking at ... we are setting up a partnership board; one of the aims and purposes of that is to provide us having ownership of some of the solutions around that sticky question, rather than it just being political. Because you need longevity of solution and longevity of thinking to bring forward the solution to the challenge that we have, rather than it just falling off or changing with political winds. The approach that the Minister - who is very aware of these particular issues - has is, let us create an appropriate

structure to jointly come together to determine what the options for change look like and to own those options for change into the future.

Deputy L.K.F. Stephenson :

But just for clarity, the political side of that, at the beginning of it, is now just with the Minister for Health and Social Services?

Director, Health Policy:

No, the group still exists but it has not met for a period of time because we have been doing the work on the structure to then take back to that group and to join those pieces of work.

Deputy L.K.F. Stephenson : Okay.

The Minister for Health and Social Services:

Worth mentioning that I am part of a team of ... there are 3 Assistant Ministers for Health and Social Services with me, so we have got a fairly large, dedicated political group already, and that works when we have weekly meetings; apart from the meetings where we come together during the course of the week as well. We try and keep the thing as well threaded as we can.

Assistant Minister for Health and Social Services:

Can I say, I think we are trying to encourage also Islanders to take responsibility for their own health and to live healthy lives if they can, with a good life-work balance and eating well, sleeping well and exercising, and ideally not smoking or vaping or taking illicit drugs, and keeping alcohol consumption as low as they can? So we need to encourage all of that too, because that is all part of the prevention.

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

Assistant Minister for Health and Social Services: There is a lot.

The Minister for Health and Social Services:

... in Public Health actually, that are focused on trying to make early changes to get things in the right direction from early days.

Deputy J. Renouf :

Can I ask where the Health strategy sits in this work? Because it seemed to me that a strategy that sets out, for example, how much care we want to do in the community, how much we want to buy abroad, what our overall health ambitions are, that that might be a useful thing to inform this work.

The Minister for Health and Social Services:

Perhaps it is slightly unorthodox, but the way we have been running to date is to identify problems, bring the threads together, and try and get on and make the changes as we go. In an ideal world, you would get all your stuff together, you would put a strategy together. But I do worry about grand strategies, that by the time you have finished putting the strategy together, there is an election, you move on, and the whole process starts again. So what we have tried to do - forgive me for being a bit basic - but we have sort of short-circuited things. We are actually working together as closely as we can and bringing about those changes, formulating ideas, trying to take them forward. I appreciate what you are saying about a strategy, and it is always there waiting to be addressed, but there are so many real day-to-day issues to get right. I made the point the other day about before you move the deck chairs around on the deck you want to make sure that the base of the boat is watertight and fit for purpose, and that is where we are at the moment. I am not being glib about the Health strategy, but I think you can see there is an awful lot of work going on, an awful lot of good, dedicated people bringing threads together, so ...

Deputy J. Renouf :

I guess the missing part in that is public involvement, and the Assistant Minister referenced that. The point about a strategy is it engages the whole Island, or could potentially engage the whole Island in the debate, and that is the missing piece.

The Minister for Health and Social Services:

I would not argue; it is. But I do not think we are quite ready for that, for reasons that I have said. Your finances have to be absolutely in order, your structure has to be clear and clean, you have to have a completely settled situation, and that is the point at which you can go forward and say ... it is all very well to decide where you want to go, but if you have not got the vehicle to get you there, it is a bit of a pointless exercise. So, to my mind, while you are putting the vehicle together, you start mapping out a sense of direction and you move forward. It is a sort of integrated process that takes place over time. I hope that makes some sense, because I am not being glib about strategy, but I think there is a time and a place for it and that is probably not quite yet.

Deputy L.M.C. Doublet :

I want to touch on the detail that you have given about different partners being involved and making sure that people involved in health are there from the beginning. How are you also ensuring that there is innovation and creative thinking and new ideas from people who maybe have never been involved in health?

The Minister for Health and Social Services:

I do not mind saying there are 2 sources of that. One is our board; we bring in a lot of external expertise and I think Chris comes with a background, as do members of the leadership team, so I think we have got a number of inputs from a number of different places so some of those new ideas, some of that new thinking continues to feed in.

Deputy L.M.C. Doublet :

I am going to throw a bit of a curveball at you here which could be a solution, I feel, and I would like to understand your views on it. In terms of healthier lifestyles and also Islanders being able to care for each other and address some of that social care need, what is your opinion on moving to a 4- day work week perhaps in the public sector as a trial, and then promoting it for private businesses, which would allow Islanders more time to exercise, prepare healthy food, and care for each other?

The Minister for Health and Social Services:

There is a social element to that and there is an economic one. For goodness sake, if it can be done without damaging the economy, fine. But what you would not want to do is to implement that, everybody is feeling fine, and your tax revenue goes down by 20 per cent.

Deputy L.M.C. Doublet :

Well, the research shows that productivity either is maintained or increased as well as well-being.

The Minister for Health and Social Services:

It is a bit of a curveball, if you do not mind me saying. Being asked to answer that on the balls of my feet is quite difficult, but in principle, it is something ... you do not dismiss things without looking at them. If you want to have a chat about that off record, I am very happy to talk about it. I would be delighted with a 4-day week. If my productivity would increase as a result, I would be really, really happy.

Deputy L.M.C. Doublet :

You still have to do the same amount of work.

The Minister for Health and Social Services: I do not know how I would do that.

Assistant Minister for Health and Social Services:

The only thing for H.C.S., they unfortunately have to work 7 days a week, 24 hours a day. Is that not right, Chris?

Deputy L.M.C. Doublet :

Just to wrap up, can I check that the panel ... if anyone wants to put one more question in, go ahead.

Deputy J. Renouf :

There were some reductions in full-time equivalent staff in the Budget; 5, I think. What is the rationale behind that?

The Minister for Health and Social Services:

That is something, if Chris does not mind, I will get help.

Chief Officer:

Is that the reduction in management costs?

Deputy L.M.C. Doublet :

It just says: "F.T.E. (full-time equivalent), reduction of 5."

Deputy Head, Finance Business Partnering for Health: Yes, I think it is Chris, yes.

Chief Officer:

Mark, is that right? Is that the 5?

Deputy Head, Finance Business Partnering for Health: It is. It is the 5 management posts.

Chief Officer: Yes.

Deputy J. Renouf :

What was the thinking behind that?

The Minister for Health and Social Services: I think it was a requirement, was it not?

Chief Officer:

The thinking behind that is that we felt that ... while we are always looking for cost savings, we felt that we could do a bit of restructuring, prioritise things a little bit better, and as a consequence of some restructuring, we managed to find I think it is £526,000 worth of savings, some of which were realised this year, but some will - that is a full-year saving - be next. It was literally looking at our structures and seeing where we could trim things. Of course, when you trim things these people are not sat there doing nothing; there are things that we perhaps had to slow down or reprioritise. But I think it was a commitment that I gave as well to the rest of the government departments, of course, who have to also reduce their management costs, as we are seeing across the civil service. But it was only right and proper that in Health we did the same, so that is why we scrutinised those posts. Andy Weir and his colleagues have been in lots of discussions about that over the weeks and that is where we got to. We were able to take out 5 posts.

Deputy L.M.C. Doublet :

Thank you. Does anyone else want to ... no? Okay. Minister, to wrap up this section on the Budget, I would like you just to outline, in terms of the Health funding, what is your biggest fear and what is your biggest hope for Health funding?

The Minister for Health and Social Services:

My biggest fear is that the need for extra money will not be addressed, and I am hopeful that it will. As I say, we have got a lot of work to do. We have got about 18 months of active time left in this Government. That is my biggest fear. What is my biggest hope is that we take a bit of a leap of faith and decide to put some more money into illness prevention, because I do think that if we do not address that problem we are going to be in serious trouble. So those would be the 2 things, I think.

Deputy L.M.C. Doublet :

Thank you, and thank you, officers, for the contributions in that area as well. We are going to move on now to women's health and I would like to ask a general question about the Women's Health Political Advisory Board. What role has this board had in discussions about prioritisation, resourcing and funding allocations in relation to all of the women's health workstreams?

Assistant Minister for Health and Social Services:

We meet every few months, and we all get together. I think you were both on the previous advisory group, were you not?

Deputy L.M.C. Doublet :

We were and we stepped down from that so that it would not conflict with our Scrutiny roles.

Assistant Minister for Health and Social Services:

I would have been very happy if you had carried on. It is just carrying on, I think, as it always did. It is great, because it is across the Assembly board; so different viewpoints, but everybody's viewpoint is very much taken into consideration.

Deputy L.M.C. Doublet :

When did the board last meet?

Assistant Minister for Health and Social Services: It was before ...

Director, Health Policy:

I think it was July. I think it was 19th July, if I remember rightly, off the top of my head, but I would need to confirm that date absolutely for you.

Assistant Minister for Health and Social Services: We have got the next meeting next week, on the 25th.

Deputy L.M.C. Doublet :

Can you advise who the membership of the board is?

Assistant Minister for Health and Social Services:

Yes, the membership is Deputy Miles , Deputy Kovacs has just come on, Deputy Barbara Ward , Deputy Elaine Millar , Deputy Lyndsay Feltham ... what are the other ones?

Director, Health Policy: Karen Stone.

Assistant Minister for Health and Social Services: Constable Stone, yes, and myself.

Deputy L.M.C. Doublet :

And that board advises you, is that correct? Can that board make decisions?

Assistant Minister for Health and Social Services:

We all work together and together we come to a consensus of what we are going to take forward.

Deputy L.M.C. Doublet :

Okay. So you take your decisions in the area of women's health based upon a consensus of that group?

Assistant Minister for Health and Social Services: Correct.

Deputy L.M.C. Doublet :

Is that the case for every political or Ministerial decision that you would make in this area?

Assistant Minister for Health and Social Services: For me, yes.

Deputy L.M.C. Doublet : Can you give an example?

Assistant Minister for Health and Social Services:

Well, the example that we have been through, we have discussed period products, we have discussed terminated pregnancy, we discussed I.V.F. Anything that comes I would always ask the rest of the panel for their viewpoint, and they come back ... if they do not agree with anything or ... to come back and then I would go back to them.

Deputy L.M.C. Doublet :

Just to pick up on one of those examples, the termination of pregnancy. Was there a consensus among the Health Board on the direction of travel?

Assistant Minister for Health and Social Services:

There was. Ideally, we would all have liked to have carried on because ... and we are committed to amending the Termination of Pregnancy Law, but unfortunately it was a consensus view that we would not be able to start until the end of 2025, beginning of 2026.

[15:30]

The Minister for Health and Social Services:

Do you mind me ... I do not want to interrupt your conversation, but it might be helpful for the room to put some context around the reasoning for that.

Director, Health Policy:

Yes. Just with regard to the advisory group's oversight of the Termination of Pregnancy Law, the way in which we work with the advisory group is when we first started to develop proposals to take the law forward, we shared the consultation document with that group. We asked their advice on that consultation document. We then went back to the group and we asked them about how they thought we should take it through the Assembly, whether or not an in-principle debate was needed, whether or not we could move straight to a debate on the legislation. So the Assistant Minister seeks that advice from the group. When it became apparent that we were not going to be able to take the termination of pregnancy work forward in the original envisaged timeframe because of the resource constraints the Assistant Minister went back to the group, explained the situation, said: "We are not going to be able to take it forward, but do you think that we should take forward" what the particular high-risk area within that law was, which was about non-ordinarily resident women not being able to access terminations. That group agreed that while it was not desirable not to take all of it forward, if one thing needed to be done to manage risk, that was the thing that needed to be done.

Deputy L.M.C. Doublet :

That is really helpful, thank you. So the decision had already been taken to not continue with the wider piece of work before it was discussed by the board?

Assistant Minister for Health and Social Services:

It was only because we unfortunately lost resource. Because we know how important it is, because we want to develop an up-to-date law that reflects current society values and meets needs of women, but unfortunately we just simply do not have the resource to do that.

Deputy L.M.C. Doublet : What resource do you need?

The Minister for Health and Social Services:

I was hoping that Ruth might be able to elaborate on the resources and the shortage of resources, not just financial.

Director, Health Policy:

Okay. The challenge we have is - and unfortunately the axe just falls this way sometimes - we had a dedicated member of staff who was working on women's health; that dedicated member of staff got a new job, the post was vacant. The Council of Ministers made some decisions around savings targets, which meant that we were in a place where we could not replace that vacant post, so we had no officer dedicated to taking forward this piece of work. It was not in any way a conscious decision that we would not continue this work; it was just driven by the particular circumstances.

The post is still vacant. In order to take the work forward - the termination of pregnancy work - if we were to start working on it again immediately, rather than having pushed any development on it forward by a year, which is where we are at the moment in terms of resourcing, we would need replacement policy resource. Replacement policy resource comes really in one of 2 ways. It comes in the form of a policy officer or it comes in the form of consultancy support. Policy officer support, I always believe, not only is it cheaper, but it is actually better because you embed people in your team and you leave legacy and learning. The challenge that we have, even if we had the money to recruit a new policy officer, is actually our ability to source an experienced, competent policy officer. In order to be a good policy officer, you have to learn your trade and that takes a period of time. In the Government of Jersey, because we are a small jurisdiction, we often struggle with getting specialist skills, and policy is one of the areas in which we struggle, which is the reason why S.P.P.P. (Strategic Policy, Planning and Performance) has an apprenticeship scheme for policy officers. That apprenticeship scheme is working well, but it still takes a number of years to take someone who does not know how to work within the policy arena to become a competent policy officer. So we have got a money issue, and we have got a resource capability issue around that particular piece of work. The other key piece of resource that we would need to be able to take this work forward in a timely fashion is law-drafting capacity. Council of Ministers are very shortly going to be making some prioritisation decisions around the whole legislation programme. The legislation programme is a list of all the legislative projects that the Ministers would like to deliver in the term. The projects on that list currently outstrip the available law-drafting capacity and resource. So there are also some prioritisation decisions, which would mean that even if I had a policy officer working on termination of pregnancy today, we might not be able to deliver that work in a timely fashion because there are 2 hurdles there.

Deputy L.M.C. Doublet : Thank you.

Deputy L.K.F. Stephenson :

Did it previously have law-drafting time booked in, as it were?

Director, Health Policy:

No, it is slightly more complicated than that because, of course, when a new Government forms, a new Government has aspirations as to the legislation it wants to bring forward, and some of that falls by the wayside, some of it takes longer, some of it takes less time. States Members come in with thoughts and propositions which change matters as well. So it is always very difficult at the beginning of Government to say: "What are all the things we want to do? Have we got resource to do it?" It is always a changing timeframe.

That women's health policy officer, what level or grade do they work at?

Director, Health Policy:

The previous officer was a grade 12 and it is a piece of work which would require a grade 12 officer. So that is approximately, with on-costs, around £100,000 a year.

Deputy L.K.F. Stephenson : Okay.

Assistant Minister for Health and Social Services:

She was really excellent, but unfortunately Social Security have nabbed her.

The Minister for Health and Social Services:

I hope you do not mind, we majored on this but I wanted to make it public that it is not just cancellation at a whim, that we decided that is not a priority. I just wanted you to understand the complexity of the situation that we are facing in order to try and prioritise what we are doing. So I hope you do not mind; I think it was worth you knowing.

Assistant Minister for Health and Social Services:

To be honest, when I started I was very much going to carry on immediately, but circumstances have changed.

Deputy L.M.C. Doublet :

Thank you and that detail is really helpful. I would like to just dig a bit deeper on ... you said something, Ruth, about: "It is the way that the axe fell." So what I would like to understand now is the kind of political dominoes that led to this. I think, Ruth, you said it was not a conscious thing, and, Minister, you have reiterated that it was not something that you decided to cut.

The Minister for Health and Social Services: No.

Deputy L.M.C. Doublet :

Therefore, it was not an intentional thing to happen.

The Minister for Health and Social Services: No.

Deputy L.M.C. Doublet :

But can I ask, if it was not intentional on your part, would anyone in the wider Council of Ministers - I do not know where that policy came from - would anyone have been aware of this when the policy to not fill vacant posts was set?

The Minister for Health and Social Services:

I think, Ruth, you would probably be a little bit more familiar with what happened in the framework of the employment circumstances, but I will come back to parts of it.

Director, Health Policy:

I cannot really speak to that; I was not privy to the conversations that were had which resulted in the decision that we would not recruit to vacant posts.

Deputy L.M.C. Doublet :

Okay. From around C.O.M., whose decision was that?

The Minister for Health and Social Services:

As you know, as a Council of Ministers, there has been an attempt to try and cut the cost of Government overall and everything has been squeezed, and I think we tried to do it in equal measure and that is the situation in which we found ourselves.

Deputy L.M.C. Doublet :

Was that a decision from the Chief Minister then that was cascaded?

The Minister for Health and Social Services:

Well, it is a Council of Ministers decision to try and keep spending to a minimum and make savings, and you cannot have it all ways around. If you want all the people that you want and that you need, it costs you more money and that is quite simple. As Ruth has just said, if we had the money we probably could not recruit the people because the skillset just is not available. So it is a double- edged sword, really.

Deputy L.M.C. Doublet :

How many policy officers does Health have?

Director, Health Policy:

My team, Health Policy, we have 5 of us at the moment and one of the members of the team is leaving in November because they are moving back to the U.K.

And they also will not be replaced?

Director, Health Policy:

It is my understanding at the moment, they also will not be replaced.

Deputy L.K.F. Stephenson :

So you will have gone down from 6 to 4? Okay.

Deputy L.M.C. Doublet :

Minister, what I would like to understand is, in terms of you advocating for your department, what does that look like? Do you go to C.O.M. and say: "Actually, we need this resource"?

The Minister for Health and Social Services:

I have to be careful how often I go to C.O.M. and what I ask for. The last time I sat there I was trying to justify an extra £24 million for the budget, so sometimes you have to take a bit of a beating and move on. I cannot complain about everything all the time.

Assistant Minister for Health and Social Services:

Can I just say that we really appreciate the excellent team that we do have and how much we value them?

The Minister for Health and Social Services: Fair comment. Very much so.

Assistant Minister for Health and Social Services: They are invaluable.

Deputy L.M.C. Doublet :

Just to go back to that, in terms of advocating, it would not be a complaint, would it? It would be a request.

The Minister for Health and Social Services: Yes.

Deputy L.M.C. Doublet :

Do you feel that there should be an exemption for something this critical, given the level of public interest in this issue around women's health? Do you think that there should be an exemption for your department and that those vacant posts should be filled?

The Minister for Health and Social Services:

That would be lovely. All I would say is that timing is important in these things and you do not always try and make demands all at the same time. So, let us see how we progress and if circumstances could permit over the course of time, let us see how things go.

Deputy L.M.C. Doublet :

So you may seek an exemption?

The Minister for Health and Social Services:

I would like to see more support for the team, because they are under real pressure.

Deputy L.M.C. Doublet :

Okay. Please keep us updated if you do seek that exemption.

The Minister for Health and Social Services:

Yes, and if you know of anybody who has got a budget surplus anywhere, we would happily remove it for the moment and invest it here because it is needed.

Deputy L.K.F. Stephenson :

Just one last point on the policy officer stuff; I find it quite interesting how it works. With S.P.P.P. sitting in Cabinet Office as well, do they have policy support that departments can draw on, or do they have specific tasks that they have to focus on and you cannot, for example, bid for half a policy officer's time for the next 6 months to work on a project?

The Minister for Health and Social Services:

It is something I cannot answer, but I think Ruth probably could.

Director, Health Policy:

The Health Policy team is part of S.P.P.P.; we are not part of the Health Department. The way it broadly works is that every Minister has a number of policy officers dedicated to their area of work; those policy officers do move around between Ministers depending on demand and depending on whether or not they are fully occupied in the policy portfolio for that particular Minister. An example would be that there is a policy officer who sits in a different team - not in the Health Policy team -

who is leading a legislative policy project on behalf of the Minister, which is about the registration of health and care professionals. So there absolutely is a sharing of resources as capacity allows.

Deputy L.K.F. Stephenson :

Great. Minister, in which case, have you asked if there is capacity across Government for somebody to take on this work?

The Minister for Health and Social Services:

I have asked if the team could be bolstered and the initial response was: "Not at this point." It is something I shall keep my eye on and if I can change that situation, I will.

Deputy L.K.F. Stephenson : Thank you.

Deputy L.M.C. Doublet :

So it is possible that the work might be picked up again next year?

The Minister for Health and Social Services:

Well, I certainly cannot make any open promise to that at all; I am not in a position to do that. But you can rest assured that I am very keen to see as much support as I can for the team because they are under too much pressure, in my view.

Deputy L.M.C. Doublet :

You cannot promise, but you are going to try to achieve ...

The Minister for Health and Social Services: Oh, yes. As I say, it is about timing.

Assistant Minister for Health and Social Services: The Minister really has already tried.

The Minister for Health and Social Services: Yes. We will see how we go.

Deputy L.M.C. Doublet : Thank you.

Deputy L.K.F. Stephenson :

There was a piece of work also that we were told about when these discussions were first ongoing, about the Women's Health Strategy stopping, but there were certain streams that would continue, but a few things were delayed because of policy officers. One of them was the contraception workstream. Could you give us an update about where that is at, please?

Director, Health Policy:

Yes, certainly. We did a contraception use survey over the summer; we hopefully next week will be publishing the feedback report of that. I am quite happy to tell you some of the key findings of that at the moment. That report told us some interesting things about women's access to contraception. One of the key questions that we were asking in that report was whether or not women were able to access and use their contraception of choice, because anecdotally we have been told that it can be very difficult for some women. Overwhelmingly, the majority of women who responded to the survey said yes, they are using their contraception of choice. Where that is not necessarily the case is in the younger age groups, and what the younger age groups were saying is: "It is not that I am not using my contraception of choice, I do not actually have enough access to information support to make a decision about what contraception I want to use and what is the best contraception for me." Also, one of the overwhelming findings of that report was that women who use the contraceptive pill want to be able to access that contraceptive pill from community pharmacists without having to go via the G.P., or without having to go through Le Bas Centre. Those arrangements have been brought forward in the U.K., and there is really very clear demand for that, so we will be looking at that as well.

[15:45]

The issue of cost did come up in the feedback, but actually it was not necessarily a priority issue. When we asked women why they go to their particular provider to use contraception, it was very often issues about: "I can park outside and there are appointments available at the time I need them, which is outside conventional working hours." Cost is not necessarily a driving factor for why women use the services that they use.

Deputy L.K.F. Stephenson :

Okay. So the policy work that will flow from that, that has got resource and that will continue?

Director, Health Policy:

The policy work that will flow from that is going to continue, but it is not going to continue at the pace at which it was planned. That is because that missing policy officer from my team, as well as doing termination of pregnancy, was also doing work around contraception. I have found alternative ways to try and progress the contraception piece of work because it is not such a large piece of work.

Deputy L.K.F. Stephenson : Great, thank you.

Deputy J. Renouf :

Minister, you recently published the I.V.F. access criteria and you have put £620,000 in the Budget for that. On what basis did you come up with that figure? Are you confident that that will meet the demand for the service?

The Minister for Health and Social Services:

I am reluctant to use the word hopeful' again, but I am going to. I am hopeful that that will meet the demand. It had to be as accurate as we could make it; I have got to hand you back to Ruth, because there was quite a complicated process that sat behind it. Ruth will give you chapter and verse.

Assistant Minister for Health and Social Services:

I think there was a very clear business case from the policy.

Deputy J. Renouf :

What I am trying to get at is, was this a financially-driven decision or was this a need-driven decision?

The Minister for Health and Social Services:

A little bit of both. It was against a formula, looking at other areas as well, and trying to come up with something that did not put too much financial ... obviously, the more money you have got the more you can do. But I think we wanted to come up with something that would be a manageable amount of money against sensible criteria. But I will hand over to Ruth and Ruth can map out that criteria much more accurately than I can.

Director, Health Policy:

We have gone through a process of mapping what we anticipate the effects of different criteria would be in terms of resources that are required. As far as we can work out - and I do say as far as we can work out - we think that the £620,000 that is provided in the Government Plan should be sufficient. My hesitancy is because there is something very important that we just do not know, which is about latent demand for I.V.F. services in Jersey. We have got no way of modelling that at all, so we have put £620,000 in it, we have put criteria in. The other thing that is really important is that we have set up a new system which will come into place on 1st January when the new trial criteria come into place, which is about modelling uptake of I.V.F. services in real time, so that if we get to the point where we think one of 2 things. Either we are not going to be able to afford that service into the future, that then provides the Minister with an opportunity to bid for more money

through the Government Plan, or to tighten the criteria to drive down the flow-put. Or if we have got sufficient money in, to do exactly the opposite, which is to extend the criteria so more women would be available. The other thing is, alongside that, our lead consultant for the Assisted Reproduction Unit, because he knows that this additional money is coming - therefore, for want of a better description, the "Jersey market" for I.V.F. is larger - that has given him the ability to start to go to U.K. provider clinics to talk to them about what purchase of services at a lower unit cost would look like, which would help us either manage cost or help us provide more I.V.F. to more people.

Deputy J. Renouf :

If the money runs out because demand exceeds the budget, will that mean that people will simply not be able to access the service, or will you have spotted that in advance and taken measures to throttle demand, or what? What will happen?

The Minister for Health and Social Services:

I think it is a case of monitoring it as we go forward and as we come through the year we will be able to map out where we think we are going to be. There are a number of different options. We can come back and try and get some more money if we can, which I think under the circumstances would be very difficult. It could be that you actually bring things to a close and start again in the next financial year and carry forward that requirement. As I say, what we have tried to do is set it at a level that, given all the thinking that has gone into this, it should just about do the job. But we will not know that until the process starts.

Director, Health Policy:

One of the things that I think is quite important is transparency in this process. We know that much is made of the fact that N.H.S. Scotland provides I.V.F. for all women who meet the criteria with no financial caps associated with it at all. But the actual reality is that waiting lists in Scotland are so long for I.V.F. that even though couples are entitled to N.H.S.-funded I.V.F., they actually purchase it privately because the waiting lists are too long. One of the things that we are aware of is we need to really monitor I.V.F. provision and we need to be open and transparent about, if we need to amend the criteria, why we are amending the criteria. Rather than just retaining criteria and pushing people into the never-and-ever of waiting list land.

Deputy L.M.C. Doublet :

If the capacity is able to be met with the current criteria and you can look to expand the criteria, would you consider expanding it to include same-sex female couples who currently face higher costs because they are required to have I.U.I. (intrauterine insemination) before they can access I.V.F.?

The Minister for Health and Social Services:

We had a discussion about that, actually, about 2 hours ago. It has got to be one of the things that we would bring back to the frame. It is not something I would make an absolute commitment to, but it is certainly something we would be happy to discuss; we discussed it earlier today.

Assistant Minister for Health and Social Services: Yes. I think we just have to see how funding pans out.

Deputy L.K.F. Stephenson :

In which case, will you be keeping data for those; not just who qualify, but who do not qualify? I know they may not all make it to you, but it seems that in the building of all of this, I think we all acknowledge the data has not been great, has it? At one stage, I do not think we even had the number of live births that were due to I.V.F. kept in Jersey. Stronger data has surely got to be a good thing.

Director, Health Policy:

Where we know - where people come to our front door even if we say "Sorry" at that front door - we will obviously keep track of that. But obviously there will be all the unknowns: all the people who do not meet the criteria, so do not come to our front door.

Deputy L.K.F. Stephenson :

Yes, obviously. Okay. Can I just ask a quick question - well, I do not know if it will be quick, but - the new criteria obviously remove the existing system which currently pays for the drug funding for more or less everybody under a certain age. So there are some people who are going to be worse off under the new system; for example, people who have already got previous children, including if they are stepchildren that they have never lived with or cared for themselves, but their partner did. That funding that has previously been spent on their drugs, is that being added to the £620,000 or where is it going?

Director, Health Policy:

As part of the modelling work, what we looked at is the monies that were currently available in the service. Obviously one of those pots of monies is the monies that were spent for medication. We anticipate that, in terms of the numbers of people who meet the criteria, that will be over £620,000 but that there is enough money in the existing current budget through doing things like not providing medication to everybody, to be able to fund I.V.F. including the medication for everyone who meets the criteria. So you are right, there is a group of people who have lost out because those people do not meet the criteria.

Deputy L.K.F. Stephenson :

But A.R.U.'s (Assisted Reproduction Unit) budget is not being reduced.

Director, Health Policy: No.

Deputy L.K.F. Stephenson :

The whole £620,000 is in addition to A.R.U.'s budget.

Director, Health Policy: Yes.

Deputy L.K.F. Stephenson : Okay. Thank you.

Deputy L.M.C. Doublet :

In terms of women's health, there is a related area. I am not sure if it is the Minister for Social Security or if it is your team leading on the period products scheme.

Assistant Minister for Health and Social Services:

I think it is the Minister for Social Security who is leading on this and she is going to give us an update next week. But I do think they are now at multiple locations around the Island, but I think they have taken them away from men's toilets.

Deputy L.M.C. Doublet :

Okay. Are there any further updates you can give at this ...

Assistant Minister for Health and Social Services: I will not know until next week, I am afraid.

Deputy L.M.C. Doublet :

Anything else on women's health? No?

Assistant Minister for Health and Social Services:

Just to say, we are taking women's health very seriously and we have got actions in train.

Deputy L.M.C. Doublet :

Great, thank you. I am going to ask a final question on assisted dying. Thank you for the law- drafting instructions which you shared with the Assisted Dying Review Panel, which is the other panel that I chair. Could you give us a brief outline on the timescales that you are working to for this piece of work?

The Minister for Health and Social Services: Ruth would be better able to answer that.

Director, Health Policy:

Sorry, you have caught me slightly on the hop.

Deputy L.M.C. Doublet : Sorry, was that unexpected?

Director, Health Policy:

Yes. As you know, you have a draft of the law-drafting instructions; the Law Drafting Office also have. They are starting work on it, but obviously we will not formally issue them until we have had feedback from the Assisted Dying Review Panel. There are some parts of the instructions that we are working on, some very specific work around law-drafting instructions for matters such as offences and protection for health and care professionals. They will be issued to the panel probably on Monday, and the law-drafting officers. At the front of the instructions, there is a timetable that sets out when we anticipate bringing the draft law to the Assembly. I cannot remember the date, but that is the date and we are on target for it.

Deputy L.M.C. Doublet :

Okay. All right, thank you. Sorry, I did throw that one in there. Okay. Did the panel want to add any other questions? Okay. Minister or Assistant Minister, is there anything final that you would like to add before I close the hearing?

The Minister for Health and Social Services: No, I do not think so.

Deputy L.M.C. Doublet :

Thank you very much for attending the hearing today. Thank you to your officers who have all provided really helpful information. We appreciate your time. Thank you to everybody who watched the hearing today, and I will close the hearing. Thank you.

[15:58]

Transcript - Quarterly Hearing with the Minister for Health and Social Services - 19th September 2024