Transcript - Quarterly Hearing - Minister for Health and Social Services - 5 March 2025

Health and Social Security Scrutiny Panel Quarterly Hearing

Witness: The Minister for Health and Social Services

Wednesday, 5th March 2025

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

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

Ms. R. Johnson , Director of Health Policy

Ms. R. Bullen-Bell, Director of Midwifery and Nursing

Mr. I. Tegerdine, Director of Workforce

Ms. D. Raffio, Deputy Director, Public Health Transformation and Commissioning

[12:03]

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

Good afternoon, everybody. This is the Health and Social Security Panel quarterly public hearing with the Minister for Health today. My name is Deputy Louise Doublet . I am the chair of the panel. I will let my panel introduce themselves.

Deputy J. Renouf of St. Brelade (Vice-Chair): Deputy Jonathan Renouf , the vice-chair.

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

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

Deputy L.M.C. Doublet :

Minister, please could you introduce yourself and your officers?

The Minister for Health and Social Services: Deputy Tom Binet , Minister for Health.

Director of Health Policy:

Ruth Johnson , Director of Health Policy.

Director of Mental Health, Social Care and Community Services:

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

Director of Workforce:

Ian Tegerdine, Director of Workforce.

Director of Midwifery and Nursing:

Roslyn Bullen-Bell, Director of Midwifery and Nursing.

Deputy Director, Public Health Transformation and Commissioning:

Daniela Raffio, Deputy Director, Public Health Transformation and Commissioning.

Deputy L.M.C. Doublet :

Is your Assistant Minister going to be joining us at the table?

The Minister for Health and Social Services: Later.

Deputy L.M.C. Doublet :

Okay, that is fine. As always, the purpose of Scrutiny in hearings is to seek information from Ministers directly for the purposes of accountability and transparency on behalf of the public and Scrutiny, as always, functions as a critical friend. Today we have 2 hours, just under 2 hours now, for this hearing but we will have to be mindful of time because we do have a huge amount of questions to get through. Some sections we have already taken out of the question plan. Minister, I would appreciate if if you could keep your answers brief but obviously including all the relevant details. If I have to cut anybody off, I apologise in advance. It is because of the time and we may also need to follow up with some of the questions in writing after the hearing. Can I just check that everybody has their mobile phones switched off, please? Welcome to members of the public who are in the gallery today and anybody who is watching online. We are going to open the hearing with some  questions  around  our recent review  into  the  prescription  of  A.D.H.D.  (Attention  Deficit Hyperactivity Disorder) medication. Minister, thank you for your Ministerial response. We would like to understand a little bit more about the progression of the plans and activity in relation to some of our findings and recommendations. First of all, the waiting list for assessment and possible diagnosis, as of 28th January, was around 924. You advised us that a seconded nurse was already successfully reducing that waiting list. Can you confirm if that nurse is still working on that and why the numbers have increased rather than decreased, as we might have expected?

The Minister for Health and Social Services:

Andy will have the up-to-date numbers. Why has it increased? Presumably it will decrease from now on. It depends on how many referrals come at any given time.

Deputy L.M.C. Doublet :

Are you aware what the waiting list is today?

The Minister for Health and Social Services:

As of this morning? I do not know. Have you checked this morning, Andy?

Director of Mental Health, Social Care and Community Services: At the end of February, 962.

Deputy L.M.C. Doublet :

Okay, so it is still going up. Could you give us some insights as to why?

Director of Mental Health, Social Care and Community Services:

The nurse has not continued with this. She has gone back to her substantive role. We have offered a ... we created in budget setting an additional post, a specialist post for a nurse who is able to prescribe and we have offered that post to someone and we are waiting for their start date and all of that. That will be a full-time post. That is a much better capacity for the service. Why is the waiting list going up? Really simply, as before, the volume of referrals; 32 referrals a month and we can see 12 to 16 people a month. That is the maximum capacity of the service. As before, every time we take someone new on to the prescribing list, the capacity for seeing new people reduces because the doctors have to then see those people to prescribe. Simply, this continues to be a capacity and demand issue.

Deputy L.M.C. Doublet :

Thank you. You said that somebody had been appointed. Is it the people hub processes that you are waiting on?

Director of Mental Health, Social Care and Community Services:

In part. I am trying to understand myself what the delay is with this post. I made contact with the post holder at the beginning of the week to try to understand what is causing this difficulty.

Deputy L.M.C. Doublet :

Are all relevant government services, whether it is people hub or any other services, aware of the urgency around the ...

The Minister for Health and Social Services:

I think everybody who is involved with A.D.H.D. appreciates the urgency. I do not think anybody is particularly comfortable about having a waiting list that is that long.

Deputy L.M.C. Doublet :

What I mean specifically is of the onboarding of this individual who has been appointed. Could you commit to go back and check, Minister, if there needs to be any unsticking of processes?

The Minister for Health and Social Services: We will certainly have a look at that.

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

Deputy J. Renouf :

Just really quickly, does that officer being in place increase your capacity? You said the capacity is 12 to 16 a month. What would it change it to?

Director of Mental Health, Social Care and Community Services:

We need to work that out. We have a meeting planned on Monday with the team and the clinical relief mental health services to do exactly this. We need to work out how we are going to utilise that one person. She is a prescriber and we need to work out are we going to get her to do more of the prescribing, which means that particularly the junior doctor might be able to do more diagnostic work, et cetera. It significantly increases the capacity of the service. How we utilise the different people will determine whether it most impacts on prescribing, waiting, support, all of that stuff.

Deputy L.M.C. Doublet :

You are not stopping at this one nurse, are you? There is another 2 that you are planning to take on board. Is that ...

Director of Mental Health, Social Care and Community Services:

That is not correct. There are 2 nurses in adult mental health services who are training to be prescribers but they do not work in the A.D.H.D. service and they are training to be prescribers in the service that they work in, which is general adult mental health services. So I think one of the things to explain is that it is not just find a nurse prescriber and put them in the A.D.H.D. service. Nurses need to prescribe within their scope of practice, so they need to have trained in A.D.H.D. and be able to prescribe in A.D.H.D. That is not what those nurses are doing. They do not work in the service now and there is no funding for additional posts in the A.D.H.D. service. They will complete their prescribing course and they will work in the services that they work in as nurse prescribers.

Deputy L.M.C. Doublet :

Can you describe what that would look like specifically for adults with A.D.H.D. then? Will there be different pathways that they are involved in?

Director of Mental Health, Social Care and Community Services:

I would detach nurses from A.D.H.D. because that is not what they are there to do. One of them works in the crisis and assessment team for example, so she will be prescribing in the crisis and assessment team. There are equally people that we see out of hours, at weekends who need prescribing for, so having nurse prescribers in other parts of the service is equally as important but it is also part of the choice of the nurse. The nurse needs to want to work in the area. We cannot just say: "You will go and work there." They need to have skills and experience in the relevant place.

Deputy J. Renouf :

To just clarify then, so you are getting one extra person and that will increase the capacity of the service. Is there anything else being done to increase the capacity of the service right now?

Director of Mental Health, Social Care and Community Services:

Yes. So the other thing that we are doing is we are delivering psychological therapies now. We know that we have got people that are waiting who ... because medicine is not everything. The sole answer to the A.D.H.D. difficulty is not just to give everyone medication. There is lots of other things that you need to do. We are now delivering, for example, a living with A.D.H.D. group, which is going to repeatedly offer to and deliver to people on the waiting list so that they can help manage and live with the symptoms in a different way.

Deputy L.M.C. Doublet :

I am trying to understand the 2 nurses because in the response to our review we were led to understand that this was to reduce capacity. Those 2 nurses will be prescribing A.D.H.D. medication but within other services so why ...

Director of Mental Health, Social Care and Community Services: They have nothing to do with the A.D.H.D. prescribing.

Deputy L.M.C. Doublet :

I am just trying to understand why they were mentioned in the response to the review.

Director of Mental Health, Social Care and Community Services:

I think they were specifically mentioned with the review, were they not? I would hope that the response does say that the nurses are not going to work in the A.D.H.D. service. Indeed it does. It says: "The 2 nurses that are undertaking the training currently do not work within the A.D.H.D. service and to redeploy them into the service, should they wish to do so, will require additional financial investment and the need to replace within their current service."

Deputy L.M.C. Doublet :

Have you established whether those nurses would wish to work within A.D.H.D. prescribing?

Director of Mental Health, Social Care and Community Services:

They are not training to work within A.D.H.D. prescribing. They are training to prescribe within general adult mental health services.

Deputy L.M.C. Doublet :

Okay, so disregarding those 2 nurses, Minister, are you planning to train any other professionals aside from this seconded nurse?

I think the point we have to make here, and I think this is going to be the answer to a number of questions here today, is we do not have any additional funding and we need to make that absolutely clear. We have not got the money to train additional people and put them into those places because we have not got any additional funding. Unless I have got it wrong, our budget is entirely spoken for. It is not for lack of wanting to. I have to say in an ideal world we would be training people. We would be reducing those waiting lists. We would also be providing better care for dementia and so on, but we are where we are and we have to be honest with you about that position.

Deputy L.M.C. Doublet :

Obviously we understand that you have a pot of money and you have to prioritise it. So is your response that the money is not being prioritised towards this service at the moment beyond that one additional nurse?

The Minister for Health and Social Services:

There is no money. I think we have to be careful about our terminology. I could give you a list of a dozen things where money should be prioritised but the budget we have is spoken for in all areas so there is no spare pot of money that can be apportioned to this or to that. At the moment we are frozen into the situation we are at the moment and unless and until we get more funding, then that position will remain, however unpalatable that is.

Deputy J. Renouf :

Just to be in the theme of being honest with the public about this, in terms of that extra person who is coming in, hopefully, starting maybe next week, will increase capacity. Will it at least get to a breakeven point, if you like, where the rough number of referrals that you are getting will equal the capacity to deal with them?

The Minister for Health and Social Services:

I do not mind making a comment on that. It strikes me, I think, a common sense approach to this that the numbers cannot keep growing because we have not got 100 per cent of our community with A.D.H.D., so there will come a time when those numbers ... the increase in the number of referrals will diminish and hopefully then we can start biting into that number and bring them down.

Deputy J. Renouf :

You are relying on the curve flattening more than you are relying on the increasing capacity that is prescribed?

The Minister for Health and Social Services:

It is worth saying that you already know that we are doing quite a lot of work about increasing funding and perhaps introducing charges in various areas of healthcare to improve the budget, so that work is ongoing. It may well be the case that in the fullness of time we can draw in more money. We can then start to look at how that money is apportioned and until that work is complete and then it has to be agreed. That is something that we will have to talk to the public about because that is a fundamental change in the funding model and that is something we are looking at.

Deputy L.M.C. Doublet :

Is it fair to say that were there additional money this is one of the areas that you would prioritise?

The Minister for Health and Social Services:

I would say it is, yes. I think that fact that we have got nearly 1,000 people on the waiting list is a concern to absolutely everybody. We do not sit here feeling proud about that. That is something we would like to see addressed.

[12:15]

Deputy L.M.C. Doublet :

Understood. I would like to ask about the waiting list. What is the current waiting time from a referral to an assessment?

The Minister for Health and Social Services:

My understanding is it is 4 years and 7 months, I think.

Director of Mental Health, Social Care and Community Services: Yes, if you are referred today.

Deputy L.M.C. Doublet :

You mentioned some other interventions, not just pharmaceutical treatment for A.D.H.D. Could you expand on what is being offered at the moment?

Director of Mental Health, Social Care and Community Services:

The psychological therapist team are initially ... they are offering a number of things, offering a number of new groups for people but one specific group they are offering, as I say, is living with A.D.H.D. That is what it is called and people on the waiting list are incrementally being invited to participate in that should they wish to do so. We think that probably what we also have to do, some people, once they come through that group, will find out about other groups that we are offering and hopefully engage in some of those as well. That is the type of stuff that we are doing.

Deputy L.M.C. Doublet :

Has there been a good uptake of that?

Director of Mental Health, Social Care and Community Services: I do not know, actually. I can find out what it is.

Deputy L.M.C. Doublet :

Thank you. Minister, these additional things that are being offered, how will you measure the effectiveness of those?

The Minister for Health and Social Services:

That is really a question for Andy because the mechanisms for measurement will be somebody that will be ...

Director of Mental Health, Social Care and Community Services:

We generally ask people about either symptoms or their experience before they start the group and we ask them again at the end of the group. That is the normal way. We specifically ask what has been helpful. If it is a few sessions of the group then we will ask people first what stuff that has really helped for them. As you would expect, different people give different answers.

Deputy L.M.C. Doublet : Is that qualitative data?

Director of Mental Health, Social Care and Community Services: Yes.

Deputy L.M.C. Doublet :

Are there any clinical measures that you can use?

Director of Mental Health, Social Care and Community Services:

This is not really a clinical group. This is more of a group that is led by our psychology assistants overseen by one of our psychologists. This is about information giving and teaching people some basic skills. This is not complicated psychotherapy. That is not what we are doing.

Deputy L.M.C. Doublet :

Okay. The panel during our evidence gathering became aware of some groups in the Island who are offering similar services. How are you supporting those groups, Minister, to deliver those services?

The Minister for Health and Social Services: Well, you will have to be specific about those groups.

Deputy L.M.C. Doublet :

So, charities, support groups. There are some that take the form of online support groups. They are offering course, they are offering peer mentoring. I understand there are a variety of different things being offered.

The Minister for Health and Social Services:

I do not think there is any more support available than they are currently getting and I do not know that there is a great deal of support from us on that at this point in time. Andy, you might know otherwise.

Director of Mental Health, Social Care and Community Services:

Shortly we will publish the neuroinclusive strategy, which is in its final draft at the moment. That has a section specifically around charities and third sector providers and getting people to work together in a different way to offer a broader and more joined-up set of approaches. I am hoping that that will take care of that for us.

The Minister for Health and Social Services:

We are engaging, I have to say. Whenever we can we have discussions with the various people involved.

Deputy L.M.C. Doublet :

Okay, so you are mindful to support those activities?

The Minister for Health and Social Services: To the fullest extent that we can.

Deputy L.M.C. Doublet : Okay, thank you.

Deputy J. Renouf :

There was talk about publishing waiting lists. Is that going anywhere?

Director of Mental Health, Social Care and Community Services:

Not yet, but we have agreed we are going to in principle. The meeting on Monday is going to agree how we are going to do it, where we are going to publish and how often.

Deputy J. Renouf :

You will communicate with people on the waiting lists?

Director of Mental Health, Social Care and Community Services: We certainly will, yes.

Deputy J. Renouf :

There was a recommendation around the dedicated hub that was rejected on the grounds of cost. I think your words were: "It is going to cost a hell of a lot more money and in any event we need more staff." Was there any kind of costed model produced or was it just a general: "Look, this is going to cost money, we are not going to do it"?

The Minister for Health and Social Services:

Unfortunately when you look in the pot and there is not a single penny, you know you cannot leave the starting blocks. It does not mean that we will not look to try to do this as things go forward. As I say, we need to have a fundamental rethink about our funding. I think in an Island where you pay 20 per cent tax and year on year you get health provision is more and more complicated, more and more expensive. We are going to have an honest discussion with the public about what sort of health service they want and how much they are prepared to pay for it. That does not mean that the idea is not a good idea in principle and it might well be one that would be supported if there was sufficient funding. As I say, anything that can help to bring down a waiting list of nearly 1,000 people on an Island of 100,000 people is something you have got to want to do.

Deputy L.M.C. Doublet :

So you are supportive in principle?

The Minister for Health and Social Services: In principle. The principle is fine.

Deputy L.M.C. Doublet :

In terms of funding, is this something that you have approached any other Ministers about? For example, the Chief Minister has a fund for pilot projects that would perhaps fit well with this.

The Minister for Health and Social Services:

No, I have not because, as I say, I have a list as long of my arm of people who make very compelling cases, both collectively about individual illnesses and conditions and specifically individuals who have got their own personal problems. I think States Members will know from some of the emails that get sent to all States Members. I think there was one yesterday evening which highlighted a specific problem and once again the problem is money.

Deputy L.M.C. Doublet :

Are you aware of how much money could be saved were A.D.H.D. or issues associated, perhaps related health issues ... money that could be saved if the treatment was improved?

The Minister for Health and Social Services:

Those principles apply to just about every area of medicine. For virtually every single one, those same principles apply, early intervention with stroke, with heart attacks, diabetes. There is an awful lot. We are working on a strategy to try to move from a reactive to a proactive health service but that is going to take an awful lot of money and we will be looking to take measures to try to see whether the Assembly is minded to support that.

Deputy L.M.C. Doublet :

I wonder if any of your team have any awareness of any perhaps public health .... of any savings, a ballpark understanding of what money could be saved due to related health issues if we treated A.D.H.D. more effectively.

Deputy Director, Public Health Transformation and Commissioning:

We do not know in relation to A.D.H.D. but as part of the Director of Public Health's annual report there is some detail in there about the case for change, focusing on prevention. We all know prevention is better than cure, but there is a bit of an invest to save because we want to double run for a period of time. When you have got increasing need and increasing complexity of need, it is quite difficult to shift current health funding to the preventative model, but we are looking at that.

Deputy L.M.C. Doublet :

Understood. Thank you. I would like to ask about the shared care model, about which I understand that there have been conversations ongoing. Could you provide an update on these conversations, please?

The Minister for Health and Social Services:

Andy can provide an update on the discussions to date. I can just say that going forward I am now due to have a meeting with the G.P.s (general practitioners) myself. Andy, do you want to comment on the discussions?

Deputy L.M.C. Doublet :

Minister, before we hand over to Andy, could you let us know what previous meetings you have had with the G.P.s?

The Minister for Health and Social Services:

On this particular issue, I have not. It has been done by the professional team.

Deputy L.M.C. Doublet :

I recall that at a previous hearing you committed to meeting with them. Is there a reason why that has not happened?

The Minister for Health and Social Services:

Yes, time as much as anything else but I have also been aware that the professional team have been in dialogue and I was hoping that that was going to unlock the situation in itself. As I say, I cannot be at every meeting all the time. Unfortunately, we still have not managed to resolve it but I am now going to, hopefully next week, meet with the G.P.s governing body.

Deputy L.M.C. Doublet :

Okay. Is that meeting in the diary for next week?

The Minister for Health and Social Services:

It is being discussed this morning and it is being requested this morning,.

Deputy J. Renouf :

So that reflects the problem that there is still an outstanding issue with the G.P.s in terms of trying to get the G.P.s involved?

The Minister for Health and Social Services:

There is. As I say, I was hoping it was going to be resolved at officer level but it has not to date.

Deputy L.M.C. Doublet :

Could you give us some information about the officer level discussions, please?

Director of Mental Health, Social Care and Community Services:

There has been a further conversation with the Primary Care Board representatives. Following that, there was a meeting of the Primary Care Board members and their decision was that they would not support a shared care model currently, so that is unchanged from the last time that we reported to you.

Deputy L.M.C. Doublet :

What was the ratio of those supporting and not supporting it?

Director of Mental Health, Social Care and Community Services:

I do not know because clearly I was not at the meeting. I just know the outcome of the meeting and we have also had the executive directors from H.C.J. (Health and Care Jersey) meet with Primary Care Board members. We had a meeting at the end of last year where we talked about this in some detail and again the view was that that is not something that they could sign up to at the moment. Clearly, from my perspective, this is absolutely key to creating the service. We would eventually get to the point where all we can do is prescribe to the people that we have diagnosed and we will not be doing assessments because there is no one else to prescribe.

Deputy L.M.C. Doublet :

We understand, Minister, from our evidence gathering that there are some G.P.s, whether it is whole surgeries or individual G.P.s, that are prepared to enter into this agreement. Is there a possibility that agreements with either individual G.P.s or perhaps one or 2 practices could be entered into?

The Minister for Health and Social Services:

I am very hopeful but I am not sure that I have got anything else to bring to the party. I am certainly going to have the discussion with them to see if they can be persuaded but I cannot sit here and guarantee that I will have any more success than Andy has, but we will certainly make every effort.

Deputy L.M.C. Doublet :

I think what I mean is is it practically possible in terms of the shared care pathway, is it possible to do it with ...

The Minister for Health and Social Services:

With their agreement, yes, it is. You do not have to have every surgery offering that facility, but it is really to try to get to the nub of why it is that they are not prepared to let certain individuals do it and that is the nub of the discussion.

Deputy L.K.F. Stephenson :

Have you got any indications about what the concerns are?

Director of Mental Health, Social Care and Community Services:

Yes, they have said consistently, so there is a couple of things. Firstly, there is training and experience, so a number of them are concerned about prescribing the types of drugs that we give for A.D.H.D. Secondly, there is a concern about capacity overall and a view that this is specialist work that should be done by specialist people. Thirdly, the issue of the availability of medicines, which is a complicating factor because sometime we will have less availability of a certain medicine and a specialist needs to then adapt or change the medicine to one that is available. That continues as before. We still have peaks and troughs of medicine availability. So at this point in time that is something they would not want to take on. But this is not just here. This is a debate that is happening in lots of jurisdictions about what is done in secondary care versus what is done in primary care.

Deputy L.M.C. Doublet :

Okay. Minister, I know you have mentioned funding at the moment but funding for training those G.P.s, if that is the main concern, would it not be worthwhile investing in that to unlock that shared care agreement if that is the sticking point?

The Minister for Health and Social Services:

If that becomes a sticking point, we need to look at what that is and how we might be able to shuffle ... there may be a case for shuffling things but, as I say, I am always very, very reluctant to commit to making financial commitments against the background of what we are confronting at the moment. I have to say, and I will make the point again because I know we are on air: we are very, very keen to get this problem resolved.

Deputy L.M.C. Doublet :

Is there potential that if there were an A.D.H.D. hub established that there could be a G.P. maybe based in the hub full or part time to deliver some services there?

Director of Mental Health, Social Care and Community Services:

Where we deliver diagnostic services from is about what is clinically appropriate. So, yes, in an ideal world I think where the new or inclusive strategy will lead us to is a place where you have a multitude of things going on in a place, and that might not just be A.D.H.D. There is a wider question about doing other work there as well so, yes.

Deputy L.M.C. Doublet :

Absolutely, thank you. Do you have anything final on A.D.H.D.? Anything on A.D.H.D. anybody?

Deputy P.M. Bailhache :

Yes, please. On the last occasion I think Mr. Weir told us that there was some consideration being given to the possibility of prioritising or triaging the waiting list. I wondered if any progress had been made on that.

Director of Mental Health, Social Care and Community Services:

We have done some work on that. The clinicians clearly have done some work on that. They have some proposals around prioritisation that we are going to talk about on Monday. I think it is fair to say there are very mixed views about this and I think we will have to make a decision about prioritisation, but certainly the clinical team have thought about how they would want to prioritise.

Deputy L.M.C. Doublet :

Thank you. The next section is going to be on the restructuring plans for Jersey's healthcare system.

Deputy J. Renouf :

I wonder if I could be a little cheeky first of all, Minister, and say you have talked a couple of times about increasing charges in some areas, which is an overarching thing. Can you give any more information about what kind of services you are thinking about increased charges for?

The Minister for Health and Social Services:  

That is very much in its infancy. I would not want to make any particular ... there was a meeting that we had to cancel today that was going to give basically a first picture of the available opportunities. So that is imminent. That is now next week. I am very, very happy to be open and honest about that as we go but what I do not want to do at a too early stage is make statements that start frightening people about this. It is going to require more money so we need to handle that very sensitively. That is very much more a public engagement thing, so we need to be cautious about what we say and when we say it.

Deputy J. Renouf :

So there is some public engagement. Good.

The Minister for Health and Social Services:

Whenever it is appropriate, it will happen. I can make more comments on that in relation to this too.

Deputy J. Renouf :

Let us talk about restructuring then. Let us try to get some information clear first of all. What stage are you at in terms of the stakeholder consultation?

We are reasonably advanced, are we not? We stay in touch with people but the main consultation work is done, is it not? Ruth has been handling that so she can you give the full details.

Director of Health Policy:

Perhaps I can explain. As you will be aware, the Minister for Health took some initial proposals, high level proposals out to consultation with key professional stakeholders. It was not a public consultation because it was focused on talking to key professional stakeholders about how we bring forward arrangements to support them to work better together. That consultation has been finished. As a result of that consultation, because it was showing universal support, we are currently working on some draft terms of reference for a partnership board.

[12:30]

As soon as those draft terms of reference are completed, we will be going back to those key professional stakeholders to talk to them about the draft terms of reference. That will settle matters as to how that board is constituted, who are the members of those boards. At that point we will also be coming and talking to the Scrutiny Panel and also P.A.C. (Public Accounts Committee) because that is a requirement of P.170/2010. Then we will be bringing those draft terms of reference and the proposals for the establishment of the partnership board to the States Assembly for decision making. So that is the status of the consultation with regard to the partnership board. As you will also be aware from the previous States Members briefing, we are proposing some internal changes to reporting lines within Health and Care Jersey and also some changes to a very small number of existing staff job roles within Health and Care Jersey. We are currently actively working on developing detailed proposals for those new reporting lines and those new job roles and we will be consulting staff about those, all affected staff about this, towards the end of this month.

Deputy J. Renouf :

In terms of the other thing that was mentioned, certainly by the chief executive of P.A.C., was a business plan, which you would expect for these kind of proposals before it goes to the Council of Ministers even. Where are you with a business plan, Minister?

The Minister for Health and Social Services:

The Council of Ministers, we keep them updated as we go.

Director of Health Policy:

With regard to a business plan, there is one area of cost within this. So obviously you develop a business plan when you have an area of cost. There is one area of additional cost within this and that area of cost relates to the partnership board. Alongside developing the draft terms of reference for the partnership board, we will be developing the associated cost and obviously the cost of the board will be dependent on the final terms of reference, the constitution of its membership, how often it meets and so on and so forth. All that information will be presented to the States Assembly for decision making on cost-benefit analysis because, as you will be aware, it is a requirement of P.170/2010 that the decision making sits with the States Assembly, but the costs associated with the development of the partnership board are very small indeed.

Deputy J. Renouf :

Picking up though, the chief executive pointed out that it was an important part of the process and he said there was active work on a business case at P.A.C.

Director of Health Policy: Unfortunately, I cannot comment on that.

The Minister for Health and Social Services:

I think what we are saying is it is going to be limited because in reality what we need to be doing in a business case is just focusing on the money. I take it you have got concerns about the structure itself. I suppose I should not be assuming anything, sorry.

Deputy J. Renouf :

I do not have enough information to say really. Nobody disagrees, I think, with the core principles of what you are trying to do. The devil is all in the detail, so I think what I am trying to establish at the moment is when will we know. When will it go to the Council of Ministers as a detailed set of proposals and then when it come to the Assembly?

Director of Health Policy:

Depending on the outcome of the consultation with the department on the terms of reference for the partnership board, we would envisage it going to the Council of Ministers in April and we would envisage it coming to the Assembly in May. Before it comes to the Assembly, we will, of course, go to Scrutiny and P.A.C. on it.

Deputy L.M.C. Doublet :

There is a draft terms of reference that is part of the consultation.

Director of Health Policy:

So this is the second phase of consultation, for want of a better description. It will be on the draft terms of reference and they are part written at the moment, just not at a stage where they are finalised ready for consultation.

Part of the problem is an overload of work, is it not, because unfortunately we do not have a team of people just sitting there waiting to draft everything. We have got a lot of pressures in a lot of areas, so it is not progressing as quickly as we would like in an ideal world, but that is just a product of where we are.

Deputy J. Renouf :

One question that I think sits underneath all of this is the way you have chosen to do it. You have obviously come under questioning about that, but one of the things that would be interesting to hear is: what are the aims in terms of public improvements that we might see as a result of this? There surely is some baselining in terms of this is what the situation is now, this is what we would expect to see in the future, relative to patients, not in terms of just job changing.

The Minister for Health and Social Services:

The whole idea of this is to deliver better patient care, is it not? I think that has got to be our focus in all areas. When we talk about restructuring, there are 2 parts to this. There is the formal creation of a health board, which is simply when you are trying to get a forum together where all the participants feel that they have an equal stake in it and they have got a forum for discussion and decision making, which we lack. It also puts us in a position where the overarching department has responsibility insofar as it can have for all elements of healthcare and somebody sits at the top with a brief and a salary that requires them to deliver a fully-integrated health service. We do not have that at the moment. It is incoherent, in my view, and that is why we are looking to get the model straightened out. Within that model, there is other work going on. I have mentioned this time and time again that, although it is just a personal opinion, I think it is shared by just about everybody else, everything was over-centralised in the Parker regime, everything came into central government and that was finance, procurement, H.R. (human relations) and I.T. (information technology) and that has caused a lot of complications. What we are trying to do ... I do not want to use the word "decentralise" but there is an element of decentralisation in this. As we have said before, everything will run through the central system but there is more autonomy within the health service itself. So we are trying to create a fully-integrated health unit so that health can look after itself. The finances can be handled by a finance director with all the required skills, the same with H.R. and the same with I.T. It is shame that digital is not on the agenda today because there is some really exciting stuff happening in that area and it is a very, very vital area.

Deputy R. Renouf :

Another time, I am sure. I am sure we can move on to it but, with respect, can I just push you on the question I asked, which was about what difference you expect the patient to see, because I understand all of that stuff in structural terms.

The Minister for Health and Social Services:

No, that is fine and, forgive me, I did not fully address that. From what I have seen in now 14 months is an awful lot of the problems we have got is the fact that things in the health service generally do not seem to be closely enough connected. A lot of things fall through the gaps at various times and that is why there are 2 elements to this. There is personal connectivity, where the right people get to talk to each other more regularly, and the other is digital connectivity, which is the overarching requirement. At the moment, there is an international standard of where we are on the digital pathway, 7 stages and we do not get to the bottom of the first stage, to the front of the first stage, that is how badly off we are. In terms of personal connectivity and digital connectivity, lots and lots of things go wrong when you go from primary care into secondary care and back out into the community, and those things need to be tightened up.

Deputy L.M.C. Doublet :

So when you say that things go wrong, I think the question is trying to focus on the patient experience.

The Minister for Health and Social Services:

The patient experience. The information does not travel as it should, partial information gets through, gaps emerge in terms of timing, so there is an incomplete pathway and timings can go wrong. People do not know and when people get sent away to the U.K. (United Kingdom) in terms of records going over and the records of the work that is done coming back. I know I am a layman but it seems very, very fractured to me and when we have had these discussions, I think there were 14 sessions we did, or more, everybody was in agreement. I said to people: "If you were designing a health service, would you design the one we have got?" Not one person in that process has said that they would have what we have got. So whether we are going in the right direction or not is yet to be seen but I think we need to be going in a direction because nobody is happy, nobody in the professional area is happy with what we have got.

Deputy J. Renouf :

The baseline is what I am after, though, the data. How will you know that this has worked? I presume there is some sort of sense of this is what is not working and these are our indicators of it not working and then we will know whether it has worked.

Deputy L.M.C. Doublet :

Is it waiting times, is it life expectancy? What are the actual measures?

The Minister for Health and Social Services:

I think one of the measures I will notice is I will get less emails in my inbox to reply to from people who are not happy with the service. I say that partially in jest but it is quite genuine.

Deputy L.M.C. Doublet :

Complaints could be a legitimate measure, could it not?

The Minister for Health and Social Services:

Complaints will be an indication. I think with all of these things you have to have a bit of faith in the concept and think it makes sense and you just get on with it. There will be measures where you will be able to get a gauge whether it is working or not.

Deputy J. Renouf :

That is critical to me. I think what you are saying is we should just suck it and see and we believe it will work. What I am saying is normally you would expect to see a data-driven approach where you say: "This is the problem, this is the baseline where we are at, this is where we want to get to and here are the measurements that will show whether we got there or not."

The Minister for Health and Social Services:

Perhaps I have not given sufficient thought to how we might analyse the success or otherwise of this. We are up against a political cycle, which is a worry, and I am always a great believer if everybody ... if you come up with a set of idea and they are finetuned by talking to people and everybody is happy with them, it just makes sense to get on and do them. You can start measuring the success or otherwise as things start coming together. As I say, we can stop in our tracks and make sure that the model is perfect and we have gone out to the public and we have got all the measures in place. You turn up at an election, somebody else comes in and the whole process starts again. There is this tension between wanting to make sure you have ticked every box to get the technicalities right and getting on with the job. I am afraid, for my sins I tend to err towards when something looks right and the professionals are all in agreement, that that is the way to go. You crack on and you get the job done. I am quite happy as a result of today's discussion to go back with the team and start thinking and perhaps we should have thought earlier. I take on board that we will need to have some measures in place to monitor.

Deputy L.M.C. Doublet :

You will get back to us on what measures you will be using?

The Minister for Health and Social Services:

Yes. I am quite happy with the principle of measuring success but for me up to this point in time the main thrust has been getting on with the job. You make a very good point about assessing.

Deputy L.M.C. Doublet :

Would you reflect on the Future Jersey indicators, which I believe are being used by Government as a whole?

The Minister for Health and Social Services: We can put them into this as well.

Deputy P.M. Bailhache :

It goes a little bit further than that as far as I am concerned because this is very interesting but I am confused, to be frank, as to what exactly is proposed. I understand that when you are trying to reorder what is a huge department with multiple problems in it, a whole lot of ideas are thrown around, but there comes a time when you must reach a decision: "This is what we want to do." It seems to me it would be enormously helpful to Members if you were to put out some short paper saying: "This is what we perceive the problems to be; this is how we are going to deal with them." It is more or less what Deputy Renouf is saying but it is perhaps a different way of expressing it.

The Minister for Health and Social Services:

I had hoped that we had done that. The engagement that we did on 5th December, there were questions asked in the Assembly.

Deputy P.M. Bailhache : It is not in writing, Minister.

The Minister for Health and Social Services:

Some of that is in writing. There is an awful lot that has been put in the public domain.

Deputy P.M. Bailhache :

I have got this. That is the integrated health and care consultation feedback report. Is there something else?

Director of Health Policy:

No, there is not a single document that captures the direction of travel that is currently being driven by the Minister for Health at the moment. There are a number of pieces of work that are going on which have the sole intent and sole aim of improving the health and care services and the access to health and care services in Jersey. The partnership board is one of them. Clearly the hospital is another one. There are individual pieces of work that are being done around specific services and around specific  areas of  public  access to  services:  termination  of  pregnancy,  I.V.F.  (in  vitro fertilisation) et cetera. We are absolutely recognising what is at the heart of your question. I think it is really important to acknowledge that the establishment of a partnership board will in itself not create positive change for Islanders. What will create positive change for Islanders is the output and the work of that partnership board. It is the key providers of critical health and care services coming together to determine what the priorities for change are and working together to deliver those priorities for change.

Deputy L.M.C. Doublet :

I am just going to stop you there because I am mindful of time. I think that is understood. What the Deputy is asking is when will that document be available with all of these principles and the model set out so that we can scrutinise it and the public can be aware of it? When can we expect to see that document?

The Minister for Health and Social Services:

When I sit here - and correct me if I am wrong - we have not got a plan to put a completely coherent document, putting all of these things together. I make the point, and Ian is going to touch on some of this, and when we finally do digital we will touch on it as well, but a lot of these things are already happening.

Director of Health Policy:

One of the first tasks of the partnership board, if it is set up, subject to Assembly approval, will be to develop a whole system health and care strategy and to own a whole system health and care strategy. I believe that that is the document to which you are referring.

[12:45]

Deputy P.M. Bailhache :

Well, you need something to get your teeth into. If you do not have any specific document with specific proposals you cannot identify them. Some people may not be entirely happy, Minister, with the proposal that the Health Insurance Fund should be transferred to the Minister for Health from the Minister for Social Security. At some stage there has to be the possibility for Members to debate that before it becomes a fait accompli.

The Minister for Health and Social Services:

They certainly will and that will come when we come with the terms of the reference for the partnership board, because that is all part and parcel of it. I make the point again, all we are doing is transferring it from one department. At the moment, there is a lot of complication in terms of benefits paid. There is an enormous amount of complexity that could be streamlined. All we are looking to do is transfer a fund in its current form with exactly the same purpose from one department to the other. It seems to be a very good idea to us and the Minister for Social Security feels the same way. I do not see any contention in that and if people have got questions that is fine, but those questions will be answered when it goes to the Assembly as part and parcel of the proposals for the partnership board.

Deputy L.M.C. Doublet :

Is the intention to keep the fund as a ring-fenced fund?

The Minister for Health and Social Services:

That is the intention, yes. As I say, going into the future I think we have to be prepared to look at everything and we have to have a fundamental review of health funding. What the recommendations are as the result of that, we shall have to wait and see but there is certainly no intention for the G.P.s not to be properly funded, that is for sure. I have been down that road myself and supported measures to not have that fund raided, so those principles will be preserved throughout. That is absolute.

Deputy L.K.F. Stephenson :

Can I just ask for some clarity, just to go back a couple of comments? Is it right, is my understanding correct that we are trying to work towards getting the system and the structure in the right place so that the big conversations about how to make the improvements for the patients happen? It is very much a staged process, which is why we do not have one big document setting it all out yet.

The Minister for Health and Social Services: Yes.

Deputy L.K.F. Stephenson :

Okay. Then at that stage when the big conversations can happen, first of all, how far down the line are we looking at that timeline-wise? If then it emerges the structure is not correct to get those things done, because it is kind of a chicken and egg situation, is it not, is the structure going to be right to serve those purposes? You might not know until you know what those aims and purposes are.

We know what the aims and purposes are.

Deputy L.K.F. Stephenson : So why have you not told us?

The Minister for Health and Social Services:

We have. We have had briefings and we have offered to do another briefing. There is a date in the diary now where we are going to brief people and people are free to come along. I think only 8 turned up last time, with 2 online. I would like to see 49 people present. We are very happy to talk to all of it and there is a logic to all of it. As I say, perhaps I am closer to it and I am a little bit confused as to why people cannot see the logic of it more readily than is the case, so perhaps we are not communicating properly. The formation of this board is, in my view, perfectly logical and all the people that we have put it to that are in the professional services are looking at it and saying: "That looks right." I do not think you can go any further than that. What you then have to do is to get on and do it and put it to a test and if it needs finetuning, then it gets finetuning. Our health service is in quite a lot of trouble. As I say, my inbox is testament to that and we need to get on and do stuff. I apologise if we are not spending quite enough time on process. That may be a fair criticism but we do really need to do something. I am afraid to date I have not seen enough things happening so things ...

Deputy L.K.F. Stephenson :

I am not being purposefully difficult. I genuinely do not understand.

The Minister for Health and Social Services:

No. I would like people to leave this room feeling a little bit more comfortable about the fact that there is really some positive stuff. I know nobody wants to focus on it but, as I say, in H.R. and recruitment there is an awful lot of good work that has been done. On the digital front, we have got a head of digital. We have a digital director and 30 people have been apportioned for that person specifically to work on health. To my mind, that is something to celebrate. That is groundbreaking stuff.

Deputy L.K.F. Stephenson :

I do feel like I was starting to get somewhere with the understanding of the staged process. If we could just go very quickly back to that.

The Minister for Health and Social Services:

Sorry, yes. I am just enthusing about it because I want to get the message across.

Deputy L.K.F. Stephenson :

It is a staged process and that is the idea, to get a system that allows everybody to sit comfortably around a table and have input. So just back to the question about timeline, about when that conversation is going to happen, be able to happen.

Director of Health Policy:

Assuming that the States Assembly agree the establishment of a partnership board, we would envisage that we will start that work with the partnership board towards the end of summer. If there is a decision by the Assembly to establish the board, recruitment of the board members, as soon as that happens we will start the conversations with the members of the partnership board about what an overarching health and care strategy looks like and what the priorities for change look like. That absolutely will be before the end of this year and, to be clear, the partnership board will be undertaking and leading public consultation during that process because that will be the conversation about what does change look like.

Deputy L.M.C. Doublet : When is that going to be?

Director of Health Policy:

That will be before the end of this year. As I have said, there is a sequence of events which is: States Assembly agree, us being able to recruit.

Deputy L.M.C. Doublet :

That first thing that you mentioned, the States Assembly agree, what States sitting will that debate be happening at?

Director of Health Policy: Hopefully it will be in May.

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

Director of Health Policy:

That is the target date for getting the report and proposition lodged so that States Assembly Members can debate it. We will then recruit the members. We will then start working with that partnership board on what a health and care strategy looks like. Going back to your point about if it turns out that the structure of the partnership board is not quite right, because it is impossible to completely know that until we commence work, the partnership board will not be in statute at first so if we need to amend and flex, we will absolutely amend and flex. The other thing to say that is really important about the reason why this approach is proposed is the Government of Jersey have historically spent a lot of time and a lot of resource historically developing health and care strategies - for example, the Jersey Care model and P.82 back in 2020 - and those strategies have not been successfully progressed. If you strip away to the core reasons for the failure to progress those strategies and create change in the past, it is because the essential system players did not feel ownership of the development or ownership of the delivery. That is the fundamental problem we are trying to resolve in the first place.

Deputy L.M.C. Doublet :

That is helpful. You mentioned P.82. What measures were used to measure the effectiveness of the actions within P.82?

Director of Health Policy:

I would have to come back to you on that because, of course, P.82 was very broadbrush. It included the development of a new hospital. That is historical. I would have to go away and I would have to find that information.

Deputy L.M.C. Doublet :

So that could be referred to when the Minister is considering the measures.

Director of Health Policy:

Yes, absolutely, and at the point at which the partnership board develops a whole system health and care strategy there will be very clear indicators of change within this, what is it that will be better for the public as a result of us doing this.

Deputy L.M.C. Doublet :

Did you finish your line of questioning, Lucy?

Deputy L.K.F. Stephenson : Yes, it is great. Thank you.

The Minister for Health and Social Services:

While some of the conversation has been taking place, I have just been thinking about examples of where things can be made to be more efficient. One of those is we have currently got a problem with talking to the G.P.s to try to persuade them to have this shared care pathway. I would not mind betting that if the G.P.s are formalised and they have got a voice and they are on part of a board, those discussions become a lot more direct, there would be a lot more trust. When I first came to this, the trust between the services and the G.P.s was really in bad shape, I have to say. There was a lot of animosity both ways round. I think that has already ... I think there is some trust building up, there is more engagement, I think, than there was. I think particularly with the G.P.s, if they are a part of a board and they have got a status, they have got a voice, those discussions will be ... the problems will be discussed on an ongoing basis. As things emerge, they will go straight to that body for discussion. There will be more trust and I think those issues would be resolved a hell of a lot more quickly than they are at the moment. That is the hope.

Deputy J. Renouf :

Just a final question perhaps on this, to Deputy Bailhache 's point really. No Minister for Health sets out to design a system that makes the system worse, so that is taken as read, maybe not by you, but I do not think any Minister for Health has stood there and said that.

The Minister for Health and Social Services: No, I would not say that at all.

Deputy J. Renouf :

The point is that, yes, you are trying to make the system better but the devil is in the detail. You believe that by putting everybody in the same room conflicts will be resolved better and so on, but it may simply transfer the conflict into a new forum. It does not make clear where the lines of accountability lie. It does not say where the resourcing will go, who will take responsibility for different things. That is the sense in which I think Deputy Bailhache 's point about wanting to see the detail, how will this actually work because then we can say whether we think it will deliver the change.

The Minister for Health and Social Services:

That is fine, but I have seen successive health initiatives come to nothing, however well intentioned the person might be. I am afraid I just come from a real world background where if you do not get on your bike and get things done, people overtake you. We are not in that situation here. There is nobody that is going to overtake the health service but you know that things just do not get done. I have to say from a political perspective I have taken the view that people might be a bit annoyed with me, they might think I am a little bit inclined to move too quickly, but you have to take a balance: do we want things to happen or not? I think we are looking down the barrel of a gun, quite frankly, with health provision becoming more and more complex and more and more expensive. I could easily sit here, I could have a very easy life and come in on a Friday, sign forms and go home again, and nothing will happen. I will not get any criticism, but I am quite happy to take whatever criticism is coming my way in order to get things done, because I think that is what we need. There is a fine balance and I do not want to revert to being hamstrung by process so that all we are doing is

delivering process and not delivering any real change. I know people might be critical of that, but there we are

Deputy P.M. Bailhache :

I have got a lot of sympathy for what you are saying, Minister, because one can get bogged down in process very easily, but at the same time you have to take people with you.

The Minister for Health and Social Services: Quite right.

Deputy P.M. Bailhache :

In order to take people with you, people have to understand what the proposal is. That is all I am saying.

The Minister for Health and Social Services:

You make a very good point and I have been drawn up a bit short this morning and I need to go away and think about maybe trying to get a little bit more information about there. I am very, very happy to take this to the public but not so much on consultation. I know there has been controversy about this but I think if you open things up for 100,000 different opinions on things that are really matters about which people will not have an intimate knowledge, there is a danger. I think once we have decided on something, I am very happy to go to the public and explain and certainly to liaise with the public about increasing charges that is a different thing. That is going to be them putting their hands in their pockets, so that is different. What we are trying to do is make progress but if the message coming from here is that we are not really putting sufficient information out there, we can, with the limited resources we have got. You have got to bear in mind I have got small teams of people who are under a huge amount of pressure from lots of different areas, so I have then got to be saying to them: "Slow down a bit, we have got to go and do this and we have got to do some more engagement", which is fine but there is a very, very fine balance. What we are trying to do is to try to get that balance right in the interest ... everything comes back down to the patient and, like I say, I see far too many complaints about far too many things and I think we can do better.

Deputy L.M.C. Doublet :

Okay, thank you. So we will await further information from you on publishing something to put some more information out there.

The Minister for Health and Social Services: A summary document, 4 pages.

Deputy L.M.C. Doublet :

And the measures that you are going to use to measure the effectiveness.

The Minister for Health and Social Services: Yes.

Deputy L.M.C. Doublet :

Thank you for that. We are going to move on to a different section now.

Deputy L.K.F. Stephenson :

Linking to the information that is out there, on 14th January the Health and Care Service Division annual plan for 2025 was published. Can you just give us a brief explanation about what that document is and where it has come from, how it was put together?

The Minister for Health and Social Services:

The team has put that together and it is basically a broad summary of what our intentions are for the 12 months.

Deputy L.K.F. Stephenson :

Is it in lieu of a business plan or will business plans for the different departments with operational delivery follow?

The Minister for Health and Social Services:  

Each department works to a process but that is something Andy can elaborate on more sensibly.

Director of Mental Health, Social Care and Community Services:

There are plans that sit underneath that. For example, in mental health services there is an annual plan that sets out a whole series of different actions, which of course relate to the overarching plan but they are not published business plans. They are the plans for the service. This is our overarching H.C.J. plan for the year.

Deputy J. Renouf :

The Chief Minister made clear at the time of the budget that there would be business plans published for every department. So far only the Minister for Treasury seems to have published one. This one does not appear on the business plan list. Is it a business plan and, if it is not, when is the business plan coming?

Director of Mental Health, Social Care and Community Services:

Yes, I think this must be, in the absence of another plan, so it is the business plan, yes. [13:00]

Deputy L.K.F. Stephenson :

Thank you. Then on to the home birth service and the internal review.

The Minister for Health and Social Services: Should I swap places with Andy?

Deputy L.M.C. Doublet :

Minister, if you could stay at the table but one of your officers could ...

The Minister for Health and Social Services:

I will stay at the table, yes. I thought I was going to be off the hook for 10 minutes. It did not work. It was worth it.

Assistant Minister for Health and Social Services:

My name is Andy Howell . I am one of the Assistant Ministers for Health and I have been working with our Director of Nursing and Midwifery on this. It was thought that with the home birthing service, we could not offer a safe service and so that was why it was withdrawn temporarily.  

Deputy L.K.F. Stephenson :

You say it was thought you could not offer a safe service. On what basis was that decision made? Were there any particular incidents for that decision?

Assistant Minister for Health and Social Services:

It was based on the professional opinion of our chief midwife.

Director of Midwifery and Nursing:

I think it was looking at all of our staff in the workforce to be able to offer a 24/7 service for the home birth service. It was looking at the child birth emergency ability. It was not looking at midwives being able to deliver a baby. It was about if you had an emergency in the community and dealing with that because obviously it is midwives that have to go to a home birth, so it was just making sure that they have got that expertise and that training. When I looked at that, there were very few people who had that training, so therefore to be able to offer it safely and efficiently, I had to make sure that I reviewed all of the training that was undertaken by each of the midwives and that is why I said that if we temporarily suspend it, that means that we can review our policies and our procedures, making

sure all of our midwives ... because we have got a junior workforce now. We have got a workforce that might be in their first year or 2 years of qualifying and I needed to make sure that that training is for them so that they are able to provide the care within the hospital setting but also at home, and it is not around just the delivery. It is actually any emergencies that can develop that we are unaware of. Therefore, that is why I have temporarily suspended and then put on the training, which will be in childbirth emergency so that all midwives then on the Island will have that training. It is not just the midwives who will have that training. It is also the paramedics. We have been working very closely with them as well to make sure that we have got a very cohesive training programme for all of our midwives and paramedics together.

Deputy L.M.C. Doublet :

Can I ask about the new training that you are going to provide? How is it different from the training that you had in place before?

Director of Midwifery and Nursing:

The training we had before was on Island. It is very much there has been lots of developments in the U.K. We have had lots of different reports, et cetera. The training that was undertaken was by individuals who, for different reasons, need not have been in the service for various reasons and, therefore, I wanted to make sure that it was very much the training that is highly recommended to everybody. Within the N.H.S. (National Health Service) it is something that they now are undertaking this training within all their organisations in relation to childbirth emergencies. Therefore, I felt that in Jersey we needed to have the most up-to-date, reliable and safe training that is undertaken by individuals who are highly commended within that process to be able to provide that training for them.

Deputy L.M.C. Doublet :

Is it a different training package?

Director of Midwifery and Nursing:

It is a different training package in that it is up to date now. The training package that we were doing on Island before was something that was done a few years ago and now they have very much expanded that training and that is through all the different reports that have come out in relation to various 3-year delivery plans for maternity across the U.K.

Deputy L.K.F. Stephenson :

So that organisation is Baby Lifeline who will be providing that. We have got 40-ish midwives, I think is correct. Will all midwives be trained and will it happen all on the same day?

It cannot always obviously happen on the same day because we have got to cover a service 24/7 as well and also we have got people who will be on annual leave, et cetera, but we have already got a second training date that will be going on later on in the year and our plan is then to work with them. We are going to train the trainer. We are very much working with our practice development midwife and our clinical effectiveness paramedic so that that training will then be ongoing throughout the year, and we will have 3 courses every year going forward. We will be working with Baby Lifeline on that as well and that is all in place.

Deputy L.M.C. Doublet :

How often do midwives have to repeat that, or should they repeat it?

Director of Midwifery and Nursing:

Our plan is that we want to repeat it every year and we always do medical emergencies. Working together and training together, that gives us the safest care. Our plan is that it will become part of our training programme going forward for all of our midwives to do that so that we are not missing out on anybody. It will be absolutely every midwife in every year, but it will be 3 episodes throughout the year that we will be doing.

Deputy J. Renouf :

Can you state when you think the home birth service will start if that programme is starting on 3rd July?

Director of Midwifery and Nursing:

I can do that training programme but obviously then I have then got to present to our chief officer with all of the review that I have done and with all the training. It is for him then to decide. That will not be my decision. That will be our chief officer's decision when that will be reinstated.

Deputy J. Renouf :

How long does that process take? You finish your first cohort of training and then decide what you want to do and present it. What sort of timescale are we talking for that process?

Director of Midwifery and Nursing:

Obviously, at the moment we are already doing that process. We are looking at all of the different policies, procedures, et cetera, so that will be once the training is completed. I will then be going to him with a paper to tell him about what we have done and whether I feel it is appropriate then for us to reinstate the service and then I have got to assure him of everything within that paper to make sure that he is happy to give the go-ahead for us to go ahead with it.

Deputy J. Renouf :

You are not giving a timeline now.

Director of Midwifery and Nursing:

That is not a timeline I think I can give because that is up to our chief officer to make that decision.

Deputy L.M.C. Doublet :

Okay, and if there is not the go-ahead at that stage in time, will all necessary resources or whatever needs to be done to make the service available, will that happen so that

The Minister for Health and Social Services:

I think we have got to be completely honest here and say that there is no absolute guarantee that the service will be reinstated. If I understand it correctly, it was only ever a service that was available as and when it was deemed appropriate and the right people were there to do it. I stand to be corrected, but I think that is right, is it not, Ros?

Director of Midwifery and Nursing: It was it is not.

The Minister for Health and Social Services:

It was not a full guaranteed 24/7 365 service and it may well be the case that we are not able to offer something we have not offered in the past and we just have to be completely honest about it.

Director of Midwifery and Nursing:

I think from that point of view I have got to look at exactly every woman who is in labour at any one given time. We would absolutely want to be able to give it but I have got to think about the ambulance service, I have got to think about every woman who is in labour, and if it is that we were very busy within our labour ward, it might be that I am too stretched to be able to provide a service because obviously we have got the same 2 midwives out. We have been very honest with our women and they already know that that if the service was able to be provided prior to the suspension then we would be able to offer it but they were aware that if it was that we were unable to because our labour ward was busy with labours at the time, we have to make sure that we are providing one-to-one care for all of our ladies not just those who are within a community setting.

Deputy L.K.F. Stephenson :

When you say there is no guarantee that the service will be reintroduced, do you mean no guarantee that it will be reintroduced at all or on a 24/7 basis?

The Minister for Health and Social Services:

The result of that will come when the work is finished, when the review is absolutely completed, and it will be done on safety grounds fundamentally. Part of that decision making will once again have to be money and how much it is going to cost. Like I say, I think what we do have to do in the first instance is make sure that there is a first-class service for maternity service and that is the core thing we have to deliver in the first instance and that will be done.

Deputy L.K.F. Stephenson :

In which case, and I do not want to suggest that we delay it any further, why are we paying for training before we have made a decision about whether we can have the service at all?

The Minister for Health and Social Services:

Ros can answer but I think we need properly trained people but, Ros, I am sure you are in a better position to answer that than I am.

Director of Midwifery and Nursing:

I think what we have always got to remember is that even if we have not got home birth service, we could always have the possibility of a woman not realising she is in labour and then delivering very quickly. We need to then provide emergency care for her with the ambulance service together so even if we did not have a home birth service up and running, we still should be able to provide that emergency care out with our hospital setting, so it would not ever be wasted.

The Minister for Health and Social Services:

The core service has to be as near perfect as it can be.

Deputy L.K.F. Stephenson :

In those scenarios, does a midwife go with a paramedic?

Director of Midwifery and Nursing: Yes.

Deputy L.K.F. Stephenson : Great. Okay.

Director of Midwifery and Nursing:

Yes, absolutely. Our paramedics are attending this training with us as well, so they are very much with us to do that training.

Deputy J. Renouf :

Can I just clarify this point, Minister, because are you saying that there is a significant possibility that there will be no home birth service reinstated as a result of the review that takes places, none at all, other than the emergency situation?

The Minister for Health and Social Services:

I do not know if I would go as far as to use the word "significant" possibility but there is a possibility. What would be wrong here is to sit here and offer a cast-iron guarantee that there is going to be a 24/7 365 guarantee.

Deputy J. Renouf : Not that, just a service.

The Minister for Health and Social Services:

A service. Let us look at the review when the time comes. What is important is that all the nurses are properly trained, and we have got a first-class delivery service. That is the main thing. The core service has to be as near perfect as we can.

Assistant Minister for Health and Social Services:

We really just want to make sure our women are safe and that we look after our staff and we listen to what our head of midwifery is saying.

Deputy L.M.C. Doublet :

Yes, I hear that and in terms of safety, Jersey has a very high level of interventions and caesarean sections. Do you agree, Assistant Minister, that it is critical that we have these offerings, such as the home birth service, so that we can work towards reducing those rates of interventions?

Assistant Minister for Health and Social Services:

I think the intervention is only done for the safety of the mother and the safety of the baby and I think sometimes we have to do those interventions. My daughter would be dead if she had not had an intervention, and her baby would be dead.

Deputy L.M.C. Doublet :

Yes, sure. Are you aware that the rates in Jersey are much higher than in other jurisdictions?

Assistant Minister for Health and Social Services:

Yes, I am, but I think that is because generally our mums are much more elderly, and they have significant risks. Perhaps some of them are diabetic. They have high blood pressure. We do not do interventions unless they are necessary.

Deputy L.M.C. Doublet :

Sure. Can I ask Ros about that? Is it the age of mothers in Jersey that is the issue?

Director of Midwifery and Nursing:

I do not necessarily think it is the age. I think it is choice, and I think a lot of our women that is through their choice. We very much look at any interventions and I look at them every month. The biggest part of it we look at is in relation to caesarean sections, the Robson criteria, and a lot of that is through choice, is that women might make that decision to do it, but we are doing an awful lot of work in relation to that choice and making sure that they are aware about our midwife bed unit. We offer tours now. We have done a new virtual tour, and we are working with our professional midwifery advocates to make sure that women know of all the choices that we have got within our maternity unit.

Deputy L.M.C. Doublet :

Sure, but the emergency C-section rate is also very high, which obviously is not by choice. What are the reasons for that?

Director of Midwifery and Nursing:

That is always a clinical picture, and I think if the clinical picture is that they recommend and obviously we do different categories of emergency caesarean sections. We look at them as well. We very much do huddles around them to make sure that they are appropriate, and they are done for absolute clarity, and we make sure that we review them. We are no different, I would say, than a lot of trusts within the N.H.S. about what they are saying about their emergency picture, but we have got to think about: what is the safety of the mum and the baby at that time?

Deputy L.M.C. Doublet :

In terms of your policy intentions, is it your policy intention to aim towards delivering a home birth service, if at all possible, obviously a safe one?

Assistant Minister for Health and Social Services: Yes. Yes, of course, it is. Yes.

The Minister for Health and Social Services:

I think we have got to be clear it comes into the category of desirable. There is vital, which is make sure we have got an absolutely first-class service, and the home births comes into the category of desirable and as we are going to see with virtually all other areas of health in terms of the difference between delivering a core service and what we would like to have.

Deputy L.M.C. Doublet :

I would just ask the Assistant Minister if you are aware of the public opinion on this? It differs from that

Assistant Minister for Health and Social Services: Yes, I do understand.

Deputy L.M.C. Doublet :

Sorry, I will just finish my question that the home birth service is seen as essential to many women.

Assistant Minister for Health and Social Services:

I think the essential service is that we provide a safe service for everyone. That is what

Deputy L.M.C. Doublet :

Yes, safe home birth service is seen as essential.

Assistant Minister for Health and Social Services: I do not think childbirth is ever 100 per cent safe.

Deputy L.M.C. Doublet :

But are you aware of the views of the community that this is essential?

Assistant Minister for Health and Social Services: I am very much aware of it, yes.

Deputy L.M.C. Doublet : Yes, sure. Okay.

Deputy L.K.F. Stephenson :

Just before we move on, I wonder if I could just ask in the course of the review to date, have any other operational issues come up that require investigation or the scope of the review to be widened at all?

No, I think I have fully done the review, and I have written the report and that will go through our governance processes next week. It will be presented, and I think then the review report should be ready for everybody but there is nothing what we outlined was in relation to our staffing and our training and making sure our equipment was all absolutely up to date. It is what we have found and now it is just actioning them.

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

Deputy J. Renouf :

A very quick follow-up, just picking up on something you just said, Minister. You said that the core service was the safe service, and it would be a desirable to have a home birth service. Is that something, therefore, that you might consider charging for?

The Minister for Health and Social Services:

I do not think anything is out of scope in terms of what we have to look for and that could be the thing that makes the difference. It is funny you should raise that as a question but I was going to offer that up as a comment so that could be something that we look at. As I say, I know you are very passionate - particularly you 2 ladies - about this and I get it. I might not be a woman, but I do get the desirability of that and if money was not an object, you can rest assured we would be looking to put that in place. Unfortunately, I did not quite realise how controversial this job is and is going to be going forward. There are some very, very tough decisions to be taken and some very hard conversations to be had and it is not an enviable position, I have to say.

Deputy L.M.C. Doublet :

Understood and just to note that we do of course have our own views on the panel, but we are here of course to represent

The Minister for Health and Social Services:

Yes, I fully appreciate where you are coming from and I do not want you to think that because I am male

Deputy L.M.C. Doublet :

Sorry, I will just finish, we are here to represent the views of the public, so we are reflecting the conversations that members of the public have brought to us, not just our own views.

[13:15]

The Minister for Health and Social Services:

That is fine and I get it and that is what I want to say. I do not want you to think that I do not understand the desirability of this because I do.

Assistant Minister for Health and Social Services:

I want to say that I have had friends who have very wonderful home births and for them it has been a great experience.

Deputy L.M.C. Doublet :

That is the idea, is it not? Great. Thank you very much. I have a very brief question on women's health. We have not gone into much detail on this issue at this hearing because we are planning a specific hearing on this which, Minister, I have made you aware of and we are looking forward to that. The Women's Health and Well-being Joint Strategic Needs Assessment Report that was published recently, can you just outline maybe some of the top things that you are planning to address from that report?

Assistant Minister for Health and Social Services: Yes, so there were 6 main things that came out of that

Deputy L.M.C. Doublet :

As briefly as you can, I am just noting the time. Thank you.

Assistant Minister for Health and Social Services:

The most important thing is that we want women on this Island to thrive and there are 6 main areas that we are looking into. We want to have healthy behaviours from childhood, prioritising gynaecological and reproductive health improvement, recognising what are determinants of health on women and girls, reducing barriers to accessing care and support and addressing the impact of the ageing population and declining birth rate. The Women's Health Group are going to be looking at those areas and then deciding what we should prioritise.

Deputy L.M.C. Doublet :

Okay. Thank you. Minister, you have spoken about funding. Is there sufficient funding to address the issues raised within this report?

Assistant Minister for Health and Social Services:

I am sure there will never be enough funding for everything on this Island. We have got the drains, we have got the climate

Deputy L.M.C. Doublet :

For this issue, is there sufficient funding?

The Minister for Health and Social Services:

I think this is simply a case of doing as much as we can in each of those categories with the money that is available.

Deputy L.M.C. Doublet :

Will you be seeking any growth funds in the budget this year?

Assistant Minister for Health and Social Services:

I am sure we probably will have to do that, will we not? I think we will have to.

The Minister for Health and Social Services:

Yes, I do not want to throw a curveball in here and it was only a matter of time before this happened, but I have been approached by a number of people recently who want me to set up a special issue for men's health. I think you might have seen somebody being interviewed on the television - a reasonably high-profile person - about this, so we have that to contend with as well. I think it probably is high time that we looked at some of the specifics about men's health and I know the same question is going to be asked: will there be extra budgets for men's issues? We come back round in this great circle of money.

Assistant Minister for Health and Social Services:

We want everyone on this Island to thrive and to have as good a health system as we can and to live well, to stay well, quick access to diagnosis and treatment if you are not well, and then to be supported with a long-term condition and then to die well. That stuff just sums it up really.

Deputy L.M.C. Doublet :

Okay, and to address the women's health needs you may seek some additional funding in the budget.

The Minister for Health and Social Services: Andy will be joining the queue, a very long queue.

Deputy L.M.C. Doublet : Was that a yes?

Assistant Minister for Health and Social Services: Yes.

Deputy L.M.C. Doublet :

Okay. Thank you. Do you want to ask anything, Lucy?

Deputy L.K.F. Stephenson : No.

Deputy L.M.C. Doublet :

Anyone want to? No. Okay, we are going to move on to the next section, Deputy Bailhache .

Deputy P.M. Bailhache :

I would like to ask a few questions around departmental culture because poor culture and low morale and difficulties of staff retention have been cited in a number of reports recently, in relation to some departments in the hospital anyway, and it would be good to understand what is being done to address those issues. Your annual plan said that there was going to be created an organisational development strategy, secondly a people and culture plan, thirdly a culture dashboard and fourthly a workforce strategy and plan and I wondered if you might tell us how those things are progressing.

The Minister for Health and Social Services:

Right. As you say, that is the plan for this year and we are only at the beginning of March, so things are very, very much in their infancy. I think it is well recognised that there are cultural problems. There is every effort being made from the executive leadership team down to recognise those issues. We have started a dialogue internally in terms of talking to people about what the problems are and trying to collate all of that. In terms of the formal process, Ian will probably be in a better position to update you on the points of detail, but it is a significant problem and something that we are all collaborating to try to resolve.

Deputy P.M. Bailhache :

Can you give us some indication of what is happening now in order to address these problems?

The Minister for Health and Social Services:

We have had the change of C.E.O. (Chief Executive Officer). I am in discussion with the current C.E.O., who unfortunately is away for 2 weeks having an operation, about setting up not a board, not a formal body but a collection of individuals to start trying to filter these problems through. We have got the Speak Up Guardians situation, which is working well. A lot of people now feel a lot more relaxed in passing information back up through the system itself, through the management system, and a good number of things are coming through to me directly. It is a case of opening up, finding out what the problems are and trying to piece together a method of dealing with it and I have to say, there is not any absolutely clear view. It is something that we are working on and trying to address as we go but there are some formal points that we will come to.

Deputy P.M. Bailhache :

If a member, for example, has evidence of abuse of the disciplinary system, where should he or she go?

The Minister for Health and Social Services:

In the first instance to Ian or otherwise possibly to the head of the service, Lesley Darwin, and people are very, very free to come through to me and they are now doing that quite readily. We have had meetings with the head of H.R. over the course of the last couple of months about making sure that people are very clear about what the rulebook says and the fact that the set of rules that we have got - employment rules - will be used more readily. It is difficult to be critical of the past, but things have not been as clear and disciplined as they might have been. I think there is a full recognition of that from Lesley downwards, right through the system, that we need to be very much clearer about what the expectations are and if those expectations are not met that there will be consequences. That is part of the cultural development process.

Assistant Minister for Health and Social Services:

I think we have recognised that members of staff have come to talk to many of us that perhaps process have not in the past been followed correctly and people may not have been treated as they should have been. We are hoping that now the culture is starting to change.

The Minister for Health and Social Services:

Full recognition but I think it is probably useful if we and Ian is sitting there anxiously waiting to speak so I think he might be able to colour in the bits.

Director of Workforce:

Recognising that we do have some hotspots where we have cultural problems, and I will talk a little bit in a moment about how we are dealing with those, but I think we also need to be careful that we do not talk down the whole organisation because when we take a look at our staff survey results, what they show us year on year is an improvement in morale and culture. We need to be really careful that when we are thinking about those hotspots, which are definite problems we need to address, we are not painting the whole organisation the same colour. I think that is really important and our most recent survey, even though our participation rates are lower than we would like, showed increase across all of the dimensions of the staff survey apart from one, and particular increase around people's engagement with leadership.

Deputy L.M.C. Doublet :

What do you put that improvement down to?

Director of Workforce:

It has just been managers and leaders working hard at doing things correctly and learning the mistakes of the past, listening to all of the reports that we have had that have been critical of the service and not repeating those and I think coming to much more of an honest, clear, well-structured process in the way we manage our people. I think some of the things which I would like to claim, things like putting in a just and restorative type of approach into our policy framework shows staff that things are done. They see that actions are taken. I think we still need to do more on feedback loops so that people understand when they do speak up what happens and that they feel some closure on that. I think our Freedom to Speak Up work which obviously centres around our Freedom to Speak Up Guardian but not only because we also have a range of Freedom to Speak Up champions and we also have all the line managers being trained on listening to people speaking up and encouraging people to speak up. Just that shift in culture of "we would like to hear", rather than "we do not wish to hear", has changed and the numbers of people that keep speaking up have been really positive. I think other things that we have done in terms of being more human as a

Deputy P.M. Bailhache : Can I just stop you there?

Director of Workforce: Sure.

Deputy P.M. Bailhache :

Speaking up is all very well and good but people who speak up need to feel that they have been listened to.

Director of Workforce:

That is right and that is closing that loop as I said, absolutely, and I think we need to do more and better. We are not there yet. There is work to do there. For example, the way we have been reaching out into the organisation recently. So just as a quick example for you, we had some anonymous reports of somebody reporting in social media that they felt bullied within the organisation. It was interesting to see the debate that was on social media, a lot of our staff saying: "Why do you not do this? Do this." They all seemed to know the process, but I put a communication

to staff and said: "Just remember these things", and a couple of people have come to me - one wants to remain anonymous, another one is willing to - and said: "I think I am being bullied. Can you help me?" absolutely opening those doors to a culture where it is okay to speak up. I think we are shifting the dial on that. I think we need to be careful not to over-emphasise where we are. We are improving in terms of culture. Our retention rates remain stable and at a low level, so people are not leaving us. There is this myth that people are leaving. Five per cent of people leave us a year. A healthy organisation you would probably say you would like 10 per cent of people to leave you in a year. Our retention rates are very good. We need to be careful because it becomes this rhetoric, which can be very negative. The other things we have done, talking about some of the areas where we know we have got problems, so we have got focus interventions going in there with our A.D.(?) team. We have got training. We have got listening events. We have got appreciative enquiry sessions. We are delivering psychological safety sessions and also often it does require us to look at: "Is the leadership in this area right? Are they being properly supported? Do they have the skills and capability to lead these areas?" One of the things I would say is on the areas that we are moving to ... and as you talked about us developing a people plan this year, one of the big areas of that people plan is to develop the capability and capacity of our managers to manage because this is not about the top team. This is all of the levels of management in organisation and if a manager is not managing well and is not capable or competent to do that, we need to support and train them better to do that.

Deputy L.M.C. Doublet : What does that look like?

Director of Workforce:

With Lesley, as the Chief People Officer, we have agreed we are going to look at leadership and development approaches across the whole of the government but particularly how well they fit for health because sometimes the broad brush of leadership and development for government, it does not always translate into a care environment, so I think we need to look at that and about the specific leadership things that we need to do. For example, we are just closing off on the Cohen Brown programme, you will be aware of, for executive leadership. There is an opportunity now to look at where we go next in executive leadership, where we go with the world-class leader stuff that goes below that and the espresso training that goes below that. We are looking at all of those but I want to look at it through a health lens because thinking about collective and compassionate leadership is more important than the service/performance leadership that perhaps is more fitting for the rest of government as a service provider of tax or there is a different vibe and I think Lesley is hearing that and we want to get into that.

Can I just say that we want to say thank you for all the members of the staff throughout the organisation for everything they do and that we want all of us to support them and to go forward positively. I think it is really hard when they keep being slapped down and slapped down, so I think we need to empower them and I think we need to listen to them and we all want to do that.

Deputy L.M.C. Doublet :

I am sure that is echoed by everybody in the room.

The Minister for Health and Social Services:

I am glad Ian has spoken. You can see why I was so keen to introduce him in the first place because there is a lot of internal work that is happening.

Director of Workforce:

May I? Just in terms of symbols of this, so we have our stars awards every year. Last year in our awards we received the highest level of nominations ever. This is people being nominated to say: "Well done. Thank you", that sort of formal recognition which is not the answer but it is an interesting indication of where we are.

Deputy L.M.C. Doublet : That is great. Thank you.

Deputy J. Renouf :

The point is well taken about the hard work and the need for appreciation but one of the things we hear continually is that a lot of people on the front line do work incredibly hard but they feel like they have concerns - and you would call them probably hotspots in particular areas - where there are problems with authority figures not responding to challenge, with people who have done things the same way for a long time and are not changing, problems with bullies, frankly. Isolated hotspots to be sure, but they are the thing that spike in public consciousness, so could you address those specific kinds of problems?

[13:30]

Director of Workforce:

Those types of areas, as I have said, where we have got the hotspots one of the things obviously that the Minister has through his advisory board, we have a people and culture subcommittee that meets every 2 months and scrutinises in detail what is going on in the organisation from a staffing and culture point of view. They will oversee the development of the workforce plan, development of the people plan, which is an organisational development plan this year. Also, within that we are

developing - and we have got an outline - what we are calling our culture hotspot thermometer, so that board will spend time looking at the areas where we have got hotspots and understanding what we are doing about it. I think, again, we need to be careful that we do not talk in big generalities about: "There is a huge problem in this organisation." We have problems and we need to deal with them so we need to identify them, which we have done through the cultural dashboard and then we need to put a range of interventions in and these are people interventions so they are not simplistic and we do not go in and just start sacking people, like you might do in a private sector organisation. It is about supporting, training, developing, reflecting, dealing with the issues and that takes time. It is a slow shift to change culture but all of those things ... since I have been here since June, I recognise all that activity going on.

Deputy P.M. Bailhache :

That is very helpful, Ian. Thank you very much indeed and I am sorry if I mentioned poor staff retention when there is no evidence for that. I do not know how that

Director of Workforce:

It is a very common myth.

Deputy P.M. Bailhache :

Yes, I do not know how these things happen. Can I just ask you about whether there is any - or maybe the Minister - information you can share with us about the review of neurology services by the Royal College?

The Minister for Health and Social Services:

Ian, I think that is something I would have to back to you.

Director of Workforce:

This was the invited review, was it?

Deputy P.M. Bailhache : Yes.

Director of Workforce:

We have not had the final report, but we have had the briefing report. I was really, really impressed by the report. They were very, very complimentary of our services. They obviously will have some areas for our improvement, which will be brilliant because we are always trying to improve, but it was a very, very powerful, very strong report. It gave very, very strong complimentary feedback for the staff and leadership within that department so I think we were really pleased with it and look forward to the formal report and obviously, as we always do, develop then an action plan to address the areas of improvement.

Deputy J. Renouf :

Are there any other reviews this year, invited reviews?

Director of Workforce:

I am probably not the best person to ask.

Deputy J. Renouf : Minister?

The Minister for Health and Social Services: Not off the top of my head. We can check.

Deputy L.M.C. Doublet :

Yes, this is the neurology review that you are speaking of, so that is already concluded. Okay, and were past and current patients able to contribute to the review in any way?

Director of Workforce:

I am not sure that that is the mechanism of the invited review. They have a methodology by which they do their Royal College review.

Deputy L.M.C. Doublet :

Okay, and what was the cost of the review?

The Minister for Health and Social Services: Off the top of my head, I am not sure.

Director of Workforce:

I am sorry, we would have to provide that for you.

The Minister for Health and Social Services:

I have got an idea of what it is, but I do not want to misquote.

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

Deputy L.K.F. Stephenson :

When can we expect the formal review, and will it be public?

The Minister for Health and Social Services:

Yes, we have made a commitment to publishing reviews, but we go through a process. When the review is finalised, we review it to make sure that nobody is compromised and I think we set out a timetable last year as to how long that would be. We give a certain number of weeks as a maximum to make sure we have checked it through. It is not with a view to alter it, to twisting it. It is to make sure that nobody is compromised as a result of it. Then it gets released. All reviews come out.

Assistant Minister for Health and Social Services: It will definitely come to this Scrutiny Panel.

The Minister for Health and Social Services: Absolutely.

Deputy L.K.F. Stephenson :

Do we know when that timeline is when we are expecting it to be published?

Director of Workforce:

I am sure we do. I do not, so I am sorry.

The Minister for Health and Social Services:

That is something that Tom would have if he was not indisposed.

Deputy L.K.F. Stephenson :

Can we add that to the list of things to come back to us?

Deputy L.M.C. Doublet :

Yes, could we have a buffer so that before it is released to the public that we could have a look at it, so we are prepared?

The Minister for Health and Social Services:

Yes, yes, we will try to make sure there is a I think we have already did we not issue a schedule where we said that X amount of days that it would go to C.O.M. (Council of Ministers), it would go to Scrutiny and then go out to the public? I think we have got a format that we work to because there had been some controversy about different dates and some stuff not being released so we wanted to have total clarity that all stuff would be released and it would be released against a programme on a timetable.

Deputy L.M.C. Doublet : Yes, that is great.

The Minister for Health and Social Services:

We can revise that, but we will try to make sure that we stick to the timetable that we have put in place

Deputy L.M.C. Doublet :

Thank you. We appreciate that.

The Minister for Health and Social Services:

because I think people have that as an expectation.

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

Deputy P.M. Bailhache :

I was just going to ask if there are any other reviews commissioned for this year?

The Minister for Health and Social Services:

I should know but off the top of my head, no. Once again, we will certainly come back to you on that when Tom is back in situ.

Deputy L.M.C. Doublet :

If you had to choose the next area for review, which area would it be?

The Minister for Health and Social Services:

Crumbs, it is not something that off the top of my head I could tell but, as I say, Ian might have an idea as to what is more pressing.

Director of Workforce:

I do not know what the area is, but I think the way just to give you some assurance in terms of how we would go about that, so in terms of our risk management processes, we would be looking at our risk registers, we would be looking at our serious incident reports, we would be looking at complaints and compliments. If there was a cluster of those, that would lead our attention to areas that we think we may need to do a deep dive on and obviously the Royal College review or whatever is a mechanism of deep diving.

Director of Mental Health, Social Care and Community Services:

We also need to be clear that external review is not always driven by concern. It should be routine so the Getting It Right First Time reviews, for example, is something we should just be doing.

Deputy L.M.C. Doublet :

Yes, but would you say, Minister, that it is important that members of the public do give feedback on services so that those clusters can be identified?

The Minister for Health and Social Services:

We have got to be a little bit careful because, as Ian was saying, the Royal Colleges, when they come over they have got a set way of doing things and I think that may be more appropriate in some areas than others. Specialist area is not really for me to comment on, but I think they have a

Deputy L.M.C. Doublet :

I mean feeding back through the established government mechanisms on the services.

The Minister for Health and Social Services: Yes.

Deputy L.M.C. Doublet :

You are nodding there. Do you want to comment on that?

Director of Workforce:

No, I was just saying I would absolutely agree with you, mechanisms of listening to the public, the patient engagement panels, the patient engagement work that we do, as well as monitoring of complaints and compliments, et cetera, this is all intelligence to help shift our focus, is it not?

The Minister for Health and Social Services:

I think if the Medical Director was here, he would probably be closer to the areas that would need addressing next.

Deputy L.M.C. Doublet :

Minister, there was some recent media reports relating to incidents of sexual assaults on staff within the department. I think there were 20 formally reported incidents in a span of 4 years. Can you confirm if those reports were alleged assaults by members of the public on staff or was it staff or both?

The Minister for Health and Social Services: This matter I have to hand straight to Ian.

Director of Workforce:

Yes, it was public on staff. The majority of it, they were over a long time and obviously, what is classified as sexual assault, we all immediately think it is the most serious type of serious assault. It may be inappropriate touching. It is not necessarily I think people's minds tend to jump to the most serious. A lot of those reports are within services where we have people that are perhaps not in their normal consciousness so they are not acting as their normal self, but obviously it is very important that staff report those to us because we need to look at our processes to make sure that we are supporting and looking after staff and protecting staff in those areas as much as we can when they are on the front line dealing with the issue in the moment. Somebody having a psychotic episode, whatever their behaviour is, that is the situation they are trying to deal with. That is the nature of health and social care services really.

Deputy L.M.C. Doublet :

Thank you. Have there been any recorded incidences of either staff-on-staff assaults or staff-on- public assaults in the last 5 years?

Director of Workforce: Not that I am aware of.

Deputy L.M.C. Doublet :

Okay. Can you confirm if Unite's suggestion of a full review of previous cases and an assessment of where learnings and improvements can then be made to reduce the incidence of these events is going to be taken forward?

The Minister for Health and Social Services:

To be honest with you, that is an area that I have not had a great deal of focus on. I will have to be wholly reliant on you.

Director of Mental Health, Social Care and Community Services:

I do not think a decision has been made on that yet. I think there is a group that has been established to think about this and to think about violence against staff as well, so the 2 are clearly interconnected. I do not think a decision has been made yet about what exactly should happen next, but it is certainly a consideration.

Deputy L.M.C. Doublet :

Thank you, and what is the timetable for making a decision on that?

Director of Mental Health, Social Care and Community Services:

The group has met twice, I think, and I think is due to meet again in 2 or 3 weeks' time, and that is as much as I know.

Deputy L.M.C. Doublet :

The decision will be made at that meeting?

Director of Mental Health, Social Care and Community Services:

Sorry, I do not know that because I do not sit in that meeting, but we can certainly find out when they will decide.

Deputy L.M.C. Doublet :

Yes, could you establish the timeline and get back to us?

The Minister for Health and Social Services:

That will be on the list of things to respond to you about.

Deputy P.M. Bailhache :

I hope this is not misinformation too, but the Bailiwick Express recently reported that Jersey's Health Department is seeing a high number of staff off sick with anxiety or stress and I wondered how you are addressing that suggestion.

Director of Workforce:

Thank you. Our sickness levels are higher than we would like them to be. They are in line with the jurisdictions, so we look at our nearest neighbour in terms of the N.H.S. We are fairly on par with them, and we have seen the same rise in staff sickness levels that the N.H.S. has seen. There is some sort of post-COVID thing. I think we are all looking at this and trying to work out exactly what is going on. There is a general population increase in sickness post-COVID as well. There are some things going on that we are not sure on, and we are seeing those being replicated within H.C.J. In terms of our level of sickness that is down to stress and anxiety, they are about 12 per cent of our total sickness reports. The highest ones, as ever, are cold, flu, COVID. Then we have gastrointestinal and about 3 or 4 down the list is stress and anxiety. They concern us, obviously,

and we look very closely at those. The board, again, the Minister's subcommittee on people and culture, is very interested in this and very concerned about what it is telling us about health and well- being, about sickness levels continuing to rise. What we have done in the first instance is to redouble our normal sickness and health and well-being actions. We have gone through 2 reviews now of everyone who is on long-term sickness to make sure that we are supporting their health and well- being as much as we can be. We are aware of everyone who is on long-term sickness - that is over 12 weeks - is being reviewed and has been reviewed by their line managers and supported by H.R. We are now working with managers to look at shorter-term sickness, so regular patterns of sickness, people that go over trigger levels of sickness, and making sure that health and well-being reviews are being undertaken properly, occupational health services are being used, staff counselling services, employee assistance programmes are all being deployed appropriately. All of those things we are obviously monitoring very closely, and we have put in place all of those normal management actions that you would expect. We now, I think, need to let them run for a little bit to see whether we see any impact on those.

Deputy P.M. Bailhache :

Do you know whether the figures are higher in the Health Department than in other departments in the civil service, Education for example?

Director of Workforce:

I am not sure. I have not looked in detail at the comparator. To be honest I do not

Deputy P.M. Bailhache :

That would be significant, would it not?

Director of Workforce:

Not necessarily because I think it is a very different business. I think the comparators we tend to look are at the other island jurisdictions, the N.H.S., people that are involved in delivering health and social care services. It is different. When I was in the N.H.S., I would look at other N.H.S. providers, not at civil service because it is a different business.

Deputy L.M.C. Doublet :

Can you advise what those figures are and where you are comparing it?

Director of Workforce:

They are broadly in a similar there is nothing that stands out for us either when we look at the determinants of sickness below their headline figure, or the headline figure. We are not stepping out of where everyone is trending.

Deputy L.M.C. Doublet :

When you say everyone, you mean U.K., Isle of Man, Guernsey.

Director of Workforce: Exactly.

Deputy L.M.C. Doublet :

Are there any jurisdictions where perhaps the Minister may be aware of some that he is aspiring towards that have exemplary healthcare systems that you could compare those levels to?

Director of Workforce:

I am not aware of anywhere that is doing anything remarkable. I am less using benchmarks from more international because we get into real issues about how things are counted and also we get into issues of especially within, for example, private healthcare providing, such as in America, where staff are not paid for their sickness so you get skewing figures that means it becomes very difficult to compare your data. I have tended to go with the jurisdictions that are more like us, but it is something that we are focused on. It is a worry not just in terms of the availability of staff to deploy for patient care but how well are we looking after the staff in terms of health and well-being.

Deputy L.M.C. Doublet :

We would hope to be much better than, say, the N.H.S. levels, would we not ideally?

Director of Workforce:

Yes, so we aspire to be better than the N.H.S.

Deputy P.M. Bailhache :

Does the Health Department conduct Schwartz Rounds?

Director of Workforce:

We do, yes. They have been very successful and we have had lots of positive feedback on them so we are a licensed Schwartz Round provider. They run regularly. There is one coming up imminently. Is it today? This afternoon one is running, and they are a great place for people to provide peer-to-peer professional support, explored through storytelling. I do not know if you are aware of how Schwartz Rounds work.

Deputy J. Renouf :

You say it is a great success, but we have not seen any output change.

[13:45]

Director of Workforce:

Well, we may be either holding back the curve, so rather than seeing a reversal, we may be seeing a slowing down but just in terms of success factors for me around Schwartz Rounds are how staff feel about them, their feedback in terms of: "Did I feel supported? Did I feel I had a place to take issues and problems?" There is a multiple range of things you need to do in order to support people's psychological health and well-being in a workplace. This is one of them.

The Minister for Health and Social Services:

You just made the point, and I think the most important measure for us, we talk about comparing with other jurisdictions but in the longer term I think what is important is how we compare to our own figures going forward and what that figure might look like 12 months from now.

Deputy L.M.C. Doublet :

Do you mean population level?

The Minister for Health and Social Services:

Yes, what that figure might look like 12 months from now. That is the important bit.

Deputy L.M.C. Doublet :

What is it, incidentally, the levels of anxiety and stress? You said it is 12 per cent. Do you know how it compares

Director of Workforce:

That is 12 per cent of our sickness. It is not 12 per cent.

Deputy L.M.C. Doublet :

Sure, yes. What is that compared to population level percentage?

Director of Workforce:

We need the Stats Department here, do we not now?

Deputy L.M.C. Doublet :

Yes, we could do with them around at every hearing really.

In a health environment you are going to get a little bit more stress than you would get in a standard work environment.

Director of Workforce:

We could definitely look at what the reported levels of psychological sickness and illness are.

Deputy L.M.C. Doublet :

Thank you. Do you want to move on to the next one?

Deputy J. Renouf : Shall we move on?

Deputy L.M.C. Doublet : Yes, go ahead.

Deputy J. Renouf :

Preventative health measures, so the annual plan talked about preventative health measures, and you have spoken about the importance of that and, indeed, in the U.K. there is a huge focus on preventative health. It is not specifically detailed in the service objectives of 2025 and I wonder what that reflects.

The Minister for Health and Social Services:

At the moment, like I say once again, where we are at the moment, it is budgetary constraints that do not allow us to do anything a lot different year on year. What we have been doing, and hopefully are going to elaborate on that a little bit more, is a lot of work about what changing from a reactive health service to a proactive health service would look like and putting some numbers alongside that. As I have said before, both digital and preventative health measures is something that we will be bringing to the Assembly, as you know, as part of a bigger package of requirements.

Deputy J. Renouf :

You mentioned in your foreword to the document, I think, things about health monitoring and initiatives for healthier living from a young age. What is going on in that space?

The Minister for Health and Social Services:

As I say, I will hand over to you if you are happy to and then we will take some questions afterwards so that you get the full picture. Rather than have a half-baked picture from me, you will get the full professional picture.

Deputy L.M.C. Doublet :

Yes, and I am just noting the time so if your answers could be as succinct as possible.

Deputy Director, Public Health Transformation and Commissioning: I will rush through.

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

Deputy Director, Public Health Transformation and Commissioning:

There is some activity already in the prevention space. The D.P.H. (Director of Public Health) annual report really made that case for change to really show that a lot of the common disease is preventable just through healthier living, making sure you do not smoke, eating well, more exercise, all of those sorts of things. We have been doing a mapping exercise to really understand what we are doing already, where the gaps are in terms of best practice and what the evidence is around prevention, and we know that prevention is better than cure and that is very much about starting as early as possible in childhood really. The J.S.N.A. (Joint Strategic Needs Assessment) work as well has showed that we have got significant numbers of our young people not doing enough physical activity. They have got poor mental health and well-being, so we are looking at opportunities for investing in whole system approaches where we really make the activities available to children, young people and families. That also helps with things like childcare potentially. We are looking at implementing a range of positive activities. We are looking at increasing access for families on income support to be able to access more positive activities. We are also looking at things like dental care and the dental service where we know that 98 per cent of dental disease is preventable and we have 25 per cent of our under 5s with some level of dental decay. We are looking at moving those services out into the community and making them much more consistent. We are also, in the adult space, making sure that there are targeted pathways and interventions. For example, we have almost 4,000 people on the pre-diabetic register with their G.P. and they get an annual review but there are not any services that are put in place to turn that curve and stop them going on to develop diabetes. We know that 40 per cent of diabetic cases are preventable. We are looking at the life course really and what services and systems we need to put in place around improving access to physical activity and lifestyle, around improved screening, around vaccination uptake to keep people safe, around community service such as G.P. and dental care and pharmacy and then moving into more of that earlier diagnostic support.

Deputy L.M.C. Doublet :

Yes, and can I focus in on diabetes, for example, and you said you need to put things in place. What would that look like to a member of the public? What would they receive?

Deputy Director, Public Health Transformation and Commissioning:

We are working actively on the diabetes prevention service at the moment. We have an oversight group with a range of people to help us design that. The way we are looking at designing that at the moment, for ease really to get a local pilot to see how it would work locally, is to take some of the evidence-based practice from diabetes reversal programmes which focus on living well, on physical activity, on weight management, all of those types of things. We have been working closely with the G.P.s to look at the targeted register that is available through

Deputy L.M.C. Doublet :

Sorry, for example, physical activity and weight management, what would that look like? Would it involve free use of the gym facilities? Would it involve subsidising healthy food? What would that look like?

Deputy Director, Public Health Transformation and Commissioning:

There is a target U.K. pre-diabetes evidence-based programme. We are adapting that for Jersey so that would look like lifestyle interventions ranging over a year support and group work. It could involve referral to Move More through Jersey Sport and other physical activity programmes as part of an integrated package of care. They take a year, the programmes, because to have that behavioural change takes a while.

Deputy J. Renouf :

Minister, the implicit - or quite explicit, I think - implication of this is that resources have to shift from treatment to prevention and into this public health. We have a heavily constrained, in fact increasing, demand for treatment budgets. How do you get from that increasing demand for treatment budgets to providing more resources into prevention?

The Minister for Health and Social Services:

You used the word "shift", and I have to say that is a word that we cannot use because we cannot shift a single penny from where we are.

Deputy J. Renouf :

Even though you plan to save money through these interventions.

Assistant Minister for Health and Social Services:

Unfortunately, you do not get the improvement until you have invested over a year's time.

We are probably going to need some more money to carry on doing what we are doing. As I say, science and technology deliver more and more treatments, more and more drugs at more and more expense. That is on the one hand and if you want to try to just shift that model to make the savings, you certainly cannot utilise that same money because you have not got enough of that to keep doing what you are doing. What this requires is new money. It needs upfront money. It is going to be quite a long-term investment but also if you look at what is required to set this up and get it all underway, if you are vaccinating and so on, get everything up to date, you need a bulge of money over a 3-year period. You need that initial input of money to set everything up and to bring everything up to date. Then you have got to carry on with a certain amount of money in addition to your money before those savings start to come through. If you never address that, you are on the back foot for good and all, and that is really difficult. I use the incidence of stroke and I think the figures were - I stand to be corrected, a shame the Medical Director is not here - we had 9 strokes in the first 6 weeks of this year and when you talk to the head of the heart department, an experienced guy tells me that with the right kit and the right system, up to 80 per cent of those strokes could be avoided but you need monitors on people's wrists so that when they get atrial fibrillation you bring them in, you put a pacemaker in, they do not have a stroke. Strokes and heart attacks, I forget which way around, one costs a quarter of a million, the other costs half. I am not sure which way around those 2 go but these are colossal sums of money and involve a huge amount of misery for the people involved and if we can shift from that model and I think every health service everywhere is trying to do it. We have to make a decision here as to whether we want to stay on the back foot doing reactive health and accepting all that that is going to mean or whether we want to make this fundamental change to try to tackle the problem to get the preventative work underway. It is a big one and that is going to be tricky but that is where we are. We are doing the preparatory work, and we are going to come up with a number and a programme.

Deputy J. Renouf : This year?

The Minister for Health and Social Services:

Yes. We have got to get this done ahead of the cycle. The Island might decide, and the Assembly might decide, that it is not a route we want to go down. That is fine but then they have to face the fact that their health costs are going to escalate and continue to escalate, and we will not be tackling issues.

Deputy J. Renouf :

You will be proposing something presumably in the Budget or Government Plan that will address this?

The Minister for Health and Social Services: Correct.

Deputy J. Renouf :

It will involve more money from somewhere.

The Minister for Health and Social Services:

Be warned, it will be a fairly sizeable sum of money because you do not do this on threepence, do you? It is not a

Deputy J. Renouf : Tens of millions?

The Minister for Health and Social Services:

Tens of millions, yes. It is, yes, but it is a debate that we have to have. We cannot keep backing away from these things. The reality is every health service on the planet is looking down the same lens and saying: "How do we go about this?"

Deputy L.M.C. Doublet :

Thank you, and can I just ask: how important is it from a preventative point of view that we do achieve this and the Assembly approves these? How important is it for the health of the Island?

Deputy Director, Public Health Transformation and Commissioning:

I think it is a crisis, and the Minister for Health and Social Services has spoken to this before. I think need is increasing. We have got an ageing population in Jersey which is bulging and coming up, which is about to hit us quite fast. I think we have to do something. It is difficult to take direct costs out of the system by doing that, as we have alluded to, because you have got your health spend going up, but it stops going up so fast. That is what we are trying to achieve. Also, it is not just about preventing people getting poor health, but it is also those who are already in poor health. It is managing their conditions better because the cost of not managing uncontrolled diabetes, for example, costs a fortune in terms of people going blind, losing legs, losing limbs. These programmes that you put in are not just about keeping the Island as healthy and well as possible. It is also about stopping that progression, which we know is happening.

Deputy L.M.C. Doublet :

Thank you, and if this investment does go in, so to maintain the service as it is plus this additional investment that you were talking about for the preventative measures, how certain are you that it will start to bring down the costs overall? How certain are you that there are effective measures that we can do to improve health?

Deputy Director, Public Health Transformation and Commissioning:

We have seen it from pilots operating in other places. In spite of getting the funding, we are going to move ahead with the diabetes prevention service. We are estimating that we can operate that service for less than £500 a person as a one-off but you are looking at over £5,000 spend a year on a current type 2 diabetic patient and that is for the rest of their lives.

Assistant Minister for Health and Social Services:

Certainly, if you stop people smoking, for example, then you stop them getting heart disease, lung cancer.

Deputy L.M.C. Doublet :

Is there anywhere in the world that is getting this right, the prevention side of things?

Deputy Director, Public Health Transformation and Commissioning:

There is lots of talk about it. No one has really bit the bullet with it really, it is fair to say, but I think one of the other challenges we have got is the inequality piece because if we look at those unhealthy behaviours, they tend to be more prevalent in some of our lower income groups. For example, smoking is over 30 per cent in manual labourers and workers compared to 7 per cent in senior management. So it is not only getting the funding and the investment and the programme right, but it is also being able to target that and making sure that we target our most vulnerable groups, just really turn that curve.

The Minister for Health and Social Services:

Can I just make a point? You talk about evidence - and I do not think anybody has tackled this head-on and done the whole thing - there are a lot of places that have tackled individual things where they have done pilot schemes, or they have done a limited amount of stuff. I was talking to Peter Bradley and he said there is an awful lot of evidence. If you collate all of that evidence then it shows you very, very clearly that it does work but it works over a period of time, and you have got to be prepared to go through the pain that is required, and it is going to be complete lifestyle changes. When I was a kid, you died at 70, 71 and that was an end to it. We are now living until 82, 85 and the idea of retiring at 60 and having a 20-year retirement, I think we are going to have to be encouraging people to work for a considerable amount of time longer. I think there are an awful lot of changes that have to come into this to make the reality checks from people because I think in fairness, we have all become quite entitled and quite used to an extraordinarily high standard of living and a low tax and I just think there are some big implications here.

Deputy L.K.F. Stephenson :

Where does responsibility for that piece of work sit? Is it being led by Public Health? Is it you as the Minister? How does it work?

The Minister for Health and Social Services:

Yes, it has been effectively driven by me as a requirement, if you like. Public Health are doing all the background work but they are liaising with all the different departments so there is a lot of integrated work happening. It is not just happening in Public Health in isolation. They are talking to everybody to try to make sure that it is a robust piece of work.

Deputy L.K.F. Stephenson : You are the lead Minister on it?

The Minister for Health and Social Services: Yes.

Deputy L.K.F. Stephenson : Yes, okay. Thank you.

Deputy L.M.C. Doublet :

Do you have any further questions on any of the sections? No, okay. Minister, that is all of our questions for today. Do you have anything

Deputy J. Renouf :

Not quite. We have got lots more, but we are going to have to put them in writing.

The Minister for Health and Social Services:

That is fine. I hope you found it fairly helpful. I cannot answer all of your questions, but I think you can see the team are doing a lot of work and I thank them all because I think there is some I hope you agree there is some really good progress being made and, as I say, this is not something that is going to be solved overnight. The plan is to get a first-class health service by the time we move into the new hospital.

[14:00]

It is a 4, 4½ year plan and I do not want to speak too soon but I think things are going well and there is a real desire among the team to get things right. Thank you for your questions. It does keep us on our toes, and I am very much looking forward to digital when the times comes because that is going to be a vital part of what we are doing, so hopefully you will put that at the top of your agenda next time.

Deputy L.M.C. Doublet :

Thank you so much for your time today and thank you for all the work that you are doing across the departments.

The Minister for Health and Social Services: Thank you.

Deputy L.M.C. Doublet :

I will close the hearing. Thank you.

The Minister for Health and Social Services: Thank you.

[14:01]