Health White Paper Review - Report - 15 October 2012

CONTENTS

CHAIRMAN'S FOREWORD...........................................................................................................................4 TERMS OF REFERENCE ................................................................................................................................5 PANEL MEMBERSHIP ..................................................................................................................................5 EXPERT ADVISORS ................................................................................................................................... 5 EXECUTIVE SUMMARY................................................................................................................................6 KEY FINDINGS.............................................................................................................................................8 RECOMMENDATIONS ............................................................................................................................... 12

1. INTRODUCTION................................................................................................................................. 15

1. BACKGROUND..................................................................................................................................... 15
2. THE REVIEW ....................................................................................................................................... 15
3. THE HEALTH AND SOCIAL SERVICES DEPARTMENT....................................................................................... 16
4. DRIVERS FOR CHANGE........................................................................................................................... 17

2. THE GREEN PAPER............................................................................................................................. 18

1. BACKGROUND..................................................................................................................................... 18
2. THE THREE SCENARIOS.......................................................................................................................... 18
3. INVOLVE REPORT.................................................................................................................................. 20
4. POPULATION: DEMOGRAPHIC DATA AND PROJECTIONS................................................................................. 20
5. CONCLUDING REMARKS ON THE GREEN PAPER ........................................................................................... 21

3. THE WHITE PAPER............................................................................................................................. 22

1. THE STRATEGY FOR CHANGE................................................................................................................... 22
2. THE THREE PHASES .............................................................................................................................. 22
3. ENHANCED COMMUNITY SERVICES .......................................................................................................... 23
4. THE HOSPITAL..................................................................................................................................... 25
5. SHAPING A NEW HOSPITAL .................................................................................................................... 27
6. PRIMARY CARE.................................................................................................................................... 28
7. CONCLUDING REMARKS ON THE WHITE PAPER CONSULTATION ...................................................................... 28

4. IMPLEMENTATION OF A NEW MODEL............................................................................................... 29

1. OUTLINE BUSINESS CASES...................................................................................................................... 29
2. CROSS DEPARTMENTAL WORKING........................................................................................................... 29
3. INFORMATION TECHNOLOGY .................................................................................................................. 29
4. RECRUITMENT..................................................................................................................................... 30

5. THE THIRD SECTOR............................................................................................................................ 33

1. THE BENEFITS OF THE THIRD SECTOR........................................................................................................ 33
2. SILKWORTH LODGE............................................................................................................................... 33
3. SERVICE LEVEL AGREEMENTS.................................................................................................................. 34
4. THIRD SECTOR FORUM.......................................................................................................................... 34
5. WILL THERE BE A DUPLICATION OF SERVICES?............................................................................................. 35
6. PARISH INVOLVEMENT .......................................................................................................................... 36

6. WHAT ARE THE FINANCIAL IMPLICATIONS?...................................................................................... 37

1. MEDIUM TERM FINANCIAL PLAN............................................................................................................. 37
2. LONG-TERM CARE ............................................................................................................................... 38
3. SILO-FUNDING .................................................................................................................................... 38
4. HEALTH INSURANCE FUND..................................................................................................................... 39

5. THE PUBLIC ........................................................................................................................................ 40

7. CONCLUSION..................................................................................................................................... 42

8. BIBLIOGRAPHY AND EVIDENCE GATHERED ....................................................................................... 44

BIBLIOGRAPHY.......................................................................................................................................... 44 WEBSITES................................................................................................................................................ 45 REVIEW HEARINGS..................................................................................................................................... 45 WRITTEN SUBMISSIONS .............................................................................................................................. 47 PANEL VISITS............................................................................................................................................ 48

9. APPENDIX ONE: WRITTEN SUBMISSIONS: WHAT DOES THE THIRD SECTOR THINK?......................... 50
10. APPENDIX TWO: SILKWORTH LODGE................................................................................................ 54
11. APPENDIX THREE: THE BOYLE REPORT.............................................................................................. 56

CHAIRMAN'S FOREWORD

The recurrent message we have heard throughout our work has been the urgent need to see reform of our Health Services and a general willingness to engage with this process.

For too long investment and change in this key public service has fallen short, or to quote one of our witnesses there has been "misinvestment". An illustration of the delay became clear when we discovered the Raftery Report, which was published in 2003 and warned the States of Jersey of the necessity to invest and plan for the future. It is surprising that we are only now, nine years later heeding this advice.

The Report and Proposition, "Health and Social Services: A New Way Forward", comes to the Assembly with a series of proposals to introduce new services. These are brought to the Assembly in outline form, alongside a number of projects that are intended to be funded at a later stage and phased in over the next ten years.

Although the States have not yet agreed the Report and Proposition, work is already underway to "work up" the business cases so that the necessary investments can be made in 2013 and new services can be delivered as soon as possible.

As a Panel, we would have liked to have seen the detail of the programme of change for the first three years, at least. Therefore, we intend to continue to meet with the Minister and to follow the progression of this process. There are many concerns over the details which will need to be addressed once it is published and the Health, Social Security and Housing Panel will play its part to ensure the best possible outcome for the public.

We are especially grateful to our advisors, Professor Gerald Wistow, Mr Michael Gleeson and Mr Seán Boyle who have provided us with their invaluable input. It has been a pleasure to work alongside such good people with a breadth of experience. And as always, our Scrutiny Officer, Kellie Boydens has worked extremely hard to get this report ready within the timeframe, we thank her most sincerely for her input.

Deputy Kristina Moore

Chairman, Health, Social Security and Housing Scrutiny Panel

TERMS OF REFERENCE

The Panel aimed to review the work undertaken by the Health department and consider the proposals contained in the White Paper with the following Terms of Reference:

1. To determine whether the options included in the Green Paper were appropriate and wide- ranging.
2. To examine how the responses to the Green Paper were analysed and reported.
3. To determine what extent the views expressed during the Green Paper consultation influenced the process of developing the White Paper.
4. To consider the implications of the proposals contained in the White Paper.
5. To examine what effect the changes will have on the community and in particular the impact on existing providers including the private and third sector.
6. To explore the manpower and financial implications of all the proposals. In particular:

1. How the department will implement the changes.
2. How the plan will be delivered.

PANEL MEMBERSHIP

The Health, Social Security and Housing Panel comprised the following Members:

Deputy Kristina Moore , Chairman

Deputy Jacqueline Hilton, Vice-Chairman

Deputy James Reed

EXPERT ADVISORS Professor Gerald Wistow

Gerald Wistow is Visiting Professor in Social Policy at the London School of Economics. He also holds a visiting chair in the School of Applied Social Sciences at the University of Durham. He has previously been Co-director of the Centre for Social Policy Research at Loughborough University, Professor of Health and Social Care and Director of the Nuffield Institute for Health at Leeds University and Chair of Hart lepool Primary Care Trust. He is currently a specialist advisor to the House of Commons Health Committee in the UK, a post he also held for ten years from1991. He has published extensively on a wide range of health and social care issues.

Mr Michael Howard Gleeson MB.ChB. (Manc.) FRCP. (Lond.)

Michael Gleeson is a retired Consultant Physician and Gastroenterologist, Jersey General Hospital (1976 – 2006). He has been past Chairman of the Medical Staff Committee, and past Chairman of the Division of Medicine. He has conducted research and publications on adverse side effects of drugs in the alimentary tract.

Mr Seán Boyle

Seán Boyle is a health planning and policy consultant with experience of working at senior level with public and private sector managers, civil servants and politicians (both local and national), and a detailed knowledge of the public policy environment in the UK. He is also a Senior Research Fellow in Health and Social Care at the London School of Economics. His clients have included the Department of Health, the Scott ish Parliament, the House of Commons Health Committee, the King's Fund, the Department for Work and Pensions, Chichester District Council, and the Criminal Justice Performance Directorate of the Home Office.

EXECUTIVE SUMMARY

The final Report and Proposition asks States Members to decide whether proposals for a redesign of health and social care services by 2021 should be co-ordinated by the Council of Ministers. By the end of 2014, the proposition calls for proposals to be developed for: investment in hospital services and detailed plans for a "new" hospital; a new model of primary care and a sustainable funding mechanism.

The Panel has reviewed both the Green and White Paper process, the KPMG analysis and the Report and Proposition. The Green Paper presented three scenarios for consideration, although the Panel found that only scenario three was presented for serious consideration. The Panel considered that scenario one could have been examined in more depth and variations of this option could have been offered. Scenario two proposed keeping funding the same or with a slight increase and was, in the Panel`s view, an unrealistic or "straw man" proposal without any credence.

Scenario three was the option that received the most public approval and was developed in the White Paper: "Caring for each other, Caring for ourselves". It constituted the guiding principle for change and a new way forward for health and social services over the next ten years.

The White Paper emphasised re-designing health and social care services to enable more care in community settings, including that provided through the primary care sector. A section on sustaining acute services was also included but it did not appear to have an equal priority in terms of timing, as a review of hospital was proposed for the period 2016 – 2018. The Panel was concerned that this approach to acute services lacked the urgency and priority it deserved, it now welcomes the greater emphasis on acute services in the Report and Proposition.

The Panel was told that one of the main reasons behind the development of intermediate care was to reduce pressure on hospital beds. This seems logical, but may not achieve the desired result as pressure on the hospital may continue to grow.

The Panel was told that the winter period is of particular concern because the hospital is running at virtually 100% occupancy throughout the year. If Jersey were to have a particularly bad winter with outbreaks of infectious diseases the hospital could run out of beds. Therefore, acute services need urgent consideration. Whether a new hospital or a rebuilt hospital is decided upon, upgrading of the present deteriorated fabric will be necessary now.

The Panel found that the potential costs of redesigning health and social care services are difficult to quantify accurately and thus present a risk to the ten year strategy. Phase one may well be affordable but it is unclear whether funding can be guaranteed for phases two and three. It is for this reason the Panel has lodged an amendment for the current States Assembly to approve a sustainable funding mechanism for health and social care before the end of September 2014.

Furthermore, the funding of a new model of primary care must be addressed as GPs are currently remunerated on a "fee per service basis". If a new model of primary care is evolved, it is hoped that it will be with the involvement and support of the GPs.

The Panel felt that this issue was of such significant importance that it lodged an amendment to the Report and Proposition (b(ii)) to bring forward proposals to develop a new model of primary care by the end of 2013, rather than 2014 in order to advance this process. Moreover, further consideration should be given to the proposed changes and how affordable they will be for individual patient groups. If additional costs are introduced, these should be made clear to the patient from the outset.

The proposals to introduce monitoring of a patient in their home such as telecare and telehealth will be new to Jersey but the benefits of which are still unproven. In the Panel`s view, these methods should be brought in cautiously by means of a pilot study. If new technologies are going to be implemented, informatics will also play a major role if they are to be successful. The Panel was informed during the review, that the Health Department's I.T systems are not integrated between primary and secondary care, and therefore this requires urgent attention.

The third sector will play an important role if more care in the community is enabled. Evidence from written submissions received by the Panel highlighted a degree of enthusiasm for the proposals but also with an element of caution. Some third sector organisations expressed the desire to be treated as equals and enter into medium to long term Service Level Agreements. The Panel has observed that at times there has been scope for greater communication with the third sector. Therefore, before new programmes are rolled out, the Health Department should work in partnership with third sector and other organisations to agree how services are managed in order to deliver efficiency improvements.

The Panel has identified that the proposition should be welcomed in general terms. The changes proposed in the Report and Proposition would amount to a major re-design of health and social services on the Island. However, the synchronous introduction of so many new services reliant on the recruitment of many specialised and experienced staff in 2013 - 2015 will, in the Panel's view, prove challenging. The proposals are intended to substantially update buildings, facilities, skills and service models so that Islanders' service and experiences of them can be improved. They are, however, both costly and, in some respects, depend on approaches to delivering health and social care which are, by definition, untested in Jersey even though this may not be the case in other health systems.

The scope of the proposed reforms is so significant that they will have major consequences for all. Islanders must be confident that these proposals are both appropriate and cost effective whilst meeting the changing demands of the community.

KEY FINDINGS

KEY FINDING 1:

The proposals contained in the Report and Proposition: "A new way forward for Health and Social Services" require significant additional funding.

KEY FINDING 2:

Some third sector organisations had reservations about whether the proposals contained in the White Paper would come into fruition and whether all the extra monies required to implement the changes would be available.

KEY FINDING 3:

The scope of the proposed reforms is so significant that they will have major consequences for all. Islanders must be confident that these proposals are both appropriate and cost effective whilst meeting the changing demands of the community.

KEY FINDING 4:

The existing data makes it difficult for comparisons over time, thus leaving it unclear whether funding has historically been able to meet changing needs or spent appropriately in relation to such needs. Therefore, it is essential that the States have more robust baseline data to monitor changes in the level of funding and its allocation to individual services over time.

KEY FINDING 5:

Although KPMG recommended that Jersey should work towards scenario three, it also identified various risks with adopting a new model of health and social care, including the risk that funding mechanisms might create financial disincentives to access primary care and other services.

KEY FINDING 6:

The survey questions contained in the Green Paper were not mutually exclusive and, therefore, did not require people to make a firm choice of one of the three scenarios.

KEY FINDING 7:

Some of the information provided in support of the various scenarios lacked detail and was open to challenge. Although most Islanders seemed to agree that scenario three was preferable, many had concerns over the implementation of the plan, the costs and associated risks. Therefore, they concluded that more information was required before they could conclusively endorse the option.

KEY FINDING 8:

The Panel questioned whether the  overall  population figures, demographic assumptions and projections used by KPMG and the Health Department could be accepted without comparison to the latest population data.

KEY FINDING 9:

In the initial MTFP planning period, the White Paper predominantly focused on improvements to community services especially in the area of intermediate care, in order to relieve pressure on hospital capacity as well as improving care and containing costs.

KEY FINDING 10:

Results of studies into the benefits of telehealth and telecare are still unproven and their utilisation has yet to be justified by evidence from randomised control trials.

KEY FINDING 11:

Although the White Paper suggests that the cost of scenario three is likely to be less than scenario one  (business  as usual),  the Panel heard from  some  hospital  clinicians that  providing  more services within the community will not necessarily eliminate the increasing pressures on hospital beds.

KEY FINDING 12:

The  current  hospital  building  is  deteriorating,  and  does  not  comprehensively  meet  modern standards. If Jersey were to have a particularly bad winter with outbreaks of infection, the hospital could run out of beds. Essentially, the hospital is not fit for all current or future purposes which might reasonably be required of it.

KEY FINDING 13:

Within the White Paper, emphasis seemed to be on re-modelling services for children, services to encourage healthy lifestyles, services for adults with mental health issues and services for older adults. The future role of hospital provision with the re-configured services deserved greater attention than it was given in the White Paper, as the Report and Proposition recognises to some extent.

KEY FINDING 14:

The Panel question whether there is sufficient GP capacity to deal with an extra 75% of A&E cases which has been suggested could have been dealt with in primary care.

KEY FINDING 15:

The Panel noted that some of the Green Paper respondents suggested that people should be charged to access A&E services.

KEY FINDING 16:

A Workforce Planner has been appointed to facilitate the development of the Full Business Cases. The Panel note that this example is one of several where work has begun in advance of the Report and Proposition being debated or approved by the States.

KEY FINDING 17:

Enhanced community services will be required to interact with the services already being provided by States Departments. Therefore, the delivery of a new model of health and social care will be dependent on close collaboration between all relevant parties.

KEY FINDING 18:

The Health and Social Services Department I.T systems require further development and there is doubt as to whether it is able to provide the necessary information to deliver the proposed improvements in services.

KEY FINDING 19:

Primary and secondary care on the Island have tended to be too isolated from each other. KEY FINDING 20:

Historical difficulties in recruiting trained nurses and other professionals have yet to be fully overcome. With this in mind, it is reasonable to question how far the Department will be able to meet the requirement for a large number of additional staff to deliver the improved services, particularly in the short-term.

KEY FINDING 21:

The appointment of a Community Physician is not envisaged until June 2014. This appointment will lead the development of services across primary and secondary care.

KEY FINDING 22:

Some Service Level Agreements with the third sector are on an annual basis due to the way the budget system currently works. This provides uncertainty for some organisations and makes it difficult for them to expand and develop their services.

KEY FINDING 23:

The newly established Third Sector Forum is a positive move to improve communication between the Health Department and third Sector.

KEY FINDING 24:

Although  a  Third  Sector  Forum  has  been  set  up,  it  has  been  designed  to  represent  all organisations. It could be argued that its remit is too wide to be effective in representing the main partners required to deliver improved community services relevant to health and social care.

KEY FINDING 25:

The potential remit of the Third Sector Forum Co-ordinator post is not fully clear. It is apparently intended that the post-holder will be asked to develop a governance framework for third sector organisations, set up policies and help to establish partnership models for government, private and third sector organisations. Our discussions with the Health Department left us unclear how this complex set of tasks would be fulfilled.

KEY FINDING 26:

Some third sector organisations felt that the new services would duplicate those they are already providing.

KEY FINDING 27:

The demise of the local welfare systems, based in each Parish, has left a number of Islanders without the personal contact which was previously available at Parish level.

KEY FINDING 28:

The long-term funding is difficult to identify and therefore funding of the proposed changes has not been identified after 2015.

KEY FINDING 29:

The different phases in the ten year programme are interdependent with each other and with the re-design of health and social care services. At this time it is hard to determine whether the Report and Proposition proposals are affordable due to economic uncertainty.

KEY FINDING 30:

The new long-term care benefit was originally to be implemented in 2013. The charge will now be introduced in 2014, but it is currently unclear how it will underpin the costs of existing or future health and social services

KEY FINDING 31:

The flow of funding around the Health system needs to be addressed as a matter of priority. A new Primary  Care  model  will  need  to  incorporate  appropriate  long-term  funding  flows  and incentivisation mechanisms.

KEY FINDING 32:

There appears to be scope for greater communication between the Minister for Social Security, the Minister for Health and Social Services and Treasury and Resources about some of the Outline Business Cases being funded by the Health Insurance Fund. The Panel welcomes the recognition in the Report and Proposition that work to develop the proposals for a funding mechanism will involve Social Security.

KEY FINDING 33:

It appears that patients will face various additional costs if they are cared for in their own homes instead of in hospital where items such as nursing care and dressings are free.

RECOMMENDATIONS

Please note: Each recommendation is accompanied by a reference to that part of the report where further explanation and justification may be found.

The Minister for Health and Social Services should ensure the following – RECOMMENDATION 1:

The initiation of the 10 year strategy should be accompanied by the provision of routine data on a consistent and comparable basis to facilitate monitoring over the full period of implementing the new strategy [section 1.3].

RECOMMENDATION 2:

The Panel welcomes the intention under proposition b(iii) to bring forward a sustainable funding mechanism and recommends that such proposals clearly demonstrate how the potential financial disincentives in existing funding arrangements will be addressed. It is hoped that the Minister will accept the Panel's amendment to bring this forward by the end of September 2014 [section 2.2].

RECOMMENDATION 3:

The Panel recognises that the White Paper was drawn up on the basis of data available at the time, but recommends that further analysis is undertaken to establish the implications, if any, of the 2011 Census and projections based on scenario three, their funding and the pressures driving service development. It will also be necessary to review the Health and Social Care Strategy in the light of any decisions that are made in 2013 regarding future population policies [section 2.4].

RECOMMENDATION 4:

If telehealth and telecare are introduced in Jersey, their initiation should be carried out as a pilot trial and accompanied by rigorous cost benefit analysis and review [section 3.3].

RECOMMENDATION 5:

The Full Business Case (FBC) for intermediate care and associated services should quantify the expected impact of this investment on demand for hospital services together with its predicted impact on patient and carer acceptability and satisfaction. Relevant baseline data on costs and outcomes should be collected and the results of introducing intermediate care services should be monitored against the baseline and predicted impacts. While recognising that the initial results of the current pilot may be less substantial than those of the fully developed new service and facilities, the Panel recommends that data from the pilot should be as widely shared as possible as they become available to inform the development and acceptability of the new service [section 3.3].

RECOMMENDATION 6:

Before  considering the  implementation  of a  charge  for  accessing  A&E  services,  further examination of where the burden is likely to fall and how affordable it will be for individual patient groups is required [section 3.4].

RECOMMENDATION 7:

The Panel is unconvinced that the introduction of Community Services will lead to a convenient balance of supply and demand between hospital care and care in the community. Rather it recommends that the Health Department should model the impact of investment in primary care and community services on the demand and supply of hospital services [section 3.5].

RECOMMENDATION 8:

The Panel recommend that GPs and other primary care practitioners are actively engaged in the ongoing development of primary care services based on a holistic approach to care and multi- disciplinary working [section 3.6].

RECOMMENDATION 9:

New and improved I.T systems should be developed and funded as a matter of urgency. This should  be  coupled  with  ensuring  highest  standards  of  patient  data  protection  prior  to multidisciplinary  teams  handling patient  information. An  integrated  I.T.  system  would help  to improve the relationship between primary and secondary care [section 4.3].

RECOMMENDATION 10:

It may be necessary to phase in new services over a longer timescale due to current difficulties with recruiting and retaining staff [section 4.4].

RECOMMENDATION 11:

Evidence suggests that there is an urgent need to develop the relationship between primary and secondary care. Therefore the appointment of a Community Physician should be made without delay [section 4.4].

RECOMMENDATION 12:

In order to assist in the development of services within the third sector, the Health Department should make every effort to enter into longer-term agreements with all providers. The intended move towards a 3 year funding envelope with the Medium Term Financial Plan will assist with this [section 5.3].

RECOMMENDATION 13:

Following the breakdown of communication between Silkworth Lodge and the Health Department, the Panel recommends that all Service Level Agreements cover a minimum period of 3 years and are monitored by a nominated lead officer. This would ensure the delivery and development of a sound working relationship that assists adaptation to changing needs [section 5.3].

RECOMMENDATION 14:

A sub-group of the Third Sector Forum that includes all key partners who currently deliver health and community services should be established by the end of 2012. This would improve working relationships  between  the  third  sector  and  the  Health  Department,  and  ensure  better communication [section 5.4].

RECOMMENDATION 15:

Before new programmes are rolled out, the Health Department should, in partnership with the third sector  and  other  organisations,  agree  how  specific  services  are  to  be  managed  to  deliver efficiency improvements [section 5.5].

RECOMMENDATION 16:

The introduction of systems for monitoring service costs and outcomes should be dovetailed with the roll out of each new service. Therefore, baseline data should be established in order for this system to be developed [section 6].

RECOMMENDATION 17:

The value and cost of services must be assessed objectively by robust monitoring. Where services are not sufficiently cost effective or gaining acceptance from the public, their continuation should be publicly reviewed [section 6.1].

RECOMMENDATION 18:

The Panel strongly support the intention behind proposition b(iii) that there should be a sustainable funding mechanism for health and social care, by the end of 2014 and the Panel recommend there should be no further slippage on the timescale. The Panel hopes the Minister will accept its amendment to bring this forward by the end of September 2014 [section 6.2].

RECOMMENDATION 19:

Regarding the Primary Care model, any changes in the funding mechanism should be justified in terms of better outcomes for the patient and patient satisfaction [section 6.3].

RECOMMENDATION 20:

Every effort should be made to allay costs for patients in homecare. Savings on the non-usage of hospital  or  nursing  home  beds  should  be  recognised  and  nursing  care,  dressings,  needles, appliances and so on should not be subject to charges [section 6.5].

RECOMMENDATION 21:

The Panel expects the Health Department to focus on protecting patients from incurring any additional costs as the Full Business Cases are worked up. The Panel recommends that, if any additional costs are introduced, these should be made clear to the patient from the outset and closely monitored [section 6.5].

1. Introduction

1. Background

The Panel had been aware that the Minister for Health and Social Services was developing a White Paper to suggest a reform of Jersey's health system. Initially, a Green Paper was published in 2011 which outlined three scenarios and asked for the views of Islanders on these and health and social care services. Following almost 1,350 responses to the Green Paper consultation, the results were analysed and developed into a White Paper: Caring for each other, Caring for ourselves.

The White Paper was also put out for public consultation and the final Report and Proposition (hereafter known as R&P) was lodged on the 11th September by the Council of Ministers. The debate will take place on the 23rd October and asks Members:

1. to approve the redesign of health and social care services in Jersey by 2021 as outlined in Sections 4 and 5 of the Report of the Council of Ministers dated 11 September 2012;
2. to request the Council of Ministers to co-ordinate the necessary steps by all relevant Ministers to bring forward for approval –

1. proposals for the priorities for investment in hospital services and detailed plans for a new hospital (either on a new site or a rebuilt and refurbished hospital on the current site), by the end of 2014;
2. proposals to develop a new model of Primary Care (including General Medical Practitioners, Dentists, high street Optometrists and Pharmacists), by the end of 2014;
3. proposals for a sustainable funding mechanism for health and social care, by the end of 2014.

The Panel began its review in April 2012 by looking at the Green Paper, responses to it and the subsequent White Paper, which consulted from 28th May until 20th July. The Panel undertook the bulk of its work whilst the White Paper was out for consultation, as there would have been little time to carry out a thorough review from when the R&P was lodged in September to the date of the debate in October.

Proposals in the R&P require significant additional funding and the Panel understands that the Health and Social Services Department has bid for growth through the Medium Term Financial Plan (MTFP). As a result the White Paper is to be debated prior to the debate on the MTFP while the latter does contain proposals which assume the R&P is approved.

2. The Review

During  the  course  of  its  review,  the  Panel  held  numerous  Public  Hearings which  included Ministers, some third sector organisations and health care employees of the States of Jersey. It also requested written submissions from charitable and third sector organisations. Some were encouraged by the Health Department's proposals but had reservations about whether they would actually come into fruition. It appeared that the main concern was that the extra monies required to implement the proposals in the White Paper would not be available. A full summary of the responses can be found in appendix one.

The Panel visited the General Hospital and Overdale and St Saviour's Hospital sites. Whilst at St Saviours Hospital, the Panel was able to go into Clinique Pinel and walk around the entire St Saviours site. In order to understand cross-island relationships, the Panel also visited Guernsey Hospital and met with its Minister for Health and Social Services, Chief Officer and Director of Corporate Services. There were many similarities between the two Islands in terms of future economic difficulties and the need to tackle health issues such as the ageing population, obesity and alcoholism.

The aim of this report is to inform the States debate to ensure that what is being proposed in the R&P  is  relevant  to  the  needs  and  resources  of  the  Island  while  also  being  capable  of implementation in ways that deliver better outcomes for local people. The scope of the proposed reforms is so significant that they will have major consequences for all Islanders. It is of paramount importance, therefore, that Islanders are confident that these proposals are both appropriate and cost effective whilst meeting the changing demands of the community.

The Panel commissioned a study by Seán Boyle, which sought to address a number of objectives in relation to the Green and White Paper process, the analysis by KPMG and a comparison with other jurisdictions. This report is referred to as the "Boyle report" (see appendix three).

3. The Health and Social Services Department

One of the main themes from the majority of Hearings was "doing nothing is not an option", in particular because there are serious capacity pressures on hospital services and community services  are  underdeveloped. Consequently,  the  Panel  has  sought  to  assess  whether  the proposed new direction for health and social care is robust enough to address these issues.

The need for increased investment was recognised as early as 2003 when the University of Birmingham produced a report for the Health Department highlighting a number of key issues. In particular, it recommended that Jersey should increase its public healthcare funding by between 3% and 7% per annum in real terms over the subsequent five years to 2007[1].

Evidence from past Annual Business Plans and Financial Reports and Accounts suggests that funding has increased year on year. However, as the Panel has noted in a previous review[2], it is not readily possible to provide real terms time series because of the change in the way figures are presented, and because of the complexity of backtracking decisions relating to spend.

A further issue which is difficult to address in the absence of such data is whether the funding available was adequate to meet changing needs over time and spent appropriately in the right areas. Therefore, over the 10 year period of the proposed strategy it will be essential that the States is in a better position to monitor changes in the level of funding and its allocation to individual services over time.

4. Drivers for Change

The Green and White Papers describe the challenges which Jersey will be facing in the future. These "drivers for change" are the main justifications for why substantial redesign of health and social care is necessary:

Population changes: According to a study by KPMG which underpinned the White Paper, between 2010 and 2040 there will be a 95% increase in the number of people over 65[3]. Since that study, the 2011 Census results have begun to become available and the Panel discusses the implications further on in the report.

Increased demand: KPMG estimated that, if services continue to be provided in the same way, Jersey would have to spend 76% more on health and social care services in 2040 than it does currently[4].

Capacity of hospital beds: An increase in the numbers of older people, coupled with an increase in demand would mean that Jersey will use up any spare capacity of hospital beds in the current system[5].

Capacity of healthcare professionals: Many Health and Social care staff are approaching retirement age. Many of these are "generalists" who can treat a wide range of conditions, however, new health professionals are being trained to be "specialists" who focus on specific areas[6]. So recruiting on a "like for like" basis will be difficult[7].

2. The Green Paper

1. Background

KPMG was commissioned by the Health Department to review how services are provided and what steps will be required to ensure that Jersey can offer quality care. The findings of the KPMG review were shared and a Green Paper was published[8] seeking views from Islanders on the future of health and social services.

Responses to the Green Paper were collected and independently analysed by Involve (experts in public engagement, participation and dialogue). Involve summarised the responses to the consultation which was held between 31st May and 19th August 2011.

2. The Three Scenarios

From the work undertaken by KPMG, the Green Paper outlined three scenarios[9]:

Scenario One: "Business as usual"

We keep the same structure for providing services as we have today, and increase spending so that services can be provided to meet growing demand.

Scenario Two: "A small increase in funding"

We keep funding almost the same, and provide what services we can within this budget and accept that many services will be subject to means testing'.

Scenario Three: "A new model for health and social care"

We change the way services are provided. For every option, the review assessed whether it would be safe and affordable for Jersey.

The third scenario was the favoured option as it was described as being "safe, sustainable and affordable[10]". Scenario one was described as "unaffordable and unsustainable[11]" and Scenario two was deemed as "potentially unsafe[12]". The Boyle report commented upon scenario two: "This is not a realistic option. It is not clear why this was put forward other than as a straw man[13]".

The KPMG report claims that Jersey will not be able to sustain the increased expenditure that will result from a population whose age structure is ageing rapidly. The Boyle report explains that often financial sustainability is assessed by looking at total expenditure per head of population, and as a proportion of Gross Domestic Product. Some measures are presented in an appendix to the KPMG report, although this issue does not seem to have been discussed to any extent in the main text[14].

The Boyle report estimated that, in 2010, expenditure as a proportion of Jersey's gross national income was 4.2%, which is considerably less than public expenditure on healthcare in the rest of the UK[15]. The Jersey figure can recalculated at 5.9% when private, user payments and third sector are included. Even with these additions, the total is considerably less than the 8.7% spent on healthcare in England[16].

The Boyle report questioned whether the level of expenditure under scenario one could accurately be described as financially unsustainable. Since the difference in expenditure between scenario one and the preferred scenario three is £28 million (9%)[17]. The Boyle report said: "given the uncertainty involved in these calculations, we would not regard this as decisive in itself"[18].

The Boyle report also questions whether sufficient options were identified for consideration and consultation. For example, of scenario three it suggests:

"This is an option that bears consideration. However, in our view, a wider range of options should have been considered. It would have been possible to look at various combinations of the elements of this option. Another alternative would have been to consider a phased introduction of different elements giving time to examine the outcome of changes before pushing forward with more".[19]

Although KPMG recommended that Jersey should work towards the scenario three model, it outlined various risks[20] with this option. One of these included the risk that existing funding mechanisms  might  create  financial  disincentives for  the  public to  access  primary  care  or community pharmacists.

The Survey

The public were asked whether they strongly or slightly agreed or strongly or slightly disagreed with scenarios one, two and three (there were also options "don't know" and "skip question"). The consultation did not force people to make a choice between the scenarios and ask them which one they most agreed with. There is the possibility that people slightly agreed with one scenario and strongly agreed with another.

Table one

Therefore, the survey itself was not designed in such a way that the answers to the questions on scenarios can be interpreted as strong support one way or the other. When no detailed choices are provided the outcome of favoured scenario three is not surprising[21].

3. Involve report

The consultation report by Involve analysed the responses and provided statistical data about the survey respondents. The report concluded that most Islanders agreed that scenario three was preferable, although many had concerns about the implementation of the plans, its costs and associated risks[22]. The Panel noted that some Islanders found it difficult to give their opinion because the costs of specific options and services in scenario three were not specified[23]. Although the analysis found Islanders are willing to accept new ways of working[24] it is important to note that some felt that they needed more information and detail to understand scenario three[25].

The other key findings of the consultation were that capping free healthcare for individuals was wrong, that paying more for health and social care was inevitable, and that some services will have to be offered off-island[26].

4. Population: demographic data and projections

The KPMG report was based on the most up-to-date data available at the time it was written but has been superseded by data from the 2011 census. The latter, for example, shows that between 2001 and 2011 the population increased by 10% (9,100). In 2011, the population figure was 97,857, some 9% difference from the KPMG figure (8,038[27]). The current population is in fact greater than the projection used by KPMG for 2040 (97,144)[28].

Table two

It is clear that there are some significant differences between the 2010 base line population data used by KPMG and the results of the 2011 Census (see table two)[31]. It is significant that in 2011 the working population is some 6,107 greater than the KPMG estimate and the 2011 figures for older people is slightly smaller. The number of younger people under 19 is greater in the Census than the KPMG estimate (2,225).

The Statistics Unit have recently published an updated set of population projections based on the 2011 Census baseline. The data which has been published is sufficiently different to the KPMG figures used by the Department in preparing the White Paper and justifies a careful review of their implications for the demand for services and the size of the working population which will be called upon to meet those demands. In effect, the most important decisions about the future patterns and totals of spending on health and social care for at least a decade was taken before all the most recent and relevant demographic data was available.

5. Concluding remarks on the Green Paper

The Green Paper put forward only one scenario for serious consideration (scenario three) as the others were presented in a way that clearly gave the impression they were not viable and hence easily dismissed[32]. This was recognised by many of the people who responded to the consultation, which was a point highlighted in the Involve report.

The Panel formed the view that the consultation process was less well designed than it might have been, if not seriously flawed. As a result, the Panel has serious reservations about the range of options presented, the process by which they were reviewed and the weight that can be placed on the results of the consultation.

Since KPMG produced its report, the results of the 2011 Census have been published and the Statistics Unit have very recently published an updated set of population projections. It is important to examine the impact of these results on the analysis presented in the White Paper[33].

The Health Department explained that the demand on services was not purely dependent on demography, and as a result had based its future planning for hospital service on current utilisation rates in order to provide a realistic and up-to-date indicator of demand "obviously the up-to-date census figures will be important but suffice to say that, with the KPMG modelling, it was based on current usage of the hospital. I think that is an important message that we need to get across because we know that there is an increase in demographics, an increase in the number of people, but we based it on our current use. So we had a realistic figure[34]"

In  practice, future demand for  services  will  be  determined by a  complex  balance of factors including demographic change and the impact of the White Paper strategy itself. To the extent that policies for prevention, early intervention and care at home are successful in changing the level and shape of demand, then current usage of hospital services will be a relatively incomplete predictor of future demand for hospital beds and procedures. The Panel will look therefore, to the Department to provide a full analysis of future demand for all health and social care.

3. The White Paper

Following the analysis of responses to the Green Paper, the Health Department drafted a White Paper based on the preferred scenario of redesigning Health and Social Services. This approach implies strategic change of an unprecedented scale for Jersey and the document also included a staged Transition Plan to provide a sequence and timetable for an implementation plan over the 10 years to December 2021.

1. The Strategy for Change

The White Paper and the subsequent R&P set out a ten year programme of change to meet what were seen to be pressing challenges to the sustainability of health and social care services. Increasing demand is combining with inappropriate estate, workforce pressures and restricted supply to create a system that will not be fit for future purposes and is reaching the limits of its existing capacity. Notable weaknesses are identified as models of care which are relatively medically dominated', have low levels of team-based practice' and, in the absence of 24 hour community services, relatively institutionalised[35]'.

This reliance on medicalised and institutionalised' services is considered more costly than, and inconsistent with, the population's preference to live in their own homes for as long as possible, providing they have the right health and social care support from the States of Jersey, the third sector and Parishes'[36].Thus the limited availability of services in the community, together with the co-payments system for primary care, were judged to result in higher than necessary use of hospital and care home services.

The overall strategy was sub-divided into a number of workstreams to be implemented in three stages. These workstreams as outlined in the White Paper included four priority service changes: services for children; services to encourage healthy lifestyles; services for adults with mental health issues; and services for older adults. In addition, eight enabling or crosscutting workstreams were identified which impact on each of the service development priorities.

Finally, a fifth service development workstream was identified within the body of the report: sustaining acute services'[37]. This seems to be of a slightly different priority from the other four in that its objectives were essentially short term and temporary in maintaining patient safety services while services were developed in the community and a new or re-furbished hospital could be built and commissioned, but this was due to take place as a review of hospital services "during 2016 – 2018"[38].

2. The Three Phases

The Transition Plan is an operational document which provides further details on the service models to be developed. It divides the implementation strategy into three phases each coinciding with a three year cycle of the MTFP.

Phase 1: 2013 – 2015

The first phase will centre on intermediate care and early intervention with a focus on children's health, social wellbeing and educational attainment[39]. Emphasis will also be put on addressing alcohol misuse and accessing rapid support which will begin in 2013[40]. Improving Access to Psychological Therapies (IAPT) will be introduced in 2013 for adults over the age of 18 who need treatment for common mental health issues[41]. Enhanced and integrated older adults services will also commence in 2013. It is also expected that oncology and renal patients will receive services through improved links with non-Jersey based providers [42].

Phase 2: 2016 – 2018

This phase aims to focus on diet, exercise and tobacco, which are the key risk factors in the development  of chronic  conditions  such  as  cardiovascular  disease,  respiratory  disease  and diabetes[43]. Screening for  key  risk factors  will  be  carried  out  in primary  care  settings and  a prevention and intervention approach will be rolled out to Sexual Health services[44]. Phase two also follows on from phase one with early intervention. With regard to children phase one concentrates on "school readiness", whereas phase two will focus on "life readiness" for children aged 5 – 11[45]. Also  during  this  phase,  the  Department  aims  to  focus  on  Mental  Health  with  a  Community Wellbeing  Centre  being  established  as  well  as  an  enhanced  Community  Services  team. Residential Services will also be improved for people experiencing poor mental health[46] and supported housing will also be developed[47].

Phase 3: 2019 – 2021

The proposals for development and redesigning are less detailed in this phase than in phases one and  two.  The White  Paper  does  state  that there  will  be  a focus on  Mental  Health,  Cancer Prevention, Healthy Ageing and Illegal Drugs[48], and care pathways for long-term conditions will be introduced but there are no full explanations as to what these will be. It does explain, however, that phase three is planned to be a consolidation period, where the significant changes introduced during 2016 – 2018 have time to stabilise[49].

3. Enhanced Community Services

Although  an  acute  services  workstream  was  subsequently  established,  the  White  Paper's development plans were predominantly focussed on enhancing community services within the four priority workstreams identified above together with a number of enabling strategies (which included primary care) that applied across all of those priority areas. It was explained to the Panel that the first three years is majored in push starting the development of a broad range of community services  including intermediate  care  services.[50] The  latter  were  justified  in  terms  of  relieving pressure  on  the  hospital  services  from  the  growing  population  of  older  people.  These developments, together with investment in new technologies like telehealth and telecare would enable people to be cared for in non-hospital settings, while also reducing costs and improving care. If they were not implemented, the hospital was expected to run out of capacity by 2017[51].

Telehealth can  be  defined  as  the  remote  exchange  of  data  between  an  individual  and  a healthcare  professional.  It  aims  to  assist  in  the  diagnosis  and  management  of  health  care conditions. Examples include blood pressure monitoring, blood glucose monitoring and medication reminders[52].

Telecare can be defined as the remote monitoring of an individual's condition or lifestyle, and aims to manage the risks of independent living. Examples include automatic movement sensors, falls sensors, and bed occupancy sensors[53].

The Kings Fund published a study in March 2012 which had investigated the impact of telehealth on the management of long-term conditions. It identified 64 studies, measuring the impact of telehealth across several health conditions. The report concluded that the evidence currently available is promising but mixed, and mainly limited to specific conditions such as diabetes and heart failure. Statistically significant levels of benefit have yet to be demonstrated[54].

Telehealth and telecare are integral to several of the Outline Business Cases but the evidence base is not yet established[55], particularly in a small jurisdiction such as Jersey. The British Medical Journal questions the advisability of a "full scale roll out"[56] at present. If rigorous cost benefit analysis and review should accompany any introduction of telehealth and telecare in Jersey, it should be as a pilot trial and subject to rigorous cost benefit analysis.

The Health Department explained to the Panel that the enhancement of community services is about offering Islanders a greater range of options and enabling cost containment in a context of growing demand rather than cost saving[57]. The Panel accepts the case for such a strategy and recognises that costs would increase if nothing was done. Some level of increased investment in community services is, therefore, likely to be necessary and beneficial but the return on such investment is not clear, including its impact on the cost and level of hospital services required (see below).

During its visits, the Panel was briefed that the early experience of piloting intermediate care is indeed helping to reduce the pressure on hospital beds. However, it is also possible that better designed community services will, as the consultant Paediatrician told the Panel, merely reduce the rate of growth in demand for hospital beds rather than compensate for it in totality[58].

4. The Hospital

The R&P asks the States to decide whether detailed plans should be produced by the end of 2014 for a new hospital, either on a new site or through rebuilding and refurbishment on the existing hospital site. The reason for the need for a "new" hospital is due to the fact that the current hospital is not fit for purpose.

The building is deteriorating and does not meet modern standards. Space allocation on wards is about half of what would now be expected for the number of beds. The configuration of six-bed bays is not consistent with the requirements of infection control and does not promote privacy and dignity for patients[59].

The Panel was told that the winter period is of concern because the hospital is running at virtually 100% occupancy. If Jersey were to have a particularly bad winter with respiratory diseases or outbreaks of infection such as diarrhoea and vomiting, the hospital could run out of beds[60]. During a recent site visit to the hospital the Panel was advised that the Renal Unit was at full capacity.

Sustaining and Developing Acute Services

The Panel noted in the previous section that the emphasis of the consultation documents was on re-designing health and social care services to enable more care in community settings, including that provided through the primary care sector. The White Paper did also include a separate section on sustaining acute services[61] but the Panel is inclined to accept Seán Boyle's view that this almost has the appearance of being an afterthought'[62], not least because it does not feature as one of the four priority service changes in the key areas identified for implementation between 2013 and 2021.[63]

The Panel wishes to be absolutely clear at this point that it fully supports the evidence-based development of a more comprehensive range of high quality services which enable islanders to live at home wherever possible. The public consultations demonstrated substantial support for this concept including a shift towards prevention. The R&P is, therefore, worthy of support for setting a radical and necessary change in direction for health and social care on the Island.

However, there are a number of respects in which the Panel thinks the R&P requires amendment, including its approach to hospital services. The Panel recognises that the current management of the hospital has enabled substantial improvements to its fabric and to patient safety. However, the leadership and investment needed to effect these refurbishments appears to have been slow in coming.

Similarly, the Panel understands that a continuing programme of refurbishment is necessary to continue  to  bring  hospital  standards  to  an  acceptable  level  and  that  such  a  programme  is underway.  The  sums  required  are  considerable.  The  Panel  was  told  that  they  amounted  to between £5 million to £8 million per year over ten years[64]. Such sums are apparently additional to that of perhaps £300m[65] for full replacement of the existing hospital either by a new build on a different site or phased rebuild on the current site.

The Panel has drawn four conclusions from its evidence about hospital services in Jersey:

1. Hospital services and services outside of hospital are part of a continuum of care which should be planned as a whole system in which the level and range of services in one part are seen to be dependent on the level and range of services in another if needs are to be met in the round' and without gaps or discontinuities of timing. Any tendency to plan hospital and other services separately should be resisted if the right' services are to be available in the right' places at the 'right' time.
2. Improvements to both hospital and community services are necessary simultaneously and at substantial cost. There is an urgent need to continue improving hospital services while also  developing  community  services  which  reduce the  demand  for  hospital  beds. Unfortunately, the longer it takes to completely replace existing hospital services, the more resources will have to be invested in the current hospital fabric and services to sustain their quality and viability but with increasingly short term returns.
3. The decision between new build and rebuild should be part of the final approval process for the R&P and MTFP. It is the Panel's view that there is a strong case for rebuild but the States should see the results of the pre-feasibility before coming to a final decision on this issue or the remainder of the strategy.
4. It is also the Panel's view that there is strong case for the intermediate care service to be developed urgently with a step down facility and associated primary and community care services. This would demonstrate in practical terms the benefits of investing in both hospital and in the community as part of a mutually reinforcing whole while also minimising short term investment of only short term value.

Accident and Emergency

Figures provided by the KPMG report suggest that there were 37,468 A&E attendances in Jersey in 2010[66]. The Boyle report calculated, using the most recent Census population data, that this would suggest a figure of 383 per 1,000 population. However, contrary to the claim in KPMG report[67], this is not more than the equivalent figure for England as a whole, which is 402 (based on

21.4[68] million attendances)[69].

It was noted that 75% of A&E attendances in 2010 were classed as "standard" which means the patient was seen by a nurse only or it was non-urgent. As a result, some patients (75% as proposed by the White Paper[70]) could potentially have been treated in primary care. Therefore, the additional knock-on effect of this must be taken into account. If, as it is claimed, 75% of current A&E attendances should be dealt with by a GP and all of these people do indeed go to their GP, will there be sufficient GP capacity to deal with this?

Some of the Green Paper respondents suggested that people should be asked to pay to access A&E services in order to prevent the cost-avoidance strategies (i.e. avoiding GP charges). If this is to be considered, where the burden is likely to fall and how affordable it will be for individual patient groups needs to be examined.

If people are only expected to pay for inappropriate attendances, it is unclear how easy it will be to distinguish  between  appropriate  and  non-appropriate  post-visit.  Furthermore,  one  must  ask whether patients can really be expected to make this decision[71].

5. Shaping a New Hospital

The range and scale of future hospital services depends on a complex mix of factors including:

• the volume and kinds of needs that emerge in coming years;
• the volume and kinds of services provided outside hospital by health, social care and other services such as housing, social security and the third sector;
• the respective roles of primary care and community health services including the third sector;
• the implications of increasing specialisation and technological developments;
• the costs, effectiveness, risks and acceptability of providing services on-island or off-island.

Such factors are common to most jurisdictions but they present particular challenges to small island communities. As a result, a range of  choices may have to be made between, for example, magnitude of acceptable risk, the degree of specialisation and local access compared to larger jurisdictions closer to other areas of greater population.

One way of addressing such tensions is through strategic partnerships with other jurisdictions and service. This could involve the subcontracting of service provision to providers off-island by their staff travelling to the island and/or islanders travelling to the providers. This already happens in the case of more specialist treatment, as it does on the mainland where regional and national specialty services are formally designated. In the modern era, complete self-sufficiency is not an option: rather the issue is the extent of self-sufficiency and shared provision; and in the latter case the provision of which services, with which providers and through what funding arrangements.

The White Paper stated that opportunities for strategic partnerships had been examined and would be explored further. The Panel has been provided with no formal details about which strategic partnerships have been explored and in what detail[72]. Nor has it seen detailed work about the level and range of services that could be provided in the new build or re-build replacement for the current hospital. It has been told, in general terms, that the "new" hospital should contain a similar number of beds to the current one.

Chief Officer:

"because there is not going to be a fall-off in patients accessing the hospital. With the demographic growth that we are seeing, as we take patients from the hospital who should not really be there and put them into more appropriate options (whether it is in the home or in intermediate care facilities) those beds will be filled by new patients coming in from the community who need the services of the hospital. So there is no transfer of money from the hospital to anywhere else[73]."

6. Primary Care

The Department explained that within the GP body there are a range of different views regarding the White Paper and its proposals. Two GPs sat on the Steering Group for the Green Paper, White Paper and final R&P. Consideration should be given as to whether this small number of GPs adequately represented the whole GP body.

The Department has held quarterly meetings with GPs to keep them up-to-date on the proposals and service models. It is unclear however, whether these have taken place since the beginning of the process, or whether this is a recent development.

The role of the GP in the new community services is not yet clearly defined. The Boyle report concludes that, regarding the new set of services, general practice will play a key role, one way or another and that it is not clear "that this is reflected in the plans we have reviewed[74]". It is stated in the R&P, however, that a Primary Care Governance Team will be established by the end of 2012, led by a Primary Care Medical Director. The team will work with GPs and other Primary Care professionals, with a view to producing a Primary Care strategy by the end of 2014[75].

7. Concluding remarks on the White Paper consultation

Each of the proposals contained in the White Paper consultation document on re-designing health and social care may have merits in their own right, but they are different in nature and scope from what the Panel sees as the main purpose of the consultation – to consult on the future funding arrangements for the health care system and the future configuration of acute hospital services[76].

There is also concern of how easily it will be to implement these investments in service. The Panel was  told  of  the  difficulties  in  recruiting  the  traditional  caring  services  (doctors/nurses)  so recruitment may prove to be an obstacle[77].

4. Implementation of a New Model

1. Outline Business Cases

The White Paper proposes changes to services in four key areas[78] and each of these is supported by an Outline Business Case (OBC) which puts forward a case for a particular service investment. The OBC's will be developed into Full Business Cases (FBC) which will be facilitated by a recently-appointed Workforce Planner[79]. It was explained that her role is to transform the OBC's into FBC's in the coming weeks. The Panel note that work has begun in advance of the proposition being approved by the States.

2. Cross Departmental Working

The  Minister  for  Social  Security  was  concerned  about  the  impact  the  White  Paper  and  its implementation will have on his Department, because it will require extra work from officers and additional resources[80].

One risk that was associated with scenario three was increased costs for home adaptations and equipment, due to more care being administered in the home and not in a hospital setting. An example of how this might have an effect on resources could be the benefit for home adaptations which is funded by the Social Security Department. In the first instance, any person who may be eligible for the grant is required to contact an Occupational Health Therapist. The Occupational Therapist determines the type and cost of the adaptation and works with two Departments. The Housing Department administers a scheme for its own tenants and the Social Security Department carries out a means test and assesses the financial circumstances of those in private rental accommodation and homeowners.

The  relevant  Ministers  should  be  mindful  of  the  impact  the White  Paper  will  have  on  their Departmental resources and whether enhanced community services will interact with the services their Departments currently provide. Communication between the Health Department and all other Departments and stakeholders is key.

3. Information Technology

The Panel was informed that the Health and Social Services I.T system is not up to speed. According to one clinician there is no future budget for the programmes that were embarked upon to expand I.T or a maintenance budget for those that have been put in place[81]. If new technologies are to be brought in, such as telehealth and telecare care, a new and improved I.T system should be developed and funded as a matter of urgency.

One GP explained to the Panel that it will be a huge challenge to get secondary care I.T systems to talk to primary care I.T systems[82]. When asked when this would be developed, she said: "I think it has gone from being on a pilot that did not work to being now in a problem box nobody wants to open[83]." In the past, there has been an isolated relationship between primary and secondary care on the Island. Therefore, it is important that primary and secondary care feed into one another, including the respective I.T. systems in order to benefit the patient[84]. Furthermore, integration of information technology is also important to support the whole process of integrated healthcare[85].

Without integrated I.T systems the development of best practice in Community Health will be hampered. At the same time, patient data protection should be addressed prior to the introduction of multidisciplinary teams handling patient information.

4. Recruitment

There are challenges in terms of recruitment and retention, particularly in certain staffing groups[86]. The White Paper proposes an expansion of some services and it is unclear whether additional needs of staffing can be met if recruitment is already a challenge. One GP said "we do not shake a tree and they fall out" training and recruiting are important factors[87].

The KPMG analysis reported that Jersey has significantly more GPs than most similar rural or isolated health systems:

1.20 1.00 0.80 0.60 0.40 0.20 0.00

Figure 1[88]: No. of General Practitioners per 1,000 population (UK and Island Jurisdictions)

However, Jersey has very low numbers of community nurses:

250

200 Other Nursing Staff inc. District Nurses

Number of School Nurses

150 Number of Health Visitrors

206

100 166

125 126

97 101 104 108

50 71 71 72 74 78

39

3 0 4 2 5 1 0 1 2 0 0 3 3 1

0

Figure 2[89]: No. of Registered Community Nurses per 100,000 population (England)

Jersey also has very low numbers of Hospital Doctors:

Jersey 38 42 26

Hereford Hospitals NHS Trust 38 72 34

Bedford Hospitals NHS Trust 33 81 38

West Suffolk Hospitals NHS Trust 41 82 41

Hinchingbrooke Health Care NHS Trust 39 75 50

Kettering General Hospital NHS Trust 36 97 38

Doncaster & Bassetlaw Hospitals NHS FT 45 128 31

England - National Average 49 128 44

Isle Of Wight PCT 59 104 62

- 50.0  100.0  150.0  200.0  250.0

Consultants  Middle Grade Doctors Junior Doctors Figure 3[90]: Workforce – Medical staff by grade per 100,000 population (England)

It is understood that the three phased approach is required because of the significant workforce challenges in attracting people to the posts and getting services set up and well established[91]. The Panel questioned whether the States could realistically recruit the numbers of staff within each timeframe (of phases one, two and three) and heard from the Chief Nurse:

"I think there are 2 things: one is, if we stand still, then we are not going to be able to sustain the services anyway, so we have to change something. In relation to nurse recruitment and retention, as a department we have done a huge amount of work, certainly over the past 6 years, in relation to doing more about growing our own[92]"

She went on to say that there is a recognition that the issue around nurse recruitment and retention needs to be fixed. She said that the Department is stuck in a position where there are generally  about  40  registered  nurse  vacancies  across  the  board,  with  an  additional  20 (approximate) that are waiting to come into the service. This results in an overall position of about 60 unfilled posts[93].

The issue around nurse recruitment and retention is complex because of the cost of rentals, partners finding employment and the added difficulty of selling or renting a home in the UK[94]. This places doubt around the feasibility of the plans for staffing the new services and the Panel wonders whether the transition phase for the introduction of new services should be phased in gradually over a longer timescale.

Despite  the  large  numbers  of  staff  to  be recruited in  2013  to  initiate  the  Intermediate  Care Services[95], it is surprising that the appointment of a Community Physician[96] is not envisaged until June 2014[97]. This physician would lead the developed service across the two boundaries between primary and secondary care and as a resource available to GPs, community nurses and people in Hospital[98].  Therefore,  this  appointment  is  a  crucial  one  that  should  not  be  delayed. When questioned on this appointment, the Department explained that an existing member of staff will be working for a fixed period of time initially to get the service up and running, and working closely with the GPs[99].

5. The Third Sector

The third sector' is the general term used to describe the range of organisations that are not public sector, private sector or parishes. It includes voluntary and community organisations both registered charities and other organisations such as associations, self-help groups and community groups[100].

If the States of Jersey is committed to transforming public healthcare services, involving organisations from the third sector will be an essential part of achieving this service redesign. As the White Paper focuses mainly on community services, the third sector as well as the parishes and private sector should play a crucial role in the delivery of these services.

1. The benefits of the Third Sector

According to the National Audit Office, the benefits vary but some of the common themes and special qualities of the third sector are as follows:

• Understanding of the needs of service users and communities that the public sector needs to address;
• Closeness to the people that the public sector wants to reach;
• Ability to deliver outcomes that the public sector finds hard to deliver on its own;
• Innovation in developing solutions; and
• Performance in delivering services[101]

2. Silkworth Lodge

During the review, several issues became apparent after the Panel had spoken to Silkworth Lodge, a drug and alcohol charity that helps people to abstain from substance misuse. Although the Panel's terms of reference (ToR) sought to examine how the changes would impact on existing providers which include the third sector, some issues that were uncovered fall outside the ToR, therefore, have been examined in appendix two of this report.

Evidence suggests that there was, and has been a breakdown of communication between Silkworth Lodge and the Health Department due to a variety of reasons which the Panel sets out below:

• Slow communication: there had been long periods of time before queries from Silkworth Lodge had been answered by the Health Department. This is not acceptable if good working relationships are to be maintained.
• Service Level Agreement payment: there was a delayed payment at the end of 2011 from the Health Department for which Silkworth Lodge received an email apology.
• Service Level Agreement management: Silkworth Lodge used to provide information on bed data on a monthly basis. When this information stopped being received, it was not followed up or questioned by the Health Department.
• Silkworth Lodge closed to new admissions: when the Health Department was advised that Silkworth was closed to new admissions, it should have questioned and followed it up.

These issues have been explored in further detail in appendix two, but they do highlight a general lack of communication between the two parties. They should be managed and addressed as a matter of priority, particularly if the third sector are going to have a bigger part to play.

In discussions with the Chairman of the Third Sector Forum, the Panel heard that other charities had experienced issues when dealing with the Health Department in the recent past, but during the last 12 months, those matters had been resolved and relationships were much improved.

3. Service Level Agreements

A Service Level Agreement can be defined as "An agreement between the provider of a service and its users which quantifies the minimum quality of service which meets business needs[102]." Service Level Agreements (SLAs) should be used to maximum effect to deliver corporate aims.

At  the  moment,  because  of  the  way  the  budget  system  works  with  funding  being  given  to Departments  on  an  annual  basis,  SLAs  are  short  term  (i.e.  yearly)  with  some  third  sector organisations.

The Chief Officer of the Health Department admitted that she would like to see longer term SLAs. She said that if the States move to a 3 year funding envelope, such as what is proposed with the Medium Term Financial Plan, it would help with having longer-term agreements with third sector organisations[103]. Annual SLAs provides uncertainty for third sector organisations as it makes it difficult for them to expand and develop their organisations.

Following the communication breakdown between Silkworth Lodge and the Health Department it would be beneficial if Service Level Agreements were more robust and monitored by a nominated lead officer. The Chairman of the Third Sector Forum said that the problem in the past has been that the professionals within Health and Social Services tended to dictate to the third sector what they would do and how they would do it[104]. He said: "You need a real partnership, a partnership of equals[105]".  A lead  officer  would  ensure  delivery  and  the  development  of  a  sound  working relationship that assists adaptation to changing needs.

4. Third Sector Forum

In 2011 it was announced that the States were to provide 2 years of start-up funding for a professional coordinator to manage the launch and development of a new Third Sector Forum. The need for a Third Sector Forum was recognised by the Association of Jersey Charities, as well as by existing agencies and States Departments[106].

A specially constituted working group was established to develop proposals for the Third Sector Forum,  whose  aim  would  be  to  support  the  professionalism  of  the  organisations,  enhance governance and standards and support the diverse range of voluntary, charitable and non-profit organisations that work to promote community values[107].

The States will be funding a professional coordinator post for 2 years. The post-holder will be asked to develop a governance framework for third sector organisations, set up policies and help to establish partnership models for government, private and Third Sector organisations[108].