Health White Paper - Ministerial Response - 13 February 2013

Findings

Comments

1

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

The full implementation of this strategy will require a significant level of funding.

The  MTFP  proposed  funding  for  implementing  the first 3 years of this strategy. This was agreed by the States in early November.

Work is now progressing on translating the Outline Business  Cases  (OBCs)  into  Full  Business  Cases (FBCs) –  detailed  operational  plans  for  the  new services, including the detailed costs and benefits.

Decisions on who will provide the new services will be made early in the new year. These decisions will be made on a balance of quality and value for money.

We will continue to monitor spending and impact very closely.  We  will  also  continue  to  progress  CSR, efficiency  and  productivity  in  order  to  secure  best value for taxpayers' money.

The Jersey Lean System has been introduced in my Department  during  2012.  This  will  continue  to  be rolled  out  in  2013  onwards,  and  will  underpin  our continued drive towards improvement in both quality and value for money.

Proposition 82  required  the  Council  of  Ministers  to bring  back  proposals  for  a  sustainable  funding mechanism  in  2014 –  HSSD  are  working  with Treasury and Resources and with Social Security to progress this.

Findings

Comments

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.

HSSD  notes  the  concerned  expressed  by  some  Third Sector  organisations  about  the  availability  of  monies. These  concerns  need  to  be  viewed  in  the  following context –

The  MTFP,  which  has  been  approved,  proposed significant funding for implementing the first 3 years of  this  strategy:  £4.5 million  in  2013,  an  additional £4.4 million in 2014 and £2.1 million in 2015. This funding will be available from 2013.

HSSD are working hard to ensure that the proposals come to fruition, through producing FBCs which are realistic and achievable. Third Sector organisations are heavily involved in this process.

The  Chartered  Institute  of  Public  Finance  and Accountancy  recent  review,  commissioned  by Scrutiny, reported "a well-developed approach being taken  which  factored  in  a  group  of  expected  cost pressures  which  were  fully  considered  and  costed", and also noted that detailed costing approaches were being applied by the Department.

Robust commissioning arrangements will be in place from 2013 in order to ensure the process for awarding service  agreements  and  for  monitoring  delivery  are transparent.

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.

This amount of change is unprecedented. HSSD and its partner organisations do not underestimate this.

Detailed plans for the planned service changes (FBCs) are  now  being  prepared.  This  is  being  achieved through a series of working groups and workshops for each  service  area,  working  with  a  range  of stakeholders including clinical and professional staff, voluntary  and  community  organisations  and  G.P.s. These  individuals  and  organisations  understand Islanders' health and social care need and what it takes to deliver services. Their input is critical to ensuring that  the  plans  are  achievable,  and  have  broad ownership and buy-in.

Things will change over time, hence HSSD will keep plans under review; will listen to professionals and to Islanders;  will  monitor  services  carefully  to  ensure delivery of efficient, cost-effective services. The FBCs will contain detailed service specifications setting out exactly  what  services  are  required;  the  metrics  and measures used to monitor delivery and timescales for implementation.

Findings

Comments

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.

HSSD have acknowledged that there is a lack of historical data, hence data and informatics are a key crossing cutting work-stream. HSSD will bring in –

more robust routine monitoring, so that Islanders can be assured that services meet need and provide value for money;

new service level agreements (SLAs), which will start to be introduced from 2013. All agreements will be clear about the data that needs to be provided.

To  date,  HSSD  has  run  this  change  programme  using robust programme management and governance. This will continue.

5

Although KPMG recommended that Jersey should work towards scenario 3, 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.

The  need  to  ensure  that  funding  mechanisms  promote effective health and social care is recognised in the White Paper  (p. 27).  This  was  identified  as  a  work-stream impacting on several areas of the proposed changes.

The  Department  will  be  working  with  Treasury  and resources,  Social  Security  and  other  departments (e.g. Housing) to ensure that any new or changed funding arrangement has the intended outcomes.

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 3 scenarios.

The  questions  in  the  Green  Paper  document  were designed  with  the  Statistics  Unit,  to  test  Islanders' viewpoints around certain important aspects of care – like who should pay and who should receive services.

In addition, HSSD took advice from KPMG and from a  professional  PR  company  (Webber  Shandwick) when we designed the Green Paper.

It is always difficult to produce public consultation questionnaires. If too many options are included, there is a risk of confusion – and the options should be as mutually  exclusive  as  possible,  so  there  is  a  clear choice.

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 3 was preferable, many had concerns over the

The Green Paper outlined 3 scenarios at a high level, to help Islanders understand the choices that need to be made, and to get their views.

Once we had a clear steer from Islanders, that was the time to work up the detail – and that's what is in the White Paper and the OBCs.

However, there was a lot of detail available at Green Paper stage – the KPMG Technical Document' was almost 500 pages long.

Findings

Comments

implementation of the plan, the costs and associated risks. Therefore, they concluded that more information was required before they could conclusively endorse the option.

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.

HSSD  figures  are  being  cross-referenced  with  the latest population data.

The analysis of future demand for hospital services is based on current number of service users, not on 2001 census figures.

Therefore "extra" people living in Jersey, as identified in 2011 census, are already factored in because they are already service users.

The Statistics Unit's 10 population scenarios confirm the very issues addressed through proposed new model for care, namely –

• The  total  number  of  older  people  in  Jersey  is growing (this is the case for all 10 scenarios).
• The growth in numbers of people aged 65+ will be significant.
• The numbers of people aged 65+ by 2040 ranges from  27,700  to  31,000  across  the  10 scenarios, with  the  average  across  all  scenarios  being 28,930 people  aged  65+.  This  accords  with  the figure  of  29,000  used  when  developing  the proposed new model of care.

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.

Both analysis and experience show that the hospital is becoming very full. If we have a surge of demand, for example over winter, we will run out of beds.

24 hour community services are not currently available in Jersey – one of the reasons the hospital is getting full.

Creating  extra  beds  in  a  hospital  takes  time. Community services can be increased more quickly, relieving pressure on the hospital.

Islanders want more community services and home- based care.

The  development  of  intermediate  care  is  a  key component  across  a  number  of  work-streams.  It provides  alternatives  to  hospital  admission  and improving hospital discharge.

Early  outcomes  from  the  intermediate  care  pilot scheme are very encouraging, with positive outcomes and  feedback  from  service  users  and  Primary  Care Professionals alike.

Findings

Comments

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.

There is evidence that telehealth and telecare work – within an integrated care system, where professionals work well together – for certain types of patients. Like many things, it's not a case of one size fits all'.

The latest UK trial showed a 20% reduction in hospital admissions.

Like all service changes, it needs to be right for Jersey, so is being planned with a range of stakeholders.

The introduction of new services, such as telehealth and telecare, will be carefully managed and monitored to ensure efficacy.

11

Although the White Paper suggests that the cost of scenario 3 is likely to be less than scenario 1 (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.

• Demand for health and social care will increase in the future, as older adults often have higher health and social care needs.
• The pre-feasibility work undertaken by Atkins shows that, if we do not increase community services we will need 173 more hospital beds by 2040. This will cost an additional £60 million.
• It also shows that, even with an increase in community services, we will still need 59 more beds.

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.

The current hospital is deteriorating and does not meet modern standards. HSSD is addressing this in 3 ways –

1. The development of proposals relating to a new hospital (recognised that one is needed in the next 10 years).
2. The development of an Acute Services Strategy, with clinicians, to identify which services need to develop them pending a new hospital.
3. The  relief  of  pressure  on  hospital  beds  and building  in  flexibility  through  projects  such  as intermediate care pilot (with non-recurrent money for 2012) and development of plans to increase 24 hour community services.

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

• The White Paper focused mainly on the need to relieve the pressure on hospital beds and build in flexibility (both immediately and in the longer term).

The White Paper –

• clearly stated the need for a new' hospital in the next 10 years (work on this has already commenced including pre-feasibility study); and
• specifically  noted  the  need  to  develop  renal  and oncology services as a priority.

Findings

Comments

deserved greater attention than it was given in the White Paper, as the Report and Proposition recognises to some extent.

It is important to recognise that the White Paper outlined the  big  ticket'  strategic  investments  needed,  not  the business as usual' changes that are already planned and will support improvements in acute services (e.g.: ICU and theatre upgrades).

In  addition,  as  already  stated,  HSSD  is  developing  an Acute Services Strategy.

14

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

HSSD is already working with G.P.s to discuss how they could/should work with the Emergency Department.

The need to develop the right model for urgent care is widely  recognised –  it  must  include  the  right  mix  of Primary  Care  and  the  right  use  of  the  Emergency Department.

15

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

The proposals contained in the White Paper do not entail any additional charges for care.

Any new charges proposed in the future will need to come before the States Assembly for approval.

16

A Workforce Planner has been appointed to facilitate the development of the FBCs. 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.

As set out in Key Finding 20 (below) there have been historical  challenges  associated  with  recruitment  of  an appropriately skilled workforce. It is therefore imperative that the plans set out in the White Paper had been subject to review but an experienced, specialist workforce planner.

The White Paper needed the right staffing models to avoid the risk of introducing changes that would not work, were out of date or that did not support and develop our staff.

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.

Health and wellbeing impacts on many other areas of our  lives –  for  example,  housing  and  employment often impact on both physical and mental health – and vice versa.

Health and social care is provided by many different individuals, professions and organisations – including other States Departments.

Throughout the planning process, HSSD has worked closely  with  a  wide  range  of  professionals  and organisations – for example, both Social Security and Housing  have  helped  developed  plans  for  Older Adults.

The  OBCs  identified  the  key  interactions,  and  the detailed FBCs will provide further detail – including care  pathways,  which  will  govern  how  care  is delivered and how organisations work together with the needs of the individual at the centre.

Findings

Comments

 Close  collaboration  between  all  providers  of  care services  is  required  to  implement  these  proposals. Therefore significant effort has and will continue to be made to engage all community and voluntary sector agencies.

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.

Information  management  and  technology  was identified in the White Paper as an area that needed to be developed to support the changes proposed.

HSSD  is  preparing  an  Informatics  Strategy  and implementation  plan  to  address  the  needs  of  the service over the next 6 years.

Investigations  are  already  underway  in  some  areas, including  the  potential  to  link  hospital  and G.P. systems to facilitate the automatic delivery of test results.

19

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

Throughout the planning process HSSD has worked closely  with  a  wide  range  of  professionals  and organisations – G.P.s, hospital staff, community and Third Sector were on every working group.

Integrated care is a key principle for the new services – organisations  and  professionals  must  work  closely together, with the needs of the individual at the centre.

The  new  care  pathways  will  govern  this,  and  will include things such as single assessment, single care planning,  multi-disciplinary  teams,  better  sharing  of information, shared case notes.

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.

HSSD has had a relatively positive and successful year in  recruiting  and  retaining  nurses.  This  has  been achieved  through  working  closely  with  SEB,  the Treasury, nursing unions and professional bodies.

Further joint work is planned to build on this in 2013 and beyond.

A similarly positive year with recruitment of senior doctors  and  further  successful  recruitment  is anticipated  in  2013.  Many  medical  staff  applicants have  expressed  a  positive  perception  of  the  White paper which has informed P.82.

Improvements have been achieved via a combination of  local  initiatives,  and  in  partnership  with  other departments/providers, including –

• Increasing places on-Island for nurse training (32 student nurses are training in Jersey).
• Back to nursing'  programme  (14 nurses applied this year).
• Placements  for  nurses  training  in  U.K. interested  in  either  returning  to  Jersey  or working in Jersey (6–9 per year).

Findings

Comments

• Nurse Prescribing – this has made Jersey more attractive as a place to work, particularly to nurses  who  currently  prescribe  in  other countries.
• Annual  on-Island  programme –  first  group through  in  2013  (14 local  nurses  will undertake the course).
• Proactive  recruitment  of  staff,  Healthcare Assistants and Registered Nurses through the nurse bank (approximately 150 appointed per year).

• Nurses  attracted  to  work  in  areas  with appropriate  levels  of  staff –  additional investment in nursing posts to increase staffing levels (circa 55 new posts over past 3 years).
• Monitoring  national/international  workforce activity and targeting recruitment campaigns, and regular promotion of Jersey.
• Relocation allowance.
• Working  with  our  partner  organisations  to support  the  development  of  the  workforce

across the Island.

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.

The OBC notes that a Community Physician should be appointed, temporarily, from mid-2013.

This role is to "work with a Consultant Nurse or Allied Health  Professional  to  focus  on  setting  up  and initiating the new model," to "up-skill Primary Care via  joint  clinics  between  G.P.s  and  the  Consultant Physician"  and  to  "provide  mentoring,  education, specialist  advice  and  support  to  G.P.s,  and  the specialist  Nurses  and  Clinical  Investigations Department will support G.P.s and Practice Nurses with ongoing education and advice".

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.

HSSD  recognise  that  annual  planning  does  create uncertainly for Third Sector organisations. The new 3 year MTFP cycle will help HSSD and others States Departments to start agreeing longer-term contracts/ SLAs, where appropriate.

In  future,  HSSD's  SLAs  will  be  monitored  by  a nominated lead officer and overseen by an appropriate Director.

HSSD is working hard to develop relationships with third sector colleagues – and this is being recognised by many.

HSSD is changing the formal of SLA documents, so that they reflect both sides of the relationship and are clear on what HSSD need to do, as well as what the third sector need to do.

Findings

Comments

23

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

Officers  from  HSSD  were  instrumental  in  helping secure start-up funding for this Forum, and an HSSD Director  is  currently  a  non-voting  member  on  the Forum.

HSSD now holds quarterly briefing sessions with the Third Sector, of which many are (and will continue to be)  heavily  involved  in  the  detailed  planning  of services.

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.

The Forum was set up with a remit across the whole sector and is undertaking work that is beneficial across the  whole  sector –  not  just  health  and  social  care organisations.

That  is  a  decision  of  the  Sector  and  one  which  is supported by HSSD.

Given the work taking place with HSSD however, the Third Sector Forum are focusing some of their efforts first on health and social care, with a view to then cascading the approach out to other sectors.

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.

The Forum is independent and these are issues to be addressed by the Forum, not be HSSD.

HSSD meets regularly with the Third Sector Forum's Chief Executive Officer who presented and outlined his  role  at  our  quarterly  briefing  session  that  the Minister and senior Officers held with the Third Sector in October this year.

We have had a number of meetings with the CEO, building  relationships  to  understand  what  the  Third Sector needs in order for HSSD to work better.

We are looking forward to continuing to work with the CEO  and  the  Third  Sector  Forum  in  the  coming months  and  years,  and  to  working  closely  with  the Third Sector to develop and deliver excellent services for Islanders.

26

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

The services in the White Paper are a mixture of brand new services, expansion of current service models and changes to the way current services are delivered. It is therefore inevitable that some of the services in the White Paper are the same as some of the services that are already being delivered – because they are valued services  and  could  be  expanded  to  benefit  more people.

HSSD anticipate that Third Sector organisations will want to continue to deliver many of these services.

Findings

Comments

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.

HSSD recognise this and therefore want to make more services available closer to where Islanders live, for example from Parish Hall s, where appropriate.

HSSD  will  work  closely  with  the  Parishes  as  new services are planned.

28

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

Funding  for  the  first  3 years  of  this  strategy  was identified in the MTFP.

In developing these proposals, consideration will be given to how the current system operates, including the impact of financial incentives and disincentives.

Part (b)(iii) of the proposition requires the Council of Ministers  to  bring  back  proposals  for  a  sustainable funding mechanism by the end of September 2014.

29

The different phases in the 10 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.

The  Treasury's  preparation  of  the  Medium  Term Financial Plan has included an assessment of all States income and expenditure over the 3 year period.

The  MTFP  proposals  were  considered  by  the Assembly  in  early  November,  providing  an opportunity  to  debate  the  economic  and  other assumptions underpinning the Plan.

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.

The Department is working with Social Security on the impact of introducing long-term care benefit and how it will interface with existing funding mechanisms and service provision.

Part (b)(iii) of the proposition outlines the requirement to  bring  back  proposals  for  a  sustainable  funding mechanism.  In  developing  these  proposals, consideration will be given to how the current system operates, including the long-term care benefit.

The Department will be working with Treasury and Resources,  Social  Security  and  other  departments (e.g. Housing)  to  ensure  that  any  new  or  changed funding arrangement is comprehensive and considers all current issues.

Findings

Comments

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.

The White Paper recognises the need to ensure that there is effective and affordable Primary Care. Both Primary Care and funding are specific work-streams.

The Department will be working with Treasury, Social Security and Primary Care providers to ensure that any new or changed primary care funding arrangements have the intended outcomes.

This  is  covered  in  part (b)(ii)  of  the  proposition (Primary  Care)  and  part (b)(iii)  of  the  proposition (sustainable funding).

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.

The  development  and  implementation  of  the  White Paper and associated work-streams have been overseen by  a  Ministerial  Oversight  Group,  including  the Minister for Social Security, the Minister for Health and Social Services and the Minister for Treasury and Resources.

This oversight group has been supported by an Officer Steering  Group,  including  senior  officers  and clinicians from Health and Social Services as well as Chief Officers from Health and Social Services, Social Security and Treasury and Resources.

The development of proposals for funding outlined in the  Report  and  Proposition  will  continue  to  be overseen politically and by Chief Officers of relevant Departments.

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.

Work is currently underway on the FBCs. As part of this  process,  the  financial  implications  and consequences of proposed changes on individuals, the Department and others will be considered in full.

Certain  services,  such  as  dressings,  are  currently charged for; it is not intended that this will change.

Therefore,  patients  who  are  cared  for  in  their  own homes will need to pay for these services, as they do now if they are treated in their own homes.

Recommendations

To

Accept/ Reject

Comments

Target date of action/ completion

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.

Accept

• HSSD has run this work programme to date using robust programme management and governance. This will continue, in order to monitor new services as they are introduced. HSSD is introducing robust routine monitoring.
• New service level agreements (SLAs) will start to be introduced from 2013. Where appropriate, these will be longer-term

agreements.

• All SLAs will clearly set out what data that needs to be provided in order to better monitor value and ensure Islanders have the right services, as the population's needs change.

Note: the target for most actions is pending confirmation as part of the FBC process.

2

The Panel welcomes the intention under part (b)(iii) of the proposition 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.

Accept

Funding for the first

3 years of this strategy is identified in the MTFP.

In developing these proposals, consideration will be given to how the current system operates, including the impact of financial incentives and disincentives.

Part (b)(iii) of the proposition requires the Council of Ministers to bring back proposals for a sustainable funding mechanism by the end of September 2014.

September 2014

Recommendations

To

Accept/ Reject

Comments

Target date of action/ completion

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 3, 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.

Accept

SEE KEY FINDING 8

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.

Accept

SEE KEY FINDING 10: FBCs will be very clear about: the expected benefits and costs of services; when and how they will be introduced; how quickly they will be brought in; the management and monitoring processes associated with new services.

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

Noted

Initial results from the current pilot study are being collated and are encouraging.

FBCs will be very clear about: the expected benefits and costs of services; when and how they will be introduced; how quickly they will be brought in; the management and monitoring processes associated with new services.

Recommendations

To

Accept/ Reject

Comments

Target date of action/ completion

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.

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.

Accept

The proposals contained in the White Paper do not entail any additional charges for care.

Any new charges proposed in the future will need to come before the States Assembly for approval.

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.

Accept

• Hospital and Community Services work in tandem to prioritise and allocate resources as appropriate.
• Detailed modelling has been undertaken by

W.S. Atkins as part of the pre-feasibility spatial assessment work. This included the impact of changing the service model as a result of investment in non- hospital services.

Recommendations

To

Accept/ Reject

Comments

Target date of action/ completion

8

The Panel recommend that G.P.s 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.

Accept

This will be done as part of part (b)(ii) of the proposition – the proposed new model for Primary Care.

This will be completed in September 2014 as time is required to fully engage with Primary Care practitioners (G.P.s, dentists, optometrists and pharmacists).

Recognise need to make sure that the funding mechanisms for Primary Care link with the sustainable funding streams for the whole of health and social care (i.e. parts (b)(ii) and (iii) of the proposition link together).

September 2014

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.

Noted

SEE KEY FINDING I8

10

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

Accept

 There should be no requirement to phase in new service plans over a longer timescale solely because of recruitment challenges if HSS joint work with SEB, Treasury and nurse representatives continues the progress and momentum in recruitment and retention

Recommendations

To

Accept/ Reject

Comments

Target date of action/ completion

seen in 2012 (SEE KEY FINDING 20).

• The detailed plans which are being produced as part of the FBCs will be tested by an experienced Workforce Planner and there will be challenges to ensure they are deliverable, given the challenges we face in recruitment and retention. (SEE KEY

FINDING 16).

• The plans will remain under review, and re- phasing will be undertaken should this prove necessary.

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.

Noted

The OBC notes that a Community Physician should be appointed, temporarily, from mid- 2013 (SEE KEY FINDING 21).

This role is to "work with a Consultant Nurse or Allied Health Professional to focus on setting up and initiating the new model," to "up-skill Primary Care via joint clinics between G.P.s and the Consultant Physician" and to "provide mentoring, education, specialist advice and support to G.P.s, and the specialist Nurses and Clinical Investigations Department will support G.P.s and Practice Nurses with ongoing education and advice" [words taken directly from the OBC].

mid-2013

Recommendations

To

Accept/ Reject

Comments

Target date of action/ completion

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.

Noted

SEE KEY FINDINGS 22, 23, 24 AND 25

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.

Noted

SEE 12 ABOVE

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.

Noted

SEE KEY FINDINGS 22, 23, 24 AND 25

HSSD is committed to working with individual Third Sector organisations and with the Third Sector Development Forum. An HSSD Director is a non- voting member of the Third Sector Forum.

It is a matter for the Forum whether it has a specific sub- committee for health and social care, although the Department would be very happy to work with such a sub-committee if it were established.

Recommendations

To

Accept/ Reject

Comments

Target date of action/ completion

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.

Noted

SEE KEY FINDINGS 22, 23, 24 AND 25

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.

Accept

SEE KEY FINDING 4 AND RECOMMENDATION 1

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.

Noted

SEE KEY FINDING 4 AND RECOMMENDATION 1

18

The Panel strongly support the intention behind

part (b)(iii) of the proposition 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.

Accept

Funding for the first

3 years of this strategy is identified in the MTFP.

In developing these proposals, consideration will be given to how the current system operates, including the impact of financial incentives and disincentives.

Part (b)(iii) of the proposition requires the Council of Ministers to bring back proposals for a sustainable funding mechanism in 2014. The Council of Ministers

September 2014

Recommendations

To

Accept/ Reject

Comments

Target date of action/ completion

agrees with the Panel's recommendation and intends to bring these proposals forward by the end of September 2014.

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.

Accept in principle

The White Paper recognises the need to ensure that there is effective and affordable Primary Care. Both Primary Care and funding are specific work- streams.

The Department will be working with Treasury, Social Security and Primary Care providers to ensure that any new or changed primary care funding arrangements have the intended outcomes.

This is covered in

part (b)(ii) of the Proposition (Primary Care) and part (b)(iii) of the Proposition (sustainable funding).

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.

Reject

SEE KEY FINDING 33

Financial implications for individuals will be considered in full and will be checked through the sustainable funding model.

Important to note that some services such as dressings, are currently charged for; it is not envisaged that this will change. Some patients who are cared for in their own homes will need to pay for some services, as they currently if they are treated in their own homes.

Recommendations

To

Accept/ Reject

Comments

Target date of action/ completion

21

The Panel expects the Health Department to focus on protecting patients from incurring any additional costs as the FBCs 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.

Accept in principle

SEE KEY FINDING 33 AND RECOMMENDATION 20

Any new charges proposed in the future will need to come before the States Assembly for approval. Important to note that some charges, such as those for dressing, already exist and it is envisaged that this will continue.