Redesign of Health and Social Services - Ministerial Response - 29 September 2014

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1

The  Peer  Review  commissioned by the Ministerial Oversight Group made  11 Recommendations  in total,  many  of  which  mirror  the Scrutiny  Panel's  Findings  and Recommendations contained in its "Health  White  Paper"  report (S.R.7/2012).

S.R.7/2012  made  33 Findings.  Of  the 21 Recommendations,  12 were  accepted,  8 were noted,  and  one  was  rejected.  In  producing S.R.10/2014, the Scrutiny Panel requested a briefing from  the  Ministerial  Oversight  Group  (MOG) Expert Panel, but did not request a briefing from the Departments  regarding  their  response.  The Departments  accepted  most  of  the  MOG  Expert Panel's findings and recommendations, but rejected or questioned other findings: the Departments would have valued the opportunity to discuss this with the Panel prior to S.R.10/2014 being produced.

Four  recommendation  themes  are  similar  in S.R.7/2012 and the MOG Expert Panel report –

 Data  to  monitor  the  impact  of  P.82/2012 investments  (S.R.7/2012,  Finding 4, Recommendations 1, 5, 16 and 17; MOG Expert Panel,  Recommendation 4).  The  MOG  Expert Panel  report  recognised  that:  "this  is  being addressed especially around the performance of the health and social care system and the health profiling of the population"

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• Prioritising  a  sustainable  funding  mechanism (S.R.7/2012, Recommendations 2 and 18; MOG Expert Panel, Recommendation 8). This is being progressed  by  the  Treasury  and  Resources Department.

• Involvement of G.P.s in planning for primary care  and  community  services  (S.R.7/2012, Recommendation 8;  MOG  Expert  Panel, Recommendation 3).  The  MOG  Expert  Panel specifically  commended  the  stakeholder engagement  and  noted  that  the  "consultation process was inclusive and thorough".

• Understanding  the  impact  of  any  proposed charges  in  A&E  on  patients  (S.R.7/2012, Recommendation 6;  MOG  Expert  Panel, Recommendation 11). It should be noted that, at present, there are no proposed charges in A&E.

Many of the findings from the MOG Expert Panel Report and S.R.7/2012 are also consistent –

• The  MOG  Expert  Panel  recommendations strongly  supported  the  health  and  social  care transformation  programme,  as  outlined  in P.82/2012. "The Panel was clear that the case for change was made and the selection of a new model for health and social care was the right one." Recommendation 1 states: "That the States continue with a new model of health and social care. The original KPMG analysis that produced  these  options  was  robust  and  the consultation  taken  since  has  confirmed  that there is widespread support for pursuing this new model". This is consistent with S.R.7/2012,

Finding 3.

• The  2 reports  agree  on  the  size  of  funding required: S.R.7/2012, Finding 1 notes that: "The proposals  contained  in  the  Report  and Proposition:  "Health  and  Social  Services:  A New  Way  Forward"  require  significant additional  funding.";  the  MOG  Expert  Panel note  that:  "The  scale  of  the  increase  in resources  required  is  difficult  to  forecast accurately,  but  the  Panel  was  clear  that  it would  be  substantial  from  whichever perspective it was viewed".

• S.R.7/2012 also noted challenges regarding I.T., which the MOG Expert Panel report identified.

In a number of notable areas, the MOG Expert Panel reported  positively  on  themes  that  had  been

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identified in the findings or recommendations from S.R.7/2012 –

• The  MOG  Expert  panel  report  specifically commended  the  stakeholder  engagement (S.R.7/2012,  Finding 2,  Recommendations 10 and 15)  and  noted  that  the  "consultation process  was  inclusive  and  thorough".  They also recognised that: "Consultation is not about ensuring everyone gets what they want but the process served to engage stakeholders and help build  alignment,  establish  consensus  and mitigate potential problems in the future".

• In  relation  to  primary  care  system  changes (S.R.7/2012,  Findings 5  and  31,  and Recommendation 19),  the  MOG  Expert  Panel findings noted that: "the mixed economy model of  provision  is  the  best  building  block  for system  reform.  The  perverse  incentives currently  operating  must  be  tackled  as  they present real barriers to system reform".

The  MOG  Expert  Panel  identified  a  number  of strengths  and  positive  aspects  of  the  health  and social care transformation programme, including its focus on system change and progression towards a single-patient record. It stated strong support for a new hospital, on dual sites, and noted that the future hospital programme must be delivered more quickly. "This scheme and the associated system reforms make a major statement to the people in Jersey and those outside about the nature and importance of the health agenda in this jurisdiction's future. This should not be underestimated"

The MOG Expert Panel report strongly supported the transformational change programme, but noted the size of the challenge and the capacity for change management.  The  report  concluded  that:  "We believe  system  integration  is  the  right  approach and applaud the efforts to build support amongst all  stakeholders",  and  Recommendation 2  states: "That  the  management  capacity  driving  system reform  should  be  considered  and  supplemented where  necessary  by  encouraging  greater involvement  from  clinicians,  interim  or  external support. Resourcing this work properly must be a priority".

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2

The  Peer  Review  commissioned by  the  Ministerial  Oversight Group,  were  not  provided  with W.S. Atkins'  full  report,  its addendum or the additional studies undertaken  by  W.S. Atkins.  The review seemed to focus on earlier work  undertaken  by  KPMG  in 2011.

The  MOG  Expert  Panel  was  provided  with  a significant amount of information, both written and through presentations and discussion. The original KPMG report was just one document in a suite of almost  30 documents  that  were  provided  to  the Panel.

Given  the  nature  of  the  review  and  the  time available, the Department considered that a detailed briefing on the future hospital project and outcome of the Strategic Outline Case was more appropriate than provision of these detailed reports.

The MOG Expert Panel received a detailed briefing, with questioning and challenge which lasted for a full afternoon. The Panel were given the opportunity to request additional documentation but did not do so.

3

The  original  intention  was  to provide mental health facilities at the  Overdale  Hospital  site.  The dual  site  hospital  proposal  has impacted  on  this  vision,  and  an alternative facility will need to be identified  as  part  of  the  Mental Health Review.

No  decisions  have  yet  been  taken  regarding  the future location of mental health services. There may be  advantages  to  co-location  of  mental  health services  with  ambulatory  care  services,  and therefore  discussions  have  taken  place  with  the future  hospital  technical  advisers  regarding reviewing whether co-location of urgently required mental health services at Overdale is advisable.

4

The  Council  of  Ministers  agreed that proposals for the new model of  primary  care  should  be delivered by the end of September 2014 in order to align them with the  related  proposals  for sustainable funding of health and social  services.  However,  the Panel  has  found  that  the  new model of primary care will not be delivered by the end of September 2014  and  a  new  date  for completion has been proposed for April 2015.

During 2013, an expert partner was sought to assist in  this.  However,  through  ongoing  discussions,  a number  of  stakeholders  felt  that  this  was not  the right solution. The procurement process was then stopped,  and  the  project  was  re-focused  with leadership  from  within  the  Health  and  Social Services Department.

The project has therefore been delayed; however, key stakeholders are fully involved and committed, and are working enthusiastically and very positively with the Department to design and develop options for sustainable primary care into the future. A public consultation on a White Paper is planned for June 2015.

5

The  development  of  the  primary care  service  model  has experienced  some  significant difficulties,  and  yet  the configuration  and  delivery  of

The configuration and delivery of hospital services has a significant dependency on a range of health and social care services, not just primary care. This has  been  clearly  identified  in  the  future  hospital planning  work,  and  the  team  leading  that  work

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hospital services has a significant dependency  on  the  nature  and implementation of that model.

continues to work with colleagues in the primary care project and P.82/2012 service developments, to understand and to work through the impacts.

The health and social care reform programme, of which sustainable primary care is just one part, aims to ensure Islanders are cared for in their own homes wherever possible. The benefits and impacts of this will continue to be modelled and monitored. The out-of-hospital' system development has one of the most significant impacts on the future hospital. The Out of Hospital system is not fully dependent on a new model of primary care, and has already been introduced  as  a  pilot  project,  with  further development this year. The model for sustainable primary care is also being developed this year; key leaders from the future hospital project are involved in  this,  and  vice  versa,  to  ensure  the  model developments progress iteratively and with a good understanding  of  the  respective  plans  and  cross- project impacts.

6

Achieving  the  Health  White Paper's  objectives  requires  an integrated  approach  to  planning and developing services across the whole system of health and social care.  The  Panel  has  found  little evidence  that  a  whole  system approach  has  been  undertaken. This  is  concerning  to  the  Panel because  if  one  work-stream  is developed  without  cognisance  of the  other, the  successful delivery of the redesign programme is put at risk.

The health and social care reform programme has taken  a  system-wide,  integrated  approach  to planning and developing services from its inception. This  is  important  because  challenges  and developments  in  one  part  of  the  system  impact significantly  on  all  other parts  of  the  system.  As presented  in  the  Green  Paper:  Caring  for  each other, Caring for ourselves' in 2011, the health and social  care  system  faces  a  number  of  significant challenges,  including  the  demands  placed  on  the hospital.  The  analysis  demonstrated  that,  if  no changes were made, the hospital would quickly run out  of  beds.  It  also  identified  some  gaps  in community  services.  For  these  2 reasons  the investment in community services was prioritised, whilst the future hospital planning work was being progressed. But it was also important to ensure that the  programme  of  service  changes  is  manageable and  realistic;  changing  every  part  of  the  system simultaneously is not possible.

In terms of encouraging the whole system to work together, and planning across the whole system –

A system-wide U:collaborate' event was held at the programme's inception, where stakeholders shared thoughts  and  ideas  and  these  were  integrated  to consider the system impact.

Each of the Outline Business Cases and each of the detailed plans have been developed with a range of stakeholders  from  across  the  system  (including

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community staff, G.P.s, voluntary sector, hospital). This helps to ensure that each part of the system has its say', and is able to challenge each of the plans on the impact that it will have on their profession, team or organisation and on their part of the system.

The  Transition  Plan  Steering  Group  has  met monthly  since  December  2010.  It  comprises representatives  from  across  the  health  and  social care system, including G.P.s and voluntary sector, whose role is to challenge the emerging plans from a system-wide perspective. The investment priorities, the Green Paper, White Paper and P.82/2012 were agreed by the Steering Group.

The Health and Social Services Ministerial Advisory Panel (HASSMAP) challenged  each  of the  plans. This  group  comprises  independent  experts  from social  care,  children's  services,  mental  health, hospital and primary care.

Each  of  the  major  projects  has  its  own  steering group or development board; these report into the Transition Plan Steering Group or directly into the Ministerial Oversight Group. Key individuals from the System Redesign and Delivery Team participate fully in these groups to ensure cross-fertilisation and integration between the different work programmes.

7

The Panel's previous review of the Health White Paper found in 2012 that the current I.T. system was not integrated  between  primary  and secondary care and was a problem which  required  urgent  resolution. The Panel has found that this issue is still outstanding.

The  Health  and  Social  Services  Department  has made good progress on the I.T. issues identified in S.R.7/2012.  The  Department  considered  a  wide range  of  issues  and  produced  an  Informatics Strategy, which was provided to the Panel as part of their  review.  The  draft  Informatics  Strategy  was agreed in January 2013 and is now being delivered. Ongoing delivery is subject to ongoing funding.

The  Panel's  reports  make  specific  comment  on integration  between  primary  and  secondary  care systems.  It  is  important  to  recognise  the achievements  to  date  and  to  note  that  the  right progress must be made against realistic timescales in order to maximise value for money. For example, the  new  primary  care  I.T.  system  (G.P.  Central Server) is currently being implemented; it would not be  sensible  or  feasible  to  attempt  to  integrate  or establish links with a system that is not yet in place.

Whilst the primary care system has been developed and  the  implementation  planned,  HSSD  has completed  the  implementation  of  an  electronic ordering  and  delivery  system  for  pathology  and radiology tests.

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Initial discussions have taken place regarding how the  primary  care  and  hospital  systems  may  be linked, and work has commenced on a business case for this.

The Department is also establishing a system-wide health and social care informatics group to further progress I.T. integration.

8

Informatics  and  technology  are essential to deliver and monitor the service changes and transformation described  in  the  Health  White Paper. The Minister for Health and Social Services acknowledged the lack of historical data, and made a commitment  in  2012  that  work would  be  undertaken  to  address this issue. The Panel has found that little  progress  has  been  made  in this  area,  which  is  disappointing particularly  when  the  need  for improved information systems was identified as far back as the 1990s.

The Department has made significant improvements and  advances  in  information  technology  and management over the past 3 years.

In particular, the implementation of the ICR project delivered –

• A  replacement  hospital  administration  system (Trakcare),  ranked  as  one  of  the  best  in  the world.

• A new child health system, enabling Jersey to excel  in  protecting  our  children  against infectious diseases.

• Modern  radiology  systems  across the  hospital introducing  electronic  storage  and  retrieval  of X-rays and scans.

• Integration between Trakcare and other hospital systems.

• A foundation, based on a world leading system, that is key to enabling the further developments and improvements to be delivered.

In addition to, and following, the main project, other significant achievements in this area include –

• The Informatics Strategy was agreed in January 2013, and is now being delivered.

• Implementation  of  electronic  ordering  of pathology  and  radiology  tests  throughout  the hospital.

• Introduction of SMS text messaging reminders for appointments.

• Implementation of case management system for mental health services.

• Implementation  of  long-term  care  assessment system to enable the introduction of Long-Term Care Benefit.

• Supporting  and enabling  the  CAB  to  develop and implement the Jersey Online Directory.

• Implementation of bowel-screening system.
• Implementation of endoscopy reporting system.

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• Agreed arrangements with Hospice to fund the implementation  of  a  Hospice-based  system  to integrate with the hospital and other systems.

• Supporting  FNHC  to  implement  a  donor management system.

• Implementation of traceability system in dental services.

• Implementation of environmental health system.

• Upgrade  of  ambulance  and  patient  transport systems, including the addition of tetra location services.

• Upgrade  and  integration  of  the  clinical investigation system.

In addition, a number of information-based projects are currently underway; these include –

• The development of an Island-wide health and social care informatics group.

• The establishment of a Standard Data Set across HSSD,  enabling  benchmarking  internally  and against UK hospitals.

• The development of business cases to support the next major systems developments –

• E-prescribing
• Community Information System

• Primary care/secondary care integration and interfacing

• Hospital Electronic Patient Record.

• The replacement and update of radiology system hardware and software.

• The  implementation  of  a  medical  desktop' solution across the Department, supporting the use of mobile devices.

• A Post-Implementation Review of Trakcare and Order Communications.

• Implementation  of  a  system  to  support  the Jersey Talking Therapies service.

This  demonstrates  a  significant  improvement  and advancement  in  information  systems  over  recent years,  and  illustrates  a  significant  current  and ongoing  programme  of  work.  It  is  important  to recognise that, as with healthcare itself, there is an almost  infinite  demand  for  information  and information  systems.  These  demands  have  to  be prioritised and managed to deliver the best possible

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value  for  money  within  the  Department's  overall capacity  to  deliver  the  organisational  change  that necessarily comes with new systems.

9

One  of  the  overall  conclusions contained in the Comptroller and Auditor General's report: "Use of Management  Information  in  the Health  and  Social  Services Department – Operating Theatres" was  that  improvements  to management  information  should be  seen  as  a  priority.  The  Panel wholeheartedly agrees and expects the Minister for Health and Social Services  will  take  heed  of  the C&AG's  report  and  its recommendations and conclusions.

The thoroughness and depth of the Report has been welcomed by the Minister. Work had commenced on  theatres  prior  to  the  Comptroller  and  Auditor General's review. An action plan was developed on receipt of the report, with work underway to address the relevant  recommendations.  A  formal  response will be submitted to the Public Accounts Committee by 1st October 2014.

Data is routinely collected on all the key aspects of theatre  usage  and  can  be  accessed  for  audit  or operational use. However, the Department accepts that the methods of data capture could be improved and that greater operational use could be made of the data currently collected.

10

The  Commissioning  team acknowledged  that  there  is  a limited  pool  of  health  staff available on the Island, which will have  an  impact  on  service development and delivery.

The Green Paper Caring for each other, Caring for ourselves'  stated  that  the  increasing  demand  for health  and  social  care  in  the  future  will  pose workforce challenges.

Most staff want to work in a supportive, modern and innovative care setting where their contribution and their full potential can be realised. P.82/2012 offers the  opportunity  to  redesign  the  workforce  and introduce expanded roles with greater responsibility; this can both attract and retain staff.

In addition to securing the right number of staff, motivation  and  retention  is  important.  This includes –

• Clear roles and scope
• Control over job performance
• Interesting career opportunities
• Good educational opportunities
• Trust and collaboration
• Recognition
• Effective communication.

The Department's workforce strategy includes –

• increasing the number of nurses employed, for example  through  pre-registration  nurse education on the Island

• expanding  nursing  roles  to  ensure  nursing careers are more attractive; for example, through non-medical prescribing

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• training  health  and  social  care staff,  such the BTech  qualification  in  partnership  with Highlands College

• delivering  more  education  and  training  on- Island;  for  example,  the  degree  and  Masters courses  delivered  in  partnership  with  the University of Chester.

Jersey  is  no  different  from  other  jurisdictions  in facing  a  recruitment  and  retention  challenge;  a proactive workforce strategy with a combination of growing our own' and recruiting off-Island, along with a good working environment and opportunities, will help to address these challenges.

Since 2010, 100 additional nurse posts have been created in HSSD. Because of the strategic approach to  recruitment  campaigns  and  local  professional training and succession planning, as outlined above, vacancies have reduced – in July 2012 there were

41.5 posts vacant out of 708; in July 2014 this has fallen to 34.2 posts vacant out of 766.

11

Since  2012,  there  has  been  an improvement  in  the  level  of communication  between  the Health  Department  and  members of the Voluntary and Community Sector.

The voluntary and community sector is a key partner in developing and delivering health and social care

services, and is also a very valuable and respected voice of the patient'. We are pleased that the Panel has  recognised  the  significant  improvement  in relationships between the Department and voluntary sector  partners.  This  has  come  about  through willingness and openness on both sides, and through the active involvement of the sector in whole system planning and delivery.

Through the P.82/2012 investments, we have been able to support the voluntary sector partners with additional  funding;  for  example,  to  support  the expansion of Hospice services. We have also been delighted  to  see  strong  delivery  partnerships building,  so  that  now  organisations  are  working together  to  deliver  services.  We  look  forward  to seeing relationships further improve and to working even  more  closely  with  our  partners  across  the system  into  the  future,  delivering  a  choice  of excellent health and social care to Islanders.

12

Recent  mediation  in  2014  has improved the relationship between the Health Department and G.P.s However,  poor  communication during  2012/2013  has  caused  a delay in the development of a new model of primary care.

The  relationship  between  the  Health  and  Social Services Department and G.P.s has been developing over the past years. As with any relationship, there have been some challenges, but these have not been with every G.P. or in every area of work.

The  Primary  Care  Governance  Team  came  into being  in  2011;  they  have  developed  positive

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relationships  with  G.P.s,  with  regular communication –  for  example,  monthly  G.P. meetings  and  monthly  meetings  with  the  primary care body, in addition to meetings with individual G.P.s and practices. We have worked together on a number of positive developments, including the G.P. Central Server and the Performers List, which was approved by the States earlier this year.

The challenges regarding the new model of primary care  arose  from  ongoing  discussions  and involvement of primary care representatives in the selection of an expert partner. As a result of the concerns  raised  by  G.P.s,  the  procurement  was halted and an alternative way forward was identified through facilitated discussions with the G.P.s. These facilitated  discussions  were  open,  honest  and positive; they were not adversarial mediations as the Panel implies.

The  relationship  with  the  primary  care  body  has improved significantly, and a primary care hub has been set up, where G.P.s work jointly with officers from the Health and Social Services Department and Social  Security  Department.  This  is  further improving relationships and understanding, and the participants  have  demonstrated  their  commitment and enthusiasm to working together in an open and trusted way.

13

One  of  the  priorities  given  to W.S. Atkins  was  to  identify  an appropriate  site  on  which  acute healthcare  services  could  be delivered. However, their evidence to the Panel stated that they found it  frustrating  that  they  were  not afforded  the  opportunity  to participate  in  meaningful  clinical team engagement.

Initially, the site selection was largely driven by size and  site  development  matters,  and  therefore  the Strategic Outline Case (SOC) could not have been meaningfully influenced by clinicians.

The  Design  Champion  co-ordinated  clinical engagement to test whether a dual site option was clinically safe and feasible. W.S. Atkins produced the SOC Addendum, which reflected the dual site design  developed  by  the  Design  Champion  in consultation with clinicians.

14

The timeline for completion of the Full  Business  Cases  to  introduce more  community  services, originally  due  to  commence  in January 2013, was ambitious and, due  to  a  number  of  factors,  the timeline changed considerably.

Phase 1 of the Transition Plan was scheduled for implementation in 2013–2015. This is still the case, and, halfway through this period, the vast majority of additional services have now been introduced and are  delivering  real  benefits  for  Islanders.  This includes intermediate care, children's respite care, pulmonary  rehabilitation,  expanded  services  at Hospice, Jersey Online Directory, rapid access for heart  failure,  oxygen  therapy  and  Community Midwifery.  The  new  services  are  offering  greater choice  for  Islanders,  with  reduced  waiting  lists,

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accessible  information  to  support  carers  and individualised  care.  There  has  been  excellent feedback  from  those  using  the  services  and  their carers; and the services are continuing to develop and improve.

As the Panel notes, the original timetable was very ambitious,  and  the  timeline  has  changed  through ongoing  discussions  with  stakeholders  and  as  a result  of  challenge  from  the  Scrutiny  Panel.  The work  to  develop  the  detailed  specifications, implementation  and  delivery  plans  started  in October  2012,  following  the  States  approval  of P.82/2012.  In  January  2013  we  undertook  a listening exercise', as some stakeholders had raised concerns regarding their involvement. Working with stakeholders, we then rescheduled the work plan to ensure that we were responding to their concerns, developing  plans  together  and  ensuring  the workload and pace of change was manageable.

15

The  impact  of  delaying  the implementation  of  community- based  care  strategies  will  have  a significant  effect  on  determining the size of the hospital.

The  initial  investment  into  community-based investments was not delayed; it started immediately after  P.82/2012  was  approved.  Intermediate  Care, end-of-life care and respite for dementia were all enhanced from late 2012, and have been developing and improving since that time. Priority investments in long-term conditions were made in mid-2013, and rapid  response  was  piloted  from  May  2014.  A winter pressures' project ran during 2013, bringing together services from across health and social care to improve discharge.

The health and social care reform programme has taken  a  system-wide,  integrated  approach  to planning and developing services from its inception. This  is  important  because  challenges  and developments  in  one  part  of  the  system  impact significantly  on  all  other parts  of  the  system.  As presented in the Green Paper Caring for each other, Caring for ourselves' in 2011, the health and social care  system  faces  a  number  of  significant challenges,  including  the  demands  placed  on  the hospital.  The  analysis  demonstrated  that,  if  no changes were made, the hospital would quickly run out  of  beds.  It  also  identified  some  gaps  in community  services.  For  these  2 reasons  the investment in community services was prioritised, whilst the future hospital planning work was being progressed. But it was also important to ensure that the  programme  of  service  changes  is  manageable and  realistic;  changing  every  part  of  the  system

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simultaneously is not possible.

The out-of-hospital'  system  development  has  the most impact on determining the size of the future hospital. The aim is to enable Islanders to be cared for at home for as long as possible, reducing the demand  on  the  hospital  and  on  care  homes.  The services  comprise  rehabilitation  and  step-up  step- down (previously called intermediate care'), rapid response,  long-term  conditions  care,  end-of-life care,  a  single  point  of  access,  and  older  adults' mental health care.

These strategies have already had a noticeable effect on the hospital: in winter 2012, up to 60 beds were closed  due  to  an  outbreak  of  Norovirus,  but  the hospital  coped  with  this  because  the  additional community services had started to be available.

The services and the system remain under review, to ensure that investments are made in those services that  can  have  the  greatest  impact  and  benefit.  In May  and  November  2013  a  snapshot'  audit  was undertaken of hospital bed use. This identified some process  improvements,  and  confirmed  that  the further investment and enhancement of community services (planned for 2014) was required. A formal evaluation  of  the  Intermediate  Care  pilot  was reported in February 2014, and plans for the future service have been developed since that time.

In  terms  of  planning  further  forward,  the  future hospital and out-of-hospital' projects both include very  detailed  demand  and  capacity  modelling. Activity modelling suggests that the new hospital requires  300 beds,  rather  than  400 beds,  which would  be  the  requirement  if  there  were  no investments in community services. The hospital is being designed and sized' for 2040 capacity. It will be  completed  in  2024,  but  will  have  the  right capacity for 2040 – so some of the capacity should not  be  needed  at  that  point,  which  allows  some degree of mitigation in the short term to the risk created by any delays in the delivery of community initiatives.

16

Following  the  implementation  of the Community Midwife Service, most  views  from  G.P.  surgeries were  positive  about  the  new system  of  providing  an  Island- wide  ante-natal  care  service  in accessible non-hospital settings.

The P.82/2012 investments are intended to improve choice for Islanders, as well as offering quality and value for money. Very positive feedback has also been received from individuals who have used the Intermediate  Care  service  and  Children's  respite care.

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17

Even  though  the  Specialist Fostering  service  was  brought forward  to  2013,  no  specialist foster carers have been appointed to date.

As at September 2014, 3 new foster carers and one new connected person carer have been approved, as well  as  3 sets  of  level 2  specialist  foster  carers (where a set' is an individual or family unit). A further 5 x level 2 carers will be approved in the near future.

The new specialist foster carers are completing their training; children will be matched to the specialist foster carers according to needs.

Due to this increase in local foster carers, no more children  have  been  placed  in  off-Island  fostering placements this year.

18

There is a lack of available health visitors on the Island to undertake training  for  the  Sustained  Home Visiting Programme, and therefore it  has  been  necessary  to  recruit from the UK. Family Nursing & Homecare are still in the process of  recruiting,  and  they  are therefore  unable  to  implement fully the Sustained Home Visiting Programme.

The  Sustained  Home  Visiting  Programme  has already  started  delivering  services.  The implementation commenced in December 2013, and the service was planned to be fully available from October 2014.

Two Health Visitors commenced in September. A further Health Visitor will start in October and the final staff member in November.

The operational planning has progressed well whilst the recruitment was taking place; the Licence has been obtained, resources ordered and delivered, and a Co-ordinator/Champion appointed.

Programme  model  training  has  been  delivered  to 50% of the current Health Visitors, and they have taken a small number of clients each to embed this training. E-learning modules have been completed, and Supervision training to support the programme has been delivered.

19

It  is  unclear  to  what  extent  the White Paper development in out- of-hospital  care  has  been  taken forward  successfully.  The  one review  undertaken  by  the  Health Department –  of  the  intermediate care pilot – is highly critical in that it indicates a lack of readiness to initiate  the  service,  as  well  as  a failure to put in place systems to monitor  adequately  the  use  of these resources.

The Scrutiny Panel has received a number of private briefings  and  held  public  hearing  regarding  the White Paper. The Panel has also been provided with a significant volume of information.

Pilot projects are designed to identify challenges and issues,  and  to  provide  the  opportunity  to  address these before the full service goes live. Intermediate Care is critical to the success of the White Paper, and  therefore  needed  to  be  piloted.  The  pilot commenced in late 2012, and has been monitored and  evaluated  since,  with  service  developments being made along the way.

In terms of the development of the out-of-hospital' system:  from  November 2013 –  January 2014, commissioning intentions' were developed. These identify what services are needed into the future, and were based on discussions with key stakeholders, an

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understanding of service gaps and needs, and the emerging  learning  from  the  Community Intermediate Care (CICS) pilot.

A formal evaluation of the Intermediate Care pilot was reported in February 2014. Also in February, the Minister approved the commissioning intentions, and agreed that a whole system approach to out-of- hospital' care would be developed, integrating the Intermediate  Care  and  Long-Term  Conditions developments into one co-ordinated system.

Since that time, FNHC have commenced a Rapid Response  pilot,  Community  and  Social  Services have  progressed  their  Single  Point  of  Referral (SPOR) and discussions have commenced regarding the integration of Older Adults Mental Health into the  system-wide  approach.  The  previously overspending CICS budget has been brought back under  control  and  resources  are  being  effectively managed.

As agreed by the Transition Plan Steering Group in late January 2014, the system development will be led through a multi-agency group, with an integrated project approach. A Development Board has been set  up,  and  a  Project  Brief  have  been  produced which outlines the key elements of this, along with the governance, deliverables and timelines.

The Development Board comprises leaders from the key  organisations  (FNHC,  HSSD,  primary  care); their role is to develop and oversee the delivery of the  out-of-hospital'  system,  and  to  address  the issues of  readiness  to initiate the  service and  the systems to monitor adequately the outcomes and use of resources.

20

Proposition  P.82/2012:  "Health and Social Services: A New Way Forward" required the Council of Ministers  to  bring  forward proposals  for  investment  in hospital services and detailed plans for a new hospital (either on a new site or rebuild on the current site) by the end of 2014. This included full  details  of  all  manpower  and resource implications necessary to implement such plans.

The Council of Ministers intends to report back to the  Assembly  with  the  outcome  of  the  future hospital feasibility study, as set out in P.82/2012.

This was originally intended for the end of 2014; however, S.R.10/2014 acknowledged that there was a  significant  change  to  the  proposed  approach  to delivery of the future hospital during 2013, resulting in the development of the dual site pre-feasibility concept in October 2013.

The  Ministerial  Oversight  Group  has  therefore approved  a  revised  timescale  for  delivery  of  the feasibility study for the future hospital, which will now report to the States during 2015.

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21

The  Ministerial  Oversight  Group considered a Communication Plan for public consultation. Its aim was to  confirm  the  preferred  site through a States decision to enable detailed feasibility work to follow, and design for a new hospital to be developed and procured. However, the  Panel  has  concluded  that  no States decision has been taken on this  issue,  despite  being  the original intention of the Ministerial Oversight Group.

S.R.10/2014 acknowledges that within Budget 2014 (P.122/2013),  the  Minister  for  Treasury  and Resources set out for the Assembly, details of the proposed Dual Site approach proposed within the Strategic  Outline  Business  Case,  and  indicated clearly that this would form the working assumption adopted  within  the  feasibility  study –  funding  for which was supported by the Assembly in approving Budget 2014.

22

Although  the  Department  has undertaken  some  form  of consultation on the future hospital, the Panel would have expected to have  seen  greater  and  more meaningful  public  consultation, together  with  a  more  detailed analysis of the results.

A public communication rather than a formal public consultation was considered appropriate, given that no  decision  relating  to  the  requirements  of P.82/2012  was  proposed.  The  Health  and  Social Services Department and Jersey Property Holdings held  an  extensive  public  communication  exercise during  the  period  between  lodging  and  debate  of Budget 2014 (P.122/2013), including –

• Four  public,  key  stakeholder  and  staff  focus groups to gauge likely public response to future hospital proposals

• Five public events open to all Islanders

• Extensive promotion via social media of a future hospital website: www.gov.je/futurehospital

• The  development  and  launch  of  video promotions  and  animations  of  the  Dual  Site concept –  these  were  widely  publicised  by written, audio and visual media

• Placing  advertisements  in  the  Jersey  Evening Post,  on  Jersey  Insight  and  other  electronic media, promoting the information available

• A  comprehensive  social  media  campaign  that resulted in over 7,250 people being made aware of  the  future  hospital  video,  with  over 1,100 viewings of the video on YouTube.

Formal consultation will be undertaken as part of the feasibility  study  in  advance  of  seeking  outline planning  applications  and  as  part  of  the Environmental and Health Impact Assessments.

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23

Concerns have been highlighted by the  general  public  and  States  of Jersey  employees  about  the  dual site  proposal  in  relation  to: operating  from  2 sites,  efficiency and transport. The Panel has seen no  evidence  that  these  concerns have been addressed.

The  communication  exercise  clearly  demonstrated that  the  public  response  to  the  future  hospital proposals  was  overwhelmingly  in  favour  of  the proposed changes.

In terms of responding to concerns raised, the Acute Service  Planning  process  has  actively  involved clinicians  and  other  staff.  Over  80 engagement meetings  having  been  held  to  inform  the  design process  already.  Concerns  raised  are  being addressed through the planning process:

The refined concept pre-feasibility design includes almost 300 staff and public car parking spaces at Overdale.  During  the  feasibility  study  phase, detailed  transport  plans  for  both  Overdale  and General  Hospital  sites  will  be  used  to  inform  a Transport Impact Assessment that will be part of the Outline Planning Application for the development. Underground  parking  is  being  considered  for  the site,  together  with  further  parking  for  the Crematorium.

The  refined  concept  pre-feasibility  design  also includes  costs  for  a  frequent  shuttle  bus  service between the General Hospital and Overdale sites. This proposal will be tested and quantified further, following the development of transport plans as part of the current feasibility study.

24

One of the reasons for rejecting the Zephyrus site (Waterfront) was the separation of the sites by the main road,  which  would  present significant obstruction to providing the  necessary  clinical  and operational links between the sites. This is inconsistent with the later proposal  by  the  Ministerial Oversight Group to operate a dual site  hospital  from  the  current hospital site and Overdale, which involves  a  substantially  greater degree of physical separation.

The 2 matters are separate, but the responses given by Ministers are consistent.

As  part  of  the  pre-feasibility  development  of  the Strategic Outline Case, several combined sites were considered  for  development  of  a  wholly  new hospital. These included a combined Waterfront site where the current Waterfront Car Park and part of the Waterfront site south of Victoria Avenue were considered together, to see whether a viable single hospital  could  be  developed  over  the  2 combined sites. The clinical adjacency possible for this site configuration was very poor, and therefore it was not progressed to shortlisting in this configuration.

This is very different from the dual site proposal within the Addendum to the Strategic Outline Case which required consideration of a partially new-built and  part-refurbished  hospital.  Here,  the  dual  site proposal separates ambulatory care at Overdale and acute  inpatient  care  at  the  General  Hospital.  UK NHS examples have proved that these 2 functions can  be  operated  on  different  locations  very successfully.

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Therefore the 2 approaches are not comparable in the way suggested in S.R.10/2014.

The first approach attempted to fit a large wholly new-built  hospital  onto  a  site  with  insufficient ground floor footprint, necessitating a bridge over Victoria Avenue. The second separates ambulatory care  from  inpatient  care  in  a  manner  proven  by exemplars elsewhere.

The point being made by the Minister for Treasury and Resources and the Treasurer giving evidence, was that combinations of sites had been considered prior to the Design Champion proposing a dual site in  response  to  the  clarification  of  the  budget available for the project, as was evident from the Strategic Outline Case provided in evidence.

25

At a Ministerial Oversight Group Sub-Group  meeting  in  February 2013, the Chief Executive of the States expressed a view that unless the  cost  of  the  scheme  could  be reduced  down  to  the  levels identified in R.125/2012 (between £389 million –  £431 million),  it would be necessary for the project to  consider  what  clinical compromises  were  necessary  to achieve  a  total  project  cost  of below £400 million.

This is correct; however, the Chief Executive was careful to refrain from proposing a suggested budget in  the  Ministerial  Oversight  Group  Sub-Group meeting in February 2013.

The  subsequent  approach  to  identify  a  sufficient budget  involved  an  extensive  review  of  other facilities,  a  cost  challenge  and  the  clinical engagement  work,  which  collectively  confirmed that, in principle, a budget of £297 million should be sufficient to enable the priorities for improvement identified  by  the  Health  and  Social  Services Department to be met. This information has been provided in evidence to the Panel.

26

Although  the  Waterfront  options had  attractions  in  terms  of potential  benefits,  costs  and  ease of  construction,  the  Ministerial Oversight  Group  Sub-Group agreed that any Waterfront option would be out of keeping with the existing  Esplanade  Quarter Masterplan,  and  would  require considerable lost opportunity costs to  replace  or  compensate  for  the loss of existing uses. Furthermore, the  options  developed  were considered  likely  to  have  a detrimental  impact  on  the development  of  the  Jersey International Finance Centre which would  form  an  income-stream considered  essential  for  the development of the new hospital.

This is correct.

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27

A  wide  range  of  sites  were considered  by  W.S. Atkins between May 2012 and June 2013, including  greenfield  sites,  and many of these were worked up into relatively  detailed  costings.  The preferred option that emerged was to rebuild on the existing General Hospital  site.  However,  the introduction  of  a  reduced  budget envelope  necessitated  a reconsideration of this choice.

This is correct.

28

Although the preferred site option developed  by  W.S. Atkins identified a total new construction and  land  cost  of  approximately £462 million,  the  Ministerial Oversight  Group  subsequently determined  a  maximum sustainable  total  capital  funding package  of  £250 million (excluding contingency).

In  June  2013,  the  Pre-Feasibility  Project  Board recommended  that  a  more  detailed  concept  for  a £250 million  first  phase  of  a  new  hospital  be presented within a revised Strategic Outline Case to the  Ministerial  Oversight  Group,  together  with  a package of proposals for transitional capacity and essential  maintenance  and  upgrades  and  the Ministerial Oversight Group agreed. In practice it proved difficult to achieve the outcomes needed by the Health and Social Service Department within a £250 million  envelope;  and  a  higher  budget  of £297 million  was  subsequently  proposed  by  the Project  Board  and  accepted  by  the  Ministerial Oversight Group, as has been provided in evidence to the Panel.

29

The  design  champion  identified that  a  single  investment  in  the General  Hospital  site  would  not maximise  the  benefit  of  the available  investment  and  would result  in  a  more  lengthy  and complicated  construction programme,  causing  significant disruption  and  inconvenience  to patients. The Panel has found no evidence of his analysis on public record to enable an assessment of the  factors  taken  into  account  or the  robustness  of  judgements derived from it.

In  the  Minister  for  Treasury  and  Resources' evidence to the Panel, the Treasury and Resources Department confirmed that there was a public record of the Design Champion's iterative development of the future hospital concept. W.S. Atkins confirmed that the Design Champion's proposals were sensible, given  the  brief.  Therefore  an  independent professional assessment has been provided.

30

W.S. Atkins felt that at times they were  set  unrealistically  short timescales  for  the  delivery  of information or reports. They also felt  that  they  were  not  able  to engage fully with key members of

This  may  be  a  correct  reporting  of  W.S. Atkins International's view; however, W.S. Atkins accepted the brief provided to them and confirmed they could achieve the timescale set.

It  is  true  that  the  Project  Board  did  robustly challenge W.S. Atkins' assumptions on occasion, as

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the  Project  Board,  and  as  a consequence  it  was  difficult  to ensure that they  fully  understood the challenges of proceeding down a  particular  route  or  direction  of travel.

might be expected on a project of such significance to the States, and this may be the reason for the view given.

31

It  was  not  until  May  2013  that W.S. Atkins were informed of the available  budget  for  the  future hospital project. While it may be appropriate that in the initial stages the  contractor  is  not  limited  by budget,  it  should  become  clear very  early  on  what  the  budget envelope  is  likely  to  be,  so  that appropriate value is obtained from consultant time and expertise.

It  is  true  that  W.S. Atkins  were  informed  of  the available budget for the future hospital project in May  2013.  However,  W.S. Atkins,  who  were employed  as  consultants,  not  contractors,  also confirmed in their evidence that it was not unusual for  a  budget  not  to  be  confirmed  until  a  public authority had determined what could be afforded.

Ministers took time to challenge all elements of the Strategic Outline Case to establish that the budget for a wholly new hospital was fully robust. As soon as  it  became  clear  that  the  cost  of  a  whole  new hospital would be unaffordable, the Project Board reviewed the available alternatives in relation to the spatial  standards,  cost  assumptions  and  re-use  of some hospital buildings.

32

A greenfield site for a new hospital would have been the best option in terms of less risk, more benefits, and a lower overall cost.

This is agreed; however, no suitable greenfield site was identified that would be capable of development for a whole new hospital.

33

The  process  followed  to  appoint the design champion was flawed. Others  were  not  given  the opportunity to apply for the post and  W.S. Atkins  were  unaware that  an  appointment  was  being made  to  conduct  work  of  direct relevance to their own pre-existing and continuing appointment.

Financial  Directions  allow  for  appointment  of consultants  where  time  does  not  allow  for  a  full procurement  and  a  suitably  experienced  and qualified  candidate  is  available,  as  in  this  case. W.S. Atkins were made aware of the appointment; their own appointment had concluded at that point, and it was an extension of their work that followed under  a  new  brief  to  produce  the  supporting Addendum to the Strategic Outline Case.

34

Although  the  dual  site  offers  a potential  solution  for  a  reduced budget, the current proposal means that 44% of the existing hospital will  be  new  build,  30%  will  be refurbishment  and  the  remainder will  be  existing  use.  This  will inevitably  result  in  a  need  for further  capital  investment  in  the future.

It is inevitable that further capital investment will be required at some point in the future for the hospital. However,  Ministers  accepted  collectively  and  in principle that the dual site concept set out in the Addendum to the Strategic Outline Case represented good value for money and an affordable investment, as well as a safe and sustainable hospital provision.

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35

The  result  of  W.S. Atkins  pre- feasibility  study  dated May  2013 was that a phased development of the  existing  hospital  site  offered the  best  location  for  key investment  in  future  hospital capacity, following which a draft Report  and  Proposition  was prepared detailing the outcome of the pre-feasibility study. The Panel note  that  this  did  not  mention Overdale Hospital or the dual site concept.

The  draft  Report  and  Proposition  was  policy  in development and was never progressed. Instead, the Ministerial  Oversight  Group  accepted  the  Pre- Feasibility  Project  Board  recommendation  to develop  a  more  detailed  concept  to  an  indicative £250 million budget. The dual site option emerged after this decision.

36

There  are  conflicting  views  on who  identified  the  dual  site solution.  On  the  balance  of  the evidence, it seems most likely that the dual site solution had not been identified as an option until it was introduced by the design champion in July/August 2013.

This  finding  is  based  upon  a  mis-communication during  the  Public  Hearing,  as  is  explained  in response to Finding 24.

37

During  the  development  of  the future hospital, options have been continually  developing.  As assumptions change, the basis for comparisons also change, and it is therefore  necessary  to  present clearly  what  is  included  in  the various  options.  This  has  not always  been  apparent  in  the documentation  provided  to  the Panel,  and  it  is  therefore questionable  whether  all  options have been compared on a like-for- like basis.

In  each  case  where  an  option  was  under  serious consideration,  a  full  feasibility  cost  estimate  was produced  in  line  with  a  consistent  best  practice protocol  (the  UK  NHS  Health  premises  Cost Guides) by a local qualified quantity surveyor. As the brief changed, so did the assumptions within the cost estimates.

38

The  proposed  dual  site  option  is not  included  in  previous  options produced  by  W.S. Atkins  and which reflected the original brief, which  in  turn  reflected  the intention of P.82/2012. The impact on patient care of this decision to go with a lesser mix of new and refurbishment has not been made clear and is not in the spirit of the decision  to  provide  new  modern hospital facilities in Jersey.

Proposition P.82/2012 "Health and Social Services: A  New  Way  Forward"  requires  the  Council  of Ministers to bring forward proposals for investment in  hospital  services  and  detailed  plans  for  a  new hospital  (either  on  a  new  site  or  rebuild  on  the current site). The dual site refined concept proposal is consistent with this proposition. Whilst a wholly new hospital has been confirmed as unaffordable, the dual site proposal includes proposals for a new hospital (the ambulatory care centre at Overdale), and  new  build  and  refurbished  hospital  on  the current site. All published communication regarding the dual site is consistent with this approach.

Findings

Comments

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Although  estimated  revenue figures  will  be  refined  alongside the  detailed  feasibility  work,  the additional  cost of  operating  on  a dual  site  is  estimated  by  the Treasury  Department  to  be  an annual  recurrent  cost  of £1.7 million  in  2019  when  the Overdale  site  is  planned  to  be opened. The Panel has found that as  the  dual  site  concept  was identified  at  a  late  stage,  a  high level  analysis  of  the  estimated revenue  consequences  had  not been  undertaken  when  all  other options were being considered.