Redesign of Health and Social Services - Report - 5 September 2014

Health, Social Security and Housing

Scrutiny Panel

The Redesign of Health and

Social Services

Presented to the States on 5th September 2014

S.R.10/2014

Contents

1. Executive Summary .............................................................................................................. 5
2. Key Findings and Recommendations ............................................................................... 10
3. Chairman's Foreword ......................................................................................................... 18
4. Terms of Reference ............................................................................................................ 20
5. Panel Membership .............................................................................................................. 21 Expert Advisors ................................................................................................................................ 21 Glossary ...................................................................................................................................... 22
6. Introduction ......................................................................................................................... 23 The proposed redesign of Health and Social Services: an overview .......................................................... 23 The Case for Change: Health White Paper ................................................................................................. 24 Health White Paper Review: A New Health Service for Jersey: the way forward (S.R.7/2012) ................. 24 Review of the Redesign of Health and Social Services ............................................................................... 26 Peer Review of Reform of Health and Social Services ................................................................................ 27
7. Whole Systems Strategic Planning ................................................................................... 30 Whole Systems Approaches ....................................................................................................................... 30 Key Enablers ................................................................................................................................................ 30 Information Services ................................................................................................................................... 31 Workforce Planning .................................................................................................................................... 35 Population Assumptions ............................................................................................................................. 37 Acute Services Strategy .............................................................................................................................. 37 Interim financial arrangements for meeting immediate pressures ........................................................... 39 Mental Health Services ............................................................................................................................... 40 Concluding remarks on whole systems approach ...................................................................................... 41
8. Stakeholder Engagement ................................................................................................... 42

Engaging with the Public ............................................................................................................................. 42 The Panel's Public Consultation .................................................................................................................. 42 Communication with the Voluntary and Community Sector ..................................................................... 44 Engaging with Primary Care ........................................................................................................................ 45 Engaging with Hospital Clinicians ............................................................................................................... 46

9. Delivery of Services in the Community ............................................................................. 48 Timeline of key milestones ......................................................................................................................... 48 Funding Out-of-Hospital Services ............................................................................................................... 51 The Tendering Process ................................................................................................................................ 54 Out-of-Hospital Services ............................................................................................................................. 56

Evaluation: Community Intermediate Care Pilot ........................................................................................ 61 A New Model of Primary Care .................................................................................................................... 62

10. The Future Hospital ........................................................................................................ 65 Timeline of hospital planning process ........................................................................................................ 66 The decision making process ...................................................................................................................... 68 Pre-feasibility study and its addendum ...................................................................................................... 74 Was the decision process effective?........................................................................................................... 77 Initial absence of a budget envelope .......................................................................................................... 77 Extraneous factors ...................................................................................................................................... 77 Late decision to change advisors ................................................................................................................ 78 Dual-site Hospital Proposal ......................................................................................................................... 78 Who identified the dual site solution? ....................................................................................................... 80 Are options comparing like for like? ........................................................................................................... 82 The basis for cost assumptions: an analysis ............................................................................................... 83 How much would a dual site hospital cost to run? .................................................................................... 85 Determining the cost of the Hospital ......................................................................................................... 86 Budget 2014 ................................................................................................................................................ 87 Budget 2015 ................................................................................................................................................ 88 Was there a States Assembly decision on the dual site proposal? ............................................................ 89 Two Hotels in Kensington Place .................................................................................................................. 91 Single Bedded Rooms ................................................................................................................................. 92 1960s Building and Peter Crill House .......................................................................................................... 94 Timescales for the Hospital Development .................................................................................................. 94 How much has the future hospital project cost so far? ............................................................................. 95 Percentage for Art ...................................................................................................................................... 96 On-Island/Off-Island Services ..................................................................................................................... 96 How are future hospital projects managed elsewhere? ............................................................................ 98
11. Implementation and Funding ......................................................................................... 99

Sustainable Funding Mechanism for Health and Social Care ..................................................................... 99

How does a New Model of Primary Care fit in with the Sustainable Funding Mechanism for Health and Social Care? ............................................................................................................................................... 100

Long-Term Capital Plan ............................................................................................................................. 101 Long-Term Care Scheme ........................................................................................................................... 102

12. Conclusion .......................................................................................................................... 105
13. Appendix One: Panel and W.S. Atkins correspondence .................................................. 107
14. Appendix Two: Peer Review of Reform of Health and Social Services .......................... 112

15. Appendix Three: Evidence Considered ............................................................................ 113 Evidence Gathered.................................................................................................................................... 113 Public Call for Evidence ............................................................................................................................. 114 Meetings, Briefings and Public Hearings .................................................................................................. 115

1. Executive Summary

This report stems from a previous review undertaken by the Panel in 2012 into the Health White Paper: Caring for each other, Caring for ourselves. The Department's White Paper was the starting point for a total redesign of Health and Social Services in Jersey. Following its publication, the Council of Ministers lodged P.82/2012 "Health and Social Services: A New Way Forward", which was approved by the States Assembly in October 2012.

In the main, the Council of Ministers were tasked to bring forward for approval proposals for a new hospital, develop a new model of primary care and a sustainable funding mechanism for health and social care by September 2014.

The Panel started its review in 2013 and aimed to consider the proposals for the future hospital project including the creation of a dual site hospital with single bedded rooms. It also aimed to identify key developments and progress since P.82/2012 was approved, and determine to what extent the Full Business Cases for new community services had fulfilled the original objectives set out within the proposition. Other factors included in the Panel's Terms of Reference which have been examined are the basic assumptions and estimates of future requirements for the hospital, on-island and off-island provision, communication with key stakeholders and funding.

The Panel made a commitment in its Health White Paper report that it would continue to meet with the Minister for Health and Social Services, and to follow the progression of the process. The Panel endorsed the Department's vision for change which aimed to produce better outcomes for Islanders, improve the efficiency and effectiveness of resource use, respond appropriately to demographic changes and relieve pressures on current services at risk of becoming over extended. However, the Panel also emphasised the importance of whole systems planning and concluded that hospital services and services outside of the hospital are part of a continuum of care which should be planned as a whole system. The level and range of services in one part are seen to be dependent on the level and range of services in another if needs are to be met without gaps or breaks in timing. Furthermore, any tendency to plan hospital and other services separately should be resisted if the right services are to be available in the right places at the right time.

Sustainability and viability of hospital services within an integrated health and social care model was the overarching objective set out within P.82/2012. This objective reflects that people at all levels in the health service recognise that they operate within a system with multiple interdependencies. Achieving this objective requires an integrated approach to planning and the need to develop services across the whole remit of health and social care. This has not always been apparent within the redesign process, and the Panel stress that where one sector develops without cognisance of the others the results can be very damaging. The lack of a whole system approach is highlighted by the absence of a new model of primary care, which should have been completed before the end of September 2014. The amount of progress made with this important piece of work is concerning to the Panel, particularly when the Minister for Health and Social Services recognised that it was essential the funding mechanisms for primary care link with the sustainable funding streams for the whole of health and social care. The Panel is unclear what impact the delay in completing the new model of primary care will have on the sustainable funding mechanism for health and social care, which the Minister for Treasury and Resources plans to publish as part of the Long-Term Revenue Plan.

The Panel's overall view is that the process followed for redesigning health and social services is very fragmented. There is no new model of primary care and no acute services strategy, which is a tool to identify and manage a number of key issues when planning acute services. The Panel remain unconvinced that the size and scale of the hospital can be decided until there is a clear direction on what services are going to be provided in hospital. This is particularly concerning when the Health White Paper approved by the States embraced a whole system approach to the delivery of health care. Furthermore, the Panel has found little evidence that the development of health care has been taken forward in a consistent way across the whole system.

The Health White Paper made reference to eight enablers in order for the redesign programme to be successful. One of these was data and informatics to provide co-ordinated management information, including data sharing across organisational boundaries. The Panel has found that the historical lack of investment in IT across the system has resulted in some paper-based systems still being used. The Health and Social Services Department admits that this is inefficient and hinders data sharing and yet there seems to be a lack of urgency to address this important issue. This is of major concern as using traditional paper-based processes to manually enter patient information into patient records is known to be less reliable than automated entry.

The Department's Informatics Strategy indicates a need for a further £12 million funding over the period of the next Medium Term Financial Plan. Although an initial phase of the Informatics Strategy is currently underway, it is disappointing that little progress has been made in bringing technologies up to modern day standards, particularly when the need for improved information systems was identified as far back as the 1990s. The development and implementation of new IT systems or applications that link hospital services with those in the community is absolutely paramount if Jersey's redesign of health and social care is to be successful.

In relation to out-of-hospital services, the Panel found that community services appear to be being implemented as individual projects rather than as part of an integrated approach to providing a whole systems approach to health and social care. Whilst the new community midwifery service is an example of a well implemented individual project, intermediate care has been the opposite. The evaluation of the service was critical of progress since 2012 and raised questions about value for money of the current model and approach.

In order to achieve whole system planning, stakeholder engagement is crucial. The Voluntary and Community Sector in particular will play an important role if more care in the community is provided. The Panel has found that since mid-2013, there appears to be greater communication and more successful engagement between the Health and Social Services Department and Voluntary and Community Sector. Many concerns were raised by some organisations, but the Health Department seem to have taken the concerns on board and modified its engagement strategy to meet the Jersey situation. This has formed the basis for some real partnerships going forward.

The ability to deliver a new model of primary care requires meaningful engagement with all primary care providers. One of the Panel's previous recommendations was for GPs and other primary care practitioners to be actively engaged in the ongoing development of primary care services based on a holistic approach to care and multidisciplinary working. During the period of this review the Panel was disappointed to learn that the relationship between GPs and the Health department became fractious, which resulted in a need for mediation in early 2014. It seems that this has improved the communication between the two parties, but poor communication in the past has delayed progress in the development of the new primary care model and it is still unclear when an agreement will be reached on a way forward.

As the transformation programme progresses, it is equally important that changes are clinically- led. From the evidence sessions, the Panel note that some clinical engagement had been undertaken, particularly since the appointment of the Clinical Lead of the Future Hospital Project, who is leading on the Acute Services Strategy. The Panel was told on many occasions that the proposals for the dual site hospital had been discussed with clinicians, but the evidence suggests that it was not until June – August 2013 when the dual site concept was suggested. W.S. Atkins, who undertook the pre-feasibility work for the hospital, stated they were frustrated that they were not afforded the opportunity to participate in any meaningful clinical team engagement during their study. This is disappointing particularly when one of the priorities given to W.S. Atkins was to identify an appropriate site on which acute healthcare services could be delivered.

There has been considerable work on the development of plans for new hospital facilities and a multitude of documents have been produced with various options included at different stages. Throughout the review, the Panel have found that it was difficult to follow exactly what had changed through the process, and what the basis for the current decision is.

W.S. Atkins provided cost estimates for 5 site options which had been gradually reduced down from a long-list of 25 potential sites. The 5 options included 3 existing hospital site variants and 2 site variants at the Waterfront. One of the reasons for the Ministerial Oversight Group rejecting the split site on the Waterfront site was the separation of the two sites by the main road which would present significant obstruction to providing the necessary clinical and operations links between the sites. With this in mind, the Panel do not understand why similar concerns have not been given the same prominence when considering the proposal to operate a dual site hospital, from the current hospital site and Overdale, which involves a substantially greater degree of physical separation.

Although both Waterfront options had attractions in terms of potential benefits, costs and ease of construction, the Ministerial Oversight Group decided 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 were considered likely to have a detrimental impact on the development of the Jersey International Finance Centre which is expected to generate an income stream considered essential for the development of a new hospital.

With regards to the decision making process for the future hospital, the Panel concluded that the proposal to go ahead with the existing hospital site in preference to any of the Waterfront options or the Warwick Farm site was not based on estimates of costs as the Waterfront was potentially a cheaper option, but on other considerations the value of which could not be included as a financial figure. The Panel also note that even though a number of other factors seem to have come into play in determining that a greenfield or vacant site would not be chosen, it would have proven best in terms of less risk, more benefits and a lower overall cost.

Originally the preferred option of constructing a new hospital on the existing hospital site was costed by W.S. Atkins who identified a total construction and land cost of approximately £462 million, however the Ministerial Oversight Group subsequently identified a maximum sustainable total capital funding package of £250 million spread over 10 years coupled with a 10 year programme of investment for the maintenance of existing hospital buildings.

Following the decision to limit the budget to £250 million, the Ministerial Oversight Group appointed a design champion in July 2013. The Panel was surprised to learn that such an important post was not advertised and that the normal process for engaging consultants was not followed. Although the timescale was tight, others, including W.S. Atkins, were not given an opportunity to apply for the post. Furthermore, W.S. Atkins were not aware that an appointment was being made to conduct work of direct relevance to their own pre-existing and continuing appointment.

The Ministerial Oversight Group proposed the funding strategy in June 2013 and requested W.S. Atkins to develop a refined proposal based on their previous pre-feasibility study but within the identified funding available (£297m). An addendum to W.S. Atkins' study was issued in October 2013, which incorporated the dual site concept.

During the Panel's review, a question arose as to who first identified the dual site solution. There appears to be different views on this depending on who is asked. Having looked at the relevant minutes over this period and taking into account a draft report and proposition (dated May 2013) supporting the redevelopment of the existing hospital site, which made no mention of the dual site proposal, it seems most likely that the dual site option was not on the table until it was introduced by the design champion in July-August 2013.

The Panel's view of the dual site proposal is that it differs completely to what was previously approved in P.82/2012. P.82/2012 explicitly commits Ministers to bring forward investment plans for hospital services and detailed plans for a new hospital (either on a new site or rebuilt and refurbished hospital on the current site). The Panel believe that it is stretching the language to describe the dual site approach as a new hospital on a new site or a rebuilt and refurbished hospital on the current one. Rather it is for partial new build and refurbishment on the current site and 100% new build on a second site.

The Panel is of the view that any proposal for a new hospital including the dual site option must be considered and approved by the States. Within P.82/2012 and the 2014 Budget, the States were never asked, or agreed that there should be a dual site hospital and the Panel conclude that no formal decision has been taken on this issue.

The Panel's overall view of the process for the future hospital is that it is flawed. There are many features of the process that are of concern. 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 did not engage fully with key members of the Project Board and as a consequence found it difficult to ensure the Board fully understood the challenges of proceeding down a particular route or direction of travel. The process followed to determine a preferred option for the hospital site was long and drawn out.

Furthermore, W.S. Atkins in producing the pre-feasibility study was not limited by a budget. Whilst this may be appropriate in the initial stages, 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. The Ministerial Oversight Group recently commissioned a Peer Review Panel (PRP) to consider and comment on the proposals to deliver aspects of the reform programme. The PRP's report highlighted a number of issues relating to the redesign process. Some of these include a "data lite" position with the absence of robust data and information in a number of areas, a point emphasised by this Panel within its review of the Health White Paper. The PRP also recommended that the provision of a new hospital is pursued as quickly as possible and the implications of the two site approach are assessed in terms of risk and mitigations are identified and applied. The Panel supports the overall conclusion of the PRP's report which reads: "This is a significant moment for Jersey. Getting this system reform right makes a big statement to the people of Jersey and those outside the jurisdiction".

2. Key Findings and Recommendations

Key Findings

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

The Panel's Key Findings are presented in five sections,  General, Whole System Planning, Community Services, Future Hospital and Funding. They have been grouped for ease of reading and are not necessarily presented in the same order throughout the report.

General

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) [section 6].
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 KMPG in 2011 [section 6].
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 [section 7].

Whole System Planning

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 completed has been proposed for April 2015 [section 6].
5. The development of the primary care service model has experienced some significant difficulties and yet the configuration and delivery of hospital services has a significant dependency on the nature and implementation of that model [section 7].
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 [section 7].

Information Services

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 [section 6].

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 [section 7].
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 Health Minister will take heed of the C&AG's report and its recommendations and conclusions [section 7].

Recruitment and Retention

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 [section 7].

Communication and Engagement

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 [section 8].
12. Recent mediation in 2014 has improved the relationship between the Health Department and General Practitioners. However, poor communication during 2012/2013 has caused a delay in the development of a new model of primary care [section 8].
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 [section 8].

Community Services

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 [section 6].
15. The impact of delaying the implementation of community-based care strategies will have a significant effect on determining the size of the hospital [section 9].
16. Following the implementation of the Community Midwife Service most views from GP surgeries were positive about the new system of providing an island-wide antenatal care service in accessible non-hospital settings [section 9].

17. Even though the Specialist Fostering service was brought forward to 2013, no specialist foster carers have been appointed to date [section 9].
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 [section 9].
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 [section 9].

Future Hospital

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 [section 10].
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 [section 8].
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 [section 8].
23. Concerns have been highlighted by the general public and States of Jersey employees about the dual site proposal in relation to operating from two sites, efficiency and transport. The Panel has seen no evidence that these concerns have been addressed [section 8].
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 [section 10].
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 £389m - £431m), it would be necessary for the project to consider what clinical compromises were necessary to achieve a total project cost of below £400 million [section 10].

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 [section 10].
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 [section 10].
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) [section 10].
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 [section 10].
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 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 [section 10].
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 [section 10].
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 [section 10].
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 [section 10].

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 [section 10].
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 [section 10].
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 [section 10].
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 option have been compared on a like for like basis [section 10].
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 [section 10].
39. 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 [section 10].
40. There is a lack of clarity around the decision-making process in determining the size of the budget and why a 100% new build hospital was unaffordable [section 10].
41. The Panel conclude that although mention was made of the dual site proposal in the 2014 Budget report, no formal decision has been taken on this issue as it was not included in the proposition [section 10].
42. The purchase of the two hotels in Kensington Place would make a sensible strategic investment for the States of Jersey as well as providing space to facilitate the development of the existing site [section 10].
43. Due to the limited budget proposed by the Ministerial Oversight Group, W.S. Atkins explained that a target figure of a 15% reduction of room sizes below the UK NHS spatial guidance has been adopted [section 10].

44. The  1960s  building  situated  at  the  current  hospital  site  has  been  excluded  from  the planning as it is not fit for clinical use. Therefore, at the end of the hospital project, the 1960s building will still stand but it is not clear what purpose it will serve in the future, or whether optimum value from the current site is being achieved [section 10].
45. Although the plan is for the Overdale site to be completed by 2019, the overall hospital project will be completed by December 2024. The cost of the project so far totals £574,534 [section 10].
46. There appears to be a lack of progress in strategic planning for acute services and services provided on-island/off-island since 2012. The acute services strategy is not complete and as with the absence of a primary care strategy, has created major difficulties for the Panel in reaching a conclusion about the robustness of the plans for the role, range and scale of future hospital services [section 10].
47. One of the reasons for the dual site concept was because of the potential disruption redevelopment of the current hospital site would cause for staff and patients. The Panel accepts that construction by its very nature does cause disturbance, but there are ways to minimise this both for patients and staff. Lessons and experience from other hospital redevelopments which have managed their levels of disturbance well could have been explored further rather than opting for redevelopment and new build over two sites [section 10].

Funding

48. The Minister for Treasury and Resources stated that the central assumption for growth in the Strategic Reserve is based upon investment returns averaging 5 per cent over the next 10 years. The Minister also stated that with such an investment return, the hospital funding of £297 million can be fully met and the Strategic Reserve would rise to a value of £810 million. It is unclear what the plan will be if the fund does not return the anticipated sum of money when it comes to funding the capital projects [section 10].
49. The Minister for Treasury and Resources made a commitment within the Budgets 2014 and 2015 that the hospital project will be fully paid for by the time it is completed and there will be no cost to the taxpayer and no debt for future generations [section 10].
50. The Long-Term Revenue Plan is being developed by the Treasury and Resources Department. This aims to provide a higher level of funding certainty and will enable long- term sustainable financial planning by the Health Department. It is understood that the sustainable funding mechanism for health and social care will be achieved via the Long- Term Revenue Plan by the end of September 2014 as agreed in P.82/2012 [section 11].
51. The Long-Term Revenue Plan will confirm the level of investment in health and social services into the future. The Panel was informed that it will not propose a separate health fund in addition to the existing Health Investment Fund and Long-Term Care Plan. The Treasury Department explained health services are a public good and as such must be rationed to prevent an unsustainable impact on the wider Jersey economy [section 11].

52. The Minister for Health and Social Services recognised the requirement that the funding mechanisms for primary care link with the sustainable funding streams for the whole of health and social care and that proposition bii and biii in P.82/2012 link together. It is therefore unclear what impact the delay in completing the new model of primary care will have on the sustainable funding mechanism for health and social care [section 11].
53. The work being undertaken to develop a new model of primary care and sustainable funding mechanism for health and social care is likely to impact on the Health Insurance Fund held within the Social Security Department. It is expected that an increase in contributions will be required from individuals in the future [section 11].
54. The Long-Term Capital Plan, published as an appendix to the Medium Term Financial Plan 2013 – 2015 and developed by the Treasury and Resources Department, estimates that £332 million would be required in 2016 for the hospital but this figure did not reflect additional costs of construction in Jersey compared to the UK. The budget figure was to be developed once there was greater certainty arising from the feasibility work [section 11].
55. Within the 2015 Budget it is proposed that contributions to the Long-Term Care Fund in 2014 and 2015 are deferred in order to balance the Consolidated Fund [section 11].

Recommendations

1. The Peer Review Panel's report on the reform of health and social services should be published by the Ministerial Oversight Group along with a formal response to its 11 recommendations before the Budget 2015 debate.
2. Detailed proposals to develop and fund a fully integrated I.T. system should be included in the Medium Term Financial Plan 2016 – 2019.
3. The Treasury and Health Ministers should respond to the specific aspects of the C&AG report: "Use of Management Information in the Health and Social Services Department – Operating Theatres" within the next three months and publish their conclusions about the implications of its findings for the work conducted to date on the planning and development of hospital and out-of-hospital services.
4. Together with the Council of Ministers, the Minster for Health and Social Services must ensure that the new population policy to be agreed by the States in 2015 is taken into consideration when determining the size and scale of the future hospital.
5. The financial and other consequences of the dual site option for the delivery of mental health services and associated facilities must be identified and understood prior to any decision involving the future of acute hospital services and where they are located.
6. Regardless of any future decision to use the Overdale site for hospital services, an appropriate site for mental health services should be identified as part of the Department's review of mental health which will be produced in March 2015.

7. An action plan to ensure the delivery of all eight key enablers should be produced along with appropriate time scales and presented to the States within the next twelve months.
8. Proposals for the new model of primary care should be finalised and agreed by the States at least two months before the Medium Term Financial Plan 2016 – 2019 is debated.
9. Work undertaken by the design champion should be independently reviewed by a fully qualified cost adviser to ensure that the overall cost of the dual site option can be compared with other options considered by W.S. Atkins on a level playing field basis. The result of this work should be published and reported to the States within a six month period.
10. Further work should be undertaken to determine what impact the proposed dual site option based on budget of £297 million will have on patient care in both the medium and longer term and a detailed explanation should be provided to the States on why a 100% new build hospital is unaffordable. This should be completed before seeking a formal decision on the site of the future hospital.
11. The Treasury Minister should provide a detailed plan setting out what actions would be taken if the Strategic Reserve does not return the anticipated return expected from investments within the next six months.
12. The Council of Ministers should lodge a proposition prior to the lodging of the Medium Term Financial Plan 2016 - 2019 to ask the States Assembly to decide on the site for the future hospital in order for a formal decision to be made on this issue.
13. A ten year timeframe to develop a new hospital is unacceptable and Council of Ministers should review both the timescale and the overall budget envelope to ensure that any new hospital will meet the future needs of the Island. This should be completed within the next twelve months.
14. The Panel recommends that percentage for art (based on 0.75%) for the total construction cost of a development should not be allocated for the future hospital project.
15. In parallel with the work being undertaken to develop a new model of primary care and a sustainable funding mechanism for health and Social care, the Social Security Minister should present to the States the long term contribution proposals to support the existing Health Insurance and Social Security Funds.

3. Chairman's Foreword

Since the approval of P.82/2012 "Health and Social Services: A New Way Forward" the Panel has undertaken an extensive review of the proposals including new community services, the future hospital project, a new model of primary care and the sustainable funding mechanism for health and social care. The main aim of the Panel's review was to ensure that the proposals contained within P.82/2012 deliver the anticipated improvements at an affordable cost and at the high standard Islanders should expect.

Evidence suggests that our Island's aging population is growing – by 2040 we will see the number of those aged over 65 increase from 14,797 to 28,882. At the same time, the population of working age adults is projected to decline by 9% (57,762 in 2010 to 52,263 in 2040). This demographic change will create a huge surge in the demand for health and social care. The existing health and social services on the Island are already close to full capacity and to accommodate this increase in demand, we, the States of Jersey, need to take action.

If the proposals contained in P.82/2012 are delivered successfully, we are heading in the right direction to accommodate this increase in demand. It is imperative that the Council of Ministers fulfil the commitments made by the States during the debate on P.82/2012. This review has highlighted some significant issues in the delivery of those commitments.

The new model of primary care will not be delivered by the agreed timescale. The States can now expect to consider a strategy, with funding options, in April 2015. The delay was due to a number of factors including a communication breakdown between the Health Department and General Practitioners. We acknowledge that a mediation session which took place earlier this year has improved the relationship and things are now moving forward. We are unclear what impact the delay has caused, as there has been much emphasis on the new model of primary care linking together with the sustainable funding mechanism for health and social care. We have been told that the sustainable funding mechanism will be achieved through the completion of the Long-Term Revenue Plan by the end of September 2014.

Our concluding thought on this matter is that there can only really be certainty over the size and cost of the hospital once both of these pieces of work have been completed together. This has led to one of our main findings that a whole system approach is not being undertaken, and yet is paramount to the successful delivery of the redesign. Another example of this is the Acute Services Strategy, which is only now being developed. We are concerned that hospital development plans are continuing to be taken forward within a context of what may be significant uncertainty about the mix and scale of acute services. We have continuously asked ourselves: how can the size and scale of the hospital be realistically decided until there is clear direction on what services are going to be provided in hospital?

In relation to out-of-hospital services, we have found that some of the new services provided within the community have been implemented successfully, such as the new Community Midwifery Service. Other services such as Specialist Fostering and the Sustained Home Visiting Service, however, have faced some difficulties with recruitment and have not been implemented fully.

With all of the change happening around primary and secondary care, it is absolutely paramount that our information systems are the best they can possibly be. We are disappointed that little progress has been made in this area, particularly when the need for improved information systems were identified in the 1990s.

In relation to the future hospital, we have reviewed how this decision was reached and conclude that a strong emphasis in reaching the decision was put on the overall budget envelope. We remain unclear how the budget of £250 million was reached and why it took so long to determine a maximum amount. The effect of a reduced budget means that a 100% new build hospital will not be provided and a dual site hospital has been hailed the preferred option. We believe this option will require further additional costs in the future.

We do support the redevelopment of the Overdale site, but believe it should be used to provide improved mental health facilities, as this was the original intention before the dual site option was identified. We are of the opinion that acute services should, if at all possible, be retained on one site and remain unconvinced that a dual site is the right way forward for Jersey's acute care.

In that regard, we have also concluded that no formal decision has been taken on the future hospital and recommend the Council of Ministers to lodge a proposition prior to the next Medium Term Financial Plan so that a formal States decision can be taken.

We do accept that change does not happen overnight, but these matters are essential if the redesign programme is to be a success. We feel that a 10 year timeframe to develop a new hospital is unacceptable, especially when money is being spent now on a continuing programme of refurbishment in order to bring the hospital standards to an acceptable level.

We would like to acknowledge the contribution made by officers within the Health Department and other key stakeholders in assisting us with our review. We are also grateful to our advisors for the support and advice they have given us.

Finally, I would also like to record my heartfelt thanks to our Scrutiny Officer and my fellow Panel Members for their dedication and hard work in producing this report.

Deputy Jackie Hilton

Vice-Chairman, Health, Social Security and Housing Scrutiny Panel

4. Terms of Reference

The following Terms of Reference were agreed for the review:

1. To consider the proposals of the Minister for Health and Social Services in relation to the future hospital project in particular –

1. The creation of a 2-site hospital with some services based at a second location
2. Separation of emergency and inpatient overnight-care from outpatient daycare
3. Single bed wards
4. The implications for cost and quality of each of the above
5. How implementation risks will be identified and managed

2. To determine whether the basic assumptions and estimates of future requirements for the hospital are well founded in relation to predicted utilisation levels, demographic projections and the Minister's preferred models of care
3. To assess the current contributions of on-island and off-island provision and the extent to which the existing analyses and proposals explain and substantiate changes in the balance and nature of their respective roles
4. To identify the key developments and progress since P.82/2012 – A New Way Forward for Health and Social Services – approved by the States in October 2012 and in particular to determine to what extent the Full Business Cases have fulfilled the original objectives as set out in P.82/2012
5. To assess to what extent key stakeholders, in particular General Practitioners and the Voluntary and Community sector, have been included in the development of the Full Business Cases and the proposals for hospital services
6. To establish what funding and other resources will be required to support the revenue as well as the capital costs of services to be provided inside and outside the hospital.

5. Panel Membership

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

Deputy Kristina Moore , Chairman

Deputy Jacqueline Hilton, Vice-Chairman

Deputy James Reed

Senator Ferguson, Co-opted Member

This review was led by Deputy Jackie Hilton, the Vice-Chairman of the Panel due to Deputy Kristina Moore being on long term leave due to illness.

Expert Advisors

The Panel has engaged Mr Seán Boyle and Mr Gerald Wistow as its expert advisors. The Panel was very pleased to be working with both Mr Boyle and Mr Wistow again, as they had assisted the Panel with its previous review into the Health White Paper.

Mr Seán Boyle

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

Professor Gerald Wistow

Gerald Wistow is Visiting Professor in Social Policy at the London School of Economics. He has previously been co-director of the Centre for Social Policy Research at Loughborough University, Professor of Health and Social Care and Director of the Nuffield Institute for Health at Leeds University and Chair of Hart lepool Primary Care Trust. He is currently a specialist advisor to the House of Commons Health Committee in the UK. He has published extensively on a wide range of health and social care issues.

Glossary

FBC – Full Business Case

OBC – Outline Business Case

MOG – Ministerial Oversight Group

HASSMAP – Health and Social Services Ministerial Advisory Panel PRP – Peer Review Panel

ICR – Integrated Care Records

C&AG – Comptroller and Auditor General

JPH – Jersey Property Holdings

PCB – Primary Care Body

MTFP – Medium Term Financial Plan

LTCP – Long-Term Capital Plan

LTRP – Long-Term Revenue Plan

JAA – Jersey Alzheimer's Association

IAPT – Improving Access to Psychological Therapies

COPD – Chronic Obstructive Pulmonary Disease

FN&HC – Family Nursing & Home Care

JOD – Jersey Online Directory

6. Introduction

A proposition (P.82/2012) which proposed a radical redesign of health and social services was approved by the States in 2012. Since then, the Health and Social Services Department ("the Health Department") has been working up plans to implement new services within the community (out-of-hospital services) and for a new hospital. The Panel agreed to undertake a review of these plans and their initial implementation as a natural progression from its previous review of the Health White Paper (S.R.7/2012).

This report is intended to update States Members and the public on progress to date in the implementation of this significant service redesign programme which will take ten years to deliver. The report's findings are based on the information the Panel has collected during 2012, 2013 and 2014.

The proposed redesign of Health and Social Services: an overview

The Health Department published a Green Paper in 2011 which asked for the views of Islanders on three scenarios for future health and social care services. The Green Paper was preceded by a KPMG report which reviewed how services were provided and what steps would be required to ensure that Jersey could offer good quality care into the future. The results of the Green Paper were analysed and developed into a White Paper: "Caring for each other, Caring for ourselves".

In order to plan and deliver the redesign of health and social services, the Health White Paper identified eight enablers[1]:

1. Workforce
2. Estates and Facilities
3. Primary Care
4. Technology
5. Data and Informatics
6. Commissioning
7. Funding
8. Legislation and Policy

These enablers were identified as being essential to the successful delivery of the programme. They are discussed in further detail later in the report. The White Paper was put out for public consultation and the final Report and Proposition (P.82/2012) was lodged in September 2012. The Proposition was accepted by the States Assembly on 23rd October 2012 and required the Council of Ministers to co-ordinate the necessary steps to bring forward for approval:

• "Proposals for the priorities for investment in hospital services and detailed plans for a new hospital (either on a new site or a rebuilt and refurbished hospital on the current site), including full details of all manpower and resource implication necessary to begin implementation of the proposals by the end of 2014";

• "Proposals to develop a new model of Primary Care (including General Medical Practitioners, Dentists, high street Optometrists and Pharmacists), by the end of 2014"; (amended during the States Debate to end of September 2014)
• "Proposals for a sustainable funding mechanism for health and social care, before the end of September 2014"

The Case for Change: Health White Paper

According to the study by KPMG, between 2010 and 2040 there will be a 95% increase in the over 65 population (14,797 to 28,882), with a 35% increase by 2020[2] (14,797 to 19,982). P.82/2012 explained that this growth would create a significant increase in demand for health and social care services. Although current services were performing generally well, they were close to capacity and would not be able to accommodate the predicted increase in demand.

Many health and social care staff are approaching retirement age which make current services vulnerable. Of these, some are "generalists" who can treat a wide range of conditions. However as there is a higher degree of specialisation in professional training now, meaning the existing consultant staff cannot be replaced on a like for like basis[3]. P.82/2012 also explained that recruitment of skilled staff is increasingly difficult given Jersey's high cost of living and the competitive remuneration packages for similar staff in other countries[4].

These are important drivers of redesign for health and social care. In summary, a new model of health and social care was identified as being necessary in response to expected increases in demand so that the skills of local staff can be used to the maximum and new roles created which will attract additional staff to work in Jersey[5]. The overarching objective of this model is for sustainable and viable hospital services operating as part of an integrated health and social care system.

Health White Paper Review: A New Health Service for Jersey: the way forward (S.R.7/2012)

The Panel presented its report on the Health White Paper in October 2012. It included a review of the Green and White Papers together with an analysis of the proposition (P.82/2012) which sought approval from the States Assembly for the redesign programme.

The Panel concluded that the proposition[6] should be welcomed in general terms, and emphasised that its scope and scale would necessitate a challenging process of whole systems planning to synchronise the introduction of many new services, some of which were reliant on the recruitment of specialised staff. In particular, the Panel recognised the importance of carefully phasing the development of services in the community with any change in the role and volume of hospital

services. The Panel also recognised existence of immediate pressures caused by the condition of existing hospital estate which could not wait 10 years.

The Panel endorsed the Department's vision for change which aimed to produce better outcomes for Islanders; improve the efficiency and effectiveness of resource use, respond appropriately to demographic change and relieve pressures on current services at risk of becoming over extended. However, it did question whether the proposals contained in the proposition would deliver the anticipated improvements in health and social services at an affordable cost and with the degree of effectiveness Islanders are right to expect.

In order for the redesign to be a success, the Panel also emphasised the importance of the relationship with the Voluntary and Community sector. It noted that, at times, better communication with voluntary and community organisations would have been advantageous. This finding was of particular significance because the Panel recognised the delivery of the new service model would depend on close collaboration not only within the publicly funded health and social care system, but also between it and the non-statutory sector.

Collaborative working was noted as a priority area specifically relating to the new funding model of primary  care  and  communication  with  GPs.  It  was  particularly  important  that  this  work  was developed with full GP involvement and support. The Panel felt that this issue was of such significant importance that it lodged an amendment to P.82/2012 to bring forward proposals to develop a new model of primary care by the end of 2013, rather than 2014. The Council of Ministers welcomed the high priority the Panel placed on primary care but was unable to accept the amendment due to the complexity of the primary care development work. However, it did agree 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.

KEY FINDING: 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 completed has been proposed for April 2015.

The Panel also concluded that informatics would play a major role in the success of new service models. The drive to develop community services would be reliant on good quality I.T. systems which ensured the highest standards of patient data handling especially if patient information is to be available to multidisciplinary teams. At the time of its review, the Panel found that the current I.T. system was not integrated between primary and secondary care and was a problem which required urgent resolution.

The Minister's Response

In  her  response  to  the  Panel's  report, the  Minister  agreed  that  the  amount  of  change  was unprecedented, and emphasised that the associated challenges should not be underestimated. The detailed plans for service changes to community services would be prepared through the development  of  Full  Business  Cases  (FBCs).  This  process  would  engage  a  wide  range  of stakeholders including clinical and professional staff, the Voluntary and Community sector and GPs.  The  Minister  also  recognised  that  these  individuals  and  organisations  had  a  good understanding not only of Islanders' health and social care needs but also the effective delivery of services  to  meet  such  needs. Their  input  would  be  critical  to  ensuring  that  the  plans  were achievable, and had broad ownership.

The Minister also advised that implementation plans would be kept under review and, if necessary, would change over time. The FBCs would contain detailed service specifications setting out what services were required, and the metrics and measures used to monitor delivery and timescales for implementation. The Minister acknowledged the lack of historical data and she advised that work would be undertaken to provide more robust routine monitoring data. This is discussed in further detail later on in the report.

Review of the Redesign of Health and Social Services

Following States approval of P.82/2012 the Department has been preparing detailed business cases for the development of key services, some of which were to be implemented during 2013. The Panel started its review into community services via the FBCs in November 2012, shortly after receiving a timeline from the Health Department. The timeline for completion of the FBCs by the end of January 2013 was ambitious and, unfortunately, due to a number of factors the timeline changed considerably.

During 2012 and 2013, the Panel's work has included several meetings with the Minister for Health and Social Services and her Officers to understand the process and revised timeline. Regular updates have been received from the Department as requested by the Panel, and the progress of the FBCs has been scrutinised during quarterly hearings with the Minister.

The Panel's original intention was to review only the FBCs and focus its attention on out-of- hospital (community) services. However the Panel agreed at the end of 2013 to add the future hospital project to its review[7]. The main driver for this decision was the degree of interdependence between community and hospital services. Undertaking two reviews would not only have been more time-consuming but also separating the two topics would have been difficult to manage.

Following its decision to merge the two reviews, the Panel revised its Scoping Document to include the hospital and approved a new set of Terms of Reference which are detailed at the front of this report. The Panel's work has included collating all of the information received during 2012 – 2014 and holding a series of meetings and Public Hearings with Ministers and relevant stakeholders. The Panel also corresponded with W.S. Atkins who were the leading consultant in the work undertaken on the pre-feasibility study for the future hospital. The correspondence can be found in appendix one of this report.

Peer Review of Reform of Health and Social Services

The Ministerial Oversight Group recently commissioned a Peer Review Panel (PRP) to consider and comment on proposals to deliver aspects of the reform programme for the provision of health and social care services in Jersey by 2021. The Panel's Membership was as follows:

• Sir David Henshaw
• Dr Patrick Geoghegan
• Mr Andrew Williamson
• Dr Clare Gerada
• Professor John Appleby

The Chairman of the PRP, Sir David Henshaw, met with the Scrutiny Panel on 30th July 2014. He explained that the review was "short and sharp", and was based on written material supplied by the States of Jersey. They met with key senior departmental officers of Health and Social Services, Treasury, Property Holdings and Social Security over three days but did not have discussions with carers, users or health professionals. The Chairman explained that the Terms of Reference for the review, which can be viewed in full in appendix two, were initiated by the Ministerial Oversight Group.

The Terms of Reference included examining the KPMG modelling work, making comments on the progress of the plans as described in P.82/2012 particularly in the context of the overall States of Jersey Reform programme, and considering the short term and longer term approach and options for sustainable funding of health and social services.

The Scrutiny Panel note that although the PRP's conclusions are at a high level, they do highlight a number of areas where more detailed consideration is required. The recommendations are as follows:

1. 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.
2. That the programme for improving the quantity and quality of relevant data and information is pursued as vigorously as possible. Knowing what is being delivered and its quality and outcomes will be of enormous help in delivering the reforms.
3. 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.
4. 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.

5. That the focus on integration and system reform be continued and deepened using GPs as a mainstay in the system. We also urge consideration of how other aspects of primary care e.g. pharmacy should be integrated in the new approach. We understand the project scope addresses this issue.
6. That the provision of a new hospital is pursued as quickly as possible and the implications of the two site approach be assessed in terms of risk and mitigations identified and applied.
7. That the governance arrangements for the integrated system be re-examined. We believe the current work is being well led, but there will be a requirement in the future for the leadership of the system to be more inclusive of clinicians in primary and secondary care and other representatives from within the system. This has to be a group which is accountable and has the authority and power to resolve problems for the benefit of patients. We are not recommending building any sort of replica of the system in the UK but rather ensuring accountability for those that are leading the system.
8. That work on building a sustainable set of funding mechanisms be accelerated and in particular that, unless already produced, the estimate for the funding gap should be subject to some sensitivity testing with respect to assumptions made on the cost or need' side.
9. That the productivity assumptions be included in KPMG's sensitivity analyses. Any mitigation of rising costs must include a review of potential productivity in the system. We understand that productivity has been addressed in the latest piece of work by W S Atkins but have not had sight of this report. We believe that productivity is a critical issue.
10. That if the proposal for increased charges - the reintroduction of charges for prescriptions and the new charge for A&E services proceed then provision is made to monitor their impact. In particular, their impact on prescribing and GP visits in total and across demographic groups.
11. That if the social insurance fund idea is pursued, then thought needs to be given to its governance arrangements (including independent audit arrangements) and its accountability to those who contribute to the fund through their taxes and levies and to all who use the health and social care services the 2040 Fund pays for.

The Scrutiny Panel has made the following observations based on the report and its meeting with Sir David Henshaw.

Although the PRP was provided with a vast amount of written material, it was not provided with W.S. Atkins full report, its addendum or the additional studies undertaken by W.S. Atkins throughout the pre-feasibility study. The PRP's focus seemed to be on the original KPMG review published in 2011, and the Scrutiny Panel question how relevant this work now is particularly when an updated set of population figures are now available.

The PRP's report recognises that there is an absence of robust data and information in a number of areas, reflecting a "data lite" position. Furthermore, the absence of this material has prevented a deep understanding of the delivery and quality of the present service and the future health needs of the population. The report also makes reference to the commitment by the Health Department that the "data lite" position will be rectified. The Scrutiny Panel note that the same concerns were raised during its review of the Health White Paper in 2012, and it is disappointing that more progress has not been made in this area.

The PRP concludes that although the development of a plan for a new model of health and social care in Jersey has taken some time, system integration is the right approach. Furthermore, there are major challenges to face in delivering the changes and close attention must be given to de- risking as much as possible in the approach. The Scrutiny Panel supports the PRP's overall conclusions particularly the last statement which reads "This is a significant moment for Jersey. Getting this system reform right makes a big statement to the people of Jersey and those outside the jurisdiction".

7. Whole Systems Strategic Planning

In its previous review of the Health White Paper the Panel concluded that hospital services and services outside of hospital are part of a continuum of care which should be planned as a whole system. This means the level and range of services in one part of the system are seen to be dependent on the level and range of services in another if needs are to be met without gaps or discontinuities of timing. Any tendency to plan hospital and other services separately should be resisted if the right' services are to be available in the right' places at the right' time[8].

Whole Systems Approaches

P.82/2012 explained that sustainability and viability of hospital services within an integrated health and social care model is the overarching objective and the outcome to be achieved. This applies to both hospital services and the health and social care system as a whole[9].

This overarching objective reflects the fact that people at all levels in the health service, from policy makers to frontline staff, recognise that they operate within a system with multiple inter- dependencies. Seeing themselves as part of a whole system enables people and organisations to understand the consequences that their own choice processes and work patterns have for others in the system, enabling the system to act strategically and adapt more intelligently. This approach is now generally accepted and has led to efforts to break down the barriers between different organisations that deliver care.

Achieving the White Paper's objectives requires an integrated approach to planning and developing services across the whole system of health and social care, including acute hospital services, mental health services, out-of-hospital services in community settings, GP-provided primary care, pharmacy provision, optometry, dentistry, social care and care for children. Actions in one sector often have knock-on effects in another. Where one sector develops without cognisance of the others the results can be disjointed.

Key Enablers

In order to plan and deliver the redesign of health and social services, the Health White Paper identified a number of "enablers". These were identified as "cross cutting" work-streams, as they impact on each of the service development plans. The 8 key enablers[10] are outlined below:

1. Workforce – a plan to provide the required workforce to support individualised care, independence and maximise the health and wellbeing of Islanders.
2. Estates and Facilities – an estates and facilities plan that ensures services are delivered from buildings that are fit for purpose and compliant with required standards.
3. Primary Care – a sustainable primary care sector with GPs and others supported to provide and co-ordinate services for Islanders.

4. Technology – to provide the technological platform, communications devices, telehealth and telecare, and fund the IT infrastructure, to include computerised patient records.
5. Data and Informatics – provide co-ordinated management information, including data sharing across organisational boundaries
6. Commissioning – ensure the needs of Islanders are identified, consulting with service users, carers, families and communities. Make evidence-based decisions regarding health and social services and support the Voluntary and Community Sector.
7. Funding – to identify funding requirements in accordance with Treasury timescales and decisions.
8. Legislation and Policy – to co-ordinate the drafting of legislation in line with States planned timescales.

The eight key enablers are important to consider when reviewing the redesign programme because they were identified as being essential to the successful delivery of the programme. The Panel comments on or makes reference to each of the key enablers throughout the report.

Information Services

This section relates to key enablers 4 (technology) and 5 (data and informatics). P.82/2012 explained that in order to enable strategic change, a number of system-wide needs have been considered including IT support and management capacity to implement change. It is clear that these enablers', along with the changes identified in P.82/2012, will be required in order for future services in Jersey to be safe, sustainable and affordable[11].  

The Health White Paper also explained the requirement for improved IT services in order to deliver the redesign of Health and Social Services successfully[12]. The Panel identified in its previous review the need for IT systems to be developed to integrate with primary care and make the exchange of data to improve patient care more efficient. At a Public Hearing with the Primary Care Body, its Chairman explained: "The difficulty is, again going back to silo working, the hospital system has developed in a silo compared with the community system and it is not only the local factors that have determined that, unfortunately. That is what has happened in the U.K. as well. We hope to be able to work as integrated models are rolled out in the U.K. and elsewhere, in conjunction with the I.T. developers in the U.K., to move things towards this model whereby the important data is there for patients when it is needed[13]."

The Department has made significant investment over recent times but this has seemed to focus solely on the replacement of hospital information systems. The additional funding required was not included within the first phase of the White Paper which is 2013 to 2015 and is planned for the second period of the White Paper developments.

Informatics and technology are essential to deliver the service changes and transformation described in the White Paper. One element of this was the development of an overarching Informatics Strategy. The historical lack of investment in IT across the system has resulted in some paper-based systems still being used. The Department admits that this is inefficient and hinders data sharing, but went on to say that the Informatics Strategy will change this once it has been implemented[14].

The Public Accounts Committee recently published its report into Integrated Care Records (ICR) which was an earlier phase of work of the Informatics Strategy. The PAC report concluded that the ICR programme did not achieve the principal objective set in the period 2004 – 2006 of a fully integrated electronic health and social care records system. As of July 2014, the Health Department remain some way short of achieving its goal as paper records are still circulating widely within Health and Social Services and records are still being updated manually.

The Panel held a Public Hearing with the clinical lead in IT, Dr Graham Prince who prior to the publication of the White Paper had been working to push forward informatics within health and social services since 2006 with the ICR programme. In relation to IT systems and the dual site hospital he said: "Having a dual-site hospital just makes the case for having an electronic system much more robust because obviously you do not want to be moving excessive numbers of paper notes up and down the hill. If our pharmacy is going to be up the hill or down the hill, there is going to have to be movement of things from wherever it is to wherever the patients need to pick it up from[15]".

Using traditional paper-based processes to enter patient information manually into patient records is known to be less reliable than automated entry and is a cause of major concern particularly in relation to dual site working. Paper based systems allow greater opportunity for human error and the process is bound to be more time consuming for doctors and nurses having to take time away from patients to enter data, recall records or write prescriptions manually.

The Informatics Strategy indicates a need for a further £12 million funding over the period of the next Medium Term Financial Plan. This allocation would be additional to the monies already allocated for the new hospital. An initial phase of the Informatics Strategy is currently underway, though the bulk of the anticipated spend is dependent on securing the £12 million funding. It is understood that provisional funding requests to support the Informatics Strategy have already been submitted to the Treasury and Resources Department[16].

The Health Department has recently appointed a Business Support Group Manager who works in the Information Services Department and two other posts are currently in the recruitment stage – a Head of Informatics and Programme Manager[17].

The clinical lead in IT explained that the Health Department originally wanted to introduce informatics into the community system as part of the ICR programme. However in 2009 there were insufficient funds to complete every element of the ICR programme. As a result, informatics in the community was de-scoped from the programme. Yet a big part of the redesign programme is to introduce more community services to relieve pressure on the hospital and this depends on the timely and accurate flow of information between different parts of the system:

Clinical Lead in I.T

"So if you are going to have a truly excellent communications system all areas of health care  have  to  communicate  with  all  areas  of  health  care.   If  you  like,  that  would  be community, it would be mental health, it would be the hospital, it would be general practice, and all of those areas need to communicate efficiently with each other and to share information with each other[18]."

It is disappointing that little progress has been made, particularly when the need for improved information  systems  was  identified  as  far  back  as  the  1990s.  The  development  and implementation of new IT systems or applications that link hospital services with those in the community  is  absolutely  paramount  if  Jersey's  redesign  of  health  and  social  care  is  to  be successful.

KEY  FINDING:  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 Comptroller & Auditor General's Report

The Comptroller & Auditor General (C&AG) recently published a report titled "Use of Management Information in the Health and Social Services Department – Operating Theatres". The C&AG's review focussed on the use of management information in acute hospital performance in relation to the use of operating theatres. It is noted that the revenue budget for operating theatres makes up 10% of the hospital's budget[19].

The Panel has extracted below the main conclusions from the C&AG's report which are pertinent to its review:

Access to relevant and high quality management information allows organisation to make strategic and operational decisions efficiently and effectively[20].

Information for decision-making is most useful when derived from high quality data. Where data is of a low quality there is an increased risk that decisions are made which do not promote organisational objectives. There is also a risk that information derived from the data is ignored in decision-making[21].

In June 2012 a new Patient Administration System, TRAKcare was implemented across the hospital. There are significant weaknesses in the arrangement for securing data quality for theatre utilisation in TRAKcare and as a result TRAKcare is providing inadequate management information about operating theatre utilisation to support decision-making[22].

Increases  to  operating  theatre  capacity  are  planned;  two  semi-permanent  operating theatres are to be built, enabling one of the existing theatres to be dedicated to maternity; and the draft Medium-Term Financial Plan for 2016 – 2019 includes consideration of a move towards a 12 hour surgery day. A six-day working week for operating theatres is also under discussion. But making informed decisions on the requirements for and use of operating theatre capacity requires good quality information on operating theatre utilisation that is not currently available[23].

Operating  theatres  are  an  expensive  resource  and  evidence-based  decision-making requires  identification  of  relevant  information  needs,  as  well  as  improvement  in  the arrangements for securing data quality and effective use of the resulting management information[24].

One of the C&AG's overall conclusions was that improvements to management information should be seen as a priority. The Panel wholeheartedly agrees and expects the Health Minister will take heed of the C&AG's report and its recommendations and conclusions.

It is also a matter of concern to the Panel that the deficiencies identified by the C&AG's report may cast doubt on the quality of the information available for and utilised in modelling and costing the scale  and  configuration  of  plans  for  future  hospital  services.  The  Panel  is  driven  by  its understanding of the C&AG report to conclude that similar weaknesses may have been present more widely in the planning processes for the redesign programmes reviewed in this present report.

RECOMMENDATION: The Treasury and Health Ministers should respond to the specific aspects of  the  C&AG  report:  "Use  of  Management  Information  in  the  Health  and  Social  Services Department – Operating Theatres" within the next three months and publish their conclusions about  the  implications  of  its  findings  for  the  work  conducted  to  date  on  the  planning  and development of hospital and out-of-hospital services.

Workforce Planning

This section relates to key enabler 1 (workforce). The Panel's previous report into the Health White Paper identified challenges in terms of recruitment and retention, particularly in certain staffing groups. The White Paper proposed an expansion to some services and it was unclear at the time whether  additional  requirements  for  staffing  could  be  met  given  recruitment  was  already  a challenge. It is understood that a three phased approach will be adopted because of the significant workforce challenges in attracting people to the posts and getting services set  up and  well established. This is still an issue and the Chief Executive of Health explained:

Chief Executive of Health

"I think one of the most challenging aspects we have of where we are at currently in this journey we are on for the 10-year transition is doing the workforce planning because it does need specific skills and we are struggling to find those skills at the moment. So we are having to get on with identifying the types of staff that we need, but we do need to inject some specific resource quite quickly now to help us with that"[25].

In  relation  to  out-of-hospital  (intermediate)  care  the  evaluation  report  drafted  by  the Commissioning team highlighted the importance of recruiting staff with the appropriate skill set. It acknowledged that there is a limited pool of health staff available on the Island and this has an impact on service development and delivery. It was noted that workforce planning needs to be mindful of the whole system impact and should focus on increasing overall capacity and capability of the workforce as a whole rather than shifting skills from one part of the system to the detriment of another[26].

The Panel are aware that recruitment and retention is still a real concern, particularly now that services are starting to be rolled out across the island. The Health Department has made some progress since the Health White Paper, in July 2011 an amendment to the primary legislation (Medicines  (Amendment  No.  3)  (Jersey)  Law  2011),  was  adopted  by  the  States  Assembly, enabling  the  Minister  to  specify  a  wider  range  of  practitioners  that may  prescribe medicinal products. Training for this started in 2013, with the introduction of an annual on-island training programme at degree and masters level[27].

Chief Nurse:

"We have got a whole range of measures in place which include the changes that we have made to our on-Island pre-nurse training. So again, that is the work we have done with Education, Sport and Culture in relation to increasing the number of places that we have year on year for local Islanders, which fits with the Island strategy as well. At the moment ... we started our first cohort last September with 15 but we can trade that up and down. There is a critical mass issue in terms of the volume that you can train at any one time, because obviously you have to have an appropriate ratio of registered nurses to students. In addition to that we are increasing the amount of time that we are able to take students

in, so previously it was anything between 2 and 3 years. We are now taking them on an annual basis and we have just recently announced that we will also be training ... offering local Islanders the opportunity to train as midwives, mental health nurses and paediatric nurses. That is with a model that we have developed with the University of Chester, through our links there. We are also able to offer a whole range of opportunities for nurses already registered in Jersey to retain them on the Island so that they get the opportunity that their colleagues may get elsewhere. That is a whole range of qualifications up to Masters level provision, which again is in line with academic access that nurses have elsewhere. We have also been working with Highlands in terms of the work that they do around the BTech (Bachelor of Technology)"[28].

The other issue regarding recruitment and retention is attracting nurses to Jersey with the cost of living being so high. This was identified in the Panel's previous report as a factor placing doubt around the feasibility of the plans for staffing the new services. At the time the Panel questioned whether the introduction of new services should be phased more gradually over a longer timescale. Although the Minister accepted the Panel's recommendation, she said that there should be no requirement to phase in new service plans over a longer timescale solely because of recruitment challenges if the Department continues to work with the States Employment Board, Treasury and nurse representatives[29].

The Panel wanted to assess how much progress had been made in this area, and it was identified by the Chief Nurse as still an area of concern: "Then the other side, as you mentioned, attracting nurses to Jersey and cost of living and everything else. We are hopeful that the work through the workforce modernisation  project  and the reform  of the way  our  nurses'  job  descriptions  are developed, the way that nurses are expected to work in Jersey is matched to their salary and that is commensurate with the work that we have been doing in relation to equal jobs of equal pay over the last 12 months"[30].

The Chief Nurse also told the Panel that she had been involved in the recruitment of a specialist nurse post and found a good candidate but unfortunately the candidate withdrew as they considered it a significant step moving to the Island: "It goes back to the same issue around housing. The cost of housing is quite startling for people[31]".

The Chief Nurse explained that work had been undertaken jointly with the Housing Department and Jersey Property Holdings to look at the accommodation stock and housing policies with a view to developing a workforce gateway: "That work is progressing slowly but it is progressing. I would not say we are in a position at this moment in time where I could say, hand on heart, we are there yet. But it is a very encouraging positive conversation"[32].

The Panel is concerned about how easy it will be to implement the investments in services to deliver the redesign programme. It is clear there are still difficulties in recruitment and this may prove to be an obstacle as more services are rolled out across the Island.

Population Assumptions

The pre-feasibility study completed by W.S. Atkins refers to the population assumptions on which future service activity requirements were estimated. It is noted that the pre-feasibility model initially incorporated the +150 Heads of Household assumption (as used in the KPMG model and the equating  to  +325  people)  and  included  the  latest  demographic  and  migration  assumptions produced by the Statistics Department in September 2012[33].

The Treasury Department advised the Panel that the States Statistics Unit had produced more recent population assumptions in September 2013 which were released after the refined concept had been developed and therefore these updated assumptions will form the basis of the feasibility study[34].

It is important to note that the States Assembly approved an interim population policy (P.10/2014) for the next two years - a planning assumption for net migration of +325 people per year to cover the period 2014 – 2015. The Chief Minister advised States Members that a future policy for population could not be set in the absence of a comprehensive planning process given the wide effect migration has on the Island's economy, infrastructure and environment. As a result, it will now be the responsibility of the next Assembly to set a future policy for population as part of its long term planning[35].

It is important that any future population policy is taken into consideration when providing for a new hospital and additional services in the community. The Panel are concerned that the population policy to be agreed by the next States Assembly will take place at the same time work is being undertaken on the feasibility study due to completed in 2015.

Acute Services Strategy

The White Paper embraced a whole system approach to the delivery of health care. However the Panel has found little evidence that the development of health and social care is yet being successfully planned and integrated across the whole system. For example, it is only now that a comprehensive acute service strategy is being developed even though a decision already appears to have been taken on both the size and location of the acute hospital facilities. In addition the development of the new model of primary care has experienced some significant difficulties. Yet, the configuration and delivery of hospital services has a significant dependency on the nature and implementation of that model.

It is still early to assess what the impact of out-of-hospital development will be but there is some evidence within the MCAP[36] audit to suggest it may have considerably greater influence on the

reduction of demand for acute services. The MCAP audit sought to facilitate improvement of care quality and reduction in delivery costs by identifying patients in hospital beds whose care could be delivered in an alternative setting. The report highlights that there may be significant scope to reduce bed days and admissions: 54% of admission and continuing stay days could have been avoided with appropriate home services or GP follow-up[37] vs. 42% in the prior MCAP study. However, any increase in home services or follow-ups via GPs must be developed with GP support, and with the provision of appropriate funding.

The Panel asked the Treasury Department whether it would have been preferable to undertake and complete the Acute Service Strategy before proposing the refined dual site concept, as there are  factors  such  as  the  MCAP  audit  which  may  necessitate  changes  in  the  design.  The Department accepted that in an ideal world an Acute Service Strategy would have been long established,  but  also  said  that the  condition of  the  hospital  and the  challenges  identified  in P.82/2012 meant that it was important to progress the development of the Acute Services Strategy and future hospital development in tandem[38].

The Panel then asked what would happen if the continuing development of the hospital strategy suggested the budget was too small. The Treasury Department acknowledged that challenges may arise during the Acute Services Strategy development. However, they did not expect that these will require a change to the budget outlined in the Addendum to the Strategic Outline Case[39].

The Panel find it difficult to understand how such an assurance can be provided in the absence of a  developed  Acute  Services  Strategy.  It  is  concerned  that  hospital  development  plans  are apparently continuing to be taken forward within a context of what may be significant uncertainty about the mix and scale of acute services that should and can be undertaken cost effectively and safely on the Island.

At a Public Hearing with the Minister for Health and Social Services, the Panel was advised that the first draft of the Strategy would be completed in June 2014. It will then go through consultation with the clinicians and health advisors from the Kings Fund, recently appointed as part of the feasibility study, will also review the Strategy. When asked when the Strategy would be completed the Department advised that it would be ready for Outline Business Case in January 2015[40].

The Panel has yet to consider the draft Strategy and is therefore not able to determine whether the timeline will be met. The Acute Services Strategy should have been completed before the work on the hospital pre-feasibility study was started. The Panel considers that the size and scale of the hospital cannot realistically be decided until there is clear direction on what services are going to be provided in hospital.

Interim financial arrangements for meeting immediate pressures

It was explained within P.82/2012 that the changes to health and social services required an increase in funding, by 2015, of over £11m per annum as identified in the Medium Term Financial Plan (MTFP). This was in addition to the additional £14m per annum growth monies (also identified within the MTFP[41]). In the following planning periods (2016 – 2021) further business cases, including detailed plans and costings, will be developed as part of future MTFPs[42]. It is also acknowledged that significant additional investment beyond 2016 will be required to implement the work streams described in P.82/2012.

The current Medium Term Financial Plan sets out the capital programme for each of the years 2013 – 2015 and the debate on the MTFP approved the capital programme, in total, for each of these years. To comply with the Public Finances (Jersey) Law 2005, the States approved a detailed list of capital projects for 2014. Below is the list of capital projects for 2014 relating to health and social services:

• Future Hospital (Phase 1) (Design Development, Preliminary Works and Transitions Capacity Requirements) (£10,200,000 for 2014) - This funding provides for preliminary activities that are required to enable the phased main works programme to be undertaken.
• Main Theatres Project (£1,837,000 for 2014) – This funding is the final tranche for a project to deliver improved theatre facilities for the hospital.
• Future Hospital – Planning (£500,000 for 2014) – This funding will provide for costs associated with the professional support necessary to develop the project master-plan and progress the feasibility study for consideration by States Members in autumn 2015.
• Integrated Assessment and Intermediate Care (£500,000 for 2014)  – This project proposes the establishment of an integrated assessment and intermediate care centre which will serve as the base for integrated adult community services for the adult population.
• Refurbishment of Sandybrook (£1,700,000 for 2014) – Sandybrook is a 28 bed facility adjacent to the Sandybrook day centre. It was built in 1999 and had not been refurbished since. Sandybrook provides nursing care for older people who have been assessed as needing continuing care to meet higher levels of care needs. The environment is outdated and not suited to the current highly dependent residents.

As set out within the recently published 2015 Budget below is the list of capital projects for 2015 relating to health and social services:

• Future Hospital – Feasibility Study and Initial Phases – Design and Planning (£22,700 for 2015) – This funding provides for the development of the feasibility study outline and Full Business Cases for the Future Hospital project to set out the proposed overall feasibility concept for the new build and refurbished Future Hospital capacity as set out in P.82/2012.

• Replacement of MRI Scanner (£2,277,000 for 2015)  -  The Health Department currently owns and operates an MRI scanner, which was commissioned in December 2007. The MRI scanner is in constant use and the unit operates Monday to Saturday, however, in 2014 it has also operated on most Sundays to meet increased demand. The MRI scanner needs replacing in 2015 and the replacement costs include the purchase and commissioning of a new machine as well as the necessary building costs associated with installation.
• Replacement of RIS/PACS (£1,567,000 for 2015) - Replacement of the Picture Archiving Communication System (PACS) and the Radiology Information System (RIS). PACS and RIS are the names given to a number of computer based systems designed to run the Radiology Department and distribute reports and images to all relevant clinicians both inside and outside the hospital. The scope also covers updating a range of hardware including the main server infrastructure and visual display equipment for viewing the images and reports.
• Limes Upgrade (£1,662,000 for 2015) - The Limes is a care home built in the 1980s to a very high standard but not refurbished since.

Mental Health Services

The Panel has been advised that the Health Department is currently undertaking a review of mental health services. Within the Terms of Reference for this review, it is explained that an overarching Mental Health Strategy is required in order to guide the future development of services, with a full review of existing services. According to the Department, a strategy will be produced in March 2015.

The Department intend to take a system-wide approach to the review which will incorporate the acute hospital, primary care, Voluntary and Community Sector provision and interactions with other States Departments where appropriate for example housing and education[43].

Within the Medium Term Financial Plan, £350,000 was identified for a Mental Health Facility Feasibility Study to be undertaken. The MTFP explained that the facilities at St Saviour's Hospital are reaching the end of their economic life and will shortly not be fit for purpose in respect of the ability to supply the desired service provision[44]. It is noted that these figures were subject to change depending on the work undertaken by the Treasury Department.

Although the MTFP suggested that a new mental health facility may be situated at Overdale Hospital the Panel has since been told that this is unlikely if the dual site proposal goes ahead. It is unclear whether another alternative site has been identified, however the Chief Executive of Health explained that Clinique Pinel has been upgraded which would give at least another 10

years' worth of life. The Department are also exploring whether it can accelerate a plan for Orchard House which needs to be rebuilt[45].

The financial and other consequences of the dual site option for the delivery of mental health services should be identified and understood in any decision involving the future of acute hospital services. The Panel is concerned whether the latter could lead to less affordable, good quality options for mental health modernisation.

Concluding remarks on whole systems approach

The Health White Paper embraced a whole system approach to the delivery of health care, and the eight enablers are considered essential to the successful delivery of the programme. The Panel has found little evidence that a whole system approach has been undertaken. As this section of the Panel report explains, little progress has been made within information services, the acute services strategy is still being developed, and there are still concerns around recruitment and retention.

KEY FINDING: 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.

8. Stakeholder Engagement

Engaging with the Public

The  Panel  notes  the  "Future  Hospital"  website  (www.gov.je/futurehospital)  includes  a  video developed to explain the future hospital proposals, an animation of the future hospital design concept, and details of the benefits planned for the "Future Hospital Project".

It is understood that the Ministerial Oversight Group initially considered a Communications Plan which identified that the Ministerial Oversight Group and Sub-Group wished to undertake a public consultation on a preferred site in order to gather views on the site's suitability compared to the alternatives. The aim was to confirm the preferred site through a States decision to enable detailed feasibility work to follow and a design for a new hospital to be developed and procured[46].

Some form of public consultation took place as the Panel were provided with a summary of the records taken of questions raised at the "Future Hospital" public communication events. Five of these were held in October and November 2013 and included single bedded en-suite wards, dual site working and provision of radiotherapy on-Island[47]. Unfortunately the records provided to the Panel did not go into any great detail about the concerns or support from the public.

The Panel's Public Consultation

The Panel itself carried out its own public consultation seeking views on the dual site hospital. The number of responses received was disappointing but of those who did respond a few reoccurring themes emerged:

• With the hospital covering two sites greater expense will be incurred with the duplication of laboratory and pharmacy facilities
• A hospital in one location would be more efficient. As many services as possible should be retained on the current hospital site for reasons of patient safety and efficiency
• Overdale could act as a "Cottage type" hospital for those less critically ill, but still needing hospitalisation or rehabilitation. Patients could be moved to Overdale once they are on the road to recovery

• Non availability of consultants in the main hospital
• Transport to Overdale –
  • The Overdale site, although magnificent in its location, could present real problems with transport
  • Overdale situated on a high plateau which could not be reached on foot very easily
  • All roads to Overdale are narrow and do not allow for speedy access
  • Shuttle buses between Overdale and Hospital could prove inconvenient, slow and costly
  • How often will buses run to accommodate patients
  • How much extra time will be spent getting to work if staff are coming from the East or West of the Island and using the bus service
  • Waste of consultant and other medical personnel's clinical time in having to travel between two sites
  • There needs to be adequate car parking spaces

The Panel also contacted the Jersey Civil Service Association[48] so that views on the future hospital could be gathered from States employees. The key points raised were:

1. In relation to the proposed satellite hospital at Overdale there was much concern about access to the premises and additional traffic in the area.
2. The proximity of the crematorium already causes problems when there is a service which results in parking and traffic problems. There was a suggestion about the possibility of re- locating the crematorium or purchasing a neighbouring field for overspill parking.
3. There was concern about patient transport issues and worry about how disabled patients would get to and from Overdale. The hill up to Overdale is steep and challenging for a fit person. Will suitable public transport be available? Currently all buses go pass the general hospital.
4. How will staffing of two sites be resolved? There are already nursing shortages and staffing two site will increase the demands.
5. Staff time spent moving between two sites will reduce the effectiveness of employees. In addition, the need to travel from one site to another may lead to adverse medical outcomes.
6. Expensive equipment will need to be duplicated and serviced. There might also be the need to have a duplication of services for example Radiology, Pharmacy and Pathology.
7. How would Out Of Hours arrangements be handled – where would the limited number of people work?
8. Pathology samples would need to be transported between sites. This increases the worry about some going missing. This could be particularly difficult during Out of Hours service.

9. Could have impact on blood donors – large number currently donate during working hours. This could change if they had to go to Overdale.
10. There are concerns about the processing of blood if the main laboratory is at Overdale but the Out of Hours is at a different site. The concerns also include the location of the blood bank and where cross matching would take place.
11. What would happen in major incidents – where would the key staff be?
12. The location of pharmacy could also introduce inefficiencies – there could be long delays if drugs had to be transported. This might result in beds becoming more clogged with those awaiting discharge.
13. The current plan is for Pathology to be located at the Overdale site, yet all of the acute services, which require a prompt Pathology service, are to be located in the main hospital. The Pathology laboratories should be located on the main site - a twin lab system will be more expensive.

Communication with the Voluntary and Community Sector

The Panel's previous review of the White Paper (S.R.7/2012) identified an important role for the Voluntary and Community Sector if more care in the community is to be provided. Evidence received during the Panel's previous review highlighted a degree of enthusiasm for the proposals but also tinged with an element of caution. Some organisations expressed the desire to be treated as equals and enter into medium to long term Service Level Agreements. The Panel also observed that, at times, there was scope for greater communication between the Health Department and the Voluntary and Community sector.

In  order for  the  Panel to  understand  in  detail  what  efforts  were  being made  by  the  Health Department to engage with other local providers in the delivery of improved community services, a survey was developed for all members of the Voluntary and Community Sector. The survey was sent to 111 representatives in total on 13th December 2012.

Although  the  level  of  responses  was  low,  some  interesting  findings  emerged.  In  the  earlier responses received through the survey, respondents were commenting on how the process was moving too fast, and some felt that they were not being listened to:

Unduly time-consuming and complex process (14th January 2013)

Didn't feel my input was taken on board and listened to (15th January 2013)

The options put forward at the very first meeting were never up for change, the charities views were not listened to. (14th January 2013)

They need to listen equally to all services and be open to different viewpoints. I found the process extremely frustrating and a waste of my time as any comments were not taken on board. We had no voice. (14th January 2013)

Some  later  comments  were  more  positive,  however,  which  may  suggest  that  the  Health Department took on board the concerns raised earlier on in the process:

This  is  a  moving  feast  because  as  the  process  has  progressed  the  opportunity  and mechanism for true engagement has been modified to meet the real Jersey situation. Thus many of the original concerns have been dissipated and providing HSS and their officers are as good as their word we now have the basis for a real partnership going forward(5th May 2013)

It is a very time consuming process but the CVS cannot afford to sit back and then complain after the event. (3rd May 2013)

We have come a long way from where we started with this process and the proof of success or otherwise will now all be in the delivery and in the forging of true two-way partnerships between the Department and VCS organisations. Proportionality, realism and flexibility is key to the building of successful arrangements as we move forward together. (5th May 2013)

Engaging with Primary Care

This section relates to key enabler 3 (primary care). The Panel recognised the importance of engaging with all primary care providers within its previous review of the Health White Paper. One of its recommendations was that GPs and other primary care practitioners are actively engaged in the ongoing development of primary care services based on a holistic approach to care and multidisciplinary working.

The Panel held a Public Hearing with the Chairman and a member of the Primary Care Body during its review. It is clear that earlier on in the White Paper process GPs felt they were not being listened to and the communication process lacked a multi-disciplinary approach: "I think from the point of view of significant events during the White Paper process, eventually we have got to a point where I think the people who are heading it up are starting to listen to us, are starting to understand the wider impact of the services that they have and the fact that one cannot just roll out these services in silos and that the impact may be sometimes unintended consequences on different parts of the service needs to be thought about[49]."

The Panel note that the relationship between GPs and the Health Department became fractious, particularly when a new model of primary care was being developed resulting in the GP's going to mediation in early 2014. Although there would seem to be some improvement in the relationship, the Minister for Health was asked to explain what happened at a Public Hearing: "There was some consultation last year, which did not quite get off the ground, so we have all, everyone together, sat back around the table at the end of last year, I think it was, and worked a way forward of everyone now engaged and going to take that next step forward of looking at the primary care with

[the Deputy Director of Commissioning] leading it and getting expert advice, whatever, as needed, as we go through[50]."

During  the  Public  Hearing  with  the  Primary  Care  Body,  the  Panel  asked  what  would  be  a successful outcome of the mediation: "A really good piece of work on sustainable primary care, which we are all very comfortable with and all feel part of and delivers what we need it to deliver to the Island. That to me is the ultimate objective of having put everyone in the same room for 2 or 3 days to talk it through, because that to me, we can all agree to behave properly and treat each other with respect and to communicate properly but the real test is getting a robust project out of the whole thing at the end because that is what we need. We need the 3 groups of individuals to work together[51]."

It seems that communication between the two parties has improved significantly with the help of mediation: "..the governance over the process feels more comfortable and we feel more equal partners in the process[52]". However, the evidence would suggest that poor communication in the past has resulted in a lack of whole system working which has ultimately delayed progress in the development of the new primary care model. It is still unclear when an agreement will be reached on the way forward. This is discussed further on in the report.

Engaging with Hospital Clinicians

P.82/2012  emphasised  that  the  new  model  of  health  and  social  care  is  a  whole  system transformation programme and its scale is unprecedented. The new system must be sequenced into a manageable series of projects, and the programme professionally managed. Furthermore, oversight at Ministerial and Corporate Director level is essential, and roles and responsibilities must be clear and the changes must be clinically-led[53].

From the evidence sessions, some clinical engagement has been undertaken and in particular since the appointment of the Clinical Lead of the "Future Hospital Project". The Panel was told on numerous occasions that the proposals and the operations of a dual site hospital had been discussed with clinicians, but this was not until June – August 2013 when the dual site concept had been identified.

W.S Atkins also recognised the importance of undertaking significant consultation with the clinical and medical directors and senior nurse to ensure that the proposed model will operate safely and sustainably[54]. In a recent letter to the Panel, W.S. Atkins explained their frustrations at not being afforded the opportunity to participate in any clinical team engagement during the study: W.S. Atkins said: "We had recommended and sought clinical engagement from the outset. Indeed, it featured in our initial interview presentation and was something we commended on numerous subsequent occasions. It was a process with which we were very familiar from other projects with which we had been involved. When evaluating the various site options, clinical engagement was not so important but, as the study progressed we highlighted in each of the SOC's we submitted, that we considered clinical engagement was essential to ensure that the Hospital Management Team were properly considering their proposed models of care and were securing the buy-in' of the clinical leadership. We did find it frustrating that we were not afforded the opportunity to participate in any clinical team engagement during our commission. The priority of our commission was to identify an appropriate site on which acute healthcare services could be delivered[55]."

9.  Delivery of Services in the Community

According to P.82/2012 the hospital is central to a sustainable system of health and social care. Modern hospital services and facilities including a "new" hospital are vital, but the need to build primary care and expand community services to offer alternatives, relieve pressure on the hospital and create a sustainable system is also important[56].

The impact of not implementing community-based care strategies has a significant effect on the hospital size. If the community strategies approved within P.82/2012 were not to be introduced, the increase in the hospital area requirement for a new hospital would rise by approximately 9,000m2, based on UK standards, and incur an additional capital cost of approximately £60 million[57].

Timeline of key milestones

In October 2012, following approval of P.82/2012, the Steering Group, Working Group, Ministerial Oversight Group and a set of task and finish groups started to co-ordinate the work necessary to shape service developments.

The four areas below were known as service workstreams and each one was developed into an FBC accompanied by service specifications. The FBCs include metric and performance measure and implementation plans. By December 2012 some workshops had been held for each of the FBCs:

1. Refocusing Children's Services: Early Intervention
2. Adult Mental Health: Jersey Talking Therapies
3. Healthy Lifestyles: Alcohol

4. Adults & Older Adults: End of Life Care, Dementia, Chronic Obstructive Pulmonary Disease, Intermediate Care

The  service  specifications  were  drafted  by  the  Commissioners  and  circulated  to  a  range  of stakeholders. The Commissioners role is to ensure that the health and social care needs of Islanders are understood and services are available to meet these needs[60]. Commissioning was identified as key enabler 6 which aims to ensure the needs of Islanders are identified and service users, carers, families and communities are consulted. Commissioners are to make evidence- based decisions regarding health and social services as well as supporting the Voluntary and Community Sector.

Some of the new services were due to commence in 2013 but unfortunately the Department's timescale had to be revised for two reasons; firstly, two workshops to discuss the specifications had to be rearranged due to the outbreak of Norovirus in December 2012. Secondly, some of the service areas proved to be more complex than others, and required more ongoing discussion[61].

The service specifications had originally been split into two categories: simple and complex. By working with key stakeholders such as GPs progress was then classified as red, amber or green. By March 2013, seven green specifications were confirmed and were reviewed by the Minister and her  independent  advisory  Panel  (Health  and  Social  Services  Ministerial  Advisory  Panel  – HASSMAP)[62]. Although the documents were considered to be at implementation stage via the green labelling, this report considers below which services are now fully operational.

In  March  2013  the  specifications  which  were  labelled  amber  were  being  reviewed  and  the Department was working with doctors, nurses, other professionals, and voluntary and community representatives with a view to finalising the documents by early June[63].

In September 2013, the Health Department explained that detailed work was continuing for the most complex services including intermediate care and long-term conditions. It was also explained that pilots were being conducted for intermediate care as well as children's respite, dementia respite and end of life care.

Funding Out-of-Hospital Services

Funding relates to key enabler 7 which is to identify funding requirements in accordance with Treasury timescales and decisions. The Panel examines funding issues in greater detail further on in the report. The funding proposals for the work-streams in each priority area of service change identified in the White Paper were incorporated into the Medium Term Financial Plan for Phase 1

(2013 to 2015) and these bids for growth were debated alongside the wider, States of Jersey, funding bids[64].

The following table was provided by the Treasury Department:

Further significant investment will be required from 2016 – 2021 to implement the work streams described in P.82/2012 which was estimated as part of the development of the Green and White Papers. Further business cases including detailed plans and costings will be developed as part of the future States Medium Term Financial Pans[65].

The Panel asked the Treasury Minister[66] to provide information on how much of the White Paper has been spent to date, and a breakdown of how much money has been spent to date on each work-stream. The Panel also requested the future planned spend in each area.

Current Spend

The Treasury explained that of the £5.418 million additional growth funding allocated to reform health and social services in 2013 in the Medium Term Financial Plan, £3.950 million has been spent. A further £1.189 million was spent in quarter 1 of 2014.

Funding has been used to create the commissioning team to support the design, commissioning and implementation of the new services. The funding has also been used to support workforce planning, recruitment costs for new staff and IT informatics development. These were identified in the MTFP as the cross cutting infrastructure work streams and the total spend was estimated to be £710,000 by 2015 (funded from Growth Allocation 2013 – 2015)[67].

Future Spend

The implementation plans for each work stream will lead to full implementation of planned services over the next few years which will be managed in a phased approach. The table below was provided by the Treasury Department and sets out the projected recurrent spend for each area which has been reprioritised from the MTFP allocations: