Staff Recruitment and Retention - Report - 21 March 2016

Health and Social Security Scrutiny Panel

Staff Recruitment and Retention at the Hospital

Presented to the States on 21st March 2016

S.R.1/2016

CONTENTS

1. Executive Summary .................................................................................................................... 4

2. Key Findings ............................................................................................................................... 6
3. Recommendations ...................................................................................................................... 8
4. Introduction ............................................................................................................................... 10 Context and Background .......................................................................................................... 10 The Review............................................................................................................................... 10
5. Hospital Workforce: An Overview ............................................................................................. 11 Workforce ................................................................................................................................. 11
6. Staff Recruitment and Retention Challenges ............................................................................ 14 What are the challenges? ......................................................................................................... 14 The effects of staff shortages .................................................................................................... 15 Reasons for leaving .................................................................................................................. 16 Recruitment in Care Homes ...................................................................................................... 16
7. Factors which affect Recruitment and Retention ....................................................................... 17 The Global Shortage of Health Workers ................................................................................... 17 Housing and Accommodation ................................................................................................... 18 Relocation Packages ................................................................................................................ 21 Employment Opportunities for Spouse or Partner ..................................................................... 22 Education Opportunities............................................................................................................ 24 Terms and Conditions of Employment ...................................................................................... 24
8. Staff Recruitment and Retention: Initiatives .............................................................................. 29 Training Packages offered by the Department .......................................................................... 29 Internal Training Opportunities .................................................................................................. 30
9. Conclusion ................................................................................................................................ 31
10. Appendix 1.............................................................................................................................. 32 Panel Membership .................................................................................................................... 32 Terms of Reference .................................................................................................................. 32 Evidence Considered ................................................................................................................ 32

1. Executive Summary

The recruitment of health and social care staff remains a challenge for Jersey due to a range of factors including high cost of living, terms and conditions and housing controls. As part of the whole redesign programme of health and social services (P.82/2012) it was recognised that investment would be required in staff, new ways of working, and organisational change.

The Panel has reviewed recruitment and retention of clinical staff at the hospital, and predominantly focussed on doctors and nurses. The Panel has found that the current vacancy rate for nurses and midwives across health and social services is 8%, which has increased from 6% since December 2015. In addition to current vacancy levels, the hospital faces imminent workforce pressures with many staff approaching retirement age.

The Panel was mindful that recruitment and retention difficulties have been a global issue for some time and the same difficulties are faced elsewhere and not just in Jersey. The fact that Jersey is a small Island is also a factor in the workforce challenge. Even though geographical isolation means that providing a significant level of hospital services locally is essential, it also means that maintaining specialist skills can be difficult due to low patient volumes.

Challenges in recruiting and retaining staff are likely to be widespread across all sectors within health and social services and not just experienced within the hospital setting given the high cost of living in Jersey and access to affordable housing. In 2013, the Statistics Unit identified that the individual earnings for key workers (which included nurses) were not sufficient to service a mortgage affordably on the purchase of a property at the lowest quartile price in Jersey.

Although the Health and Social Services Department provides staff accommodation, it is important that the housing stock is maintained to an acceptable standard. Work has been undertaken recently on key worker accommodation by the Strategic Housing Unit in the form of a Housing Strategy. As part of the strategy, current and future requirements of key workers will be included as part of a housing needs survey.

A large selection of the housing units within the hospital estate are single rooms, but recently there has been a shift towards two-income families relocating to Jersey instead of single people. There is a clear need for more units that are of a decent size and which cater for families and couples.

The relocation packages offered by the Health and Social Services Department are important because they could be a deciding factor for someone considering applying for a job in Jersey. Job relocation can be an expensive process, so it is important that the packages offered by the Department are attractive to potential employees. Research into other jurisdictions in that regard would be beneficial to ensure that Jersey relocation packages are at least as good as others.

Employment opportunities for other members of the family unit may also be a deciding factor for someone considering moving to Jersey, as there is no guarantee that a spouse or partner of a nurse or doctor (for example) would be able to find employment. Some people, after accepting a job at the hospital, have then left their post due to their spouse or partner being unable to find employment. The Panel heard that this compounds the accommodation issue because if they are unable to find employment, they are unable to contribute towards living costs. Therefore, high cost of accommodation and unpredictable employment opportunities are likely to be two major hurdles couples face when one applies for a job at the hospital.

Bearing in mind the shift in the demographic of nurses relocating to Jersey where it is now more common for a nurse to relocate with a family, education opportunities have also been identified as an issue. The cost of a university education could act as a deterrent because if teenage children want to attend university, they will be treated as overseas students, even though they may have spent most of their life in the UK.

The Panel has also found that professional indemnity insurance has become a major issue for hospital consultants in Jersey due to an increase in premiums. One consultant explained that insurance premiums have changed dramatically in the last five years, his personal experience seeing an increase from £1,500 a year to £14,000. This might deter some consultants who are considering living and working in Jersey and is an issue which needs to be resolved.

There is a major disparity of annual leave entitlement between the UK and Jersey for nurses, which may also act as a deterrent, particularly if a nurse has been working in the UK for a number of years. Nurses in Jersey are entitled to 26 days paid leave per year plus 2 statutory days and 9 bank holidays, whereas in the UK nurses are entitled to a minimum of 35 days (which is gradually increased in relation to the amount of years in service).

At first glance, Jersey compares favourably with the UK in terms of remuneration. However, it is important to note that the cost of living in Jersey is 20% greater than the UK average. Unlike Jersey consultants, UK consultants benefit from an awards scheme, and if working in London both nurses and consultants receive an annual high cost of living allowance. Therefore, high remuneration rates in Jersey are not necessarily an incentive to attract staff outside the Island.

The Panel conclude that the States of Jersey has a real challenge to plan and sustain the supply and demand of future health staff, particularly the nursing workforce, at a time of financial constraint. The report has identified a range of factors that may deter someone from applying to work at the hospital in Jersey. Improved working environments and changes to staff terms and conditions will be key in recruiting and retaining clinical staff in the future.

2. Key Findings

Key Finding 1: Jersey General Hospital faces imminent workforce pressures with many staff approaching retirement age. This, combined with the difficulties of recruiting and retaining qualified staff, makes current services vulnerable due to staff shortages.

Key Finding 2: Evidence shows that the main reason why clinical staff leave their roles is because they decide to leave the Island.

Key Finding 3: The salary of a nurse is, on its own, insufficient to fund a mortgage for the purchase of a property on the lowest quartile in Jersey.

Key Finding 4: There has been a shift towards two-income families relocating to Jersey instead of single people, but the housing stock within the hospital estate has not reflected this shift. Within the current stock a lot more single accommodation is available than family units.

Key Finding 5: Relocation packages are important when trying to recruit externally as they could be a deciding factor for someone considering applying for a position. If relocation packages elsewhere are more generous, this could put Jersey at a disadvantage when embarking on a recruitment drive.

Key Finding 6: High cost of accommodation and unpredictable employment opportunities for a spouse or partner are likely to be two major hurdles couples face when one applies for a position at the hospital.

Key Finding 7: There has been a shift in the demographic of nurses relocating to Jersey where it is now more common for a nurse to relocate with a family. However, the cost of a university education could act as a deterrent for this population of nurses because if their teenage children want to attend university they will be treated as overseas students even though they may have spent most of their life in the UK.

Key Finding 8: Professional indemnity insurance has become a major issue for hospital consultants in Jersey due to an increase in premiums. The necessity of having to pay and the uncertainty of what contribution the Health and Social Services Department makes could act as a deterrent for consultants elsewhere who might be considering applying for a position in Jersey.

Key Finding 9: In the UK, nurses are entitled to more annual leave than is currently provided in Jersey. The disparity of annual leave entitlement between the UK and Jersey could be a deterrent for a nurse considering relocating to Jersey.

Key Finding 10: Other jurisdictions offer financial incentives such as award schemes and high cost of living allowances. There are no similar incentives in Jersey and the higher remuneration rates here are not necessarily an incentive to attract staff from outside the Island.

Key Finding 11: The Health and Social Services Department has been successful in training nurses and midwives locally.

Key Finding 12: In 2014, the Health and Social Services Department successfully offered a Return to Practice course for nurses wishing to return to nursing after a career break. However, a course has not been offered subsequently.

3. Recommendations

Please note: Each recommendation is accompanied by a reference to that part of the

report where further explanation and justification may be found.

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

Recommendation 1: Negotiations should continue in order to resolve the disparities between terms and conditions and employment mechanisms in Jersey and Guernsey so that collaborative work within the medical profession can take place between the two Islands [section 6].

Recommendation 2: The Panel is encouraged that the Health and Social Services Department is reviewing whether consultants should travel to Jersey to see several patients, rather than sending patients off-Island. The Panel recommend that the findings of this piece of work should be shared with the Medical Directors Group and reported back to the States Assembly before the end of 2016 [section 6].

Recommendation 3: The Health and Social Services Department should investigate and maintain a record of the factors which lead to its hospital staff deciding to leave the Island. This will enable the Department to ensure its employment practices encourage better retention of staff [section 6].

Recommendation 4: The Panel is encouraged that consideration has been given to recruiting from Portugal, Madeira and Poland. The Panel recommend that research into recruitment from these jurisdictions is continued and that relationships are established between the Department and their health authorities so that recruitment and exchange of staff can be made to work in the interests of all parties [section 7].

Recommendation 5: The Minister for Health and Social Services and the Minister for Housing should pursue discussions with Andium Homes with a view to providing appropriate accommodation for health staff to rent or purchase. The outcome of these discussions should be shared with the Scrutiny Panel in September 2016 [section 7].

Recommendation 6: The Health and Social Services Department should ensure that the Jersey relocation package is competitive with other jurisdictions [section 7].

Recommendation 7: The Panel recommend that there should be discretionary powers under the Control of Housing and Work (Jersey) Law 2012 to grant "Entitled to Work" status to a partner of a medical professional moving to Jersey provided that partner can demonstrate the settled long-term nature of their relationship [section 7].

Recommendation 8: Clinical staff considering moving to Jersey with a family should be made aware, via written communication, that Jersey based students are treated as overseas students when applying for university places in England and therefore are liable for increased fees [section 7].

Recommendation 9: The Panel recommend that the uncertainty regarding professional indemnity insurance for consultants is brought to an end and that the Minister for Health and Social Services expedites a decision concerning the contribution of premium reimbursed for their public practice by the end of 2016 [section 7].

Recommendation 10:  The Health and Social Services Department should increase holiday entitlement for nurses in Jersey to bring it closer to that in the UK [section 7].

Recommendation 11: The Health and Social Services Department should explore the feasibility of introducing financial incentives in order to attract more clinical staff from elsewhere. In particular, the Department should consider the introduction of a retention bonus after a period of service [section 7].

Recommendation 12: The overall price level for consumer goods and services in Jersey is 20% greater than the UK average. If the Health and Social Services Department is to resolve recruitment issues, the issue of pay levels that are appropriate to higher costs of living in Jersey must be addressed [section 7].

Recommendation 13: The Health and Social Services Department should maintain its training programme and, if possible, enhance it in order to attract more students to remain on-Island once qualified [section 8].

Recommendation 14: The Health and Social Services Department should undertake a public awareness campaign regularly to try and attract nurses back into the profession. The Department should also contact former members of staff living in Jersey to ascertain the reasons why they left the nursing profession and what might attract them to return [section 8].

4. Introduction

Context and Background

Traditionally, Jersey has found the recruitment of health and social care staff to be challenging due to a number of factors including the cost of living, staffing terms and conditions and immigration controls[1]. In 2012, the States Assembly agreed to a complete redesign programme of health and social services by approving P.82/2012 "Health and Social Services: A New Way Forward".

The redesign programme was developed in response to expected increases in demand so that the skills of local staff could be used to the maximum and new roles created which would attract additional staff to work in Jersey[2]. The overarching objective of the redesign programme is to have sustainable and viable hospital services operating as part of an integrated health and social care system[3].

It was recognised in P.82/2012 that many health and social care staff were approaching retirement age which could make current services vulnerable. Another factor is that some consultants are generalists who are able to treat a wide range of conditions. Nowadays, however, there is a higher degree of specialisation in professional training which means the existing consultant staff cannot be replaced on a like-for-like basis. 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.

The Review

This review has explored recruitment and retention of clinical staff at the General Hospital (the "hospital"). The Panel had a strong interest in recruitment and retention of staff at the hospital given that, as a result of P.82/2012, greater emphasis has been given to providing care in the community in order to relieve pressure on the hospital. If more care is provided in the community, the makeup of hospital staff resources will change and P.82/2012 identified that investment would be required in staff, new ways of working, structures and organisational change[4].

As part of the review, the Panel was keen to understand what works in helping to reduce levels of turnover and what measures can be taken to influence retention. The Panel's review has included speaking with employee representatives, human resources officials and the Minister for Health and Social Services. The Panel is very grateful to those who assisted and contributed to its review, in particular to the Health Department for passing on key statistics the Panel had requested.

5. Hospital Workforce: An Overview

Workforce

As of January 2016 the Health and Social Services Department employed 2,616 people. Within the hospital, clinical staff (consultants, doctors, specialists, nurses and midwives) accounts for 1,212 people which makes up 47.4% of the total workforce within the Department[5]. There are many people who work in the hospital, but the main groups include:

• Doctors: Doctors can be categorised into three main groups[6]:

1. Consultants: Provide senior clinical leadership, consisting of direct clinical care to individual patients and the supervision and support of doctors in training. Highest attainable qualification.
2. Staff Grade or Associate Specialists (often referred to as Middle Grades): These doctors are the mainstay of the medical workforce at the hospital. They are employed as permanent members of staff and have qualifications one level short of Consultant.
3. Junior doctors: Mainly doctors in training who come to Jersey as part of the Wessex deanery rotation, and are therefore not permanent employees.

• Nurses and midwives: Nurses can be categorised into the following groups[7]:

1. Senior Nurse/Head of Nursing: Undertakes the role of a nurse, but manages others across a division or group of service or they may have a corporate responsibility for a specific function or a divisional lead role with budget responsibility.
2. Lead Nurse: the Lead Nurses provide nursing leadership for a specific division such as Medicine or Surgery. They also provide a line management function for Senior Sisters within that division.
3. Senior Sister/Sister: Undertakes the role of a nurse and also has line management responsibility for a health care team. They may be required to manage a budget for their area.
4. Specialist Nurses: carry out the role of a nurse in a particular specialist area and undergo training and study in the specialism to do this.
5. Staff Nurse: make up the majority of the nursing workforce and supervise the work of Health Care Assistants.
6. Health Care Assistants: staff who deliver direct patient care to support the work of registered Nurses.

• Professions allied to medicine: This includes therapists, pharmacists and radiographers.

• Janitorial staff: These individuals include porters and catering staff.
• Clerical staff: These individuals include receptionists for hospital units, hospital operators, hospital administrators and medical secretaries.

The Panel's report concentrates on clinical staff (those professionals who provide medical care to patients) and predominantly focusses on doctors and nurses. The table below shows the number of full time equivalent (FTE) staff within health and social services (including clinical staff) by paygroup and the current number of vacancies as of 31st December 2015[8]:

The table shows that the vacancy level for the overall headcount of nurses and midwives is just over 14%. However the Panel was told that the figures shown in the table overstate the extent of vacancies for nurses and midwives because they include:

• Around 15 vacancies that are associated with P.82/2012 initiatives which are planned but not yet implemented;
• Around 25 vacancies where someone has been recruited but has yet to start in the post;
• 30 vacancies that are on hold for the "The Limes" redeployment;
• 12 vacancies required for the student nurse cohort (who are due to move into post in summer 2016);
• 11 vacancies that were filled by agency nurses due to winter pressures and vacancies awaiting decision on permanent recruitment;
• Around 30 vacancies relating to posts that are in the process of being redesigned[9].

On 7th December 2015 the Panel was told that the vacancy level across the whole of health and social services was 6%[10]. As of February 2016, this has increased (for the whole of the nursing and

midwifery workforce) to just under 8%[11]. The Panel is concerned with this percentage as it is generally accepted that vacancy levels start to become problematic at 5%:

Deputy G.P. Southern :

"But nonetheless it is generally accepted that the figure that starts to be problematic is around 5 per cent, is it not?"

Head of Workforce and Planning:

"It is, but it is a seasonal trend that we see every year from October onwards, October, November and December. That is when we see most of our attrition of nurses either retiring or leaving the Island or leaving for whatever reason, so that is why the figure is 6 per cent at the moment. All year it has been sitting around 3 per cent to 4 per cent, so we have done very well this year."[12]

At the start of the Panel's review, it was provided with a vacancy table showing a different set of figures compared to the table on the previous page. It is important that data is measured consistently in order to produce comparable figures, as the Panel was unable to compare them on a like for like basis. Confusion has arisen from the inclusion or otherwise of non-registered nurses in the vacancy rates for nurses and midwives. If non-registered nurses are excluded from the figures, the current vacancy rate for registered nurses and midwives is 5.8%[13] which is still a cause for concern for the Panel. The Panel find it unsatisfactory that the figures provided have overstated the extent of the vacancies.

In addition to current vacancy levels, the hospital faces imminent workforce pressures with many staff approaching retirement age[14] which makes current services vulnerable due to staff shortages. The Department's Acute Services Strategy 2015 explains that recruitment of skilled clinical and non- clinical  staff  is  increasingly  challenging  given  high  costs  of  living  in  Jersey  and  competitive remuneration packages for similar staff in other jurisdictions[15].

6. Staff Recruitment and Retention Challenges

What are the challenges?

The Health and Social Services Department's workforce is under increasing pressure. KPMG reported in 2011 that many consultants and nurses are approaching retirement age and almost 50% of consultant and nursing staff were due for retirement during the period to 2020[16]. The Panel requested the most recent figures from the Department which are illustrated in the table below:

Retirements (FTE)

% to Current FTE

P.82/2012 explains that staffing in health and social care is highly reliant on very small numbers of individuals, particularly in medical staffing[17]. There is an increasing trend towards sub-specialisation in medical training, whereby doctors working in secondary care focus more on a particular area, which increases the number of staff needed to replace those leaving or retiring[18]. This means that every retiring hospital doctor may need to be replaced by a number of specialist doctors[19].

P.82/2012 explains that Jersey experiences challenges with attracting and retaining health and social care staff, particularly nurses. This is partly due to high cost of living, competitive pay packages in other countries, some rules for entry and residency and the personal profile of nurses, who are more likely to have families and are usually sole wage earners when they arrive. There are also global shortages in some skills, such as theatre practitioners and neonatal nurses[20].

The fact that Jersey is a small Island has also been identified as a factor in the workforce challenge. P.82/2012 explains that a population of approximately 100,000 would be considered too small in the UK to support comprehensive hospital services and very specialist social care services as this would normally be provided for a population of over 250,000. However, geographical isolation means that providing a significant level of hospital services locally is essential[21]. Therefore, due to low patient volumes, maintaining specialist skills can be difficult. Doctors should see a sufficient number of patients to ensure that they are "fit to practise" which maintains key skills and ensures patient safety[22].

In order to help alleviate this challenge, the Panel asked the Minister whether consultancy services could be shared with other jurisdictions, particularly with Guernsey. The Minister explained that discussions had taken place with Guernsey and the Isle of Man about whether services could be delivered jointly in addition to specialists visiting the Island to provide care[23]. The Hospital Managing Director also said:

Hospital Managing Director:

"We have recently appointed a new ophthalmology consultant and a new urology consultant, both of whom have met with their counterparts in Guernsey and their skill set complement one another. So they are working, between them, to say which patient should I see in Jersey with my skill sets and which Jersey patients might be better seen by the person in Guernsey. We have not got any joint appointments and that could probably cause some difficulty because our terms and conditions and our employment mechanisms are very different between the 2 islands. But there is certainly a lot of desire, I think, and enthusiasm from the new consultants coming into work with colleagues so that we offer the best for our patients, even if we do not have joint appointments. There is nothing to say we cannot do that in the future but at the moment the 2 employment mechanisms are very different."[24]

The Minister advised the Panel that the Department was also looking into whether consultants should travel to Jersey to see several patients, rather than sending several patients off-island[25].

The effects of staff shortages

According  to  a  KPMG  report  in  2015,  "A  New  Vision  for  Healthcare:  An  Island  Healthcare Perspective", staffing costs are usually the single largest expenditure item for healthcare providers. Staffing shortages can lead to a reduction in staff morale, reduced patient health outcomes and increase the cost of healthcare provision.[26]

The use of agency staff

Sometimes staff shortages require the use of agency workers or additional overtime payments. For example, the hospital has experienced a shortage of trained nurses within theatres and anaesthesia division who have skills in anaesthetics, scrub and/or recovery. Due to this shortage, five agency nurses were covering vacancies across the theatres and anaesthesia division in February 2015[27].

On average, agency staff cost about 70% more than permanent staff. This is due to the agency charges plus travel and accommodation charges. For specialist roles and midwives, the charges can be higher (twice the salary of a permanent member of staff[28]) as there are not as many specialist external agency staff to choose from[29].

The Chief Nursing Officer for England acknowledged that while some agency nurse capacity is necessary to cover unplanned absences and vacancies and meet unexpected spikes in demand, reliance on agency staff is not just costly, but can result in lack of continuity and less effective teamwork which can have a significant impact on patient care.[30]

Reasons for leaving

Retention can be defined as keeping a person in an organisation. Sometimes within the healthcare setting, it can mean keeping a person working on a particular unit, rather than losing them to elsewhere in the same hospital[31]. The table below lists the reasons why doctors, midwives and nurses have left their role from 2010 – June 2015:

Recruitment in Care Homes

Although the Panel's review was focussed primarily on staff recruitment and retention at the hospital, it wrote to all nursing homes to find out whether they had any difficulties recruiting nursing staff. The main themes of those that responded are as follows:

• There is a shortage of qualified nurses resident on the Island requiring the posts to be filled with nurses from elsewhere.
• Hospital nurses who work in nursing homes as bank staff sometimes cancel shifts at short notice due to accepting shifts at the hospital.
• Housing costs and the cost of living were identified as an issue for nurses from abroad.

The submissions received by the Panel illustrate a number of difficulties in recruiting qualified nurses resident in Jersey.

7. Factors which affect Recruitment and Retention

The Global Shortage of Health Workers

The Panel is mindful that recruitment and retention difficulties have been a global issue for some time and therefore the same difficulties are faced elsewhere and not just in Jersey.

Worldwide

In 2013 the World Health Organisation (WHO) warned of the serious implications for billions worldwide due to the shortage of healthcare workers, which is estimated to grow to 12.9 million by 2035 from the current deficit of 7.2 million. The projected increase relates to factors such as an ageing health workforce with staff retiring or leaving for better paid jobs without being replaced, coupled with not enough young people entering the profession or being adequately trained. [32]

UK

According to the Royal College of Nursing (RCN), secure staffing is the most important issue facing the profession, but a lack of investment in the supply of nursing numbers, as well as underfunded training and remuneration, means the workforce is in crisis[33].

The RCN conducted a survey based on freedom of information requests to 36 acute, community and mental health trusts in London. The survey found that the vacancy rate had increased from 14% to 17% as the number of empty posts rose from 8,000 to 10,140[34]. The RCN explained that, in order to fill the workforce gap, there has been a rise in nursing staff being recruited from abroad, particularly European countries[35].

The nursing workforce crisis in the UK may have an impact for the Jersey workforce in the future. Due to social and cultural links with the UK, Jersey staff are often drawn from the UK market:

Deputy G.P. Southern :

"We are still largely recruiting from the U.K., are we, from an English-speaking market?"

Hospital Managing Director:

"Largely, because our registration requirements are the same as the U.K., so we expect doctors to all be G.M.C. (General Medical Council) registered and nurses to be N.M.C. (Nurses Medical Council) registered, so we tend to attract from that market." [36]

There may be greater reliance on sourcing nurses from elsewhere due to the workforce challenges in the UK. The Hospital Managing Director also explained:

Hospital Managing Director:

"It may well be that we will attract more from Europe. We have already had some interest from some European doctors wanting to relocate to Jersey. They have contacted me and said: "What is the situation here?" so I explained to them that they would have to be registered with the G.M.C. in the U.K., which is relatively straightforward for somebody that has trained and worked in Europe. So we would not dismiss anybody from other parts of the world if they have got the right qualifications and skills and we can get them appropriately registered."[37]

Recruiting from Portugal, Madeira and Poland was also mentioned as there is a strong logic for Jersey to look at those countries in terms of the workforce reflecting the community that lives in the Island.

Housing and Accommodation

The difficulties in recruiting and retaining staff are likely to be widespread across all sectors within Health and Social Services and not just experienced within the hospital setting given the high cost of living in Jersey and resultant access to affordable housing.

According to a Statistics Unit report: "Jersey Housing Affordability", in 2013 the individual earnings for the key workers considered were not sufficient to service a mortgage affordably on the purchase of a property at the lower quartile price in Jersey. Of the three types of key worker considered in the analysis (which included nurses), affordability issues were most severe for teachers and nurses. The earnings of a nurse or teacher amounted to less than three-quarters of the income required to service a mortgage on the purchase of a dwelling at the lower quartile price.[38]

Housing stock within Health and Social Services

A stock condition survey of all the Health and Social Services Department's residential staff accommodation was carried out in 2013[39]. This identified a total stock of 224 dwellings in two portfolios; 99 residential units on hospital sites and 125 purely residential elsewhere. The table below shows the stock composition:

The survey identified that the housing stock was in a good state of repair (excluding 4 flats at Grosvenor Terrace and Overdale Lodge, the latter was noted to be in poor condition and would require significant work before being re-let). The survey noted that the housing stock required continued expenditure over a 30 year planning term in order to maintain all properties within Health and Social Services to a good, tenantable standard. The total expenditure was forecast to be £5,403,211 over the 30 year period. This equates to £23,560 per dwelling, or an average of £819 per dwelling per year (excluding Grosvenor Terrace).

The survey also identified that 3.6% of the tenanted stock (8 dwellings) was deemed non-decent in accordance with the Decent Homes Standard. The 3.6% total would increase to 37.9% by December 2018 if no relevant work were carried out on the stock[40].

The Panel received written testimonies from the Jersey branch of the Royal College of Nurses (RCN) and the Jersey Civil Service Association. Their views were that the current housing stock had not been maintained to an acceptable standard. The RCN said:

Royal College of Nursing:

The RCN believe the standard of accommodation in H&SS is mixed with less money recently been available to keep them maintained to an acceptable standard and there have been some horror stories where people have been placed. The RCN again would like to commend the accommodation office who acted promptly when made aware of any problems. There will always be a need for accommodation not only for new staff but agency staff brought in on short term contracts therefore the quality needs to be maintained. The debate on affordable accommodation the RCN accept does not only affect nurses but it will remain a significant factor when Nurses look at applying and relocating to Jersey[41].

A collective response from members of the Jersey Civil Service Association (Health Union: Prospect) said:

Jersey Civil Service Association:

"Another issue is the standard of the staff accommodation. Countless times I have heard conversations from quite senior staff about their time in the same accommodation (built new in the 80s) which they had endured with the view that 'you shouldn't bite the hand that feeds you'. Point is, if people don't feel they have a 'home' when they work long shifts and are faced with complaints day in and day out, they just won't stay."[42]

The needs of key workers are being included in the Housing Strategy Framework which is explained in greater detail in the next section. Andium Homes has suggested that the existing staff accommodation held within the Health Department could be transferred to it in order to ensure:

1. Key Workers are able to have access to an appropriate home which matches their housing needs on a basis which is consistent with tenants in the social rented sector and in strict compliance with the Residential Tenancy Law and any future regulatory framework established by the States.
2. Properties are used more effectively. Overcrowding and under occupancy can be avoided. Some existing health properties might be better used for social housing and some existing social rented housing properties might better suit key worker uses. A single residential property management company would be able to manage uses across the portfolio more effectively and for the overall benefit of tenants.

3. Subject to suitable controls over residential qualifications, key workers could be offered opportunities to purchase an affordable home under Andium Homes Deferred Payment Scheme which offers up to a 25% deferred payment subject to means testing, reducing the price payable for a 3 bedroom house to approximately £260,000. Andium Homes is considering an extension to this scheme to increase affordability further where necessary by also offering a 10 year Deposit Loan in addition to the long term 25% deferred payment bond.
4. Properties transferred to Andium Homes remain in the overall ownership of the States through the States ownership of the Company[43].

Andium Homes has recognised that under existing arrangements there are limited housing options for some health key workers and many of them face difficulties in securing affordable housing. As a result, Andium has suggested changing the accommodation that is currently available to key workers, and in particular new migrant key workers, by offering them access to affordable rental homes and the opportunity of purchasing on its Deferred Payment Scheme. Furthermore, Andium suggested that this change could form part of a new key worker recruitment and retention strategy[44].

The Strategic Housing Unit will be publishing a Housing Strategy which will set out what the Council of Minsters intends to do to improve the Island's housing situation. Objective 1 in the Draft Housing Strategy is to "ensure the supply of homes meets the identified needs of the Island". The Strategic Housing Unit aims to achieve this by developing detailed housing plans for specific groups which include key workers in order to provide them with the right accommodation.

"Housing key workers, especially those in the health and social services, who have proven to be less able to afford housing, are a key priority of the [Housing] Minister. The strategy will set out a definition of key workers together with development of an associated housing policy[45]."

The Panel held a public hearing with the Minister for Housing and discussed the Housing Strategy in relation to key worker accommodation. The Panel identified that a large selection of the housing units within the hospital estate were single rooms. The Principal Planner of the Island Plan review told the Panel that it was important to understand the current and future requirements of staff which would be included as part of a housing needs survey[46].

There is evidence, however, that a shift has emerged whereby the Department used to recruit single people who were content to live in single accommodation but now it is usually a two-income family unit. The Chairman of the Royal College of Nursing explained that the demographic has changed whereby nurses are no longer training straight from school:

Chairman, Royal College Nursing:

" Quite often you will find that people were coming into nursing now who have a got a second career, they have had a career for a number of years, they have come back ... they have gone and done nursing so they have often got families and children and such like that they bring with them. I would think that has certainly been on factor which has been highlighted

to us on a number of occasions when recruiting a nurse from the U.K. who has got their own family, the issues of coming across to Jersey"[47]

The Head of Workforce and Planning said that the housing stock is mostly single accommodation, and that there is a lack of accommodation for families or couples which are of a decent size:

Head of Workforce and Planning:

"We  do  have  some  limited  accommodation.  It  is  mostly  single  accommodation which addresses immediate need and certainly the need to accommodate any temporary staff as in locums or agencies. What we do not have very much of is accommodation for families or couples of a decent size. Hopefully, in the new year, once the Minister has approved, we will try and do some work with the Strategic Housing Unit to look at Health and Social Services housing needs, which would help to inform the housing survey going forwards in terms of recruitments and retention" [48].

Relocation Packages Consultants and Doctors

Consultants, staff grades and associate specialists are eligible for a relocation package of up to £8,000 and are funded for a visit to Jersey with their partner and dependents in order to search for accommodation (this is repayable on a decreasing scale if the consultant leaves within 5 years of being appointed) [49].

They are also able to access Health and Social Services accommodation for up to 12 months at a subsidised rate. According to the Department, this offer is rarely taken up by consultants but frequently taken up by staff grades and associate specialists[50].

Junior doctors have their travel to Jersey paid for by the Department and are also able to access rent free accommodation in Health and Social Services property, though utility bills are paid for by the individual[51].

Nurses

Nurses are also eligible for a relocation package of up to £8,000 and are funded for a visit to Jersey with their partner and dependants in order to search for accommodation (this is repayable on a decreasing scale if the nurse leaves within 5 years of being appointed) [52].

Included in the £8,000 relocation package is a recruitment supplement of £3,000. The £3,000 can be paid into a nurse's first salary. However, nurses have the option to opt out of receiving the supplement as a lump sum and can request to claim all of their relocation expenses (up to £8,000) through production of receipts. If a nurse chooses to receive the recruitment supplement as a lump sum, they can only claim relocation expenses up to £5,000. The Panel spoke to the Chairman of the Jersey Royal College of Nursing who clarified after the hearing:

Chairman, Royal College of Nursing

"the £3000 has not been stopped but Nurses who are appointed to post need to tick a box on the form if they want it upfront or just leave it rolled up in the £8000 expenses allowance. This was a change as previously it was paid with new staffs first month's pay and it was not refundable. I understand it is now like the rest of the relocation package it needs to be repaid if they leave with in a defined time period. This change was not discussed with Staff Side[53]"

The packages offered by the Health and Social Services Department are important because they could be a deciding factor for someone considering applying for a job in Jersey. Job relocation can be an expensive process so it is important that the packages offered by the Department are attractive to potential employees. The Panel would urge the Department to research the relocation policies of other competitor jurisdictions to ensure our offer is at least as good as others.

Employment Opportunities for Spouse or Partner

A nurse (or other medical professional) moving to Jersey from abroad will be issued with a "Licenced" status by the Population Office as they are deemed to be an "essential employee". A spouse of an essential employee will be issued with "Entitled to Work" status, whereas a partner will only have "Registered" status:

Assistant Chief Minister:

"Under the Law, partners of people who are entitled, entitled to work or licenced person do not receive entitled to work status by virtue of that relationship. This is only the case for persons who are married or in civil partnerships.

Instead, partners are awarded residential status based on their own residence and in their own right, and so would normally be classified as registered if newly arrived in the Island.

This enables these partners to work in the Island, but the number of positions they can obtain is limited by the Law, placing them in a similar position to other newer migrants."[54]

There is no guarantee that a spouse or partner of an essential employee will be able to find employment in Jersey. In particular, the jobs available to a partner with "Registered" status is limited. If an employer does not have a licence to employ a partner on a registered status and wants to employ him or her in another category, it is the employer's responsibility to apply to the Population Office. The Population Office may support the application, but the decision is dependent on the nature of the employment and the ability of the employer to demonstrate that they have been unable to secure a locally qualified person to undertake the role[55].

This will be a risk factor inevitably taken into account of those who are considering coming to work in Jersey. There are also some administrative steps an unmarried couple relocating to Jersey must take in relation to the Control of Housing and Work Law 2012:

• If an unmarried partner wants to apply for a post that requires him or her to have lived in Jersey for the last five years, the couple must submit an application to the Population Office and provide documents addressed in both names, wherever possible, to prove that they have been in a permanent relationship and living in the same household for the last three years.
• If all documents are unable to be provided in joint names for the whole three year period, documents addressed to each person may be acceptable if they show the same address[56].

The Panel spoke to the Director of Corporate Policy who said if such a situation arose at the Population Office, the fact that the partner was a nurse (or other medical professional) would be taken into account when the application was received. Nevertheless, the fact that a partner does not have access to all jobs even though he or she can apply for a change in status could be a deterrent for those considering relocating to Jersey.

The Panel wanted to find out whether this was a reason why essential employees, after accepting a job at the hospital, then left their post. The Head of Workforce and Planning said:

Head of Workforce and Planning

"It is usually a combination of things. It is usually the male partner of the marriage or the household, it compounds the accommodation issue, because if they cannot get employment, then their ability to pay the rent like any other household that is in full employment is impaired"[57].

Therefore it seems that there are likely to be two major hurdles someone faces when applying for a job at the hospital: high cost of accommodation and unpredictable employment opportunities for a spouse or partner.

Education Opportunities University

A potential deterrent for relocating to Jersey with a family is the cost of going to university. The current situation is that if teenage children want to attend university and have relocated to Jersey from the UK, they will be treated as overseas students, even though they have spent most of their life in the UK. When the Panel spoke to the consultant representative, he confirmed that this has been an issue:

The Deputy of St. Ouen :

"Are there any issues about moving? What about education provision? We have heard from other professionals that depending on the age your children are when they come to Jersey, they might not be eligible for grant assistance from the Island. Is that something that has affected the doctors to your knowledge? Grant assistance to university".

Hospital Consultant Representative:

" I know some people that have decided not to move because of the age of their children, they are coming to the end of their school careers and looking to university, you know, is now the right time to come? I think people with younger children take that as a risk for the future. It is certainly something that is starting to crystallise in my mind as my children get older, and the potential costs that a university education might be".[58]

Terms and Conditions of Employment Professional Indemnity Insurance

The Health and Social Services Department provides professional indemnity insurance for its staff including  nurses,  therapists,  junior  doctors,  middle  grade  doctors,  locum  doctors  and  some consultants. Consultants are contractually obliged to have personal indemnity insurance in place at all times. In the UK this is usually just required to cover their private practice because of Crown indemnity (where their public practice is covered). In Jersey, however, consultants require indemnity insurance for both their public and private activity[59].

The Health Department does reimburse the consultants recognising the public element, for example: if a consultant earns more than 10% of their annual public salary in additional income from private practice then the Department will reimburse 50% of their insurance premium; if they earn less than 10% the Department reimburses all of their insurance premium. There are 8 hospital consultants who have all of their premiums reimbursed which represents about 12% of the consultant body[60]. There is an exception to the rule that consultants are expected to source their own indemnity insurance for 3 of the 4 obstetric and gynaecology consultants. This is due to changes a few years ago to the premiums for consultants seeking indemnity cover who do not work on mainland UK being dramatically increased. It was agreed at that time that the corporate policy would cover these consultants as part of the overall policy. These consultants make a contribution to the Health Department to represent their private activity cover[61].

The Panel spoke to a consultant representative at the hospital who explained that insurance premiums have changed dramatically in the last 5 years. His personal experience has been an increase in his insurance premium from £1,500 a year to £14,000 a year[62]. He said this might deter some consultants who are considering living and working in Jersey:

Consultant Representative

"It is something that we find to be a major problem and a consultant coming to ... thinking about coming to work in Jersey, when they look, they come to scout around and think about their salary and work out how much they might be able to make in private practice and look at house prices and look at schools and then hear that their insurance policy might be £14,000 a year, that might be a difficult circle to square[63]".

The  consultant  representative  also  explained  that  discussions  were  taking  place  with  the Department regarding professional indemnity insurance albeit at a slow pace:

Consultant Representative

"..[the Hospital Managing Director] has assured us that she and [the Chief Executive Officer] and the previous Minister for Health and the current Minister for Health have looked at this issue and find it to be a thorny one but discussions are taking place. But this discussion has been on the table for 5 years, really since the sudden exponential rise in premiums has been found, and I have seen no movement at all in this issue at all. Exactly where the stumbling block is I do not know[64]".

The Panel questioned the Hospital Managing Director on this issue who said that discussions were taking place and different options were being explored. Any major move away from the current model of consultants insuring themselves with an indemnity provider will require States approval.

Annual Leave: nurses

In the UK, nurses are entitled to more annual leave than is currently provided in Jersey. Nurses (grade 4) in Jersey are entitled to 26 days paid leave per year[65]plus two statutory days and nine bank holidays[66]. In the UK, however, nurses are entitled to 35 days paid leave for the first 5 years in service, 37 days after 5 years and 41 days after 10 years in service[67].

The fact that there is a disparity of annual leave entitlement between the UK and Jersey could be a deterrent for a nurse considering relocating to Jersey, particularly if they have been working as nurse for over 10 years in the UK. The Human Resources Director explained to the Panel that nurses' annual leave entitlement was an issue being looked at as part of the Workforce Modernisation Programme:

Human Resources Director:

"The one that tends to stick out, that people comment on, is what U.K. nurses would probably describe as quite a modest approach to annual leave entitlement. Jersey tends to be much lower in the public sector - either social workers or nurses - on annual leave, but on pay and pay rates we are generally comparing reasonably well, except at the very top of the scale, where that needs some assessment, because that is all being swept up under the workforce modernisation programme now, which was originally driven by nursing"[68]

Remuneration

The table on the next page shows NHS England rates and Jersey rates of pay for consultants. At first glance, Jersey compares favourably with the UK. However, there are a few factors which need to be taken into consideration:

• The overall price level for consumer goods and services in Jersey (including housing costs, education and health) is 20% greater than the UK average[69].
• UK consultants benefit from a Clinical Excellence Awards Scheme, which does not apply in Jersey. These awards range from £3,000 to £75,000[70].
• NHS consultants and nurses who work in central London receive an annual high cost living allowance of £6,000.[71]

The tables below shows NHS England rates and Jersey rates of pay for nurses:

England 2015 Nurses

Min  Max

Pay  Basic  Basic

Band  Pay  Pay  Example Roles

1  £15,100  £15,363  Administration 2  £15,100  £17,800  Administration

Microbiology assistant, secretary, occupational therapy 3  £16,633  £19,461  assistant, physiotherapy assistant,

Mortuary, radiography or occupational therapy assistant, 4  £19,027  £22,236  office manager, nursing auxiliary

5  £21,692  £28,180  Nurse and Midwife

6  £26,041  £34,876  Junior Sister/ specialist senior staff nurse

7  £31,072  £40,964  Senior Sister

8A  £39,632  £47,559  Nurse & midwife consultant, higher management

8B  £46,164  £57,069  Nurse & midwife consultant, higher management

8C  £55,548  £67,805  Nurse & midwife consultant, higher management

8D  £65,922  £81,618  Nurse & midwife consultant, higher management

9  £77,850  £98,453  Chief Pharmacists managing large/multiple departments

It would seem that nurses pay in Jersey is higher than in the UK. However when the Panel spoke to the Chairman of the Royal College of Nursing (Jersey branch) he explained that the high cost of living in Jersey balances out the pay:

Royal College of Nursing:

"certainly the pay looks on paper higher in Jersey than what it is in the U.K. for most grades of staff. I would not question on paper that Nurses Pay in Jersey is higher grade for grade, but when you factor in the high cost of living, housing costs and difficulty for the partners of nurses to get jobs in the island it makes moving to Jersey much less financially viable."[72]

The Panel wanted to find out what a similar jurisdiction offered in terms of financial incentives and found that Guernsey offers a retention bonus of £3,000 after a two year service to staff working in hard to recruit areas such as acute and mental health. Guernsey also provides all nurses with an annual bonus in February (pro rata to start date) of £1,097[73].

8. Staff Recruitment and Retention: Initiatives

Training Packages offered by the Department University of Chester: Nursing and Midwifery

The Department has been running nurse training for at least ten years. The programmes currently available are largely run in partnership with the University of Chester[74].

The three year degree level programme for pre-registration adult nursing is open to Islanders on an annual basis and is run on island. The Department explained that the interest in this programme has been significant and has attracted local people who would not have been able to pursue a career in nursing if they had been required to leave Jersey to train. The decision on how many students to let take the course is based on the expected retirements, turnover and skill mix changes within the Department (at present, the Department takes between 10-15 students annually). In February 2015, the Department had approximately 45 students in training (1st, 2nd and 3rd year students) [75].

In addition to the pre–registration adult nursing programme, the Department also offers training in Midwifery.  In  February  2015,  there  were  three  pre-registration  midwifery  students  on  the programme[76].

It is recognised that there will be local students who want to train outside of Jersey. Those students are offered a point of contact with the Department and encouraged to join the nurse bank as a healthcare assistant whilst they are students. The Department explained that this has proved successful in attracting Jersey students back to the Island on completion of their programme, as they have the opportunity when they return in the university holidays to do some temporary work on the bank which familiarises them with the Department[77].

Return to Practice

The Department also offers a "Return to Practice" programme for trained nurses who have either had a career change or a career break. This programme offers nurses an opportunity to return to the profession. A programme was delivered in 2014 which was completed by 13 nurses[78]. The Panel asked the Department to provide further information about the course and was informed that, as the course is intensive (theory and clinical practice run over three months) there was no capacity to run another course before 2017. It was also explained that, since 2014, not many people have been interested in undertaking the course, and in order for it to be viable there needs to be a cohort of 6 to 8 nurses[79].

In 2011, open sessions where organised by the Department which aimed to attract nurses back to work. This attracted a range of candidates who wanted to re-enter the profession[80]. The Panel is unaware if a similar campaign has been undertaken since 2011. The decrease in interested candidates since 2011 may be a result of a lack of awareness about the return to practice course. The Panel would urge the Department to undertake an awareness campaign to see if this had an impact on the numbers of interested candidates. As part of an overall workforce strategy, the Department should encourage qualified nurses to return to the profession.

Consultants and Doctors

The Consultant contract (in line with the UK Consultant contract) provides for 10 hours each week funded Supporting Programmed Activities' (SPAs) within their timetable. This time is designed to allow doctors to maintain their knowledge base and access material to support their clinical duties, for example, reading relevant clinical journals, attending peer learning, attending mandatory and statutory training, attending hospital training events and so on. It also allows for consultants to undertake specific work for their Department over and above their clinical duties for example, audit, engagement with LEAN projects, or engagement with Future Hospital planning[81].

All  Consultants  and  Middle  Grade  staff  are  entitled'  via  their  contract  and  the  registration requirements of the General Medical Council to 30 study leave days over a 3-year period, usually equally taken as 10 each year. In 2014, 1022 study days were taken by medical staff[82].

Internal Training Opportunities

All medical staff are required as part of their registration with the General Medical Council to demonstrate Continual Professional Development. This is discussed and documented at their annual appraisal. In addition to practical and analytical programmes, the Department offers many internal training opportunities that are usually related to skills required and annual updates, for example, resuscitation courses.

9. Conclusion

The States of Jersey has a real challenge to plan and sustain the supply and demand of future health workers, particularly the nursing workforce, at a time of financial constraint.

The Panel acknowledge that progress has been made in recent years in the delivery of training packages so that nurses and midwives are trained locally. This can only have a positive effect on recruitment and retention levels. The Panel believe that wherever possible training packages should be enhanced to encourage more local students to remain on-Island once qualified.

The Panel has identified several factors which may deter hospital staff considering relocating to Jersey. One of these factors includes high cost of living where the overall price level for consumer goods and services in Jersey is 20% greater than the UK average. If we are to resolve recruitment issues, the issue of pay levels that are appropriate to higher costs of living in Jersey must be addressed.

Other factors include access to affordable housing, terms and conditions and education and employment opportunities for other members of the family unit. Further work is currently being undertaken into some of these areas including access to affordable housing for key workers by the Strategic Housing Unit and changes to terms and conditions via the Workforce Modernisation Programme.

The Panel found that leaving the Island was the main reason why clinical staff left their roles between 2010 and 2015. Although there are no details as to why staff left the Island, investing in improved work environments is likely to be a positive step in improving retention levels of all healthcare professionals, and the Panel hopes that the future hospital will help in this respect.

10. Appendix 1

Panel Membership

Deputy Richard Renouf , Chairman Deputy Geoff Southern , Vice-Chairman Deputy Terry McDonald

Terms of Reference

1. To examine the "Jersey Factors" which result in a difficulty to recruit and retain
2. To determine what improvements have been made to staff recruitment and retention since P.82/2012 "Health and Social Services: A New Way Forward" was approved by the States
3. To examine what, if any, initiatives are being trialled to improve the skill set within the hospital
4. To determine whether there is a sufficient supply of nurses accommodation and whether it is affordable

Evidence Considered Public Hearings

• 14th September 2015: Mr K. McNeil, Royal College of Nursing
• 17th September 2015: Ms S. Sansom, Royal College of Midwifery
• 18th September 2015: Deputy A.E. Pryke, Minister for Housing

 Mr P. Bradbury, Director, Corporate Policy

 Mr R. Buchholz, Principal Planner, Island Plan Review

• 21st September 2015: Dr D. Lawrenson, Consultant Paediatrician, Consultant representative
• 7th December 2015: Senator A. Green, Minister for Health and Social Services Mr T. Riley, Human Resources Director

Ms H. Blain, Head of Workforce Planning

Ms J. Mesny, Head of Education Learning and Development Ms H. O'Shea, Managing Director, Hospital

[1] KPMG, A Proposed New System for Health and Social Services (main document), 2011, page 91

[2] P.82/2012, Health and Social Services: A New Way Forward, page 8

[3] P.82/2012, Health and Social Services: A New Way Forward, page 59

[4] P.82/2012, Health and Social Services: A New Way Forward, page 59

[5] Information received from the Health and Social Services Human Resources Department, 8th February 2016

[6] Information received from the Health and Social Services Department, June 2015

[7] Information received from Head of Workforce Planning, January 2016

[8] RCCO – Residential Childcare Officers

[9] Information received from the Health Department, 26th February 2016

[10] Public Hearing with the Minister for Health and Social Services, 7th December 2015, page 8

[11] Information received from the Health Department. 19th February 2016

[12] Public Hearing with the Minister for Health and Social Services, 7th December 2015, page 8

[13] Oral question asked by Deputy Southern , 23rd February 2016

[14] Acute Services Strategy, 2015, page 7

[15] Acute Services Strategy, 2015, page 7

[16] KPMG, A Proposed New System for Health and Social Services (main document), 2011, page 130

[17] P.82/2012 Health and Social Services: A New Way Forward, page 12

[18] KPMG, A Proposed New System for Health and Social Services (main document), 2011, page 130

[19] P.82/2012 Health and Social Services: A New Way Forward, pages 12/13

[20] P.82/2012 Health and Social Services: A New Way Forward, pages 12/13

[21] P.82/2012 Health and Social Services: A New Way Forward, page 12

[22] KPMG, A Proposed New System for Health and Social Services (main document), 2011, page 22

[23] Quarterly Hearing with the Minister for Health and Social Services, 23rd April 2015, page 17

[24] Quarterly Hearing with the Minister for Health and Social Services, 23rd April 2015, page 18

[25] Quarterly Hearing with the Minister for Health and Social Services, 23rd April 2015, page 20

[26] KPMG, A New Vision for Healthcare: An Island Healthcare Perspective, 2015, page 11

[27] Written Question by Deputy L. Doublet , February 2015

[28] Information received from the Health and Social Services Department, June 2015

[29] Information received from Head of Workforce Planning, January 2016

[30] Royal College of Nursing: The UK Labour Market Review 2015, page 3

[31] The role of hospital design in the recruitment, retention and performance of NHS nurses in England, 2004

[32] WHO (2013). A universal truth: No health without a work force.

[33] Royal College of Nursing: The UK Labour Market Review 2015, page 4

[34] Royal College of Nursing FOI Survey, July 2015

[35] Royal College of Nursing: The UK Labour Market Review 2015, page 3

[36] Public Hearing with the Minister for Health and Social Services, 7th December 2015, page 16

[37] Public Hearing with the Minister for Health and Social Services, 7th December 2015, page 16

[38] Jersey Housing Affordability Report 2013, States of Jersey Statistics Unit, page 17

[39] Ridge and Partners LLP, Stock Condition Survey of States of Jersey Health and Social Services Department Residential Staff Accommodation, October 2013, page 3

[40] Ridge and Partners LLP, Stock Condition Survey of States of Jersey Health and Social Services Department Residential Staff Accommodation, October 2013, page 11

[41] Written Submission, Royal College of Nursing, July 2015

[42] Written Submission, Jersey Civil Service Association, July 2015

[43] Written Submission, Andium Homes, July 2015

[44] Written Submission, Andium Homes, July 2015

[45] Housing Strategy, Consultation, November 2015

[46] Public Hearing with the Minister for Housing, 18th September 2015, page 11

[47] Public Hearing with the Chairman of the Royal College of Nursing, 14th September 2015, page 2

[48] Public Hearing with the Minister for Health and Social Services, 7th December 2015, page 23

[49] Information received from the Health and Social Services Department, June 2015

[50] Information received from the Health and Social Services Department, June 2015

[51] Information received from the Health and Social Services Department, June 2015

[52] Information received from the Health and Social Services Department, June 2015

[53] Public Hearing with the Royal College of Nursing, 14th September 2015, page 4

[54] Correspondence received from the Assistant Chief Minister, Senator P. Routier, 7th October 2015

[55] www.gov.je

[56] www.gov.je

[57] Public Hearing with the Minister for Health and Social Services, 7th December 2015, page 22

[58] Public Hearing with Hospital Consultant Representative, 21st September 2015, page 22

[59] Written Question by Deputy R. Renouf , October 2015

[60] Written Question by Deputy R. Renouf , October 2015

[61] Written Question by Deputy R. Renouf , October 2015

[62] Public Hearing with Hospital Consultant Representative, 21st September 2015, page 9

[63] Public Hearing with Hospital Consultant Representative, 21st September 2015, page 9

[64] Public Hearing with Hospital Consultant Representative, 21st September 2015, page 12

[65] Working as a Nurse in Jersey: Human Resources Department, August 2013, page 4

[66] Information received from the Health Department 26th February 2016

[67] www.rcn.org.uk/employment-and-pay/nhs-conditions-of-employment

[68] Public Hearing with the Minister for Health and Social Services, 7th December 2015, page 18

[69] Statistics Unit, Jersey-UK Relative consumer Price Levels for Goods and Services, 2013, page 1

[70] Information received from Human Resources Department, December 2015

[71] Information received from Human Resources Department, December 2015

[72] Chairman, Royal College of Nursing, 22nd February 2016

[73] Information received from Guernsey Health and Social Services Human Resources Department, January 2016

[74] Written Question by Deputy M. Higgins to the Health Minister, February 2015

[75] Written Question by Deputy M. Higgins to the Health Minister, February 2015

[76] Written Question by Deputy M. Higgins to the Health Minister, February 2015

[77] Written Question by Deputy M. Higgins to the Health Minister, February 2015

[78] Written Question by Deputy M. Higgins to the Health Minister, February 2015

[79] Public Hearing with the Minister for Health and Social Services, 7th December 2015, page 32

[80] Course for "Return to Practice" nurses, December 2011, www.gov.je

[81] Information received from the Health and Social Services Department, June 2015

[82] Information received from the Health and Social Services Department, June 2015