States Assembly | Report - Follow-up Review of Mental Health Services

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Follow-up Review of Mental Health Services

Health and Social Security Scrutiny Panel

22nd April 2022 S.R.8/2022

CONTENTS

Chair's Foreword ........................................................................................................... 4
Executive Summary....................................................................................................... 5 Key Findings ......................................................................................................................... 7 Recommendations .............................................................................................................. 14
Introduction .................................................................................................................. 18

The Panel's Follow-up Review .................................................................................... 18
Background ................................................................................................................. 18
Methodology ................................................................................................................ 19

Impact of the COVID-19 Pandemic on Mental Health Services ............................... 21

Initial actions of Adult Mental Health Services in the COVID-19 pandemic ............. 21
Governance ............................................................................................................. 22

Impact of the COVID-19 pandemic on the strategy for Adult Mental Health Services ......................................................................................................................... 23

Emergency Powers ............................................................................................... 25
Impact of Lockdown ................................................................................................. 26
Establishment of the Community Triage Team / Home Treatment Team................ 30
Listening Lounge ..................................................................................................... 32
Access to General Practitioners (GPs) .................................................................... 33
CAMHS: Impact of COVID-19 ................................................................................. 33
COVID-19 impact on staff numbers ....................................................................... 36
Impact of Lockdown on carers ............................................................................... 37
Communication to AMHS service users during the COVID-19 pandemic ............. 38
AMHS and frontline emergency services ............................................................... 38
AMHS and the States of Jersey Prison Service .................................................... 39

Independent Review of Adult Mental Health Services in Jersey ............................. 42

Additional funding of £500,000 for Mental Health Services ..................................... 51
Assessment of Mental Health Services in S.R.4/2019 .............................................. 55 Background ....................................................................................................................... 55 User experience of Mental Health Services ...................................................................... 55

Mental Health Strategy ....................................................................................... 55
Using Mental Health Services ............................................................................. 63

Priority Issues to be addressed ......................................................................................... 66

Leadership and Accountability ............................................................................ 66
Recruitment and Retention ................................................................................. 76
Mental Health Estate ........................................................................................... 84
Co-locating Services ........................................................................................... 94

Place of Safety .................................................................................................... 95
Parity of Esteem ................................................................................................ 108

Other areas to be addressed ........................................................................................... 110

Co-production ................................................................................................... 110
Partnership working .......................................................................................... 112
Role of General Practitioners ............................................................................ 114
Moving from CAMHS to Adult Services ............................................................ 120
Separation of Adult and Child Services ............................................................ 127
Models of Care .................................................................................................. 132
Transgender Pathways ..................................................................................... 138

Other Areas ................................................................................................................ 142

8.1 Off-Island Placements ............................................................................................... 142

Conclusion ................................................................................................................. 145 Appendix 1: Panel Membership and Terms of Reference ............................................. 146 Panel Membership ......................................................................................................... 146 Monitoring for Conflicts of Interest ............................................................................. 146 Terms of Reference ....................................................................................................... 147

Chair's Foreword

The first review by the Health & Social Security Scrutiny Panel following election was of Mental Health Services, which was launched in July 2018. It was felt by the Panel that a review of how the Mental Health Services had moved forward, and an assessment of whether the recommendations had been implemented should be the Panel's final review of this term of office. The Panel also felt that the impact of Covid-19 on the service should be included.

The sites were revisited, and further information gathered from third parties, and we thank them all for their contributions.

There will be a need for the future Minister for Health and Social Services and the future Chair of the Heath & Social Security Scrutiny Panel to continue to monitor Mental Health Services in order to ensure that Islanders are provided with the best possible care.

I would like to thank the other members of the Panel; Deputy Pamplin, Deputy Alves and Senator Mézec and, also, the Scrutiny officers who have worked tirelessly through the last four years to provide us with guidance and administrative support without whom it would not have been possible to produce such excellent quality reports.

Mary Le Hegarat

Chair, Health and Social Security Panel

Executive Summary

Shortly after the start of the 2018-2022 electoral term, in July 2018, the Health and Social Security Scrutiny Panel (the Panel) undertook a review Assessment of Mental Health Services' and later published its report (S.R.4/2019) in March 2019 which included 24 key findings and 21 recommendations.

Further investment was subsequently provided to Adult Mental Health Services (AMHS) per the 2020-2023 Government Plan (approved in 2019), including capital investment in the mental health estate in 2020.

As part of the scope of this review, the Panel wanted to assess whether the recommendations it had identified in S.R.4/2019 had been specifically addressed. The review has also considered the context of COVID-19 and other subsequent developments, such as the States Assembly's decision to pursue the Jersey Care Model approach and the publication of an Independent Review of Adult Mental Health Services in Jersey – which are part of the Health and Community Services' (the Independent Review) in November 2021.

In chapter 4 the Panel has considered the impact of the COVID-19 pandemic on mental health services. We learned that, whilst the pandemic has helped raise awareness for mental health and wellbeing, there are concerns that there has not been enough recent focus on people who suffer with serious mental illness. The Panel has suggested that the services should be reviewed as part of the next Government Plan, particularly outlining the support offered to people with severe mental illness.

The pandemic accelerated the establishment of some services, such as the Community Triage Team and the Home Treatment Team, however, the Panel was advised that there is further work required to embed these within a coherent community model of care, which is expected to be agreed by the end of April 2022. The Panel has recommended that the Minister publish further details about the community model of care and provide further details on the implementation and change process.

The Panel has also been made aware that the pandemic has impacted waiting times for the face-to-face community provision from AMHS. A backlog saw patients waiting longer for appointments, particularly for Jersey Talking Therapies and the Memory Assessment Service. This was due to the initial closure of some services at the start of the pandemic and, also, the subsequent redeployment and / or sickness of staff.

The Panel heard about the impact of the pandemic on carers when support services were changed and has recommended that the Minister engage with Carers Jersey to develop draft legislation for carers.

The pandemic has also been given as the reason for the delay of the replacement Mental Health Strategy and limited progress made with the Mental Health Improvement Plan, however, the Panel was advised that there are plans for a new strategy to be drafted during the course of 2022.

The Independent Review was published in November 2021 and the Panel explores the impact of this on AMHS in chapter 5. The Panel noted that a number of the findings from the Independent Report echoed those of S.R.4/2019. Furthermore, changes had been made to the management and leadership of AMHS, including the creation of a new role - the Director

of Adult Mental Health and Social Care. This appointment had invigorated the process of reviewing strategy and future direction for mental health services, including a staff engagement programme which is intended to receive their feedback on the requirements for key areas of change.

The Panel learned that AMHS has taken on large numbers of actions and that process of prioritising these, with consideration of the resources available to fulfil them is underway. The Panel recommended that this process is transparent, and details should be made available as to what is (and is not) taken forward.

The Panel learned that, as a result of the Independent Report, Adult Mental Health and Adult Social Care ceased the process of integration. At the date of the Panel's review the two care groups were operating separately, and a decision would be taken during summer 2022 regarding their integration. The Panel requests that an update is provided by September 2022, together with clarity about where the decision has been made.

In chapter 6, the Panel reviewed the intentions for the £500,000 of additional funding from the COVID-19 reserve that was assigned to AMHS following the amendment to the Government Plan for 2022-2025 (P.90/2021).

The Panel was not provided with a clear breakdown of how the funding would be spent but has recommended that it should be reported to the incoming Health and Social Security Scrutiny Panel by the end of September 2022, with specific details about how the funding will benefit frontline services and service users.

In chapter 7, the Panel has identified each of the 21 recommendations made in S.R.4/2019 and look at these individually in order to assess progress.

In overall summary, whilst an initial address to S.R.4/2019 was made with the Mental Health Improvement Plan, progress in developing faltered due to the pandemic priorities. The Panel is also concerned about the delays to some projects, such as Clinique Pinel, and the emergence of themes such as the lack of a coherent and coordinated approach – both with AMHS and between other government departments to tackle some of the bigger issues such as cost of living.

Key Findings

KEY FINDING 1: Service provision for Adult Mental Health Services (AMHS) was prioritised at the outset of the COVID-19 pandemic and a temporary reshaping of the AMHS community services during the COVID-19 outbreak was undertaken. This included the new Mental Health Liaison Team (also referred to later in this report as the crisis and community triage teams), and the new Home Treatment Team.

KEY FINDING 2: Responsibility for business and continuity planning for Adult Mental Health Services sits with the service line and plans are reviewed by the executive and the Health and Community Services Board.

KEY FINDING 3: The COVID-19 pandemic has helped raise awareness of mental health and wellbeing and has provided a focus on primary mental healthcare; however, it has impacted the replacement of the mental health strategy and progress of the Mental Health Improvement Plan. Moving forward, it has been suggested that the Adult Mental Health Service should refocus and provide targeted investment for severe mental illness (SMI) and that the new public awareness should be used as an opportunity to reduce stigma about SMI.

KEY FINDING 4: A written communication was provided to relevant staff in respect of the Emergency COVID-19 Mental Health (Jersey) Regulations, which amended (in April 2020) some of the existing statutory requirements set out in the Mental Health (Jersey) Law 2016 during the period between April and September 2020.

KEY FINDING 5: The COVID-19 lockdown and pandemic has significantly impacted the waiting times for, and the delivery of, existing face-to-face community provision of Mental Health Services, particularly Jersey Talking Therapies and the Memory Assessment Service.

KEY FINDING 6: The establishment of crisis prevention and intervention teams had been planned before the COVID-19 pandemic. The Community Triage Team and the Home Treatment Team were established by the Adult Mental Health Services team during the challenging circumstances of the COVID-19 pandemic lockdown and need to be reviewed as part of the new community model of care to establish optimum working.

KEY FINDING 7: Approximately 3,500 Islanders have accessed close to 11,500 appointments at the Listening Lounge (counselling service) since it was established in November 2019. There is little pre-pandemic data to use as a comparison for how COVID-19 specifically affected the demand and use of this service.

KEY FINDING 8: CAMHS caseload has increased from 800 children and young people in 2020 to just under 1,000 in 2022.

KEY FINDING 9: CAMHS has seen increases in referrals for eating disorders, self-harm, anxiety, depression and requests for neurodevelopmental assessments such autism and Attention Deficit Hyperactivity Disorder since the start of the pandemic.

KEY FINDING 10: CAMHS created inpatient support at the Meadow View facility for a small number of people during the COVID-19 pandemic, due to difficulties sourcing off-Island beds for children that required crisis in-patient care.

KEY FINDING 11: The creation of a CAMHS specific duty and assessment team allowed for quick screening of CAMHS referrals.

KEY FINDING 12: Face-to-face services were maintained by CAMHS throughout the period of lockdown.

KEY FINDING 13: CAMHS has used agency staff to meet operational requirements through the pandemic period. Following the approval of the Government Plan for 2022-2025, funding has been secured to redesign the CAMHS service and create additional permanent roles, for which recruitment has started.

KEY FINDING 14: Staffing levels are a factor in the delivery and provision of mental health services in all sectors and it is recognised that reduced staffing capacity – including due to COVID-19 related absence - has impacted waiting times.

KEY FINDING 15: In addition to patients and service users of mental health services, carers (often voluntary, or familial carers), have been impacted by the challenges and changes brought about by the COVID-19 pandemic when supportive services were closed or paused.

KEY FINDING 16: Communication to service users is vital – we have heard that there was poor communication from services through the pandemic and that some people have been negatively affected by wider government and media messaging.

KEY FINDING 17: At the outbreak of COVID-19 in 2020, an agreement with Adult Mental Health Services provided a Mental Health Nurse Practitioner to advise and work in partnership with the States of Jersey Police and the States of Jersey Ambulance Service.

KEY FINDING 18: The States of Jersey Prison Service relationship with Adult Mental Health Services is largely through the relationship with the Community Psychiatric Nurse. The relationship works well but there is little succession planning in place.

KEY FINDING 19: The Health and Social Security Panel was advised that the response time from the Community Triage Team to requests for urgent assistance from the States of Jersey Prison Service for mental health crisis has, in some instances, been several days.

KEY FINDING 20: The COVID-19 pandemic has not particularly impacted the States of Jersey Prison Service relationship with Adult Mental Health Services; however, it has increased the workload of the prison healthcare staff significantly.

KEY FINDING 21: Some of the recommendations in the Independent Review of Adult Mental Health Services in Jersey – which are part of the Health and Community Services' reflected similar findings and recommendations identified in the Panel's Assessment of Mental Health Services' (S.R.4/2019). These included the requirement for Adult Mental Health Services to have clear objectives and measurable outcomes. There were also themes around the importance of co-production and communication and review of the models of care.

KEY FINDING 22: Action was taken to change the leadership and management structure following the publication of the Independent Review of Adult Mental Health Services and the Director of Adult Mental Health and Social Care (a newly created role), became effective on Monday 10 January 2022.

KEY FINDING 23: Adult Mental Health Services had a plethora' of over 200 actions assigned to it following the previous Mental Health strategy, S.R.4/2019, and subsequently the Mental

Health Improvement Plan. A process of prioritising these, with consideration of the resources available to fulfil them is underway.

KEY FINDING 24: A mental health services staff engagement programme commenced in February 2022. One workshop has been undertaken involving 60+ staff and has specifically focused on developing proposed future models in 3 key areas.

KEY FINDING 25: Maintaining staff morale is important, especially when discussing challenges and change and professionals within the service have shown motivation to develop the service and dedication to their daily care roles.

KEY FINDING 26: Adult Mental Health and Adult Social Care are operating as two separate care groups, however, the overlap and interface between the two would be strengthened over a period of approximately six months (advised from 28th February 2022). A decision would be taken after that time as to whether integration of the services would be pursued further.

KEY FINDING 27: The Panel was not provided with an exact breakdown for the intended spending of the additional £500,000 of funding assigned to Mental Health Services as part of the 2022-25 Government Plan, however, it was confirmed that the majority of the additional £500,000 funding would be allocated to develop new clinical roles and increase capacity within clinical services, in addition to funding the role of Director of Mental Health & Social Care. The Assistant Minister for Health and Social Services indicated his preference that a portion would be assigned to services for people with Autism and the Panel was advised that there would be a consultant pharmacy role.

KEY FINDING 28: A Mental Health Improvement Plan was established in November 2019 to address the findings of S.R.4/2019, however, there is no current strategy in place for Adult Mental Health Services. There are plans to refresh the mental health strategy by the end of 2022 and publish a strategy for the next few years.

KEY FINDING 29: A mental health strategy with clear objectives will be a key factor for facilitating joined up partnership working. It will enable the creation of a supportive system of services that will, in turn, provide better care and outcomes for patients and service users.

KEY FINDING 30: The Panel has not found any evidence of outcome-based measures used by the Government to monitor its performance in relation to mental health, work on this had been incorporated in the Mental Health Improvement Plan but was ceased due to COVID-19 and resource challenges. No further annual Mental Health Quality Reports have been produced after the report for 2016/17.

KEY FINDING 31: A change to the management of mental health services and creation of the new role, Director of Mental Health and Adult Social Care, has initially invigorated the process to review strategy and future direction for mental health services.

KEY FINDING 32: A dementia strategy is being produced by the Government of Jersey, but not under the remit of Adult Mental Health Services (AMHS). AMHS will be a key partner in any dementia strategy.

KEY FINDING 33: Service users for AMHS have a number of ways to provide feedback about services, however, there are concerns that the way feedback is currently collected does not provide the opportunity to capture a full cohort of views. An annual community survey for mental health services patients will be undertaken in 2022.

KEY FINDING 34: Formal delegation of functions to an Assistant Minister, relating to the responsibilities for mental health services, has not been consistent since November 2020. Details about the delegation of functions by the Minister for Health and Social Services are available under individually searchable ministerial decisions, but are not easily accessible, or up to date, on the relevant page of the gov.je website.

KEY FINDING 35: The Mental Health Improvement Board (MHIB) last met in November 2020, however, its last minuted meeting was September 2020. The cessation of meetings was reportedly due to the COVID pandemic and was a decision taken by the Chair of the MHIB (the former Director General of Justice and Home Affairs) who has since left the employment of the Government of Jersey. A decision has been made to change the MHIB to a Mental Health Strategic Systems Partnership Board (MHPB) following the external Independent Review and this will be co-chaired by the Director of Public Health and the Director of Mental Health and Adult Social Care and is due to be established in April 2022.

KEY FINDING 36: The Panel understands that any long-term solution to recruitment and retention issues for Adult Mental Health Services (AMHS) will only be found following the successful co-ordination of different strands of work relating to planning and future modelling. For example, reviewing and potentially adjusting the workforce model for AMHS, the development of the community mental model of care and the development of the Jersey Care Model. The Panel believes that responsibility for this coordination and pressure to advance the workstreams should sit with the Health and Community Services Board.

KEY FINDING 37: The workforce model for Adult Mental Health Services (AMHS) will be reviewed for appropriateness, as it needs to be aligned with the models of care for AMHS and the wider reaching Jersey Care Model. There could be opportunities for existing job roles, such as Support Workers, to be expanded as part of the workforce review.

KEY FINDING 38: A Mental Health nursing degree can now be undertaken on-Island and it is hoped that this will create home grown talent. Clarity over the future provider for this degree is required.

KEY FINDING 39: Cost of living, particularly accommodation, remains a problem in Jersey and this impacts Adult Mental Health Services and Health and Community Services as it deters prospective candidates for key-worker roles from coming to live and work here.

KEY FINDING 40: The Department Strategic, Policy, Planning and Performance is undertaking a piece of work to address Government-wide problems (both immediate and long- term) relating to key-worker accommodation.

KEY FINDING 41: The Government does provide a relocation package for some workers moving to Jersey.

KEY FINDING 42: Orchard House is still being used to house the Adult Acute Assessment Unit, although the intention is for this to be short-term, until the new facility at Clinique Pinel is ready. Refurbishment work to address safety issues in Orchard House was started in October 2019 and completed by the end of 2020 – the work had been suspended for a time due to the COVID pandemic. A full Health & Safety audit has not been undertaken at Orchard House as follow up since 2018. However, assessments by the Jersey Nursing Assessment and Accreditation System (JNAAS) have been undertaken, which include a range of health & safety related indicators.

KEY FINDING 43: The Panel understands that Jersey Property Holdings is responsible for the property and engineering maintenance of the sites occupied by Mental Health Services, particularly, Rosedale House, Clinique Pinel, Orchard House and La Chasse.

KEY FINDING 44: Cedar Ward (on the first floor of Clinique Pinel) remains in operation through the building works at the site to extend the unit. There have been challenges faced by the clinical team on Cedar Ward and the contractor team at Clinique Pinel because of the ward's location adjacent to (and directly above) the current building works.

KEY FINDING 45: On completion, Clinique Pinel will also house Cedar Ward (the Older Adult Assessment Unit), the relocated Adult Acute Assessment Unit (currently in Orchard House) and a place of safety', which was added to the scope of the project in July 2019.

KEY FINDING 46: The building works at Clinique Pinel were originally due to complete in January 2022. This was extended to 25th May 2022 and has subsequently been delayed further.

KEY FINDING 47: Co-location of mental health services and physical health services has been planned as part of the site application for the development of a General Hospital at Overdale.

KEY FINDING 48: The place of safety used at present includes the Emergency Department and occasionally other locations within the General Hospital, the Police station, Orchard House, and Robin Ward (for children).

KEY FINDING 49: The place of safety currently in use does not provide suitable conditions for patients in crisis. Completion of the purpose-built site at Clinique Pinel has been delayed, likely until September 2022.

KEY FINDING 50: There are no plans to have a separate place of safety for children and young people. Clinique Pinel will be used as a place of safety for both adults and children and operating arrangements will be put in place to ensure appropriate safeguarding measures.

KEY FINDING 51: No specific detail has been confirmed about the location of the place of safety in the future (i.e. if mental health service are relocated to the new hospital campus), but the Panel understands that the intention would be to co-locate all the services on the new hospital site and move from Clinique Pinel.

KEY FINDING 52: Frontline emergency services, such as the States of Jersey Police and the States of Jersey Ambulance Service, are often called to attend incidents which are later logged under the umbrella' of mental health. Further work to enhance and review the relationship with the Community Triage Team has been suggested by both those emergency services.

KEY FINDING 53: If further triage support can be provided at the initial point of contact with the emergency services, this could facilitate a better patient experience – in that they will get to where they need to be quicker and will also reduce the pressure on other services and the General Hospital / emergency department.

KEY FINDING 54: Significant delays have been identified in dealing with individuals suffering from crisis – this has been identified to us by the States of Jersey Police, the States of Jersey Ambulance Service, and the States of Jersey Prison Service. The Director of Mental Health and Adult Social Care has advised that Adult Mental Health Services should work towards the

standard that anyone referred in a crisis should be seen for a face-to-face assessment within 4 hours.

KEY FINDING 55: People who are suffering from a mental health crisis, including those detained under Article 36 of the Mental Health (Jersey) Law 2016, are sometimes transported in inappropriate conditions (such as a caged police van) to the place of safety.

KEY FINDING 56: Valuing mental health and physical health equally with parity of esteem', remains a key concept, however, further work is required to ensure that this is embedded in practice across health care services.

KEY FINDING 57: The Panel has been advised that there has been some effort to undertake a co-production approach in the provision of mental health services, for example the Expert by Experience (EBE) meetings, but it has been acknowledged that there is the opportunity and desire for AMHS to do more. Training on co-production is available from the Jersey Recovery College.

KEY FINDING 58: The idea of "joined-up", coherent and co-ordinated services has been a common theme from charities and organisations who have contributed to the Panel's follow- up review of Mental Health Services.

KEY FINDING 59: The development of the Jersey Care Model and the review of sustainable healthcare funding will be key factors in the future costs of healthcare to patients. Patients seeing their GP for consultations about mental health are not provided with different fees to those who present with a physical problem.

KEY FINDING 60: There is now a monthly transition meeting between CAMHS management, senior CAMHS practitioners, adult mental health management and service users aged 17.5 years old, to discuss and plan transition arrangements from CAMHS to AMHS.

KEY FINDING 61: A draft transition policy for CAMHS service users is in place and is due to be ratified by Children, Young People, Education and Skills.

KEY FINDING 62: Schedule 1 of the Misuse of Drugs (Jersey) Law 1978 would need to be amended to allow a greater number of healthcare professionals to prescribe medication to Child and Adolescent Mental Health service users.

KEY FINDING 63: A Child and Adolescent Mental Health Services performance report will be available in early 2023, that describes service user casework, transition performance and feedback.

KEY FINDING 64: The Terms of Reference and a four-year programme of work have been developed for the Joint Peer Group which provides governance and oversight between the Department of Health and Community Services and Department of Children, Young People, Education and Skills.

KEY FINDING 65: Since the Panel's review, S.R.4/2019, several new services have been established for example a Listening Lounge' (through an outsourced contract) and a home treatment team and a community triage team have also been established through Adult Mental Health Services.

KEY FINDING 66: A coherent model of care has not been put in place for the Adult Mental Health Service. The Panel has been advised that different mental health services have different models of care, however, the final community model for mental health services will be agreed by the end of April 2022. This model of care will describe the overarching structure / delivery and objectives for community mental health services. When a new community model of care is adopted, there will be an implementation period that will include staff training and transition.

KEY FINDING 67: Work is being undertaken on a co-ordination of care framework which will assist with the care for individuals with complex and multiple needs from different services. This will be the equivalent to the Care Programme Approach (CPA) in the United Kingdom which was recommended by the Independent Review of Adult Mental Health Services in Jersey.

KEY FINDING 68: Health and Community Services has undertaken discussions with Liberate Jersey in relation to mental health pathways for transgender Islanders, has in place a contractual relationship and a draft business case with a London-based Gender Identity Clinic and a draft pilot gender clinic partnership between Liberate and the Jersey Youth Service.

KEY FINDING 69: £3,316,721 was spent on a total of 25 off-Island bed placements for Islanders with mental health issues in 2021. 5 of these beds were for prisoners.

Recommendations

RECOMMENDATION 1: The Minister for Health and Social Services should commit to reviewing the services and investment for people with mental illness as part of the next Government Plan. This should particularly outline the scope of services and support provided for people with severe mental illness in Jersey.

RECOMMENDATION 2: The Minister for Health and Social Services should engage with Carers Jersey in 2022 to develop draft legislation for carers. Work to develop the legislation should include, where appropriate, the parity of esteem concept, which will ensure that mental health and physical health are valued and treated equally.

RECOMMENDATION 3: The Minister for Health and Social Services should ensure that the work to review the community care model includes a detailed consideration of the service required by States of Jersey Prison Service (SoJPS), including succession planning for staff changeovers and illness. The Minister for Health and Social Services should also arrange for the implementation of a service level agreement between Adult Mental Health Services and the SoJPS. This should be implemented by the end of 2022.

RECOMMENDATION 4: The Minister for Health and Social Services should publicly share a structure chart of the management and governance structure for Adult Mental Health Services in an appropriate section of the gov.je website, which should be updated if / when Mental Health and Adult Social Care separate. The Panel suggest that this is in line with the recommendation made by the Comptroller and Auditor General (C&AG) Health and Community Services (HCS) Report and is supportive of this practice being used across HCS for transparency of public service.

RECOMMENDATION 5: The Minister for Health and Social Services should, by the end of December 2022, publish a document detailing the priority actions for Adult Mental Health Services (AMHS) including outcomes / measures. This should be incorporated into the new Mental Health strategy. For transparency and to maintain an accurate record, a document should also be published detailing the actions that will not be taken forward by AMHS at this time.

RECOMMENDATION 6: The Minister for Health and Social Security should provide an update to the Health and Social Security Panel, by the latest at the end of September 2022, in respect of the status of the review work that has been undertaken to consider whether the integration of Adult Mental Health and Adult Social Care can recommence. For governance purposes, it should be made clear where the decision about the future integration of the two care groups will be made.

RECOMMENDATION 7: The Minister for Health and Social Services should report to the incoming Health and Social Security Panel by the end of September 2022 to confirm how the £500,000 of additional Government Plan funding will be allocated within the budget for Mental Health Services and, also, identify how, or if, it has beneficially impacted frontline services and service users.

RECOMMENDATION 8: Adult Mental Health Services should document its position and any limitations of its input as a key partner' to the dementia strategy. AMHS should commit to

supporting and responding to the objectives developed by the dementia strategy and, when possible, incorporate these into the outcomes-based reporting for mental health.

RECOMMENDATION 9: The Minister for Health and Social Services should, on a quarterly basis, ensure that anonymised feedback from service users is published, together with up-to- date information about how co-production and accessibility have been addressed by Adult Mental Health Services in the period (for example, for service users who do not speak English as a first language, or others with communication or connectivity challenges).

RECOMMENDATION 10: The Minister for Health and Social Services should ensure that a patient advisory service is provided through an independent body to both in-patients and community patients of AMHS.

RECOMMENDATION 11: The Minister for Health and Social Services should ensure that the political responsibility for mental health services is formally recorded in an accessible way for the public. For example, a list of responsibilities or policy areas should be detailed on the government website. These areas of information should be reviewed, at a minimum every quarter, for accuracy. Furthermore, any delegations of responsibility or function to an Assistant Minister should be formally recorded by way of a Ministerial Decision as soon as possible. The Panel makes this recommendation in relation to mental health services but suggests that it could be considered across the Ministerial portfolio in the interest of transparency.

RECOMMENDATION 12: The Minister for Health and Social Services should ensure that the terms of reference, membership and reporting lines of the Mental Health Strategic Systems Partnership Board (MHPB) are made public. Health and Community Services should clarify the administrative support and resource that will be provided to the Chair and the MHPB so that it can fulfil its proposed function.

RECOMMENDATION 13: The Minister for Health and Social Services should provide the Health and Social Security Scrutiny Panel with details of any changes to workforce roles in Adult Mental Health Services, including the timeframe for change, by the end of September 2022.

RECOMMENDATION 14: The Minister for Health and Social Services should provide the Health and Social Security Scrutiny Panel with information on how all the workstreams within Health and Community Services relating to recruitment and retention of staff are being co- ordinated. This should be provided by the end of December 2022.

RECOMMENDATION 15: The Government should prioritise its work on keyworker accommodation. Whilst the Department Strategic, Policy, Planning and Performance may be leading the work, there should be increased Ministerial support to facilitate a joined-up solution to this problem across departments and secure appropriate funding.

RECOMMENDATION 16: The Government should consider trialling and funding specific incentive schemes to attract and retain key workers for Health and Community Services and target recruitment of skilled individuals in areas such as Mental Health. Incentives could be financially beneficial to the employee, for example, offering tuition reimbursement dependent on length of service, or providing payment to student nurses for shifts to assist with costs of living. Alternatively – or additionally – professional and personal benefits should also be explored, for example, developing links to educational establishments and research and innovation to enable professional development (making Jersey somewhere that people want

to come and work or gain experience), or leading on alternative initiatives that would be considered outside the box' for HCS, for example funding schemes that would support shift workers with childcare that suits their working hours.

RECOMMENDATION 17: The Government should review the adequacy of its relocation package and, where possible, collate specific feedback from both candidates who have accepted roles and candidates who have rejected roles and those findings should be reported publicly to the HCS Board.

RECOMMENDATION 18: The Minister for Health and Social Services and the Minister for Infrastructure should urgently, in May 2022, provide a joint update in relation to the completion date of the contract and the commencement of services at Clinique Pinel. Following the formation of a new Government, updates should be provided on a monthly basis until completion.

RECOMMENDATION 19: The transport of patients suffering from a mental health crisis, including those detained under Article 36 of the Mental Health (Jersey) Law 2016 (the MH Law) should be reviewed by the Minister for Health and Social Services, in collaboration with the emergency services, as a matter of urgency. The Minister for Health and Social Services should arrange for the Community Triage Team to be equipped with a suitably appropriate vehicle that would assist the SoJP and SoJAS with the transport of individuals in these circumstances.

RECOMMENDATION 20: The Minister for Health and Social Services should publish details of the separation and safeguarding arrangements that are to be established for the place of safety in Clinique Pinel. There should be clear lines of responsibility as to how the place of safety will be operated, including details about how Health and Community Services (HCS) professionals will work collaboratively together in any scenario where a young person is detained at Clinique Pinel under Article 36, or admitted there for treatment. The Children's Commissioner for Jersey should be consulted on the arrangements and given the opportunity to contribute. This should be actioned before the place of safety at Clinique Pinel becomes operational.

RECOMMENDATION 21: The Minister for Health and Social Services should consider whether a separate place of safety could be provided for children and young people in the medium to long term.

RECOMMENDATION 22: If Adult Mental Health Services do relocate to the new hospital location, the Minister for Health and Social Services should give consideration to the long-term use of Clinique Pinel, for example, as a separate mental health location for children in crisis.

RECOMMENDATION 23: The Minister for Health and Social Services must demonstrate that the refreshed strategy for adult mental health and the new Mental Health Strategic Systems Partnership Board utilise genuine co-production. Staff should be offered training in what co- production means and why it is important.

RECOMMENDATION 24: The Minister for Health and Social Services should review and propose an amendment to the Misuse of Drugs (Jersey) Law 1978 which would address the issues clinicians are faced with in relation to the prescription of medication for mental health services. Any amendment should seek suitable ways to ease pressure on the narrow

accessibility of the prescriptions process and, ideally, allow a wider remit of healthcare professionals to prescribe medication to patients.

RECOMMENDATION 25: The Minister for Health and Social Services should, by the end of September 2022, publish a document detailing the community model of care for mental health services and provide further details on the implementation and change process.

RECOMMENDATION 26: The Government should commit to retaining dialogue with Liberate Jersey about developing and improving the pathways for transgender people. Information about the progress of the pathway should be made public by the Government.

RECOMMENDATION 27: The Minister for Health and Social Services should arrange for an independent review of the commissioning process for the acquisition of off-Island beds in relation to mental health services and secure hospital support.

Introduction

The Panel's Follow-up Review

The Health and Social Security Scrutiny Panel launched a review Assessment of Mental Health Services' on 31st July 2018 and its report, (S.R.4/2019) was published on 6th March 2019.

The Panel has maintained an interest in the provision of Mental Health Services through this term of office and felt that it would be appropriate to revisit the review and formally report on the progress and change since S.R.4/2019 was published. The Panel launched its follow-up review on 1st February 2022.

The Panel is also conscious that, since S.R.4/2019 was published, there have been other significant changes to the wider context in which Mental Health Services are being delivered. This includes some very visible and tangible effects across all aspects of the community, most obviously, the immediate impact of the COVID-19 pandemic. Additionally, high level strategic decisions have been taken that will also directly impact the long-term delivery of Mental Health Services. This includes the decisions by the States Assembly to adopt the development of the Jersey Care Model (P.114/2020, debated November 2020) and the decision to change the site of the proposed new general hospital (P.123/2020, debated November 2020).

We have sought to provide a summary update of progress against each of S.R.4/2019's recommendations in chapter 7 of this report. However, before reviewing these in detail, the Panel wanted to examine how the pandemic had affected the provision of Jersey's Mental Health Services and impacted its service users. Our findings on the impact of COVID-19 on the provision of Mental Health Services are detailed in chapter 4.

Furthermore, in November 2021, Health and Community Services made public a report titled Independent Review of Adult Mental Health Services in Jersey – which are part of the Health and Community Services' (the Independent Review') which identified some key issues with the delivery of Adult Mental Health Services. The Panel recognised the importance of addressing this Independent Review and it is discussed in chapter 5.

Finally, the Panel wished to assess how the £500,000 of additional funding for Mental Health Services, as approved by Amendment 9 to the Government Plan 2022-2025 (P.90/2021) will be used. The Panel was pleased that its amendment, which was lodged amidst the context of concern about the pressure that Covid-19 was placing on services, was accepted by the Council of Ministers. This is addressed in chapter 6 of this report.

Background

As background, Jersey has a range of mental health services, delivered through primary and secondary care. Services are provided through the Government of Jersey's provision and, also, the independent sector, not for profit and charitable organisations.

For the purposes of this review Mental Health Services' will refer to the provision by the Government of Jersey. This includes Adult Mental Health Services (AMHS), through Health and Community Services Department (HCS) and Child and Adolescent Mental Health Services (CAMHS), provided through Children Young People Education and Skills

Department (CYPES). We have also taken the opportunity in this review to ask about the mental health service available to prisoners at H.M. Prison La Moye.

As per the relevant page on gov.je (accessed on 21st March 2022), AMHS as provided by Health and Community Services includes the following:

Orchard House: Adult Acute Assessment Unit
Cedar: Older Adult Assessment Unit
Beech: Dementia Assessment Unit
Clairvale: Recovery & Reablement Service
Adult Community Mental Health Team
Crisis & Home Treatment Team
Older Adult Community Mental Health Team
Older Adult Primary Care Mental Health Team
Older Adult Hospital Liaison team
Memory Assessment Service
Alcohol & Drug Service
Mental Health Legislation Team
Jersey Talking Therapies (JTT)
Psychological Assessment and Therapies (PATS)
Jersey Adult Autism Service (JAAS)

The scope and timescale of the Panels' review has not permitted it to look into each of the bulleted services above in great detail. It has instead focussed its review within the thematic sections outlined above.

Health and Community Services is now publishing indicators for mental health and social care as part of its quarterly report. The Panel has welcomed this approach and the commitment from the Minister and executive team for transparency, however we note the Comptroller and Auditor General's comments that "However, there continues to be limited benchmarking of services at a granular level in comparison to other jurisdictions"[1]. It is recognised that the new reporting is not intended to create a culture of blame but to help a constructive progress, and this is welcomed.

Methodology

Unlike the Panel's last review, we have not undertaken a large data gathering exercise, or survey to poll service users on their experiences of Mental Health Services. This report is intended to be a short and targeted review which will provide the public with information about Jersey's Mental Health Services and summarise what we have established are the plans for the future direction for the service. We hope that this report will be a constructive reflection and also provide a suitable handover of the subject to the next scrutiny panel.

The Panel held a public hearing with the Minister for Health and Social Services on Monday 28th February 2022. Additionally, because of the Panel's findings and recommendations relating to Child and Adolescent Mental Health Service (CAMHS) in S.R.4/2019 we also undertook a public hearing with the Minister and Assistant Minister for Children and Education on Friday 25th February 2022. The Deputy of St John is the Assistant Minister for Health and Social Services with responsibility for Mental Health and is also the Assistant Minister for Children and Education with political oversight responsibility for CAMHS and attended both hearings with the respective Ministers.

Following the public hearings, the Panel also received responses to questions in writing from both the Minister for Health and Social Services (2 letters sent, 1 combined letter response) and the Minister for Children and Education (1 letter).

The Panel undertook site visits (accompanied by the Minister and Assistant Minister for Health and Social Services) to Rosewood House, Clinique Pinel, Orchard House and La Chasse on 22nd February 2022. The Panel revisited Clinique Pinel with the Minister for Infrastructure on 4th April 2022. We were welcomed to the CAMHS office in St Helier on 24th February 2022 and also visited H.M. Prison La Moye on 6th April 2022.

The Panel has also received submissions from the Minister for Home Affairs in respect of the States of Jersey Police, States of Jersey Prison Service and the States of Jersey Ambulance Service as there is integral partnership workings between these services and AMHS.

The Panel also wrote to the Minister for Infrastructure to query the status of building work on the mental health estate, and we received a letter in response.

The Panel sent targeted letters to 25 relevant organisations to ask questions about the perception of Mental Health Services and the impact of COVID-19. We received 8 pieces of written evidence that the contributors were happy for us to share publicly. These are available to view here.

The Panel is grateful to everyone who has taken the time to contribute to our review.

As the Panel previously stated in S.R.4/2019, we recognise that Jersey's Island situation makes it difficult for people to access alternatives services for their mental health and we do not want to deter anyone from seeking help. This report has been drafted by Scrutiny in its capacity as a critical friend to the Government and we hope that it will offer insight into the quality of the service today and, if necessary, set out areas for improvement. Please view our findings and recommendations in this light.

The Panel emphasises that nothing you read in this report should prevent you from seeking help with your mental health, if you think you need it.

Impact of the COVID-19 Pandemic on Mental Health Services

The declaration of the COVID-19 pandemic by the World Health Organisation (WHO) on 11th March 2020, and subsequent local lockdown restrictions and mitigating public health measures has touched all sectors of Jersey's community.

As part of its follow up review, the Panel wanted to examine how the pandemic had affected the provision of Jersey's Mental Health Services, including the impact on service users and demand for the service. There is also a recognition that the COVID-19 pandemic raised awareness of mental health and wellbeing in the general population, and also created an increased demand for certain services, as many people faced new challenges and pressures. In their submission to the Panel's review, Mind Jersey advised that:

An overall increase in referrals to our children and family provision and our adult service suggest the effects on mental health is widespread and calls for a joined-up response to ensure easy and timely access to the best support.[2]

The scope of this review attempts to focus on the impact of COVID-19 on the provision of mental health services. Analysis of the appropriateness of the 2020-2021 COVID-19 response does not fall into the scope of this review therefore the Panel will not comment on that aspect at this time.

Initial actions of Adult Mental Health Services in the COVID-19 pandemic

The Panel sought to understand what the action plan and priority was for Adult Mental Health Services (AMHS) at the start of the COVID-19 pandemic in March 2020. The Chief Nurse, Health and Community Services, advised the Panel in a public hearing that:

Chief Nurse, Health and Community Services:

. So just in relation to the outset of COVID and when it first hit Jersey, our main priority at that time was to make sure, first of all, that we were prioritising service provision, so those in most need of services still had access to services, but also that we were very clear in relation to our workforce numbers and our overall bed base. If you remember at the time, the forecasting for COVID impact in Jersey overall was predicted that potentially we would need to increase our inpatient bed base across our whole environment and that included mental health beds as well. So our initial focus was very much on working with mental health services to make sure those in most need of services still had access to services and where possible face-to-face appointments could be held as well. In terms of the specific detail, I would need to go back and refresh that. We would need to provide something in writing to the panel.[3]

As a follow up to the public hearing, the Panel sent a letter to the Minister for Health and Social Services to see further detail about the timeline and detail within the action plan for AMHS at the start of the COVID-19 pandemic. The Minister's response explained that:

Minister for Health and Social Services:

An initial set of actions were undertaken in late March 2020 as the HCS Covid response arrangements were being developed in detail and the Gold command structure was established. This included a reconfiguration of operational responsibilities across mental health services, PPE / infection prevention arrangements, and revised arrangements for service delivery – including the identification of priority services and redeployment of some staff to sustain these.

These were further developed and a detailed Temporary reshaping of Adult Mental Health Service community services' document was formalised in 2020.[4]

The Panel was provided with a copy of the Temporary reshaping of Adult Mental Health Service community services' document in confidence as part of this review. To briefly summarise, the document provides details about the lines of reporting and organisational structure (including naming responsible persons for contact purposes) under the COVID-19 service provision and provides further detail about the newly established Mental Health Liaison Team (also later referred to in this report as the Crisis Team and the Community Triage Team), including contact details and flow charts to describe how a patient would move through this service. There are also details about the Home Treatment Team, the Mental Health Contact Team, and messages from community partners.

The Panel has not been provided with details about how widely this document was distributed within the AMHS staff, or the date of any circulation. The document is also titled as a temporary reshaping', however, it has not been confirmed to the Panel if the document has since been superseded or replaced, or whether any of the temporary structure has been adopted permanently.

We were not provided with any specific details about the action plans for inpatient AMHS.

Governance

The Panel wanted to understand how decisions were made for AMHS during the COVID-19 pandemic.

Deputy C.S. Alves :

... Where does the responsibility for the business and continuity planning sit in the structure of H.C.S.? Is it at board level or within individual service management?

Chief Nurse, Health and Community Services:

It sits at service level. So within individual service management they were responsible for developing those plans but as the executive and the board, we would have to have oversight of those plans to ensure that they were appropriate.

The Director for Mental Health and Adult Social Care also advised the Panel that it was important to remember the context at the start of the pandemic for the health service, as it was entering into new territory:

Director for Mental Health and Adult Social Care:

I think it is really important to remember that at the start of COVID every health service everywhere was operating in an entirely new situation and without a manual. No one really knew exactly what to do, so anything that any service did I would contextualise by saying people were doing their absolute best at the time to maintain safety. There were lots and lots of concerns about particularly physical contact with people. So the mental health services really quickly did a R.A.G. (red, amber, green) rating assessment of the services that they provided, what they needed to carry on providing as an absolute priority, and that included the inpatient services, 24 hours services and access services, the points at which people would come into the service, and community services.[5]

The Panel had asked for details of changes to the HCS risk register and any Red/Amber/Green ratings in its letter to the Minister for Health and Social Services, but these were not provided.

Amongst other things, the Mental Health Improvement Board (MHIB) had been set up to introduce good governance in support of the identified improvements and to support the senior leadership team'[6] however, as evidenced further in section 7.3 in this report, the MHIB ceased to meet in November 2020 reportedly due to the COVID pandemic and the Panel received a number of submissions which reflected that this had hindered strategy and partnership working. The Panel is concerned that a significant governance function for AMHS was stopped during a time when its reported function and purpose would be needed in the pandemic emergency.

Impact of the COVID-19 pandemic on the strategy for Adult Mental Health Services

The Government Plan 2022-2025 (debated and approved by the States Assembly in December 2021) stated that:

The impact of Covid-19 on Islanders' mental health cannot be overlooked. We continue to commit to delivering services that will most effectively meet the needs of people with mental health conditions as well as those whose mental wellbeing has been adversely affected during the pandemic. Our Mental Health improvement plan is progressing well and will continue in 2022 with the aim to embed improvements to mental health services, ensuring we deliver the best care and support.[7]

As explained later in the report (in section 7.1), a successor to the Mental Health Strategy 2016 – 2020 was not drafted due to the COVID-19 pandemic. A Mental Health Improvement Plan (the Improvement Plan') was drafted in November 2019 following the publication of S.R.4/2019. Health and Community Services have reported [8] that progress has been made, however, the Improvement Plan has not been published.

In a submission to the Panel as part of this review, the Jersey Recovery College advised that the pandemic had a negative impact on the work to improve mental health services:

There has not been as much progress made as we all would have liked on systemic improvement, the Pandemic has been hugely derailing.[9]

The Panel has received submissions from organisations which indicate their experience and observations that individuals suffering from severe mental illness have been deprioritised during the COVID-19 pandemic. Focus on Mental Illness advised that:

"Covid-19 has promoted public health measures in the general population and resources have been allocated to early intervention for mild to moderate mental health problems. However, its impact on those affected by SMI [severe mental illness], a vulnerable population, is less addressed and there is a big gap in terms of the resources available. There doesn't seem to have been any recognition of the importance of early intervention for those affected by SMI, and the risk and costs when we don't get it right. Targeted investment in early intervention for those affected by SMI will prevent further deterioration of mental health, relapse, and reduce the burden on family, the wider community, and mental illness services."[10]

This was echoed in a submission from Mind Jersey who said:

Currently it appears as if the adult mental health (AMH) service is acting as an emergency service with little time for delivering early intervention for people with high level needs.[11]

In a public hearing, the Panel asked the newly appointed Director for Mental Health and Adult Social Care for his assessment on mental health services in Jersey. As part of the response, he indicated that COVID-19 had focused mental health care on lower severity issues and primary health care, and suggested that focus should return to those with more severe illness:

Director for Mental Health and Adult Social Care:

I would personally say that we need to refocus slightly. We need to hear more about serious mental illness and the needs of people who have illnesses like schizophrenia. I can absolutely understand post-COVID - and this is true in most jurisdictions - there has been a surge of activity around primary mental health care, around people who have low-level anxiety and so on, but what we must not do is over-focus on that and forget about the people with the severe and enduring long-term mental illness because they are often the people who have the greatest needs but also the quietest voice in terms of having their needs met.[12]

There is an important distinction between mental health and mental illness. The submission to the Panel from Mind Jersey also suggested that the pandemic could provide an opportunity to educate and inform people about this and to begin to reduce the stigma about mental illness:

Our collective community response provides a real opportunity to reduce stigma and build a more hopeful narrative around mental health and illness. The pandemic has created opportunities to begin an Island wide joined-up education and awareness campaign around the similarities and differences between mental health, mental illness and wellbeing. Communities of people expressing collective fear and stress about a virus is a very good example of how it is perfectly normal and ok to feel anxious when presented with a threat, but that not everyone who feels anxious has an anxiety disorder.[13]

Emergency Powers

Another impact of the COVID-19 pandemic was the unprecedented approval of various emergency powers. The Emergency COVID-19 Mental Health (Jersey) Regulations (the Regulations') were approved by the States Assembly in April 2020 and can be viewed here P.46/2020.

The Regulations amended some of the existing statutory requirements set out in the Mental Health (Jersey) Law 2016, in order to support continued delivery of mental health services to people who are a risk to themselves or others during the Covid-19 period [14].

The Regulations could only be used if the Minister declared an extraordinary period' (and this was never actioned), however, had included powers in relation to; changes to the individuals who could authorise emergency admissions; the length of time that emergency admissions could be extended; an increase to the time individuals could be detained by a nurse; removal of the requirement for a second opinion approved doctor; the powers of court in relation to accused persons suffering mental disorder; and, conveyance of accused or convicted persons to hospital.

The Panel had reviewed the regulations prior to their adoption and, despite concerns, had provided support for their adoption as they were intended to address and assist with the potential significant pressures on the Island's healthcare system in the pandemic crisis.

Whilst it was never necessary for the Minister to declare an extraordinary period', the Panel wanted to establish what communication had been provided to front line staff about the new powers and any guidance or training they received in the event that these powers were ever required. We were advised:

A written communication was provided to relevant staff in April 2020 which set out that the amendments had been passed and the process by which these would be enacted. A summary of the amendments was also attached as part of the briefing, and these were discussed within team meetings to increase awareness.

Due to the nature of the amendments – and the small number of professional staff involved – it was not considered necessary to provide training.[15]

Impact of Lockdown

Broadly, in relation to the impact of the COVID-19 pandemic on the prevalence of mental health symptoms and mental disorders, research evidence referenced by the World Health Organisation noted that "though data are mixed, younger age, female gender and pre-existing health conditions were often reported risk factors". There is a reflection of this locally, as Mind Jersey's Lockdown Stories found that "people with pre-existing mental illness, young people, women working from home and marginalised communities were among the most likely be negatively affected"[16] by the COVID-19 lockdowns.

In a public hearing the Panel asked for details about how mental health services adapted and were impacted during the COVID-19 lockdowns in 2020 and 2021. The Director for Mental Health and Adult Social Care advised that services and staff resources were prioritised at the start of the pandemic, which resulted in a reduction of face-to-face contact and services:

Director for Mental Health and Adult Social Care:

the mental health services really quickly did a R.A.G. (red, amber, green) rating assessment of the services that they provided, what they needed to carry on providing as an absolute priority, and that included the inpatient services, 24 hours services and access services, the points at which people would come into the service, and community services. Some other services were reduced or for periods of time temporarily stopped in order to facilitate that and that was predominantly a staffing issue. There was a need to move staff around in order to maintain those services in a safe way. That is entirely normal. That was the case in any health system anywhere in their initial response to COVID. I think the consequence of that was that there were a group of people who had less direct face-to-face contact than they would have had ordinarily. A lot of staff did not work. They were working remotely for a period of time and consequently some of the contact, the mental health contact, was done virtually and that was new. That was something that had not happened before, so it took a bit of time for the service to adapt to that but they did that well, I think, is my assessment of it.[17]

The Director also explained that the AMHS had to adapt to new physical care challenges facing its patients and it did so in an exemplary way:

Director for Mental Health and Adult Social Care:

I think there were really quite significant changes that they had to make to the delivery of some of the core services. So in the inpatient setting, for example, the first person to die of COVID on the Island was in the mental health service, so mental health nurses, who normally look after people with psychiatric illness were suddenly nursing folk with infection prevention measures in place, physical health issues that they might not have otherwise dealt with. The way that the service adapted to manage that I think again is exemplary, frankly, and they have managed infection prevention well subsequently. There has certainly been an impact.[18]

The Panel wanted to clarify which services were impacted during the COVID-19 lockdown and learnt that this significantly impacted the face-to-face community services provision of AMHS:

Senator S.W. Pallett:

Can you be clear about which services stopped, which services temporarily were suspended and what you did to support people that had their service or their treatment curtailed at very short notice?

Director for Mental Health and Adult Social Care:

I do, of course, have to caveat this by saying I was not here, so I am relying on the information that has been provided to me. I understand that some of the direct face-to- face community services were temporarily suspended, particularly the Jersey Talking Therapies, the Listening Lounge and there was a reduction or change in the way that, for example, the Memory Assessment Service worked. I will use that as an example because it is a good example, that because of the frailty of the population that will be worked with by the Memory Assessment Service there was a significant reduction in face-to-face contact. The service continued to provide some support to people virtually and there was some direct contact but they were not able to do diagnostic work as part of their normal routine work because you have to do that in a face-to-face way. But I would say again this is absolutely consistent with any mental health system that I am aware of.[19]

Memory Assessment Service

As referenced above, the Memory Assessment Service had to change its way of working and reduce face-to face appointments. The submission to the Panel from Dementia Jersey highlights the impact that the COVID-19 pandemic, and lockdown backlogs, have had on the service:

We understand that the Memory Assessment Service (MAS) was suspended at the height of the pandemic and staff were re-assigned. For over a year now there have been significant backlogs as a result and the waiting time for an appointment at the MAS now is around 9 months according to our clients. As at mid-February MAS estimated that they have 135 patients waiting to be seen. 36 of those will be seen within six weeks (referral to diagnosis) established by the Royal College of Psychiatrists. The other 99 are outside the 6 weeks and they are working on triaging those 99 individuals and allocating cases accordingly to level of impairment, risks, etc. to other medical colleagues within the Older Adults Mental Health Team.[20]

Jersey Talking Therapies (JTT)

The Panel received a number of submissions which referred to the closure of JTT in the initial lockdown in 2020:

During the initial lockdown Jersey Talking Therapy was closed down - this was very disappointing and difficult to understand as if there is any health service most suitable to virtual/phone delivery psychologic services are surely it. This abandoned the very people to be most affected by the lockdown and caused significant harm.[21]

The Panel was informed that a number of staff from JTT were redeployed into the COVID wellbeing support team:

Director for Mental Health and Adult Social Care:

a percentage of therapists from Jersey Talking Therapies were seconded very quickly in COVID into the wellbeing support offer. That reduces the impact, that reduces your capacity within the service, but other than that I cannot give you a factual answer as to why that was reduced other than to say again that is very, very common with all mental health systems that I know. There was an absolute requirement to redeploy staff and resource into front line and 24-hour services to maintain the safety of those services.

Senator S.W. Pallett:

How long before there was re-engagement with clients after the service was suspended? Director for Mental Health and Adult Social Care:

My understanding of all of the services is that service people were R.A.G. rated. There was an assessment undertaken by the service of the level of input and intervention that the service user would need. Some people maintained contact over the telephone, some people did not have direct therapy, formal therapy, but they had a contact offer and a support offer, and some people, I understand, waited. What I do not have is the detail of which numbers of people were in those brackets but there was always maintained through the COVID period direct access to services available. So if people were waiting, for example, for counselling but their position changed or deteriorated there was absolutely and always the opportunity for people to be seen, reassessed and to receive a higher level of input if that was required at the time.[22]

The Panel was also advised in the submission from Liberate Jersey that their organisation was utilised to help bring down the waiting times for JTT:

We were involved in a piece of work with Government in August 2020 to bring down the waiting times for accessing JTT. This realigned JTT's offering so it was seeing the higher level cases, in recognition of the fact that other service providers were able to see lower level cases. It also formed the Mental Health Network that enabled all service providers in the network to cross-refer and clients to self-refer. This work brought the waiting times down significantly at that time.[23]

Increased demand for Services

The Health and Community Services quarterly Quality and Performance reports (Q&PR), which were first published in June 2021, indicate activity numbers and trends for certain parts of the AMHS. A snapshot of the Q&PR from June 2021 is provided below:

We have not done a detailed analysis of the activity reports, but from this it is possible to see the points for peaks in numbers for the JTT service.

In a submission to the Panel from the charity, Focus on Mental Illness, the Panel was informed that:

The evidence from service providers, including ourselves, would indicate that there is a greater need for support for islanders' general mental health. More people are becoming mentally ill due to stress and the Covid-19 pandemic has tapped into a lot of vulnerability. The impact of Covid, in terms of the increase demand for mental illness services, has placed even more pressure on a service already in crisis. People affected by SMI [severe mental illness] report that the "uncertainty and limitations" imposed as a result of Covid-19 has increased their general anxiety levels.[24]

With reference to the waiting list backlogs in the AMHS the Panel was advised that a recovery plan was in development to respond to the demand:

Director for Mental Health and Adult Social Care:

As with any service, where things are shut down temporarily then you end up with a bit of a backlog. So we know that in some of our services we have got a backlog around particularly psychological therapies and again in line with any health system anywhere we are having to develop recovery plans to say how will we now deal with that backlog and make sure that people get seen in a way that is appropriate and as quickly as possible within the limitations of the resource that we have got.[25]

It was identified that whilst AMHS had significant backlogs, the patients often sought assistance from charity providers. Mind Jersey advised that:

Waiting list have expanded again for talking therapies and people are frequently accessing Mind trainee counselling provision whilst waiting for appointments.[26]

The demand for Mind's peer support programme, in relation to perinatal mental health support, was also referenced in the submission by the Maternity Voices Partnership who indicated that there was a 4-month waiting list for this service after it launched.[27]

Establishment of the Community Triage Team / Home Treatment Team

As referenced above, at the start of the pandemic, the Adult Mental Health Services produced an (unpublished) Temporary reshaping of Adult Mental Health Service community services' which included details of a new Mental Health Liaison Team and Home Treatment Team (HTT).

The Mental Health Liaison Team is also referred to as the Crisis Team' or the Community Triage Team (CTT)' in evidence collected by the Panel. We will refer to it as the CTT.

The Panel is aware that the Government Plan 2020-2023 had included plans and a business case for further crisis support and, therefore this was in the pipeline of expected projects for the service. Because of the pandemic, plans were escalated and adapted accordingly.

In a public hearing with the Minister for Health and Social Services, when asked about the impacts of the pandemic on services, the Assistant Minister for Health and Social Services advised that:

Assistant Minister for Health and Social Services:

Certainly we were not able to provide all of the services that we would have liked to during that period, for obvious reasons, but out of the ashes rose a phoenix because we were able to increase our community support network and move staff into the community to make the lives of people with mental illness much steadier.[28]

This was echoed by the Director for Mental Health and Adult Social Care, who praised the establishment of the CTT and HTT teams in the pandemic circumstances:

Director for Mental Health and Adult Social Care:

In the midst of all of this stuff, the service managed to pull together quickly and implement a crisis and home treatment team, which is remarkable, frankly, from my perspective and really should be applauded. So there was a step in the middle of the crisis pandemic that led to the development of a more coherent model for people in crisis and in the community.[29]

The Panel asked for more details about this workstream:

Deputy C.S. Alves :

You mentioned there the establishment of the crisis and home treatment team. Are you able to give us a bit more of an overview, including plans for it in the future as well?

Director for Mental Health and Adult Social Care:

Yes, certainly. If we separate out the 2 components, the crisis team provides a quick response for anyone that is in crisis and at the moment that is predominantly people who are either referred into the community services, people who are referred by the police, particularly around things like Article 36 but also other folk that the police are concerned about; anyone where there is a crisis and it is felt that we need to undertake an assessment quickly to work out what is happening. That team is available 24 hours a day, 7 days a week for adults and our plan at the moment ... we are having 6 conversations with C.A.M.H.S. (Child and Adolescent Mental Health Service) as to how we start to develop in the C.A.M.H.S. arena and possibly work the 2 services together in some way. The other component part of the service model is home treatment and that is really important for a couple of reasons, firstly because we know that lots of people who historically were admitted to hospital did not need to come into hospital and do not want to come into hospital. They can be treated at home and I will give an example. Historically people were admitted because they needed to receive medication twice a day but now the home treatment team can go out and administer medication twice a day if required, so you can maintain people at home if it is clinically safe to do so and that is terribly important because, of course, we do not want to take people to hospital unless we absolutely have to. That is part of the whole community model. It works closely with the liaison service where people are in hospital and have mental health needs and that has developed in the last couple of years but also with the generic community mental health team, so the mainstream mental health services in the community. We are currently in the process of reviewing that community model because one of the things that has happened, I think inevitably, is that as services have developed particularly quickly they have not necessarily tied in well together. We have the services but we do not have a service that works in a coherent way all together as one system. I described it the other day as it is a bit like having a jigsaw where the pieces just do not quite fit together. We have started a piece of work, which we started 2 weeks ago and will complete at the end of March, redesigning our community model so that we are much clearer about what crisis does, what home treatment does and how we make sure that wherever possible we maintain people in the community unless they need to come into hospital and then of course they will come to hospital.[30]

The establishment of the CTT and the HTT has been highlighted as a success for AMHS which has resulted from the pandemic circumstances. The Panel has noted that new services such as crisis prevention and intervention' teams had been planned as additional investment since 2019 (pre-pandemic), however, the pandemic accelerated the plans and establishment of the teams.

The Panel notes comments from the Director for Mental Health and Adult Social Care relating to how the quick development of the community services, such as the CTT and the HTT has impacted the coherency of the system. The community model of care is being reviewed by AMHS (and is discussed further in section 7.14).

Listening Lounge

The impact of certain AMHS services closing had a knock-on effect for other third-party organisations and service providers such as the Listening Lounge.

The Listening Lounge is a free to access counselling and peer support service which was launched in November 2019. It is run by L.I.N.C Mental Health and Wellbeing and is supported with funding from the Government of Jersey.

Between November 2019 and February 2022, the Panel is advised that approximately 3,500 Islanders have accessed 11,500 appointments at the Listening Lounge.[31] Due to its date of establishment, there is little pre-pandemic data to use as a comparison for how COVID-19 specifically affected the demand and use of this service.

In its submission to the Panel, the Service Lead at the Listening Lounge advised about the key issues presented by patients at the Listening Lounge during the COVID-19 pandemic:

Depression, anxiety, and stress have consistency been the most common presenting issues throughout. For many people visiting us, it has been the first time they have experienced a difficulty relating to their mental health. In terms of other key issues, the leading reported concerns month to-month have been loneliness & isolation and the impact of covid, followed by relationship difficulties, concerns around employment and financial worries.[32]

However, the Panel was also advised that the issues presented to the Listening Lounge during the periods of COVID-19 lockdown were different. There was reportedly an increase in volume of cases and a change in the types of difficulty presented:

The provision of Mental Health Services has been greatly affected by Covid-19, particularly during periods of lockdown when the delivery of some services was disrupted, and others closed entirely. At these times we saw not only an increase in demand, but a change in the types of difficulties experienced by those contacting us, with a greater number of people seeking support for thoughts of suicide, self-harm, eating disorders, historic trauma, and psychosis.[33]

The Panel received submissions which referenced the establishment of the Listening Lounge as a positive change, as it provided an early intervention mental health service. The submission provided to the Panel on behalf of the Primary Care Body indicated that:

The provision of the Listening Lounge has been a considerable improvement in mental health provision for milder conditions and to fill the gap whilst patients wait for Talking Therapy input. This service has in general been well received and many patients find brief interventions from peer support or simple counselling to be all that is required to get them back on track.[34]

The Listening Lounge also highlighted in their submission that the pandemic had changed people's availability for access to services during usual working hours and advised that they had subsequently had to adjust their capacity to accommodate more flexible accessibility times for service users:

A further impact of Covid-19 relates to opening hours and capacity at different times throughout the day and week. For many, working from home meant greater flexibility during the day and for a period we saw an increase in daytime availability and demand for support during the traditional working week. As restrictions have eased and many have returned to usual working environments it has been necessary to shift some resource to ensure there is appropriate capacity during evenings and at weekends."

Access to General Practitioners (GPs)

During the COVID-19 Pandemic, the States Assembly approved Draft COVID-19 (Health Insurance Fund) (Jersey) Regulations 202-' (P.45/2020) which saw an agreement between Health and Community Services and GPs to secure GP services during the pandemic (initially for a period of four months). For the agreement period there were also fixed fees for certain services and no patient charges for Covid-19 related activities.

This point is not exclusive to mental health services, however, it is relevant to note as individuals may approach their GP with concerns about their mental health or mental illness and they can act as a gateway for early intervention or referral to other services.

CAMHS: Impact of COVID-19

As referenced above, there is evidence that young people and people with pre-existing mental illness were amongst the groups that were most likely to be negatively impacted by lockdown. The Panel also references the Children's Commissioner for Jersey's report, Covid-19 Response: Impact on Children and Young People' which states that:

Our survey showed that children with pre-existing mental health needs were disproportionately affected as some services were impacted due to the pandemic making it harder for children to access support. School closures meant that the normal mechanisms in place to support children were no longer there.[35]

In order to gather evidence about the provision of mental health services for children and young people in Jersey, including the impact of COVID-19 on CAMHS, the Panel decided to invite the Minister for Children and Education to a public hearing on 25th February 2022.

During the public hearing, the Panel asked about the impact of COVID-19 on CAMHS during the period of mandatory COVID-19 restrictions in 2020 and 2021. The Head of Children's Health and Wellbeing, CYPES (Head of Children's Health and Wellbeing), informed the Panel that year-on-year increases in CAMHS referrals had resulted in a caseload of just under 1,000 children and young people in 2022, up from 800 in 2020:

Deputy Mary Le Hegarat :

"Please could you provide the panel with an overview of how C.A.M.H.S. was affected operationally during the COVID-19 lockdowns in 2020 and 2021?"

Head of Children's Health and Well-Being:

"has been a growing prevalence of mental health issues of children and young people, and we have seen growing prevalence here in Jersey and elsewhere in terms of referrals to services. During the COVID pandemic and lockdown this has been accelerated considerably. So in 2021 C.A.M.H.S. received 855 referrals, which was up from the 683 in 2020 and 661 in 2019. At the same time the caseload has risen to just under 1,000 children and young people currently, up from 800 in 2020."

KEY FINDING 8: CAMHS caseload has increased from 800 children and young people in 2020 to just under 1,000 in 2022.

The Head of Children's Health and Well-being observed that similar trends had taken place in the UK, with the number of children and young people aged 5-16 years old presenting with a mental health disorder rising from one in 9 in 2017 to one in 6 in 2021:

Head of Children's Health and Well-Being:

"These trends have been seen in other jurisdictions as well, with data from N.H.S. (National Health Service) England showing the number of children and young people aged 5 to 16 presenting with mental health disorders has risen from one in 9 in 2017 to one in 6 in 2021."

The Panel learned that Jersey had seen increases in referrals for eating disorders, self-harm, anxiety, depression and increases in requests for neurodevelopmental assessments such autism and Attention-Deficit-Hyperactivity-Disorder:

Head of Children's Health and Well-Being:

"we have seen an increase in referrals for eating disorders, for self-harm, for anxiety and depression, and also increases in the number of requests for neurodevelopmental assessments such as autism and A.D.H.D. (attention deficit hyperactivity disorder)."

In summing up the impact of COVID-19 on CAMHS, the Head of Children's Health and Wellbeing advised the Panel that CAMHS had faced difficulties sourcing off-Island beds for children that required crisis in-patient care, and that this had resulted in the creation of the Meadow View in-patient facility at short notice:

Head of Children's Health and Well-Being:

"The other problem we had during the pandemic and lockdown was securing beds off- Island for children who needed crisis inpatient care. So the service created Meadow View at very short notice, which provided some inpatient support for a small number of people during the pandemic, which was not easy and was not without its challenges but it kept a number of young people safe and gave them the treatment they required."

The Panel sought more information about how CAMHS had adapted its services during the periods of lockdown caused by COVID-19, and learned that the creation of a CAMHS specific duty and assessment team allowed for quick screening of CAMHS referrals:

Deputy Mary Le Hegarat :

"How did you adapt your services while we were in lockdown?" Head of Children's Health and Well-Being:

"I think one of the most helpful things that was done was the creation of a specific duty and assessment team within C.A.M.H.S. That was managed with some COVID monies that were identified and the recruitment of a number of agency nurses from off-Island. The ability of having a dedicated duty team meant that certainly referrals were screened quickly."

KEY FINDING 11: The creation of a CAMHS specific duty and assessment team allowed for quick screening of CAMHS referrals.

The Panel asked about the provision of face-to-face CAMHS consultations during the COVID- 19 lockdown, and was advised that whilst these had been subject to adaptations, such as virtual therapy and check-ins, the provision of face-to-face consultations had continued throughout lockdown:

Deputy Mary Le Hegarat :

"So were you able to still do face to face consultations?" Head of Children's Health and Well-Being:

"Yes, absolutely. Obviously, a number of children and young people that get referred to the service are experiencing some considerable difficulties, so it still relies on our staff, as it would do in other nursing staff in the general hospital, to still continue with direct contact. Where possible the service adapted and some therapy and some check- ins and some other appointments were done through more virtual means."

KEY FINDING 12: Face-to-face services were maintained by CAMHS throughout the period of lockdown.

COVID-19 impact on staff numbers

During the course of its review the Panel heard about the wider challenges around the recruitment of specialist staff for mental health services (this is explored further in section 7.4).

In a public hearing with the Minister for Children and Education we learned that, during the COVID-19 pandemic, CAMHS had been relying on agency staff to operate. We were advised that CAMHS had 30 permanent staff, 6 agency nurses and 2 locum psychiatrists and, following the CAMHS redesign, there were 9 additional permanent roles being advertised. The Head of Children's Health and Well-Being advised that:

Head of Children's Health and Well-Being:

I think to date the service has been reliant on agency staff, particularly through the pandemic in terms of trying to produce capacity. There was reliance on recruiting agency type staff from the U.K. Now the Government Plan monies are in place from 1st January we are looking to replace all our agency staff eventually with permanent members of staff.[36]

The Panel was provided with assurance that there had been good responses to the (seventeen) job adverts and that there would be interviews held for each available post.

In addition to recruitment challenges in finding and attracting staff, the Panel was also aware that illness and isolation requirements due to COVID-19 had also impacted staffing numbers across different services and sectors. In a submission to the Panel, the Jersey Recovery College advised that:

All services – statutory, private and third sector - are still being impacted by staff absences due to COVID. We are hearing from our service users that it has been more difficult to speak to adult mental health and we have found it difficult to secure private therapists to support our team.[37]

The exception reports detailed in the Quarterly and Performance Report prepared by HCS indicate that, inter alia, reduced staffing capacity (related to sickness, vacancies and leave) has been a factor in increased waiting times for AMHS services such as JTT.

The submission to the Panel by Focus on Mental Illness also reflected that:

Service users observe an exhausted and overstretched workforce, poor working conditions, and staff that openly express their desire to do more for their service users.[38]

Impact of Lockdown on carers

The COVID-19 pandemic has also highlighted the role of carers in the support they provide to patients, which was exacerbated by closure of services, or staff unavailability due to sickness. The Panel notes comments made in the Carers Jersey (CJ) strategy, Dare to Care', which stated that:

The Coronavirus Pandemic was especially difficult for many Carers in Jersey. They provide unpaid care to family or friends at home and many support services closed leaving them alone.[39]

The submission from Focus on Mental Illness advised that:

Our work with families has highlighted the continued impact that covid-19 has had on Jersey's mental health services. The introduction of a Traffic Light system and staff sickness levels continues to impact patients and families. As many have not had their community support return to pre-pandemic levels, it is highly likely that families will continue to have to step up the level of support they provide for their loved ones.[40]

The submission to the Panel's review from Mind Jersey reflected on the importance of carers in the community generally and how their needs should be addressed, for the long-term, with specific legislation:

Commitment from public sector to implement the triangle of care training which clearly sets key elements required to achieve better collaboration and partnership with carers in the service user and carer's journey through mental health services. This is important as without legislation carers needs are frequently not addressed. This will also support the implementation of the Jersey Care Model as we will all be looking after those that care for others.[41]

The Panel is aware that in the CJ strategy suggests the development of legislation for carers, and CJ identifies it as a key deliverable for their strategy.

Communication to AMHS service users during the COVID-19 pandemic

The Panel has also been advised about the importance of communications to AMHS service users. The Listening Lounge advised that it had received feedback which indicated that there was poor, or little, communication from services which negatively impacted individuals' care:

One of the key issues we have heard from islanders throughout the pandemic relates to poor communication from services, which at times has had a detrimental impact on care. This relates to a lack of clarity regarding appointments, care plans, transition between services and points of contact. We are still now being contacted by people who were engaged with Mental Health Services prior to Covid-19, or were due to be, but have since been discharged having received no contact at all.[42]

In addition to this aspect relating to communications, Jersey Recovery College advised us that the pandemic public health restrictions and the communication of these and related media heightened negative feelings:

Our service users have also said that the restrictions and government/media messaging has heightened feelings of isolation and fear. This will take time to address as we come out of the Pandemic and it's important there are multiple, available services to support this.[43]

AMHS and frontline emergency services

The Panel wrote to the Minister for Home Affairs and asked for details about how the COVID- 19 pandemic had impacted the States of Jersey Police's (SoJP) work that overlapped with the mental health services. We were advised that:

The outbreak of COVID in 2020 saw the SoJP and Jersey Adult Mental Health Service (JAMHS) agreeing to provide a Mental Health Nurse Practitioner (MHNP) to advise and work in partnership with the SOJP & States of Jersey Ambulance Service (SOJAS).

The enhanced collaboration initiative sought to manage the COVID crisis which saw a number of restrictions placed upon the whole community.

Agencies were aware that Mind Jersey, a Mental Health Charity, had seen a spike in calls into their service and that there was a significant increase in people who are under extreme levels of stress with deteriorating Mental Health.

The MHNPs assisted in ensuring the most appropriate options were considered and accessed for the individual in crisis, which informed decision making and risk management in a timely and proportionate way.[44]

The Panel also asked whether any significant changes had been made to the work or service as a result of COVID-19. In the response on behalf of SoJP we were advised that:

No significant changes have been made as a result of COVID. []

The SoJP recognise that to deal effectively with Mental Health cases must be a partnership effort and that working in isolation will absolutely not realise a permanent solution.[45]

In relation to this, the Panel received a briefing from the Chief of Police on 28th March 2022 and were advised about the importance of collaborative partnership working in relation to mental health. The Panel was also advised about the increase in mental health incidents that required police attendance, however, it was highlighted to the Panel that "There is no evidence to suggest that this increase in demand is down to COVID".[46]

The Panel noted the working relationship between AMHS, SoJP and the States of Jersey Ambulance Service (SoJAS) in relation to the establishment of the CTT. SoJAS advised us that:

There was a good working relationship between AMHS and the Ambulance Service in regard to planning services, particularly through the setting up of the CTT trial. Resourcing issues and Covid has impacted on this in recent years, though both services attend a range of multi-disciplinary meetings whereby safeguarding, quality and safety are discussed. There is always opportunity to improve relationships.[47]

AMHS and the States of Jersey Prison Service

The Panel wrote to the Minister for Home Affairs with queries in relation to the States of Jersey Prison Service (SoJPS) and, also, had the opportunity to visit the SoJPS at H.M. Prison La Moye on 6th April 2022.

The Panel understands that the SoJPS has its own internal health team, employed by the SoJPS, however, there is support provided for mental health services from AMHS. This relationship is managed through a Community Psychiatric Nurse (CPN). Whilst this relationship is reported to work well, the Panel was advised that the level of support from AMHS has decreased since the Panel's previous review into Mental Health Services, for example the Consultant Psychiatrist support has been intermittent. The Panel has been advised that the relationship is positive, however, that there is little succession planning for the role, or support if the CPN is leaving or on sick leave. SoJPS also advised that they are able to directly refer to the CTT and the HTT, "however this does not work very well, and we rely on the CPN to escalate if a referral is being bounced' between teams".[48] It was also noted that the access to the CTT could be slower on weekends when the Prison was without the CPN. In the Panel's site visit to H.M.Prison La Moye it was explained that the response time from the CTT has, on occasion, been days [49]. The Panel heard from the Director of Mental Health and Adult Social Care in a public hearing on 28th February 2022 that the response time for a crisis assessment from the CTT should be 4 hours, and this was what the service was moving towards.

The Panel queried how the COVID-19 pandemic had impacted SoJPS working with mental health services and, also, whether any significant changes had been made to the work / service as a result of COVID-19. We were advised in a letter from the Minister for Home Affairs that:

It is not felt that the pandemic has too much of an impact, referrals were processed in the same way, face to face consultations were prioritised and cancelled only when we had active infections for the first and second outbreaks here. Waiting lists have not grown. We have not had any significant negative feedback from prisoners; however, we plan to ask this specific question in the next prisoner survey (April / May 22). The pandemic has increased the workload of healthcare staff significantly, to the point where Healthcare staff have been impacted from a mental health perspective – specifically burn-out and fatigue[*]. Despite this we have not noted any specific mental health impact on staff – morale seems to be positive.

[]

No permanent changes have been made. We had already started to use video as a means of consultations, out-patient appointments etc. This has been developed with the introduction of TEAMs so may be a permanent feature to replace and supplement before the pandemic and was used as a template on how we subsequently managed this. If anything, staff will be more aware of infection & transmission which should have a positive impact.[50]

*During the fact-checking process it was highlighted to the Panel that the comments made above relating to staff burn-out and fatigue are anecdotal and not supported by evidence.

Independent Review of Adult Mental Health Services in Jersey

On 19th November 2021 Health and Community Services published a report titled Independent Review of Adult Mental Health Services in Jersey – which are part of the Health and Community Services' (the Independent Review'). The Independent Review was commissioned by Health and Community Services and cost £10,200.00 [51].

The executive summary in the Independent Review stated:

The reviewers found the following key issues within Adult Mental Health Services:

There is a lack of senior management leadership and direction.
A lack of a system of MDT [multi-disciplinary team] working such as the Care Programme Approach or an equivalent.
Within Adult Mental Health, there are inadequate systems to learn from Serious Incidents.
Silo working professionally and within teams.
Lack of a system to ratify, manage and implement policies and procedures.
Poor management supervision structures.
Within Adult Mental Health on a positive note, the reviewers spoke with many professional staff who had a real motivation to develop and improve the service and have the potential to achieve positive change. Inpatient services have made some recent improvements, but further work is required.[52]

The Independent Review produced ten recommendations which can be read in full here, but are summarised below:

Adult Mental Health Senior Management Structure: should be reviewed to ensure it is fit for purpose. Adult Mental Health Services (AMHS) require clear, regularly reviewed, objectives and define measurable outcomes. Suggestion that the integration of AMHS and Adult Social Care should be put on hold "until such time the AMHS is considered safer"[53].
Care Programme Approach (CPA) or equivalent: There should be a clear project plan, including staff training, for the introduction of a CPA. The staff group and patients should be involved in its development. It must include a clear model of MDT working and utilise best practice from other services.
Jersey Care Model (JCM): AMHS need to develop in the context of the plan for the JCM and have a clear model of care that is understood across HCS. Management structures should follow the chosen care model and objectives ought to be defined, with measurable outcomes. Each component part of the system needs to be understood in the context of the whole system, rather than working in a silo.
Adult Mental Health Management Roles: Management roles in AMHS should be reviewed to ensure that they receive regular supervision, have clear objectives, and understand their role as part of a whole system. The Mental Health Nurse Consultant (MHNC) should have a clear link into the Chief Nurse Office and the role of the MHNC should be reviewed and defined in line with the JCM and best practice.

Policies and procedures: there must be a clear process for developing and agreeing policies within the Adult Mental Health care group, and where there are delays, there must be an escalation process. An overall Clinical Risk Management Policy is a priority for AMHS. As a matter of urgency, emergency Electroconvulsive Therapy (ECT) need to be planned and commissioned in line with best practice guidelines.
Community Mental Health Team (CMHT): the CMHT staff should work across clear catchments areas. Further consideration should be given to mental health nurses and social workers undertaking community visits, as appropriate.
Consultant Psychiatrists: consultant job plans should be reviewed to ensure they facilitate multi-disciplinary team working. Job plans should be in line with the Royal College of Psychiatrists recommendations. There should also be a clear process that audits the use of polypharmacy to ensure it is in line with best practice.
Adult Mental Health Inpatient Services: the model of care for in-patient wards should be reviewed to ensure effective MDT working, continuity of care between inpatient and CMHT services, and to ensure there is a clear emphasis on safety and therapeutic interventions. Inpatient services would benefit with an overall improvement plan, linked to recommendation 9.
Royal College of Psychiatrists (RCP) accreditation / best practice: consideration should be given to joining the RCP networks across a range of specialities in mental health, working towards accreditation in each area, and using the networks to maintain best practice and share learning.
Communication: there needs to be a clear communication process that informs and allows all Adult Mental Health Services staff to feel involved in the development of services.

The terms of reference for the Panel's review consider the impact and outcomes of the Independent Review. We have not had the opportunity to speak with the authors of the Independent Review but have instead focussed our attention on the forward planning and the Department's initial response.

On publication of the Independent Review, it was stated that the following initial actions had been taken by the Department:

reviewing existing Adult Mental Health Management team and supporting the service with a team with delegated executive authority led by the Deputy Medical Director
ceasing the integration of Adult Mental Health and Social Care services
updating and ratifying policies
initiating a weekly executive oversight meeting chaired by Director General
agreeing the Nurse Consultant 'line of sight' to Chief Nurse office

recruiting an experienced Director of Mental Health [54]

The Panel was pleased to learn that the Independent Review had been commissioned by HCS, however, was concerned about its findings and reflected that a number of the findings and recommendations mirrored, or were similar to, those that were identified in the Panel's Assessment of Mental Health Services' (S.R.4/2019). The Panel believes that this indicates a lack of progress and specific action on a number of matters within the past 3 years. For example, themes of some of the findings and recommendations included the requirement for Adult Mental Health Services (AMHS) to have clear objectives and measurable outcomes. There were also themes around the importance of co-production and communication and review of the models of care.

The Panel notes that some immediate changes were made to the management and senior leadership team of AMHS in November 2021 and that the appointment of the Director of Adult Mental Health and Social Care (a newly created role), became effective on Monday 10 January 2022 [55].

At the quarterly public hearing with the Minister for Health and Social Services on 4th February 2022, the Panel was introduced to the new Director for Mental Health and Social Care and was given the opportunity to ask him questions about his plans for the future operational direction of AMHS.

Deputy K.G. Pamplin:

So give us a bit of straight-talking now. What is your sense? You have been here a month, you must have read our review, you have heard a bit about the Island's issues in the past. We are trying to get to grips with things. So what is your straight-talking assessment of what you see?

Director for Mental Health and Adult Social Care:

There is a lot to do. There is some very good practice. I have seen in the past 4 weeks some really good care, examples of care that I would be really happy for my relatives to receive. I have spoken with a large number of staff who are really dedicated, want to deliver things differently, are committed to bettering the mental health and well-being generically as well as specifically around illness. I would personally say that we need to refocus slightly. We need to hear more about serious mental illness and the needs of people who have illnesses like schizophrenia. I can absolutely understand post- COVID - and this is true in most jurisdictions - there has been a surge of activity around primary mental health care, around people who have low-level anxiety and so on, but what we must not do is over-focus on that and forget about the people with the severe and enduring long-term mental illness because they are often the people who have the

greatest needs but also the quietest voice in terms of having their needs met. We have an opportunity. I really do believe that there is an absolute opportunity to do some things that are really quite creative and ground-breaking because of the size of Jersey, the structure in Jersey. The issues here are different to most of the issues in places that I have ever worked before in terms of demand and capacity, but some of the issues are the same. The last thing that I would say is that we have to focus on re-engaging and working in a collaborative way with staff across our services. So we are next week commencing a staff engagement programme, which is an open programme for all staff working across mental health and social care to come and really add their voices to what do we focus on and how do we prioritise and make change. Then we need to be held to account for delivering the things that we say we are going to do.[56]

Specifically in relation to the Independent Review, the Panel was advised that:

Director for Mental Health and Adult Social Care:

in terms of the external review is really important to flag because what the external review said was there are some core governance oversight and leadership issues that need to be attended to before some of the rest of the stuff can happen. So clearly in the last 4 weeks since my role has been in post that is the thing that we have been really focusing on.[57]

The Panel has not had sight of the new governance and leadership structure but would suggest that documents to detail this, including the relationships to underlying service lines are made public.

In relation to this, the Panel points to the Comptroller and Auditor General's Report into Governance Arrangements for Health and Social Care – Follow Up' (C&AG HSC Report) which was published on 13th September 2021.

The C&AG HSC Report recommended, inter alia, the documentation of a comprehensive and publicly available Health and Social Care Integrated Governance Accountabilities (IGA) Framework which should include:

terms of reference of committees and groups;
relationships between the committees and groups;
memberships, workplans and frequency of meetings;
arrangements both within HCS, within Government and within the whole Island health and social care system; and
the Jersey Care Model and Our Hospital project governance arrangement.[58]

Action lists

The Panel was also advised about the pressure and expectation placed on the capacity of AMHS because of the excess of actions that had been ascribed to the service:

Director for Mental Health and Adult Social Care:

So one of the things that we have been doing in the last couple of weeks is going back through looking at not just the Scrutiny review and the recommendations that came from that and the actions and the things that have been done, but there is a plethora of other action plans associated with mental health services, in excess of 200 actions. So we have been looking at where are we with those things, what are the things that have changed and what are the things that we really need to prioritise over the next couple of months?[59]

The Panel asked for further information about what was realistically achievable at its public hearing on 28th February 2022 and was advised about the process for the prioritisation of actions and changes for AMHS:

Director for Mental Health and Adult Social Care:

I am hoping that the approach that I have articulated, which is the 4 lots of 3-month plans, is the way that we do that. We need to engage people in the conversations about what we prioritise and how we prioritise things. That can be tricky sometimes because people will have their own favourite ideas or things that they most want to do and sometimes we will be saying: "No, we are not doing that initially, we are doing something else." Clearly sometimes that might annoy some folk but we have to be able to be clear and honest about our rationale for that. I think that we, as I say, have started by setting out the things that are an absolute priority, which is about the overarching structure of the service and making sure that we operate in the way that we should be operating moving forward. Now the next steps are ... and obviously, as I say, prioritising particularly direct access so that people can get into the system and know what they are going to get. Once we have done that we will then move on to the next group of things. But you are absolutely right, there is a real issue about capacity and needing to be honest about capacity is finite. That is not just true of here, that is anywhere, frankly, but here it is a particular issue.[60]

In addition to the feedback approach outlined above, the Panel learnt that the newly created Mental Health Strategic System Partnership Board (as detailed in section 7.3 of this chapter) would be reviewing progress of actions against the previous Mental Health Strategy and the Mental Health Improvement Plan [61].

KEY FINDING 23: Adult Mental Health Services had a plethora' of over 200 actions assigned to it following the previous Mental Health strategy, S.R.4/2019, and subsequently the Mental Health Improvement Plan. A process of prioritising these, with consideration of the resources available to fulfil them is underway.

RECOMMENDATION 5: The Minister for Health and Social Services should, by the end of December 2022,publish a document detailing the priority actions for Adult Mental Health Services (AMHS) including outcomes / measures. This should be incorporated into the new Mental Health strategy. For transparency and to maintain an accurate record, a document should also be published detailing the actions that will not be taken forward by AMHS at this time.

Collecting feedback from staff

The Panel asked for further information about the staff engagement programme, which had commenced in February 2022, and was provided with details about the format for the communication and opportunities provided for staff feedback. The Independent Review stated that the staff group should be involved in the plan for a care programme approach.

Deputy K.G. Pamplin:

Give us an update on the new staff engagement programme that we heard about at the last quarterly hearing?

Director for Mental Health and Adult Social Care:

We had the first meeting. We had a good staff attendance. Essentially, deliberately the meetings will be done in 2 ways. We will present information and provide people with an update and then we will have an open session for staff to do, kind of questions and answers and talk to us about the stuff that is important. I have written out to all staff inviting them to participate in the process because I think that is really important and also told people that if they cannot come to the forums, which is only one of the vehicles, then there is an opportunity for them to come directly to me or to my leadership team to raise concerns and issues, ideas, et cetera. As well as people telling us what does not work, very often staff in services have got really good ideas about things that could be new or different, so we want to encourage that. The next forum is either next week or the week after, but it is not just that. We are looking at an electronic platform currently to have a staff dialogue, an open staff dialogue for people to be able to talk about themes and issues and share ideas because otherwise what you get is often one-way communication and then we wait a bit and then we go back out. I would like it to be much more live than that, frankly. Lastly, the way that we make change has to be really key to this. So when we held the workshop to look at how we redesign our community services, we had over 60 staff and that included a range of front line staff, support workers, qualified staff, et cetera, but we also had stakeholders. So we had C.A.M.H.S. there, we had Social Care there, because we need to be much more inclusive and engaging in the way that we do this type of work really. So this will become our norm, I hope.[62]

In a letter from the Minister for Health and Social Services, the Panel was advised that the February staff workshops included over 60 staff from across AMHS and other partner services. It was advised that the focus was to look at best practice for models of care and to consider how these could apply in Jersey. The Panel was also advised that the workshop specifically focused on developing proposed future models in 3 key areas:

Access to care in a crisis and home treatment as an alternative to admission
Community Mental Health team function
Transitions [63]

The Director for Mental Health and Adult Social Care highlighted the impact that a focus on tricky' challenges for AMHS had on staff morale, and the importance of balancing challenging issues with recognition of the hard work and dedication that was evidenced by staff on a daily basis:

Director for Mental Health and Adult Social Care:

To date my experience has been that there has not been much difference of view among most of the people that I have spoken to in the 7 weeks that I have been here about what the key challenges and issues are. There are differences of view about who is to blame, there are differences of view about what the solution might be, but pretty much people are saying and naming the same things as being a challenge. What we must not do ... this is all about balance. We have to make sure that we can talk about the stuff that is tricky but we also acknowledge and talk about the stuff that is good and the hard work that people have put in and the fact that people still get up every day and come to work and provide care for people, often in very challenging circumstances. If we get that balance wrong then all we do is just demoralise people further and that is the last thing that we want to do, is it not?[64]

The Panel is aware that the reviewers of the Independent Report spoke with many professional staff "who had real motivation to develop and improve the service and have the potential to achieve positive change"[65] and is encouraged that this echoes with the Panel's own experience of meeting with AMHS staff on site visits.

Wider networks and place within the Jersey Care Model

As referenced in other sections of this report, there is a recognition that AMHS needs to develop within the wider network and system, particularly in light of the Jersey's decision to pursue the Jersey Care Model approach, which includes principles of community-based care. The Panel asked about this finding from the Independent Review in a public hearing:

Deputy K.G. Pamplin:

One of the recommendations from the independent review was: "The importance of the development of adult mental health services must be considered within the context of the Jersey Care Model." The first question is: could there have been a better job at the outset - it is in tranche 2 this year - and how do improve that to ensure that that recommendation is met as the care model continues?

Director for Mental Health and Adult Social Care:

I think the direction of the mental health services fits nicely with the care model, which is about community-based care, about making sure that where possible people are supported at home, that they receive the range of services that they need to receive from the system and that when you come into hospital you get a good experience that lasts for as short a time as possible and provides you with the treatment you need. I think that is consistent. I think we are already thinking about, for example, direct access points, how does that work with the Jersey Care Model in terms of single point of access. I think there is a lot of water to go under the bridge in terms of the detail but there is nothing in terms of the direction of mental health services that is not consistent with the model that is set out. I think that the point that is made about the Jersey context is terribly important. We are not going to replicate all of the specialised services that you would have in the U.K. here because we have not got the capacity to do it, we have not got the resource to do it. That is a challenge but it is also a real opportunity because I think there is some stuff that we could do really well and differently here. When we talked about care co-ordination earlier and the care programme approach we are not just lifting the English system and applying it here, because that will not work, but we can have a really good system here that would be, frankly, a step ahead of the review that is happening in the U.K. at the moment around the care programme approach because the system in Jersey lends itself really nicely to that. So we have to keep checking: are we using best practice? Where there is an evidence base, are we using it? The evidence base is no different in Jersey or anywhere else, frankly, but are we then making sure that our systems and processes around care delivery fit with Jersey and the needs of Jersey. I think that is going to be an ongoing bit of work.

The Minister for Health and Social Services:

Can I just add that I see it as key that we involve our community providers: Mind Jersey, Youthful Minds, the Recovery College, Focus. All of those have got excellent work to do and contribute and want to, and they are keen to be involved in that redesign.[66]

The Panel has received submissions as part of this review which also reference the importance of a joined-up system of working (see chapter 7 for further details).

Integration of Adult Mental Health and Adult Social Care

As a result of the Independent Review, and the recommendation that the integration of AMHS and Adult Social Care should be halted until AMHS was "considered safer",[67] the process has been paused. However, the Panel noted that the newly created directorship post was for the "Director of Mental Health and Adult Social Care" and asked for some clarity about the status of the integration and the structure of these areas:

Senator S.W. Pallett:

I just want to delve into the plan regarding the integration of adult mental health and adult social care. Obviously in the previous structure before you came along the roles were split, so can you just update us on who is responsible now for adult social care? Is it you or how is that structure going to work?

Director for Mental Health and Adult Social Care:

So currently it is me, is the answer. I am the Director of Mental Health and Adult Social Care and currently the services operate as 2 care groups. There is some interface in the middle, there is some overlap and essentially they have 2 different management structures that sit separately and there was some previous integration that was then separated back out. We are reviewing that. We are not reviewing that quickly, so we are going to continue for the next couple of months to have them as 2 separate care groups, but we are going to strengthen the interface and the overlap and there is certainly some more work that could be done there. I think probably in about 6 months we will then take a collective view as to whether moving back to integration is the right thing to do or not, but for the time being it makes sense just to leave them as they are and settle them down.[68]

Additional funding of £500,000 for Mental Health Services

In November 2021, the Health and Social Security Scrutiny Panel lodged an amendment to Proposed Government Plan 2022-2025: P.90/2021' in order to increase the funding for Mental Health Services by £500,000 in 2022 (Amendment 9). In the report appended to the Amendment, the Panel had stated that their intention in proposing the additional funding was to assist the services which were experiencing pressure as a result of the Covid-19 pandemic, for example to address the identified backlogs and target the particular areas of need. It was proposed that £500,000 of the sum held in the General Reserve for Covid-19 should be used as the source of funding for this expenditure. The Panel was pleased that its amendment was accepted by the Council of Ministers.

As background to the Panel's Amendment, it had noted that the Government's 2021 mid-year review pointed to £1.6 million of additional investment in Mental Health services (between 2020 and 2021), however, highlighted that much of the work that was done, for example improvements to facilities and new services such as crisis prevention and intervention' teams had been planned as additional investment since 2019 (pre-pandemic), but that the pandemic had accelerated these plans. The Panel was of the opinion that additional pressures caused by the Covid-19 pandemic deserved additional and appropriately considered funding and not the re-prioritisation of funding that was initially intended for other matters.

In the Government Plan 2022-2025, the Government acknowledged the impact of the Covid- 19 pandemic on mental health and wellbeing [69], and a key strategic priority of the Government is: We will improve Islanders' wellbeing and mental and physical health by supporting Islanders to live healthier, active, longer lives, improving the quality of and access to mental health services, and by putting patients, families and carers at the heart of Jersey's health and care system'.[70]

The Panel held a public hearing with the Minister for Health and Social Services and the Assistant Minister for Health and Social Services on 28th February 2022 as part of its follow up review. In response to a query from the Panel about what areas would be prioritised for the £500,000 of funding we were advised that:

Assistant Minister for Health and Social Services:

Certainly from a political point of view we perceive a gap in the service to people who are autistic. We are working on that service to try and increase its efficiency and to decide whether or not putting some of that £500,000 into that service might improve that service.

The Assistant Minister noted however that this was not the only priority area and requested the Director for Mental Health and Adult Social Care to provide some further detail on how the Department would consider the allocation the additional funding. He advised:

Director for Mental Health and Adult Social Care:

If I explain to the panel the process that we are using to determine this. It links the piece around recovery plans, the formal recovery plans. There are 2 parts where we have decided already we need to allocate some of the money. The first is to the

leadership structure of mental health services because I think everybody here has said that that needs to be reinforced, and I think that is absolutely right. The second is we have agreed that we are going to implement a consultant pharmacy role, because one of the big gaps is pharmacy and medicines management and management of long- term illness and particularly the relationship between medicines management and physical health issues, for example, in our population. So we have agreed that we have a business case that we have supported for a consultant pharmacist in mental health, so a pharmacist with very specific expertise in mental health to work alongside the medics particularly. The remaining money will be allocated based on the formal recovery plans, so it will go into psychological therapies, but we need a realistic assessment. I could say today we need to employ 10 consultant psychologists, for example, but that will not happen. It certainly will not happen overnight and it certainly will not happen in a way that will get us what we want to get in a timely way. So we are working through detail with the services currently as to what needs to be prioritised around those recovery plans and we will allocate the money against that, so it is highly likely it will be psychological therapies, autism, A.D.H.D. (attention deficit hyperactivity disorder) which we call neurodevelopmental disorders, those areas. But it is about what can we get, what can we best spend the money on and how can we most quickly impact our waiting lists, where there is a waiting list.

In the hearing, the Panel asked for further details about the money that would be spent on the leadership structure for mental health services and was advised that it would be formed by both front-line service leadership and management, but the detail of this was still to be determined. The Director for Mental Health and Adult Social Care stated:

Director for Mental Health and Adult Social Care:

So you have an external review of mental health services from last year that says the leadership structure is not working and the services need to be led and managed, hence the creation of my post, for example. So if we do not do that, if we do not put leadership capacity and management capacity into services where that does not exist, things will not get better. There is a really clear evidence base around leadership in health services and management in health services about the impact of that. So, simply, if we do not do that, if we do not in some way make sure we have an interim management structure in place that we put in almost immediately when I arrived to make it clear and safe and understand people's roles and responsibilities ... as you know, we have previously talked about, there is lots and lots and lots of developmental work to be done in the mental health services. It is not going to do itself. The people who are providing direct care are not going to be leading significant system change, for example, because they are providing direct care. That is their job. So you have to have the infrastructure to get us to where we want to get to.

The Panel was then advised that decisions about whether recruitment would be done on a long-term or short-term basis would depend on the type of work that was identified as a requirement.

Senator S.W. Pallett:

In terms of system change, are you talking about people who are going to come in and work for a short period of time to change the system or be longer-term appointments?

I think it depends on what we want to do. So if we want to do a very specific piece of work, for example, around redesigning something then the logical things to do would be to bring in someone with expert skills and experience in that something, get them to do that piece of work and then off they go. If the conclusion is that we need a stronger, longer-term management structure then bringing someone in temporarily is not the right thing to do for that. It is about getting someone in to work with the services over a period of time.

Senator S.W. Pallett:

Okay, and what is the timeframe so we can understand what the management structure might look like?

Director for Mental Health and Adult Social Care:

I think that we will be really clear within the next 2 weeks where we want to allocate the growth moneys and the rationale for that, and we should be able to articulate both of those things.[71]

The Panel asked for further details in a letter to the Minister and received a response on 25th March 2022:

Please can you provide further detail to advise where the growth money will be allocated for the management structure changes?

The majority of the £500,000 growth money is being allocated to developing new clinical roles and increasing capacity within our clinical services. Following a budget review, the new role of Director of Mental Health & Social Care will be funded from the growth money.[72]

The responses do not provide a breakdown of exactly how the additional funding will be allocated. The Panel does not wish to provide any prescriptive recommendation in relation to the proposed usage of the additional £500,000 funding, however, notes that the original source of the funding, per the Amendment is the COVID-19 Reserve. The original intention of the funding resulting from the Amendment was to address the identified backlogs in waiting lists for patients and target the particular areas of need for service users and specifically Covid related pressures and service recovery.

The clinical roles indicated to in our hearing included a consultant pharmacist in mental health and psychological therapies, or neurodevelopmental disorders and these would be allocated based on how best the waiting lists could be impacted.

The Panel acknowledges that issues had been identified with the leadership of Mental Health Services in the Independent Review of Adult Mental Health Services in Jersey – which are part of the Health and Community Services' (the Independent Review'), see chapter 5 for further details. Additionally, the Panel received submissions which suggested that "failings in leadership capability"[73] were one of the factors for a perceived lack of service improvement

and progress in AMHS. A comment collected by Focus on Mental Illness from a member of their user participation group stated:

...There needs to be an urgent effort to do what has already been recommended and promised, rather than indulge in further lengthy consultation. There needs to be consistent long-term leadership with the authority and resources to implement change, with genuine input from service users, and a shift towards meeting individual needs over the implementation of impersonal policies.[74]

The Panel accepts that there are changes required to the leadership structure of AMHS and welcomes the executive's attention in addressing the issue, however, notes that it would not expect the changes required to be funded specifically as part of the Covid-19 recovery. There needs to be assurance that funding for long term positions and the changes to management and leadership are built into base / core budgets and not sourced from additional one-off funding.

The Panel would like clear evidence that the £500,000 additional funding has been spent well, as part of the wider budget spend, and that it has created a direct improvement in the service provision for users and identify how this has impacted waiting list times for patients.

KEY FINDING 27: The Panel was not provided with an exact breakdown for the intended spending of the additional £500,000 of funding assigned to Mental Health Services as part of the 2022-25 Government Plan, however, it was confirmed that the majority of the additional £500,000 of additional Government Plan funding would be allocated to develop new clinical roles and increase capacity within clinical services, in addition to funding the role of Director of Mental Health & Social Care. The Assistant Minister for Health and Social Services indicated his preference that a portion would be assigned to services for people with Autism and we were advised that there would be a consultant pharmacy role.

RECOMMENDATION 7: The Minister for Health and Social Services should report to the incoming Health and Social Security Scrutiny Panel by the end of September 2022 to confirm how the £500,000 of funding will be allocated within the budget for Mental Health Services and, also, identify how, or if, it has beneficially impacted frontline services and service users.

Assessment of Mental Health Services in S.R.4/2019 Background

In order to focus this follow-up review on the progress made against the recommendations from the Panel's review Assessment of Mental Health Services' (S.R.4/2019) that was published on 6th March 2019, we have separated this chapter into sections that will focus on each of the recommendations, as set out in S.R.4/2019. We hope that this will provide a concise and easy to follow format.

Recommendations will be set out in a table at the start of each section, accompanied by a very brief summary of the current position and Panel's evaluation of the progress made.

User experience of Mental Health Services

Mental Health Strategy

Original Recommendation

Current position

Evaluation of progress

1: A part of its refresh of the Mental Health Strategy, the Government should develop some clear objectives from which progress can be measured. These should be published on the Government's website.

The Minister accepted this recommendation from the Panel in 2019.

The Mental Health Strategy 2016-2020 has concluded.

No successor strategy has been drafted and published and COVID is cited as the reason for this.

No current objectives for AMHS are publicly available.

A Mental Health Services Improvement Plan 2019/2020 was drafted following the publication of S.R.4/2019, but not made publicly available.

It is hoped to have a new Adult Mental Health Strategy published by the end of 2022.

The new Mental Health Strategic System Partnership Board will be involved in the publication of the new strategy for AMHS.

The Minister accepted this recommendation from the Panel in 2019, however, the Panel can find no evidence that any time-bound strategy objectives were publicly communicated as part of a strategy refresh.

A new Mental Health Strategy needs to be agreed and published as a matter of priority.

2: The Government should The Panel has not found any The work to create publish a list of the outcome- evidence of outcome-based outcomes-based measures based measures and measures and indicators the in order to monitor indicators it will use to Government uses to monitor performance were drafted as monitor its performance in its performance in relation to part of the Mental Health relation to mental health by mental health. Improvement Plan, but the end of 2019. The aspects of this were not information it collects in In 2019 the Minister's progressed.

relation to these measures intention was to publish an New management change and indicators should be annual Mental Health Quality has reinvigorated the published on a yearly basis Report (MH QR) which strategy and actions thereafter. includes activity and prisonisation.

outcome data, however, no

This recommendation was annual MH QR was

accepted by the Minister in produced after the report for

2019. 2016/17.

The Panel was advised that the outcomes strategy "fell by the wayside"[75] due to prioritisation of resources.

All actions that have been assigned to AMHS are being reviewed to decide priority within the service's capacity.

Adult Mental Health Strategy

The Mental Health Strategy which was reviewed by the Panel as part of S.R.4/2019 related to the period 2016-2020 (the Strategy). The Panel's original review, S.R.4/2019 had highlighted that the publication of the Strategy was a welcome step but had evaluated that its implementation had been "piecemeal". In the 2019 ministerial response it was explained that there has been and continues to be some difficulty in implementing the full ambition of the strategy, which has been compounded by workforce shortages'.[76]

The Panel is aware that a Mental Health Services Improvement Plan for the Adult Mental Health Service (the MHIP) was drafted in November 2019, which was intended to state plans of action until the end of 2020. In relation to the MHIP, the Health and Community Services Business Plan for 2022 states:

Although significant progress has been made in 2021 it is likely that some projects will need to be completed in 2022. There will also be reviews of previously completed initiatives [77]

The purpose of the MHIP included addressing the findings of S.R.4/2019, however, the detailed document was not published.[78] A copy of the plan was provided to the Panel in confidence.

The Panel noted that a successor to the 2016-2020 Strategy for AMHS has not been produced to date. In the Minister's response to S.R.4/2019 it was indicated that a new mental health strategy to set the strategic direction will be required from 2021 and work will commence on this during late 2019/2020.'[79] The Panel asked about the Department's plans to replace the Strategy for AMHS. It was advised that one of the reasons a new strategy had not been published was because of COVID, and it was indicated that the strategy for AMHS would be refreshed in 2022:

Deputy M.R. Le Hegarat :

.... The previous mental health strategy ran from 2016 to 2020, are there plans to publish a new strategy to clarify the new strategic direction of the services?

Director for Mental Health and Adult Social Care:

Yes, we need to review, we need to refresh and review the previous strategy, which of course would have happened. It was in the improvement plan previously but was parked as a result of COVID. I think one of the things that we would want to do by the end of this calendar year is to have absolutely refreshed the mental health strategy and published another one for the next few years.[80]

Objectives for the Mental Health Strategy

The lack of objectives in place for Adult Mental Health Services was highlighted in the Independent Review, as discussed in chapter 5 of this report.

As a follow up to recommendation 1 of S.R.4/2019, the Panel could not find evidence that any clear objectives were published as part of the previous Mental Health Strategy to work towards. In the ministerial response it was confirmed that:

The Minister is committed to ensuring that the outstanding work relating to the current strategy is accompanied by a specific set of time-bound objectives that underpin the delivery plan. He will publish the plan on the Government website by June 2019.'[81]

The Panel were not aware of any additions following the publication of the Strategy but requested specific clarification of whether any objectives had subsequently been published. We were directed [82] to a link to the Strategy's publication on gov.je in 2015 via the following link: https://www.gov.je/news/2015/pages/mentalhealthstrategy.aspx indicating to us that no time-bound objectives had subsequently been published.

The Panel received submissions from local organisations who were concerned about how the lack of objectives - and an overall strategy - was impacting the ability for partnership working in relation to mental health services. The Service Lead at the Listening Lounge advised:

We are also lacking a current Mental Health Strategy for Jersey which is essential to bring together overarching objectives.[83]

Furthermore, the Jersey Recovery College advised that:

There is a lack of strategic direction in mental health which exacerbates siloed working. There is no current mental health strategy, the Mental Health Improvement Board has been disbanded and the current commissioning structure does not support partnership working. There is a Mental Health Improvement Plan, but we have had very little involvement with it. The Mental Health Improvement Board is being replaced by a Systems Board, chaired by Public Health, which is a welcome move, but has yet to be established. The Commissioning Strategy has been redesigned and is being launched this year, but again that will take time to embed. We have the Mental Health Network which meets bi-monthly but this is an operational network, and without a strategy to align with and a commissioning structure to support joined-up solutions, the network can only achieve a small part of its potential. We believe a strategic approach is required to move the mental health agenda forward and this needs to be co-produced with service users and families. We also need more focus on suicide prevention.[84]

Mind Jersey advised that:

Since 2018 a lot of changes seemed to have taken place around structures and processes within mental health systems. Today date (sic) the benefits do not seem to be working there (sic) way down to those most in need. There are ongoing challenges across the public and voluntary sector in measuring outcomes and service user experience. It is also difficult to do this without clear objectives as highlighted in the review. In the striving for data and the impact of interventions the person's quality of life often gets overlooked.[85]

In section 7.10 of this chapter, the Panel has documented the evidence it has received about the role of partnership working and we review the role of the new Mental Health Strategic System Partnership Board in section 7.3.

The Panel has noted a repeated theme about how objectives and outcomes-based measures can assist the wider network of mental health services and organisations. There is concurrence that strategy and objectives are key to partnership working and this, in turn, provides better outcomes for patients and service users.

Outcome-based measures

The Panel did not find any evidence that outcome-based measures and indicators are used to monitor performance in relation to mental health services. In 2019 the Minister had acknowledged that performance measures to date have, in the main, related to activity rather than outcomes.'[86]

The Panel is aware that, in response to S.R.4/2019, the draft Mental Health Improvement Plan (MHIP) was created in November 2019. The MHIP was structured around four overarching outcomes and each of these had underlying actions and details. However, the MHIP remains unpublished, and it is unclear how much was embedded to working practice.

In response to recommendation 2 of S.R.4/2019, it was highlighted that there was an intention to publish an annual Mental Health Quality Report (the Quality Report) which would include both activity and outcome data. The Minister anticipated that the Quality Report for 2018 would be produced in September 2019 and that thereafter it would be produced in March of each year.

The Panel noted that there had been an annual Quality Report produced for 2016/2017 but no further reports had been published. The Panel queried this in a letter to the Minister in March 2022:

The Mental Health Strategy for Jersey (2016-2020) stated an intention to publish an annual Mental Health Quality Report. Please could you confirm why no further annual reports were published after the report for 2016/2017?

This appears to have been lost in transition between responsible officers, and it is likely that this was not prioritised against other urgent actions, reviews and action plans that were subsequently developed.[87]

The Panel was disappointed to learn that this was a work stream that was not considered to be a priority for AMHS. In a public hearing on 28th February 2022, in response to a question about the reprioritisation of funding, the Director for Mental Health and Adult Social Care referenced the work on outcomes measures as an example of something that had been de- prioritised:

Director for Mental Health and Adult Social Care:

One of the things that I would say, and I do not think it is a financial answer, is that inevitably there were things that were delayed or there were pieces of work that started as a consequence of the previous Scrutiny Panel review but then either stopped or were much slower in terms of their delivery. I think that was the reality in terms of prioritisation of use of resource. I think a good example of that is the piece of work on outcome measures started but is yet to complete. It needs to be readjusted and restarted because it was one of the things that fell by the wayside.[88]

The Panel sent some queries in writing to the Minister for Health and Social Services and asked for further information about why this had occurred.

Please could you provide some further details about why the outcomes of the previous strategy "fell by the wayside"?

It appears that some of this work was superseded by subsequent reviews, action plans and other operational priorities – although many of the themes and objectives / actions were replicated and therefore continued to be advanced as part of the later mental health improvement plan.

a. Please advise whether the work on these outcomes will recommence as part of the refresh of the mental health strategy?

Yes – the intent is for the [Mental Health] Strategic System Partnership Board to review progress against both the previous Mental Health Strategy and the Mental Health Improvement Plan (to support the setting of collective priorities and develop a shared position of where mental health services currently are) and then commence a refresh of the Strategy towards the end of the year.[89]

The Panel was concerned to learn that significant workstreams for AMHS, particularly relating to core strategy, had not been considered and progressed as a priority by management. Work to address the findings of the Scrutiny report S.R.4/2019 had begun with the MHIP, however, we learned that implementation of this was impacted by COVID and resource challenges.

We note that Health and Community Services began publication of a quarterly Quality and Performance report in June 2021. The Panel welcomes the transparency of this reporting process but notes that the reporting data relates to activity in mental health services (not outcomes).

Evaluation and forward look

The Panel notes that whilst its recommendations 1 and 2 were accepted by the Minister for Health and Social Services in 2019, and work was initiated with the MHIP, actions were not followed through in practice.

We have been advised that the impact of COVID stopped the development of any mental health strategy for 2021 onwards and that the annual Mental Health Quality Report was lost in transition between responsible officers'. This is in addition to the context detailed in chapter 5, in relation to the plethora'[90] of actions that had been attributed to AMHS, including those from the Strategy and the Improvement Plan. The Director for Mental Health and Adult Social Care advised the Panel that:

Director for Mental Health and Adult Social Care:

I can now list over 200 actions that have been attributed to mental health services for this year, ranging from very minutiae pieces of action to wholescale system review and developing new services. This system does not have the capacity to do that and, therefore, we have to be really clear about prioritisation and how we prioritise the things that we do. Again, publicly we should account for that. We should be able to say: "This is why we have chosen this rather than this"[91]

The Panel has heard about the plans for future improvement and planned changes to AMHS following the publication of the Independent Review and this was detailed in chapter 5. The Panel has tried to be mindful of this aspect when drafting this report and producing any further recommendations in respect of AMHS, however, in the Panel's capacity as a critical friend it is important to highlight what has not worked and ensure that a refreshed approach going forward has more beneficial outcomes and impact for patients.

The scope of this review does not include an analysis of the success of the previous Strategy. However, we have identified that it has not created the legacy for mental health that was perhaps initially intended. Nor has the MHIP had the positive influence on strategy and direction that was intended to improve the patient experience after the publication of S.R.4/2019. The patient experience needs to be kept at the forefront of any new strategy and there needs to be a clear leadership plan in place to take this forward effectively.

In terms of moving forward, the Panel recognises that steps have already been taken to address a number of concerns and the Panel is pleased that a refreshed mental health strategy for AMHS will be produced by the end of the calender year for 2022.

The Panel refers to Recommendation 5 in chapter 5 of this report which suggests that the Minister should publish a document detailing the priority actions for AMHS including outcomes / measures. We also recommended that a document should be published detailing the actions that will not be taken forward by AMHS at this time, for transparency purposes.

Children and Young People's Emotional Wellbeing and Mental Health Strategy 2022-2025

Separately, the Panel notes that it has been briefed on the Children and Young People's Emotional Wellbeing and Mental Health Strategy 2022-2025 (the CYP MH Strategy). Further comment on the CYP MH Strategy is made in section 7.12 but the Panel has not undertaken an in-depth review of it at this time as it falls outside of the scope of this follow-up review.

Dementia Strategy

On a related matter the Panel has noted that work is being undertaken by the Government of Jersey to produce a dementia strategy. Dementia is not considered to be a mental health condition or illness, but it does affect a person's mental health.

As detailed in the introduction to this report, the remit of AMHS includes the Dementia Assessment Unit, the Memory Assessment Service, and support from various teams to Older Adults. The Panel wanted to understand how the strategy would sit with AMHS. In a public hearing the Panel was advised by the Director of Mental Health and adult Social Care that:

What is important though about a dementia strategy is it is not a strategy that is owned and held by mental health services. A dementia strategy has to be a whole system strategy that thinks not just about mental health services but also about people's physical healthcare, about their social care needs, things like housing and also carers and how we support people to look after their relatives with dementia where that is the appropriate thing to do.[92]

We asked for some further information about this and were advised in writing that the responsibility for the development of the dementia strategy sits with the Improvement and Innovation team within Health and Community Services.[93] In a letter to the Panel, the Minister for Health and Social Services explained:

It is expected that Adult Mental Health services will be a key partner in the development and delivery of the [dementia] strategy – with specific focus on the delivery of timely assessment, diagnostic and support services for people with dementia, as well as the provision of specialist inpatient care when this is required and provision of specialist mental health advice and support to the General Hospital including for patients with dementia or other cognitive impairment – and that the Strategic Partnership Board will have a role in supporting the development and oversight of the strategy.

We are also currently exploring options for our mental health services in Jersey to be a research site for international research relating to dementia care and treatment. [94]

In a submission to the Panel as part of this review, Dementia Jersey suggested that:

Dementia Jersey requests that objectives and measures for this [dementia] strategy are incorporated into wider high level reporting for mental health.

The Panel recognised the requirement for any dementia strategy overlays more than the AMHS remit, however, in line with the themes of partnership working and a coordinated, joined-up network for care, including that as part of the Jersey Care Model, feel that the integration of the AMHS essential services to any dementia strategy is key.

KEY FINDING 32: A dementia strategy is being produced by the Government of Jersey, led by the Improvement and Innovation Team in Health and Community Services. Adult Mental Health Services will be a key partner in any dementia strategy.

RECOMMENDATION 8: Adult Mental Health Services (AMHS) should document its position and any limitations of its input as a key partner' to the dementia strategy. AMHS should commit to supporting and responding to the objectives developed by the dementia strategy and, when possible, incorporate these into the outcomes-based reporting for mental health.

Using Mental Health Services

Original Recommendation

Current position

Evaluation of progress

3: The Government should regularly ask service users for their views and opinions on the quality of the mental health services it provides. In light of our survey, the Government should start this regular engagement in Q1 2020. Regardless of the tools that the Government uses to collect user feedback, the results should always be published.

This recommendation was accepted by the Minister in 2019

Feedback from service users is sought in a range of ways, however, the annual survey which was intended in 2019 has not been actioned yet.

There are plans to conduct an annual community survey for service users in 2022.

Further work is required to collect systematic feedback from service users and to ensure that this is utilised in the co-production of services.

Service-user feedback

The Panel's survey approach in 2018/9 received responses from 340 service users and provided a valuable insight into AMHS at that time. The Panel felt that the feedback it received evidenced the importance of collecting feedback from service users. In the ministerial response to S.R.4/2019 it was confirmed that:

we will strengthen our approach to obtaining feedback going forward, and ensure that co-production is embedded in everything that we do.[95]

Furthermore, the Minister's comments provided against the Panel's 2019 recommendation stated that:

the intention is to create an annual survey which will be designed and co-produced with service users and carers. The results will be published on the Government website. In addition our intention is to collect routine outcome measures that are meaningful to people with lived experience and their carers, and pilot these during 2019/20.[96]

In a public hearing on 28th February 2022, the Panel asked for details about the various ways in which AMHS collected patient feedback. We were advised by the Director for Mental Health and Adult Social Care about the following formats for collecting patient feedback:

Formal complaint process;
Inpatient services: regular ward meetings to collate feedback;
Regular Experts by Experience (EBE) group: managers from the mental health system meeting with people who are using the system and that is facilitated by charities';
Proactive encouragement for feedback; and
Informal approaches to staff.[97]

The Director for Mental Health and Adult Social Care expanded on this:

Director for Mental Health and Adult Social Care:

It is no good just saying: "Yes, we collect people's views." It is about what you do with them, but there is evidence that that does happen. What we are going to do moving forward is make that a bit more systematic. We are also going to replicate ... in other places there is an annual community survey so anybody who is on the books of the community mental health services gets the survey sent to them and they are also told where they can get support, not from workers in the system but from, for example, their sector partners to help fill it in if they need that. We are going to do that this year and particularly we need to make sure that we do that in multiple languages and that we make it as accessible as possible to people. Some people do not have internet access, for example, so how are going to make sure that they are able to fill in the form and get it back to us. We are really thinking at the minute about how we make that accessible. That is the sort of stuff that we will keep on doing. There will be routine processes but people get a bit turned off by surveys, do they not? I think you have to have lots and lots of ways of people giving us their feedback and their experience.[98]

We received a number of submissions which reflected on co-production and service user feedback on AMHS. Further detail on co-production is provided in section 7.9 of this chapter.

When asked what, if anything, could improve the patient experience of mental health services, one of the responses provided by Focus on Mental Illness was:

An uninterrupted and uninfluenced range of platforms for service users to be empowered and involved in all aspects of care and service delivery. The voice and experience of people affected by SMI has not so far featured in much of the improvement work. There is a willingness on the part of services to work with services users, for example the introduction of EBE [Experts by Experience] meetings. However, this work continues to be led by professionals with outside influence from third sector agencies. Attempts at authentic engagement are in the main through a carefully selected group. This has resulted in the majority of JAMHS [Jersey Adult Mental Health Service] service users having no real voice in the delivery and planning of the services they receive.[99]

As support for this statement Focus on Mental Illness provided some quotes from members of their user Participation group, which said that there should be:

Proper co-production with service users. Not just tokenistic, random requests for feedback AFTER service development.

Continuing to involve service users and listening to their experiences and then hopefully reaching a decision of how best to help it move forwards.[100]

The challenges around the collection of patient feedback is not an issue that is unique to AMHS, as it has been identified as a recommendation across Health and Community Services (HCS). The Panel references the report by the Comptroller and Auditor General Governance Arrangements for Health and Social Care – Follow up' (the CAG Report), published on 13th September 2021. The CAG Report and recommendations related to HCS as a whole, but the Panel had noted that its eighth recommendation; Develop a comprehensive, integrated approach to capturing and using patient views across all provisions of health and social care' had been recorded as not implemented.

The CAG Report recommendation included capturing patient views through a Patient Advice and Liaison Service (PALS) as a good practice approach.[101] In the December 2021 Quality and Performance Report for Health and Community Services (QPR), it was stated that a PALS desk has been set up at the hospital outpatient department to deal with queries and resolve low-level issues.[102] It is unclear how this service will impact and be used, or extended to the patients of AMHS. The Panel is aware that My Voice, a charity, is available as the advocacy service for AMHS patients.

The Panel welcomes the news that an accessible service user survey for community patients will be undertaken in 2022 and that a range of approaches will be used to collect feedback from patients and influence co-production see section 7.2. As per its original recommendation, the Panel highlights that engagement with service users, including any views and opinions on the quality of the mental health services provided, should be published. This should be done in a suitable and sensitive way.

KEY FINDING 33: Service users for Adult Mental Health Services have a number of ways to provide feedback about services, however, there are concerns that the way feedback is currently collected does not provide the opportunity to capture a full cohort of views. An annual community survey for mental health services patients will be undertaken in 2022.

RECOMMENDATION 9: The Minister for Health and Social Services should, on a quarterly basis, ensure that anonymised feedback from service users is published, together with up to date information about how co-production and accessibility have been addressed by Adult Mental Health Services in the period (for example, for service users who do not speak English as a first language, or others with communication or connectivity challenges).

Priority Issues to be addressed

During its 2018 Review, the Panel identified a number of issues within Jersey's mental health services that needed to be addressed by Government as a priority, these included:

Leadership and Accountability
Investment in People and Places
Mental Health Estate
Parity of Esteem

Leadership and Accountability

Original Recommendation

Current position

Evaluation of progress

4: The Government should consider the merits of having a designated Minister for Mental Health to provide sufficient leadership for mental health in Jersey. Alternatively, the Government should transfer official responsibility for mental health to a designated person. The Government should demonstrate that it has considered this matter and set out its decision in response to this report.

This recommendation was rejected by the Minister in 2019.

The Assistant Minister for Health and Social Services was formally delegated certain political oversight functions relating to AMHS on 23rd December 2021, following his appointment as an Assistant Minister on 25th November 2020. The Assistant Minister had been overseeing mental health services during the year, before the formal delegation was made.

The Panel suggests that, going forward, there needs to be clear and transparent political responsibility and delegation of functions in relation to mental health services. For the political leadership to have a meaningful impact, there also needs to be a clearly defined relationship between the Minister and / or Assistant Minister and the executive structure within the department for AMHS.

5: The terms of reference, membership and reporting lines of the Mental Health Improvement Board should also be made public. The Board should be chaired by a senior officer in Health and Community Services. Membership of the Board should include operational representatives from all frontline services that interact with mental health as

The Mental Health Improvement Board (MHIB) last met in November 2020. It is reported that the meetings stopped due to the COVID pandemic.

A decision has been made to change the MHIB to a Mental Health Strategic Systems Partnership Board. This will be chaired by the Director of

The Panel is concerned that the MHIB did not meet for a significant length of time.

The meetings had stopped for nearly a year before the Chair of the MHIB left the employment of the Government of Jersey.

We have been advised that the new Mental Health Strategic Systems

well as appropriate third Public Health* and is due to Partnership Board is part of sector organisations. Its establish in April 2022. the implementation of the membership should also response to the external include at least two people *During the fact-checking review of Mental Health with lived experience of process the Panel was services and is focused on mental health problems. advised that the first meeting bringing together a

of the Mental Health representative and strategic This recommendation was Strategic Systems partnership group.

partially accepted by the Partnership Board had taken

Minister in 2019. place and it had been agreed

that it would be co-chaired by

the Director for Mental

Health and Adult Social

Care.

Role of the Assistant Minister for Health and Social Services

Recommendation 4 set out that a dedicated Minister for Mental Health or designated person should take official responsibility for the Islands mental health services, however, the ministerial response to the Panel's 2018 Review asserted that integration of mental health services with other health services could be "strengthened at a political level by assigning lead responsibility for mental health to an Assistant Minister for Health and Social Services."[103]

The Panel found evidence of four separate Ministerial Decisions relating to Delegation of Functions' and Assistant Minister Appointment', between May 2019 and December 2021. Two of these specifically related to the delegation of responsibility for mental health services:

28th May 2019 (MD-HSS-2019-0027) - Delegation of Functions: Health and Social Services [104] The Minister for Health and Social Services delegated the political oversight responsibilities for Mental Health Services to Senator S.W. Pallett, in his role as an Assistant Minister for Health and Social Services.
24th July 2019 – (MD-HSS-2019-0036) – Delegation of Functions – Health and Community Services: Assistant Ministers [105]: Delegation of political oversight functions relating to mental health services to Assistant Minister for Health and Social Services, Deputy Hugh Raymond and Senator Steve Pallett.
25th November 2020 – (MD-HSS-2020-0092) – Health and Social Services – Assistant Minister Appointment:[106] Appointment of the Deputy of St John, Deputy Trevor Pointon, as an Assistant Minister.
23rd December 2021 – (MD-HSS-2021-0043) – Health and Social Services – Delegation of Functions – Assistant Minister (Adult Mental Health Services):[107] The Minister for Health and Social Services delegated the political oversight responsibilities for Mental Health Services to Deputy of St John, Deputy Trevor Pointon, in his role as an Assistant Minister.

The Panel notes that there was a gap between the resignation of Senator Pallet as Assistant Minister in November 2020 and the formal delegation of responsibilities for Mental Health services to Deputy Pointon. Deputy Pointon was appointed Assistant Minister in November 2020, however, the formal delegation of responsibility for mental health was not assigned until December 2021. However, it appears that an informal delegation had been in place.

The Panel queried the lack of a Ministerial Decision to formally delegate the powers to the Assistant Minister in a quarterly public hearing on 17th November 2021:

Deputy C.S. Alves :

Minister, as of today there is still no ministerial order delegating official responsibility to your Assistant Minister for adult mental health services shown to be online or provided to us [] Can you on record say that this has been done and provide us with that by the end of this hearing?

The Minister for Health and Social Services:

I have every confidence in Deputy Pointon, who has been overseeing the mental health services under my remit. We may not have got round to a formal delegation but that does not need to be the case. He has been exercising the functions of an Assistant Minister and I am very satisfied with that.[108]

The formal delegation of the responsibility followed after this on 23rd December 2021.

Furthermore is we compare the functions and responsibilities delegated to the Assistant Ministers it is clear there is a difference between the scope of their remits. Senator Pallet had a specific list of areas of responsibility and there were two areas that related to the delegated responsibility where the Minister reserved decision-making powers:

MD-HSS-2019-0027 – Delegations to Senator Pallet

The scope of delegation covers all areas relating to Mental Health Services, including strategic planning, operational delivery, and management of the associated workforce. In relation to his specific area of responsibility only, Senator Pallett would also be able to lodge propositions, make statements and respond to ministerial questions. He would also be able to sign Ministerial Decisions relating to the business areas under these responsibilities.

Responsibility would extend specifically to the following –

Refreshing the mental health strategy
Refreshing the suicide prevention framework
Developing a well-being strategy
Developing a dementia strategy
Providing political oversight as a member of the Mental Health Improvement Board
Overseeing the recruitment, retention and training programmes of the
associated workforce
Ensuring development and co-production of mental health and well-being

services with all stakeholders, including third sector partners and G.P.s
Considering applications under the Mental Health (Jersey) Law 2016 and making associated Ministerial Decisions
Overseeing the transition arrangements for CAMHS and ensuring the smooth working of ongoing liaison between HCS and CYPES in relation to CAMHS
Overseeing the provision and refurbishment of mental health estate facilities (subject to the Minister retaining responsibility in relation to point 1 below)
Promoting good mental health and well-being generally in all areas of Government policy and in Island life
Dealing with Ministerial questions and enquiries made by States Members, media or the Public
Dealing with Scrutiny enquiries and answering related questions at Scrutiny hearings.

The Minister for Health and Social Services retains political oversight for all Health and Community Services business, and therefore would expect to be fully briefed on developments in these delegated areas. He would propose to specifically reserve decision-making powers in 2 areas that relate to the delegated responsibility –

The location of mental health estate facilities where considered in conjunction with the future Hospital.
Ongoing reviews of mental health and capacity legislation and the continuing implementation of that legislation.[109]

In contrast, the delegation to Deputy Pointon in December 2021 did not include a detailed list of responsibilities and the Minister had reserved decision making powers in three of the areas relating to the delegated powers: two areas were the same as above, but the additional area was the redevelopment of the mental health estate at Clinique Pinel and Rosewood House.

MD-HSS-2021-0043 – Delegations to Deputy Pointon

To include all areas relating to adult mental health services, including strategic planning, operational delivery and management of the associated workforce. In relation to this specific area of responsibility only, the Assistant Minister would also be able to lodge Propositions, make statements and respond to ministerial questions. He would also be able to sign Ministerial decisions relating to the business areas under these responsibilities.

As the Minister retains political oversight for all Health and Community Services business, he would expect to be fully briefed on developments in these delegated areas.

The Minister would reserve decision-making powers in three areas that relate to the delegated responsibility:

The redevelopment of the mental health estate at Clinique Pinel and Rosewood House

The location of mental health facilities where considered in conjunction with the future hospital
Ongoing reviews of mental health and capacity legislation and the continuing implementation of that legislation [110]

It is unclear why the Minister decided to retain decision making powers in relation to Clinique Pinel and Rosewood House in MD-HSS-2021-0043, however, further commentary on these sites is detailed in section 7.5 of this chapter.

The Panel is concerned that the lack of formal delegation to an Assistant Minister for the period from November 2020 to December 2021, indicates that there was a lack of substance underneath the delegation of responsibility.

Furthermore, at the time of writing, the Panel noted that the relevant Delegation of Functions' page on the gov.je website contained outdated information in relation to the delegated functions for the department (listed under Health and Social Services'). This publicly available information should be kept up to date.

We also note that, as per the HCS Business Plan for 2022 the ministerial lead assigned to the initiative Deliver outcomes identified in the MHIP' is listed as the Minister for Health and Social Services and not the Assistant Minister [111].

The Panel suggests that, going forward, there needs to be clear and transparent political responsibility and delegation of functions in relation to mental health services. For the political leadership to have a meaningful impact, there also needs to be a clearly defined relationship between the Minister / Assistant Minister and the executive structure within the department for AMHS.

The Mental Health Improvement Board (MHIB)

The Panel had made recommendation 5 of S.R.4/2019 due to concerns about the suitability and adequacy of the plans for the MHIB. The related key finding was:

Key Finding 7: We are seriously concerned about the structure of the Mental Health Improvement Board. We are concerned that it is chaired by the Director General of the Department of Justice and Home Affairs and we are concerned that it does not have anyone with lived experience of mental health services on the Board.[112]

The Panel was aware that the chair of the MHIB (the former Director General of Justice and Home Affairs) had left his role in Government in autumn 2021, therefore the Panel wanted to understand what had happened to the MHIB since that time.

During a quarterly public hearing in February 2022, the Panel learned that the Director for Mental Health and Adult Social Care had spoken with the Director of Public Health about how to utilise the MHIB:

Director for Mental Health and Adult Social Care:

"So I had a helpful conversation with [Director of Public Health] about how do we utilise what was the Mental Health Improvement Board to really focus on what is the whole system, how do we best make use of the resource that we have? Then underpinning that, an issue around workforce, role redevelopment, recruitment and retention."[113]

The Panel understands that the MHIB will be changed into a Mental Health Strategic Systems Partnership Board (MHPB). In a public hearing the Panel asked about the differences between the new MHPB and the previously existing MHIB:

Deputy Kevin Pamplin:

Could you just explain again the structure of that [the MHPB]? But what will be done differently because obviously sometimes when something was not working it could be given a new name but the same things probably still happened? How are we going to see the outcomes of that?

Director for Mental Health and Adult Social Care:

So my understanding of the Mental Health Improvement Board and the plan that was developed is that the focus of the board was about checking that what had been said in the plan was happening. That is a very transactional: "Is this happening or not? Yes or no" and then we move on to the next thing. That is not where I hope we get to.[114]

The Director then set out the vision for the new MHPB, which included making sure that responsibility for mental health services in Jersey was held collectively, and provided specific examples of stakeholder interactions where improvements could be made:

Director for Mental Health and Adult Social Care:

"I hope the Mental Health Partnership Board is a place where people around the table collectively hold responsibility for the mental health system so there is an ability for people to challenge are we doing the right thing, are we developing the right models, are we spending our money in the right way, but also really thinking about how do all of the bits of the jigsaw fit together. How do we make sure, for example, that health and clinical staff particularly are doing the right tasks that clinical staff should be doing and that where other parts of the system, particularly third sector and voluntary agencies but also increasingly people who use services, can provide work and support and help the system move along that they are doing that? So a good example of that is around the Memory Assessment Service where at the moment we have clinical staff doing a lot of work that I would describe as support work that could be done by third sector partners and others. That then allows the clinical staff to focus.

[]

We would be having that around the table with the system partners and saying: "Where do we think this money should best be spent?" and people would have different ideas about that. How do we make sure it is different? Well, I think it needs to be a public thing. I am very clear, my approach is that we say really clearly and publicly: "These are the things that we are going to do" and then people can hold us to account for them. We should be able to say: "This is what we have done, this is the impact it has had and these are the measures that we are using."[115]

The Panel queried the above understanding of the MHIB and queried if it had been intended to be used in the co-production of services:

Senator S.W. Pallett:

Can I just come in here? Whether I agree or disagree with your comments around the Mental Health Improvement Board, I certainly do not think it was set up just to sign things off. It very much was around co-producing services. So I think that is underestimating what that board was doing. What is going to happen to the Health Improvement Plan? There were a lot of good things in that. I presume it has not just been thrown in the bin and we start from scratch again.

Director for Mental Health and Adult Social Care:

No, not in the slightest. Apologies if I have misunderstood. My feedback around the Mental Health Improvement Board is from people who have talked to me about it and were there or were part of it and their view was that it was a process: "Has this been done or not?"

Senator S.W. Pallett:

I was there and I do not think it was process-driven board. Director for Mental Health and Adult Social Care:

Of course it has not been thrown in the bin. We have already looked at and updated and have been regularly updating all of the 80 actions in the Mental Health Improvement Plan. So we have looked at where we are against all of those and they will form some of the priority work.[116]

The Panel had previously recommended in S.R.4/2019 that the terms of reference (ToR), membership and reporting lines of the MIHB should be made public. The Panel could not find a copy of these on gov.je at the time of researching this report but were advised that they had been available. With reference to the Director's comments earlier in the hearing about public accountability, the Panel also asked whether the ToR for the MHPH would be public:

Deputy Kevin Pamplin:

to go back to our recommendation 5, it literally says: "The terms of reference, membership and reporting lines of the Mental Health Improvement Board should be made public." Are these the sort of things you are talking about that will be all public?

Director for Mental Health and Adult Social Care:

Precisely. I understand that the terms of reference for the improvement board were made public. They were put on the website, I am told. I think what then happened was that the Mental Health Improvement Board ceased to meet as COVID came in and that has been the problem there.[117]

The Panel made some further enquiries about the cessation of the MHIB in correspondence with the Minister:

When was the last meeting of the MHIB?

The last meeting of the MHIB was held on 16th November 2020 – there is an available agenda for this meeting, although have been unable to locate any subsequent minutes. The last set of minutes available is for 28th September 2020. The intent following the last meeting was for the MHIB to convert to a Partnership Board. Draft Terms of Reference had been communicated to MHIB members.

Has decision been communicated to the stakeholder groups?

I understand this decision was communicated to MHIB members as above.

When was the decision taken and by whom?

The MHIB was chaired by the Director General for Justice and Home Affairs (JHA). The decision to convene, pause or discontinue the Board is a decision of the Chair, and appears to have been made around November 2020.[118]

The Panel has not had sight of the minutes of the MHIB, so we are unable to assess any further details provided for it ceasing to meet. The Panel asked whether the MHIB had been unsuccessful, and whether this was the reason for the change:

Senator Steve Pallett:

you believe the Mental Health Improvement Board has been unsuccessful, is that the reason for the change?

Assistant Minister for Health and Social Services:

The reason the Improvement Board has not been successful is that it had to cease functioning and its replacement in the new board will be very much more flexible and will put decisions into the hands of people who are providing services, both the mental health service itself and those people in the community; Mind, Recovery College and other providers. They will be able to work together to provide better services for people with mental ill health.

Director for Mental Health and Adult Social Care:

If you look at the Improvement Board plan and the actions there is some stuff that was absolutely done and completed and there is some stuff that was started and has not got to full fruition and there is some stuff that did not really start. From my perspective as someone coming into the system, was it an abject failure? No, of course it was not. It clearly delivered some stuff, really important stuff. I have talked about the crisis team earlier, there has been real progress around co-production, for example, so you referenced that earlier...[119]

In submissions provided to the Panel, organisations who had been involved in the MHIB advised us that the lack of meetings for that group had hindered progress on a number of matters, for example network working. The Service Lead at the Listening Lounge advised that:

The Mental Health Improvement Board has not met consistently, and this has impeded progress relating to improvements and key priorities.[120]

Furthermore, the submission from Jersey Recovery College suggested that the lack of MHIB meetings had impacted strategy:

The Mental Health Improvement Board has not met regularly over the past few years leading to a lack of joint up thinking across the system and a lack of direction.[121]

The Panel has confidentially been provided with a copy of the draft terms of reference for the new MHPB when we asked for some further details from the Minister. We were also advised that:

Please can you provide some further details about the establishment, structure, membership and terms of reference of the new Mental Health Partnership Board?

The new Mental Health Strategic System Partnership Board is part of the implementation of our response to the external review of Mental Health services, with the aim of creating a strategic partnership forum that brings together key partners – including representation of service users and carers – to oversee and develop a single coherent mental health system. The Partnership Board will be supported by the operationally-focused Mental Health Network, which is already well established. The Partnership Board will be chaired by the Director of Public Health. It seems that the development of a similar partnership board is a direction that was intended following the pause / cessation of the previous MHIB but appears to have not been progressed due to Covid. The Partnership Board will meet for the first time in April. The proposed (final draft) Terms of Reference [*are attached here], and will be discussed & finalised at the first meeting. These include the structure, membership and objectives of the Board. [*Document provided in confidence to the Panel 25/03/2022.]

The Panel noted that the Director of Public Health had been proposed to chair the MHPB and queried whether it should be an individual with specific experience in mental health. The Director for Mental Health and Adult Social Care responded to advise that the involvement of the public health department was usual in other jurisdictions:

Director for Mental Health and Adult Social Care:

I can only say from my conversations with the Director of Public Health that he is happy to do that. It is very normal so my experience from elsewhere is that system partnership boards are very much led by public health because we need to think about mental health as a public health issue.[122]

The Panel later reviewed the minutes of the Health and Community Services Board from 8th November 2021 which stated:

"There is now real opportunity as the Mental Health Improvement Board (MHIB) needs to be revisited & a new MH strategy needs to be developed: mental health partners are keen to progress these.

[]

[Director General HCS] asked what the plans are for the MHIB. [CEO Mind Jersey] advised that her understanding is that this has been paused & [Director of Public Health] has agreed to Chair once it has recommenced. Meeting with community & voluntary sector & also asked for representation from the voluntary sector. [Director General HCS] will discuss this with [Director of Public Health]. [CEO Mind Jersey] also welcomed advice / guidance about how to make the recommendations visible & talked about.[123]

The Panel was subsequently advised during the factual accuracy checking process for this report that the first meeting of the MHPB had agreed to appoint the Director of Mental Health and Adult Social Care as a co-chair.

Recruitment and Retention

Original Recommendation

Current position

Evaluation of progress

6: If prospective candidates applying for mental health roles cannot afford to live in the Island then either salaries need to increase or a way of mitigating the high cost of living need to be found. The salaries of key mental health staff should be reviewed and adjusted so that they are competitive with the UK when Jersey's cost of living is taken into account.

This recommendation was accepted by the Minister in 2019.

The Panel learned that recruitment to mental health roles was still challenging. On 4th February 2022 there were 55.78 vacancies within the mental health care group.

Cost of living, particularly accommodation costs, remains a key barrier to recruitment.

The Panel was advised that the challenge of recruiting skilled workers was not unique to HCS, but also faced other departments (for example, Children, Young People, Education and Skills) as well.

We learned that the Strategic Policy, Planning and Performance Department (SPPP) was

leading a piece of work to review keyworker accommodation.

The Panel opines that cost of living and accommodation costs need to be addressed as a matter of urgent priority by the Government.

Benefits and alternative incentives should be explored to encourage skilled people to work in Jersey in mental health services.

Little impact or policy change has been made since the Altair report on keyworker accommodation was published in May 2019.

Whilst SPPP may now be leading the work to review keyworker accommodation, there should be increased Ministerial support to facilitate a joined-up and longer-term solution to the problem.

7: In addition to assisting with pay and cost of living, the Government should do more to help successful applicants with moving and settling in the Island. The

The Panel has found evidence that some support and relocation support is available to prospective candidates.

We have not analysed whether the support provided is adequate or done any comparison of how the support available compares with other jurisdictions.

Government could provide for example, resettlement loans/grants, assistance with the cost of importing a vehicle, registering for a driving licence, obtaining a registration card and childcare.

This recommendation was accepted by the Minister in 2019.

8: Recruitment and retention problems in Jersey's mental health services should not prevent the Government from making progress on improving these services. Regardless of whether the number of staff increases, the Government should focus on improving ways of working within current resource constraints and focusing on investing in existing staff by giving them access to, for example, appropriate training.

This recommendation was accepted by the Minister in 2019.

The workforce model will be reviewed for appropriateness and needs to be aligned with the community model of care and the Jersey Care Model. There could be opportunities for existing job roles (such as Support Workers) to be expanded.

A Mental Health nursing degree can now be undertaken on-Island.

Co-ordination of different workstreams (such as adjusting the workforce model for AMHS, the development of the community mental model of care and the development of the Jersey Care Model) is essential to finding a suitable solution for recruitment and retention problems.

A standard process for capturing and monitoring vacancies in HCS should be adopted to ensure consistency in reporting.

Recruitment and vacancies

In a public hearing, the Director for Mental Health and Adult Social Care advised the Panel that the work focussed on recruitment and retention was considered an important longer-term piece, with no quick fix:

Director for Mental Health and Adult Social Care:

Underpinning that [prioritised work] there is a couple of pieces of work that will not be done quickly but will have really significant impact. One is around recruitment and retention, so that is about looking at how we recruit, the roles that we are recruiting to, how we retain staff once we get them, and that is particularly around training and career development, having opportunities to develop new skills, et cetera.[124]

The Panel has used quarterly public hearings to request updates on the vacancy levels across areas of HCS. On 4th February 2022 the Panel was advised that there were 55.78 vacancies within the mental health care group. These were detailed as vacancies for: 21 registered nurses, 9.5 healthcare assistants, 3 medical posts, 3 social work posts, some psychological therapies and allied health professional posts spread across community services, and 10 admin vacancies.[125] This compares to figures provided in response to a written question last year, which detailed that there were 66 vacancies in Adult Mental Health (out of a total staff of 314.31 full time equivalents).[126]

The Panel is also aware of recent findings and recommendations by the Public Accounts Committee (PAC), from its Performance Management Review': P.A.C. 2/2022. The PAC found that Although the Target Operating Model for Health and Community Services has been implemented, the Department still experiences high levels of vacancies in some areas'.[127] It was also noted that in responses to a number of Written and Oral Questions on the vacancy and turnover rates within Health and Community Services the Minister had acknowledged that there had been issues in the gathering, validation and reconciliation of some vacancy information. PAC suggested that there should be a central requirement for how data on vacancy levels is measured and reconciled across Health and Community Services'.[128] This finding contributed to its recommendation that there should be a standard requirement and processes for the capturing, validating and reporting of data on vacancy levels.'[129] The Panel supports the PAC's recommendation that there should be a standard process for the capture and reporting of vacancies within HCS.

Specifically, in respect of the AMHS vacancies as at February 2022, the Director for Mental Health and Adult Social Care explained that:

Director for Mental Health and Adult Social Care:

A lot of these posts are out to advert currently and a number of them have people in process, so we are at the point of either offering jobs or people waiting to start. But of course what we now need to overlay and think about is how many new posts we will be creating with the additional monies. It is essential that we have a workforce plan that supports that. In the context of 20 registered nurse vacancies, there is no point saying we are now going to create another 20 registered nurse posts if we think we are unlikely to recruit to them. This is a place where ... you asked earlier about what I thought about an overall, this is a place where there is real opportunity. The workforce models are still quite traditional here and there are real opportunities, particularly for people like support workers, Jersey folk who work in our services who really want to do more and have potential to do more, we need to create workforce roles that allow them to do that. That is happening a lot elsewhere, so it is one of the things that we will be developing into our service development in the next few months.[130]

The Panel notes that there could be further changes to the workforce model for AMHS. Changes and developments need to be coordinated with work that is being undertaken around the community mental model of care (as discussed in section 7.14), which in turn needs to be developed in the context of the Jersey Care Model (as identified by the Independent Report).

The Panel is mindful of how the challenges with staff and recruitment are directly impacting patient care:

Difficulties in recruitment and changes in structures appear to leave little time for staff to build up therapeutic relationships with service users and families. People who are living with long term mental illness tell us that many team members try very hard to support them but feel that there is less practical outreach support and approaches that take account of the challenges of their lives.[131]

The Panel is also aware of the service redesign of Child and Adolescent Mental Health Services (CAMHS), which will see the creation of a number of new job roles in that department. The Director for Mental Health and Adult Social Care referred to this in the hearing and provided the Panel with the following assurance:

Director for Mental Health and Adult Social Care:

Just to urge a note of caution, one of the things that we need to really think about, given that we have a finite resource, is how, as we develop specialised services such as some of the C.A.M.H.S. new services, we do not see a massive attrition of staff from adult mental health services into those services. That is something that happened a lot in the U.K. in the last few years where people have not wanted to work in core mental health services because they are off doing the new and shiny stuff. So we have been having conversations across adult mental health and C.A.M.H.S. about not creating workforce plans that destabilise either of us because that is really important.[132]

The Panel was interested to learn how skilled employees could diversify their careers without leaving the organisation (i.e., the employment through the States' Employment Board).

Deputy M.R. Le Hegarat :

what work is done to keep employees but maybe allowing them to diversify from where they are?

[]

Medical Director, Health and Community Services:

I think you raise a really, really good point and [Chief Nurse, HCS] and I have had numerous conversations about the education and development offering that we need to provide to our staff. But I think we need to be even more flexible than that. We need to have roles where people may want to come to the Island for shorter periods of time, come and get a qualification, move back to the U.K. It helps them with funds around housing and moving families here and we need to develop much more closer links with more educational establishments in the U.K. and soon we will already have a lot but we need to exploit that and use that. But I think you are absolutely right, people who come to Jersey if they believe that they will be developed and maybe get a qualification, get experience and then see elsewhere and then move back and, hopefully, some of those people will stay more permanently.[133]

The Panel recognises that recruitment and retention remain a challenge for areas across the Government and notes the suggestions that have been made about how this could be resolved going forward.

Training

As referenced above, the Director for Mental Health and Adult Social Care has referred to potential changes to the workforce model and creation of new workforce roles to upskill existing staff and local people.

Additionally, there is now the opportunity for people to undertake a Mental Health nursing degree on-Island and it is hoped that this will support home-grown talent'[134] for the future. A mental health nursing degree programme started in September 2021. This course was provided through the University of Chester, however, during the factual accuracy checking process the Panel was advised that the contract had concluded and that the department was in the process of identifying the next provider for Mental Health nurse training.

In a public hearing the Chief Nurse, Health and Community Services advised:

Chief Nurse, Health and Community Services:

In relation to training, thanks to some Government funding we started our mental health nurse training on-Island last September. We have a cohort of 6 students on the programme at the moment with a view that we will next have an intake in 2023. We had more students than we had places apply and we do have a waiting list of Islanders who want to come on to various programmes, not just the mental health one. We hope to grow that in the future further now we have got a small team of lecturers within the department who all come from a mental health background. That is working really well and that will start to feed our supply going forward.[135]

The Panel is encouraged that the training courses for student nurses are popular and notes that no fees are charged for these courses. However, it has also come to our attention that there is no wage paid to student nurses for the work they undertake during training [136]. In relation to the identified challenges for costs of living in Jersey, the Panel feels that this will not actively encourage some people who might have an interest in applying to train as nurses and mental health nurses, as they will not be able to afford to work at the same time.

KEY FINDING 37: The workforce model for Adult Mental Health Services will be reviewed for appropriateness, as it needs to be aligned with the models of care for AMHS and the wider reaching Jersey Care Model. There could be opportunities for existing job roles, such as Support Workers, to be expanded as part of the workforce review.

KEY FINDING 38: A Mental Health nursing degree can now be undertaken on-Island and it is hoped that this will create home grown talent. Clarity over the future provider for this degree is required.

Cost of Living

In 2019 the Panel found that cost of living in Jersey was a factor which put off prospective candidates from taking up jobs in the Island. It had been identified by the Panel as a priority issue in S.R.4/2019, however, the Panel was aware that recruitment was an area that remained challenging for HCS overall, not just AMHS.

In a public hearing on 28th February 2022, we queried what action had been taken to address the recruitment challenges. The Assistant Minister for Health and Social Services advised:

Assistant Minister for Health and Social Services:

Yes, we, along with all of the other essential organisations within Government, are having a problem with recruitment, not just with the recruitment but retention, as you say, and there are specific problems in the Island that are not even unique to the Island but they do need to be addressed in the wider sense for education, for health, for mental health, for the civil service to bring in the people that they need and to keep them here given the cost of living and the price of housing. But we have been doing some work on this [137]

The Chief Nurse, Health and Community Services, expanded on this and advised the Panel about the work to address the longstanding challenges created by the cost of housing in Jersey:

Chief Nurse, Health and Community Services:

In relation to housing and cost of housing, it is a perennial problem for which there is not any straightforward solution and I say that with some years of exasperation. I have sat in front of this panel and we have talked about it many times before. There is a renewed focus on it across Government at the moment and I am involved in a piece of work looking at key worker accommodation. Again we are not the only department that struggles. C.Y.P.E.S. (Children, Young People, Education and Skills) are also struggling with housing for the children social workers and more recently we have heard about uniformed services that are now also starting to struggle as well. [Director General] is heading up that piece of work, so it sits within S.P.P.P. (Strategic Policy, Performance and Population) as a department. There are 2 sort of elements to it at the moment. One is trying to address an immediate issue that we have got more demand than we have supply, and that is with combined issues within our department and also within children's services. Then the other is looking at a longer-term solution, all building on the work that Altair did previously independently for the Government of Jersey. So I have not actually got an answer. We will all have a party when we have an answer, but it continues to be a difficult problem.[138]

The Panel noted the Report on Key Worker Housing' produced by Altair for the States of Jersey dated December 2018 and published in May 2019 which made a number of recommendations relating to key workers and employment practices. However, there is little evidence that any work resulting from that has assisted in the progression of a solution.

The cost of living in Jersey is a problem which has been identified for some time but appears to have been exacerbated in the past 4 years. The Panel has had the opportunity to meet AMHS staff at its site visit on 22nd February 2022 and we informally heard about the pressures of accommodation and cost of living for individuals. The fact that this is a recurrent problem, which affects all sectors of Government, is a concern to the Panel and indicates a lack of a coherent solution.

The Panel acknowledges that the challenges associated with the cost of living are a wider issue and responsibility for a solution cannot sit solely with AMHS or HCS and need to be Government-wide.

The Panel had identified that recruitment across Health and Community Services (and other areas of Government, including CAMHS) had remained a challenge since the findings of S.R.4/2019. In its quarterly public hearing, the Panel heard from the Associate Director of People Services – Health, that there were some actions being taken to address this and the overall HCS workforce had reportedly grown over the year to 2021:

Associate Director of People Services – Health:

We have some bespoke programmes to try to get into those areas specifically using some external expertise to identify those cohorts of skilled staff to bring them on to Island.

[]

So we are not relaxed about the position. We recognise that there are challenges in certain areas. But when you look at the workforce growth, we have grown through the year, which is a good place to be.[139]

Assistance with relocation

The Chief Nurse, Health and Community Services explained that:

Chief Nurse, Health and Community Services:

In relation to relocation, the Government does now provide that relocation service who want to access it. There is 2 companies that support new staff coming to the Island and the feedback that we get from staff is that that is very well received. Of course there is relocation costs included within that.[140]

The Panel sought further information about the level of support offered to potential recruits. The following information is detailed on the page Relocating to Jersey as a nurse or midwife' on gov.je [141]:

There are additional links on the above webpage which provide further information about aspects of life in Jersey.

The Panel has not undertaken any research to determine the adequacy of the above relocation package, or how this would compare to other jurisdictions.

KEY FINDING 41: The Government does provide a relocation package for some workers moving to Jersey.

Mental Health Estate

Original Recommendation

Current position

Evaluation of progress

9: The government shoul prioritise finding replacement for Orchard House in the short t medium term. The Government should als improve governance withi Orchard House includin setting appropriate standards and performanc processes to ensure tha staff but especially servic users remain safe. These should be developed an implemented by the end o 2019.

This recommendation wa accepted by the Minister in 2019

d a

o n

e t e

d f

Orchard House which sits on the south side of La Route de la Hougue Bie, St. Saviour , and is used for the Adult Acute Assessment Unit, is still in use.

Refurbishment work on Orchard House – to maintain its short-term use - commenced in October 2019. The work was suspended due to lockdown and was completed by the end of 2020.

A full Health & Safety audit has not been undertaken at Orchard House as follow up since 2018, however, assessments by the Jersey

The Panel is pleased to see that the refurbishment of Orchard House made some improvements to the environment for patients but notes that this is a short-term location for the Adult Acute Assessment Unit.

The relocation of Orchard House to Clinique Pinel was first endorsed in May 2016. The Panel notes that the scope of the project at Clinique Pinel has changed since the original feasibility study, but is concerned that, almost six years after the decision to move Orchard House, it is still in-situ.

Nursing Assessment and Work at Clinique Pinel has Accreditation System experienced delays and (JNAAS) have been relocation expected for later undertaken and this includes in 2022. However, the Panel a range of health & safety question whether this project related indicators. was provided with sufficient

priority, given the Delays to the completion of significance of the concerns building work at Clinique that had been raised about Pinel (on the north side of Orchard House in 2019; the Route de la Hougue Bie, St. urgent need for an adequate Saviour) are delaying the place of safety; and the move of the Adult Acute minimum disruption to Assessment Unit from patients located in Cedar Orchard House. This site is ward.

the medium-term solution

before the co-location can be

arranged in the long-term

once decisions are made

about the new hospital.

Responsibility for the building work at Clinique Pinel sits with the Minister for Infrastructure and the Director of Jersey Property Holdings.

Background

The Panel had made the above recommendation after the following key findings were highlighted in S.R.4/2019:

Key Finding 11: The quality of the mental health estate is completely unacceptable. Many of the buildings are dilapidated, uninviting and not fit for purpose. This is having a detrimental effect on staff and service users. In some cases the poor quality of the estate is failing to keep both service users and staff safe. It is highly likely that this is having a negative impact on recruitment of mental health staff.[142]

Key Finding 12: Orchard House (the Island's adult in-patient mental health service) is particularly bad. It recently failed a health and safety inspection. We received a significant number of complaints about Orchard House via our survey, when collecting personal testimony and from our expert witnesses. In particular we note that there appeared to be little therapeutic activity for patients to do while they are there.

The Panel had understood that the short-term plan was for Orchard House to undergo improvements to safety standards and then, in the medium term, the adult in-patient services

would be relocated to Clinique Pinel. As detailed further in section 7.7 of this chapter, the works to develop Clinique Pinel have experienced a number of delays and, therefore, at the time of this review, Orchard House remains in use.

The Panel sought clarity from the Minister for Health and Social Services regarding its understanding about the current intentions for the sites in St Saviour used by AMHS:

Once the building work at Clinique Pinel has been completed and is ready for occupation, please can you outline how this will affect the location of services in the buildings around the sites in St Saviour?

The current operational, patient facing buildings across both the north and south of the site are as follows:

North - Clinique Pinel and Rosewood House. South - Orchard House and Maison Du Lac.

Services from both south buildings will relocate to the north site, mainly into Clinique Pinel. Rosewood House will continue to provide inpatient Dementia care in the refurbished area of that building. We are currently exploring the potential use of the other part of Rosewood House to maximise effective use of the building.

Please can you clarify your short-term plans for the use of the Orchard House building for Adult Mental Health Services? Will it remain in use / partially in use until the new hospital facilities are operational?

The plan is to stop using Orchard House as an inpatient facility. There is yet to be a decision on whether any other HCS teams could use the facility short term. Jersey Property Holdings have identified the south of the site as a proposed housing redevelopment site. Our understanding is that the site will be handed over to Jersey Property Holdings before the new hospital has been delivered.[143]

Refurbishment at Orchard House

The 2020-23 Government Plan included approval for £3,930,000 of funding for capital mental health improvements across Orchard House, Clinique Pinel and Rosewood House. It was noted that this would be supplemented by an existing £2 million funding allocation. Further details can be found in the Panel's Government Plan Review 2020 (section 5 of S.R.13/2019), which can be found here.

The Panel visited Orchard House on 22nd February 2022 and noted that the refurbishment works had made a visible impact on the feel of the space, the Panel opined that there was more natural light and the space seemed more welcoming for patients in comparison to its previous visit. There is no publicly available information about the portion of cost incurred in relation to the refurbishment of Orchard House.

In a public hearing the Director for Mental Health and Adult Social Care shared some of the feedback he had received about Orchard House and advised that the environment was being used as part of the care delivery for patients:

I have heard directly from both staff and people who use the services that the physical changes in Orchard House have been really, really important and really positive. I met with a group of service users recently to remind who we are talking about, how awful their physical environment was prior to some of the changes. Certainly heard directly from some of the staff, the fact that they feel that the ward is far, far better now than it was before. I personally like the way and I think we saw on the tour, did we not, how they were adapting the environment? They have got a wall where they have service users writing their hopes and aspirations and thoughts on, they are utilising the environment as part of the care delivery now, which is great; that is exactly how it should be. Overall, the feedback has been really positive.[144]

The Panel also received comments about the Orchard House refurbishment in submissions to this review. In response to a question from the Panel (namely: do you consider that there have been any good or positive, changes in the delivery of Mental Health Services in Jersey in the period since 2018?') we received the following comments:

Jersey Recovery College:

The environment at Orchard House has improved and it's encouraging to see service users shaping the service with weekly meetings.[145]

Focus on Mental Illness:

Refurbishment of the estate for adults in need of inpatient care and those accessing the community mental health centre. Investment in these temporary fixes to a longer- term problem was hard won'.[146]

[]

There is more therapeutic activity available for patients' receiving treatment in Orchard House, including an activities coordinator and occupational therapist.[147]

The Panel was pleased that improvements had been made to the in-patient environment at Orchard House, however, was conscious that this was for the short-term. Prior to the refurbishment, in 2018, health and safety improvement notices had been served by the Health and Safety Inspectorate in relation to Orchard House. The Panel has been advised of the processes in place to ensure compliance with safety in Orchard House, however, this does not include a full Health and Safety audit:

When was the most recent Health and Safety report produced for Orchard House? What did this identify?

A full Health & Safety audit has not been undertaken at Orchard House in recent years.

However, a number of other processes are in place which assess compliance with various aspects of health & safety. For Orchard House these include :

• PMVA audit (completed July 2021 – identified need to update training compliance)

• Ligature Anchor Point Risk Assessment (Feb 2022)

• Risk Profile exercise (partially completed April 2021)

• Regular Health & Safety Walkabout tools (last Feb 2022)

The Jersey Nursing Assessment and Accreditation System (JNAAS) assessment also incorporates a range of health & safety related indicators. Orchard House was assessed in August 2021, where the key issues identified related to the need to increase training compliance (as per the Prevention and Management of Violence and Aggression (PMVA) audit), the need to improve collaboration in production of care planning & risk assessment, and compliance with policy in relation to medications management. Some other minor estates actions were identified. A follow up spot check was undertaken in March this year and the medication issues were found to now be compliant.[148]

In response to a question about what ongoing assessment there was in Orchard House, the Panel was advised by the Director for Mental Health and Adult Social Care that:

Director for Mental Health and Adult Social Care:

Then there will be ongoing assessment, so the J.N.A.S.S. process is an ongoing process. I know that they will be assessed again at some point against standards and in the end of course you will get to the formal J.C.C. (Jersey Care Commission) assessment of the service, which will include a lot of the same standards that is in J.N.A.S.S.[149]

We understand that the Jersey Care Commission do not currently have jurisdiction over hospital-based services or Mental Health services under the Regulation of Care Law, however, understand that the remit of the JCC could be extended in the future.

Maintenance of the Mental Health Estate

With reference to the previous findings about the dilapidated' mental health estate, the Panel wanted to clarify where responsibility lay for maintenance of the sites occupied by mental health services.

We were aware of comments in the P.A.C.3/2021 (Follow -up review of Estate Management by the Public Accounts Committee, published on 15th October 2021) which had explored the Corporate Landlord Model and highlighted that there were:

some facilities that have specific medical technical or security specifications and maintenance requirements across Health and JHA that will require specialised or regulated maintenance and management and these will stay with the operating organisation.[150]

However, it was noted that, as per the Island Public Estate Strategy 2021-35 (Estates Strategy) the St Saviour site(s) were not listed in the list of exceptions where maintenance is carried out by the directorate (for example the General Hospital and Overdale Hospital). We sought confirmation and further details from the Minister for Infrastructure:

Does IHE or JPH have any involvement with the property and engineering maintenance of the sites occupied by Mental Health Services, particularly, Rosedale House, Clinique Pinel, Orchard House and La Chasse?

Minister's response

JPH in its capacity as the corporate landlord has oversight for the maintenance of sites occupied and administered by the Health and Social Services Department.

a) If so, please could you outline the process for any maintenance requests? Minister's response

The Island Public Estate Strategy 2021-35 sets out in section 1.6 the Maintenance provision and future direction'.[151]

The initial part of this response is confusing, as it claims that the corporate landlord has a blanket oversight on the maintenance for Health sites, and omits the specific exceptions named in the Estates Strategy maintenance provision. The Panel had been seeking to specifically clarify the responsibility for named sites. However, based on the evidence provided to us, the Panel understands that the JPH is responsible for the maintenance

There is also an element of ambiguity in this response, as the reference to section 1.6 in the Estates Strategy does not provide any information about the practical process for how maintenance issues are logged (and who can log them) through the Concerto system (we believe) and how they are tracked, monitored, reviewed, closed, etc. The Panel had informally spoken with staff in Orchard House about maintenance and heard anecdotally that the process and speed of response had improved.

Delays at Clinique Pinel

The Panel has queried the timeline for the completion of the building works at Clinique Pinel, which were originally scheduled to complete in January 2022.[152]

The Panel requested a timeline from the Minister for Infrastructure to outline the building works at Clinique Pinel, in order to understand how this was impacting Orchard House. We were provided with the following information:

Minister's response

A HCS paper entitled Orchard House Relocation (dated 12th May 2016) which sought to relocate the operational assessment and treatment activities undertaken at Orchard House to Clinique Pinel, was endorsed by the Health and Social Services Corporate Management Executive.

A subsequent Feasibility Study was undertaken by JPH in conjunction with HCS in 2017.

The outcome of the 2017' feasibility study was to extend and modify Clinique Pinel to create a single ageless' acute mental health facility.

At that juncture, it was proposed to keep the existing Beech Ward (Dementia Assessment Unit) within the same building (i.e. within Clinique Pinel).

In 2018, £2,000,000.00 of existing HCS Capital Funding was re-allocated to progress these works.

A review in early 2018 with the new HCS leadership (pertaining to mental health) resulted in significant changes to the scheme. These alterations reflected proposed changes to HCS's service delivery model (and expectations) for supporting functional illness moving forward. The main change was to relocate Beech Ward to Rosewood House.

At about the same time the Health and Safety Inspectorate (HSI) issued a formal Improvement Notice (ref: IN/TF/VA/04/18/03 dated April 2018) to make essential improvements to Orchard House.

A further updated feasibility study was agreed in February 2019. This was subsequently updated in July 2019 to include a Place of Safety.

The current / agreed scheme now seeks to provide a dedicated Acute Mental health Facility within Clinique Pinel that includes 26 en-suite (anti-ligature) bedrooms and a place of safety on the ground floor and eight overspill' bedrooms and a tribunal suite / training facility on the first floor.

As noted above, to facilitate these works Beech Ward (located in Clinique Pinel) required relocation to Rosewood House. This necessitated two small extensions and some internal alteration work to Rosewood House.

In the interim, and to address the urgency of the HSI Inspectorate's Improvement Notice a schedule of essential upgrade and refurbishment works were undertaking to the existing Orchard House. These works commenced in October 2019. The works were suspended due to lockdown and were completed by the end of 2020.

Works commenced on Clinique Pinel / Rosewood House on 21.09.20, with a completion date of 31.01.22.[153]

The Panel wanted to establish what the reason was for the delay and received the following explanation from the Minister for Infrastructure:

We understand that there have been a number of delays to the building work at Clinique Pinel and handover from the contractor will not take place until September 2022. Please can you outline the reasons that have been given for the delay?

Minister's response

Since the works commenced two extensions of time has been granted due to exceptionally inclement weather, the need to relocate a JEC main, additional works (i.e. additional work instructed to remedy a legacy issues' relating to the existing building/structure (i.e. firestopping) and additional/essential upgrade works to address safeguarding issues that were only identified once the existing building was vacated (anti-ligature improvements), and the late receipt of an asbestos survey.

The contract completion date has therefore been extended to the 25.05.22.

On the 04.10.21 the contractor tabled a revised target completion programme (for discussion purposes) showing a completion date of 19.09.22. This is some 17 weeks behind above-mentioned contract completion date of 25.05.22.

JPH have independently had site progress assessed against the contractor's latest programme. Progress appears to be slipping.

The contractor have been asked to review and updated their programme. This is awaited.

Under the contract the contractor are required to use his best endeavours to complete on time.

The current contract completion date has not been reached and it is hoped that additional resources will be provided to catch up.[154]

The Panel is concerned that the delay to the works is impacting the provision of patient care. During the Panel's site visit to Clinique Pinel on 22nd February 2022, the Panel observed how Cedar Ward (the Older Adult Assessment Unit) on the first floor of the building remained operational amidst the building works and we heard about the challenges that had presented for clinical staff.

The Panel revisited Clinique Pinel on 4th April 2022 with the Minister for Infrastructure and representatives from the contractor to hear about the challenges in the delivery of the project, particularly noting its location as adjacent to and underneath Cedar Ward as a specific challenge for the building works.

We have been advised that it was necessary for Cedar Ward to remain operational during the building work as there is no alternative provision for patients [155] and there are some very specific requirements, for example, anti-ligature facilities.

In the Panel's discussions on site in April, it was referenced that the revised completion date (referenced above as 19th September 2022) was in doubt due to further slippage against the timetable. The Panel had queried whether there were any clauses in the building contract to address delays, and we were advised that:

The form of contract between the contractor and the Minister for IHE, is the JCT 2011 (Joint Council Tribunal) Standard Form of Building Contract With Quantities - 2011 Edition with local amendment, which is the Government of Jersey's standard form of contract for traditional construction projects. The contract includes clauses that (i) permit the contract period to be extended (for permissible events), and (ii) for damages to be applied for non-completion.[156]

The Panel also asked about how the delays to the contract was communicated and were advised that:

The Lead Nurse attends the monthly site meetings and weekly updates dates and is aware of these revised completion dates. The HCS Estate Manager receives a copy of the site meeting minutes.[157]

Whilst the Panel is pleased that the Lead Nurse is directly involved and informed for operational purposes, we query if the wider communication to HCS for management purposes is as effective as it could be. We have not asked HCS about the process which occurs after the HCS Estate Manager receives a copy of the minutes, however, would expect that there should be a better, more coherent communication between JPH and HCS on such an important matter.

As detailed in section 7.3 of this chapter, when the Minister for Health and Social Services formally delegated functions to the Assistant Minister (MD-HSS-2021-0043 dated 23rd December 2021) the redevelopment of the mental health estate at Clinique Pinel and Rosewood House was a decision-making power that was reserved to the Minister at that time. Under the Mental Health (Jersey) Law 2016 Law the Minister must make provision in Jersey for the care and treatment of persons suffering from a mental disorder and approve establishments or premises for the purpose of the care and treatment of patients.

However, the Panel understands that the political responsibility for the capital project building works lies with the Minister for Infrastructure and the responsibility for executive oversight and management sits with the Director for Property, Jersey Property Holdings.[158]

The Panel wanted to understand how the Minister for Health and Social Services had remained involved:

Senator S.W. Pallett:

Clinique Pinel ... What oversight or actions have you taken to try to mitigate against that delay with the contractor and with Jersey Property Holdings because it seems to be a never-ending delay?

The Minister for Health and Social Services:

Yes, I can say not just disappointing, it is so frustrating because this has taken so long. I have not personally received any reports from Jersey Property Holdings because it is a Jersey Property Holdings project. I do not know whether the date we have been given, September is still under challenge or whether there is any mitigation measures to try and bring it forward. I am in a position where, as far as I am aware, that is the date that has been given.[159]

In a letter, the Panel asked the Minister for Infrastructure what discussions had taken place between Infrastructure, Housing and Environment / Jersey Property Holdings and HCS in relation to the level of priority and importance of the building works at Clinique Pinel. The response stated that scope of work was based on the agreed feasibility study, however, it was highlighted that this had increased since the project began. We were advised that this related to:

additional work instructed to remedy a legacy issues' relating to the existing building/structure (i.e. firestopping) and additional/essential upgrade works to address safeguarding issues that were only identified once the existing building was vacated (anti-ligature improvements).[160]

In relation to Clinique Pinel, the Panel also asked the Minister for Infrastructure:

Has this project been considered as a priority?

Minister's response

Yes, as noted above these works have been contracted and are under construction.[161]

The Panel understands the diversion of this capital project to the remit of Jersey Property Holdings and the Minister for Infrastructure, however, is concerned that there has been a distance between the project and the Minister for Health and Social Services and Health and Community Services management who should be responsible for driving this as a priority project.

KEY FINDING 46: The building works at Clinique Pinel were originally due to complete in January 2022. This was extended to 25th May 2022 and has subsequently been delayed further.

Co-locating Services

Original Recommendation

Current position

Evaluation of progress

10: As part of its work to develop a new General Hospital, the Government should conduct an assessment of what mental health services could be co- located with the future hospital.

This recommendation was accepted by the Minister in 2019.

Plans for the new General Hospital at Overdale include a building dedicated for mental health services.

Details and plans for the new General Hospital are not yet finalised, therefore – at the time of this report - there remains a level of uncertainty over the future of co-located services.

New Hospital

The Panel previously recommended co-locating mental health and physical health services and believed that the expected redevelopment of the General Hospital in Jersey provided an opportune time to do this.

At the time of writing this report, the States Assembly has approved that the location of the new General Hospital should be Overdale (as per P.123/2020), however, a public inquiry was underway into the planning application for the new hospital at that site.

The Panel is aware that the current plans for the new hospital at Overdale (planning reference P/2021/1670) do include a specific mental health building.

In a letter to the Minister for Health and Social Services the Panel asked what further detail could be provided about possible future co-location of services. We received the following response:

Please can you outline what discussions have been had about the mental service provision at the new General Hospital?

There is a specific mental health user group as part of the Our Hospital programme and there have been a number of meetings (22). To date, it has been agreed that mental health provision will be co-located on the site of the new hospital and draft plans for the

inpatient design have been jointly developed. It is recognised that these plans are still in development and the mental health user group continues to meet.[162]

The Panel had seen plans of the proposed location of the building and, in a public hearing, questioned the suitability of its placement next to the existing cemetery and current crematorium's rose garden. The Minister for Health and Social Services responded to allay concerns:

Minister for Health and Social Services:

Can I just say I do not think there is a direct overlooking because there is a car parking area and then a road before the rose garden? There is planting around for the car parking area.[163]

Regardless of the specific details of the Overdale / new hospital plans, it appears that co- location has been accepted by both user groups and executive leadership as the appropriate way forward. The new Director for Mental Health and Adult Social Care opined that:

Director for Mental Health and Adult Social Care:

Co-location is absolutely the right thing, it is superb co-locating the mental health service with the General Hospital but we just need to make sure the environment works best.[164]

KEY FINDING 47: Co-location of mental health services and physical health services has been planned as part of the site application for the development of a General Hospital at Overdale.

Place of Safety

Background

A place of safety' is a legal definition under Article 34 of the Mental Health (Jersey) Law 2016:

place of safety" means –

an approved establishment;
in a case where, for the purpose of preventing harm to the person in question or to any other person, a police station is the most secure or suitable place, a police station; and
any other place –

(i) which may be designated as such for the purpose by the Minister, or (ii) the occupier of which consents to receive a person for a specified temporary period;[165]

Original Recommendation	Current position	Evaluation of progress
11: An appropriate place of safety should be created within the existing hospital	As per the Panel's recommendation, a place of safety was created in the	There has been action taken to address the recommendation, however,

until an alternative arrangement can be found. Children and adults in mental health crisis should be separated.

This recommendation was accepted by the Minister in 2019.

General Hospital in 2019, however, it was recognised by staff that it was not an optimal solution for provision of an appropriate place of safety.

A decision was made to purpose build an appropriate place of safety' at Clinique Pinel for the medium-term. The completion of this building work has been delayed to September 2022.

At the time evidence was collected for this review (February 2022), the place of safety' used included: the Emergency Department and occasionally other locations within the General Hospital, the Police station, Orchard House, and Robin Ward (for children).

There are no plans to have a separate place of safety for children and young people.

Once operational, the place of safety' at Clinique Pinel will remain in use until there are new co-located services at the new General Hospital.

the various place of safety' locations that are in use are not considered optimal and, in some cases inappropriate.

A fully functional and fit for purpose Article 36 suite'[166] / place of safety' is not yet operational in Jersey.

Clinique Pinel will be used as a place of safety for both children and adults. We have been advised that there will be appropriate separation and safeguarding arrangements in place when the place of safety is being used for a young person.

12: The Government should explore alternative options for dealing with people in crisis. This could include, for example, "crisis intervention teams" which provide a more patient centred approach.

This recommendation was accepted by the Minister in 2019.

Plans had been made for the establishment of a crisis team in 2019, however, the establishment of this service was expedited by the urgent need for it in the pandemic.

The Community Triage Team has been established and provides 24/7 cover for

Progress has been made with the establishment of the Community Triage Team.

Further triage support should be considered, including consideration about the transport of individuals in crisis.

adults experiencing mental health crisis.

There is no dedicated support for children in crisis available at present.

Current place of safety'

In S.R.4/2019, the Panel found that:

Key Finding 14: Jersey does not have an appropriate place of safety for children or adults in a mental health crisis. People in crisis are often detained in inappropriate environments such as police cells. It is inappropriate for young people to be detained on Robin Ward (the children's ward in the General Hospital) or Orchard House (the Island's adult in-patient mental health service).[167]

As detailed in the table above, the Panel had recommended (Recommendation 11) that an appropriate place of safety should be created within the existing hospital until an alternative arrangement was found. As part of this follow-up review the Panel sought to establish which locations are used as a place of safety' in 2022. In a public hearing we asked for clarification of all the locations that are used as a place of safety for adults in mental health crisis. The Assistant Minister for Health and Social Services advised that:

Currently, Chair, a total (sic) inappropriate police cell would be one venue and provision in E.D. (Emergency Department) another venue. But it is part of the development at Clinique Pinel to provide a place of safety and that is the plan, both for adults and for children. Of course for children Robin Ward is still a place of safety for young children.[168]

He later expanded on this:

the fact of the matter is that we are not tied to utilising the place of safety in E.D. [Emergency Department]. But in recent times it has been the case that single rooms on the private wing have been utilised and staffed by C.A.M.H.S. nurses or C.A.M.H.S. professionals. They have been able to manage individuals in that way when the need is demonstrated. There are other venues within the hospital that are used as a place of safety and very appropriately so.[169]

The Panel had also sought further information about the locations used as a place of safety specifically for children and young people. The Head of Children's Health and Well-Being advised the following in a public hearing:

I am aware certainly over the time I have been here of 2 young people who have been taken out of hours to the police station as a place of safety. In both instances it was considerable risk involving risk to life for those people and that was deemed the most appropriate place. The majority of young people are taken to the emergency department for review there. In terms of our inpatient admissions we have had people placed overnight to Robin Ward and on occasions into Orchard House, so there certainly needs to be further discussion going forward about our places of safety and about the issues that we have by using Robin Ward and Orchard House as places of inpatient admission for safety and for treatment as well.[170]

In response to written queries form the Panel, the Minister for Home Affairs provided the Panel with some data relating to the number of place of safety detentions:

Please can you confirm the number of people who have been removed to a place of safety under the Mental Health (Jersey) Law 2016, since it came into force (broken down by year / month)?

171

The Panel notes that the numbers reflecting all place of safety detentions' have varied over the past six years, and reduced in 2021, however, this contrasts to the number of mental health incidents' (as defined by SoJP), which has increased significantly since 2019 (noting 2018 in the table above is not reflective of a full year).

The Panel wanted to establish which place(s) of safety were most frequently used, however, we were advised that it was not possible to provide us with details about the location of the place of safety without reading each individual log.

Comparing the location of the place of safety to 2018/19, the Panel notes that action was taken to address the provision of a place of safety in the General Hospital, however, it was subsequently identified (in 2019) that this was not optimal'.[171] The medium-term solution planned was for the place of safety to be located at Clinique Pinel (sited on La Route de la Hougue Bie, St. Saviour) after it had undergone some capital development work and expansion.

Deputy K.G. Pamplin of the Minister for Health and Social Services regarding a faculty to provide a place of safety for Islanders in relation to their mental health: (OQ.231/2019)

will the Minister advise whether a new facility to provide such a place of safety will be established as a matter of urgency?"

The Deputy of St. Ouen (The Minister for Health and Social Services):

A place of safety had previously been identified as the General Hospital; however, following a recent review, it has been recognised by staff and clinicians that that does not provide an optimal solution and so a medium term plan has been put in place to provide a place of safety as part of the Clinique Pinel and Orchard House capital plan. Ultimately, I believe mental health services, including a place of safety, should be co- located in our new General Hospital.[172]

Regarding the place of safety that has been provided in the Emergency Department (ED) at the General Hospital, the Panel heard from Focus on Mental Illness who advised us that:

Jersey does not have an appropriate place of safety and those affected by SMI [severe mental illness] describe worsening conditions.[173]

A member of Focus on Mental Illness's user participation group provided the following feedback:

The provision of crisis care at the ED remains inadequate: it takes time to mobilise the support, and people in crisis may be left unattended for an indefinite period; there is no door on the room used for consultation, and consequently, no privacy.[174]

Clinique Pinel as the location for the new place of safety'

As detailed in section 7.5, above plans have been underway to relocate Orchard House (adult in-patient mental health service) to the Clinique Pinel site since 2016, however, it has been highlighted that the scope of the project has changed during that time.

In an extract from Hansard in October 2019, the Minister for Infrastructure noted that the place of safety' was included in the scope of the project from July 2019:

The original timeframe to complete the entire relocation of Orchard House to Clinique Pinel was by the end of next year. However, the scope of this project has grown considerably since the completion of the original feasibility study in 2017. Indeed, the current plans were only formally signed off last month. To provide the desired 21 en suite anti-ligature bedrooms within Clinique Pinel, all to be located on the ground floor level, requires Beech Ward to be relocated to Rosewood House. This action now requires Rosewood House to be extended and altered to accommodate these additional patients. There was a late addition to the scope of work in July 2019 to include a place of safety within Clinique Pinel. This has now been included.[175]

As detailed in section 7.5, above, the Panel noted that the building works at Clinique Pinel, which were originally contracted to complete in January 2022, had suffered two delays and was now anticipated to complete in September 2022 [176] at the earliest.

A timeline of the building works process was provided to the Panel in a letter from the Minister for Infrastructure in March 2022 (a full copy of the letter is available here and it is quoted in section 7.5).

The submission provided to the Panel by the Minister for Home Affairs, on behalf of the States of Jersey Police, indicated that:

The lack of a fully functional and fit for purpose Article 36 suite continues to prove challenging. Managing people with MH (mental health) challenges within the ED (emergency department) environment is less than ideal.[177]

A separate place of safety for children and young people

As detailed in the table above, in 2018 the Panel had also recommended that children and adults in mental health crisis should be separated after receiving evidence to this effect.

In addition to the short-term placement in a place of safety, children and adults should be separated for treatment when they are in crisis. The Panel is aware that six young people were admitted to Orchard House for treatment in June 2021.[178] At its quarterly public hearing with the Minister in August 2021 the Panel asked the Assistant Minister about this situation and he provided the following update:

there are currently under 5 adolescents engaged in Orchard House. The difficulty we have is that the adolescent community does not have an inpatient facility and will not have an inpatient facility until we have a new hospital, which is some considerable time away. Social Services are working on trying to create a therapeutic care home to enable there to be a bit of slack with this problem, but the numbers of people being admitted to Orchard House have remained steady and indications are they are diminishing. We have not, for some considerable time, admitted an adolescent to Orchard House other than those individuals that currently occupy the space.[179]

The Panel sought further clarity from the Minister for Health and Social Services about the plans for the place of safety at Clinique Pinel:

Will the place of safety located in the newly refurbished Clinique Pinel be used for children and young people?

Yes.

a. What consideration has been given to providing a separate place of safety for children and young people?

Due to the need to ensure that a place of safety is able to safely manage someone who has been detained under Article 36 - and may therefore be in acute distress and present with challenging behaviours or potential risks to others- there is a requirement to ensure the availability of staff to meet any immediate safety & risk needs. Therefore it has been concluded that currently there is not an appropriate alternative option to provide a separate place of safety. The operating arrangements for Clinique Pinel will ensure that appropriate separation and safeguarding arrangements are in place when the place of safety is being used for a young person.[180]

The Panel notes that resourcing and operating arrangements are given as the reason for not having a separate place of safety for children and young people, rather than it being the optimum scenario for the patient. In the Ministerial Response to S.R.4/2019 there was reference to a proposal for developing a crisis house' for children as part of the business case for the Listening Lounge, however, we are not aware what came of these plans.

RECOMMENDATION 21: The Minister for Health and Social Services should consider whether a separate place of safety could be provided for children and young people in the medium to long term.

Future location of the Place of Safety

As detailed in section 7.6 of this chapter, there are current plans to co-locate the mental health services provision with the new hospital in the future. There has been no specific detail yet about the scope of that project and whether it would also include a purpose-built place of safety.

The Panel feels that long term consideration must be given to the best use of the Clinique Pinel building, as a purpose-built mental health facility.

KEY FINDING 51: No specific detail has been confirmed about the location of the place of safety in the future (i.e. if mental health service are relocated to the new hospital campus), but we understand that the intention would be to co-locate all the services on the new hospital site and move from Clinique Pinel.

Dementia

In a submission to the Panel from Dementia Jersey relating to their comments on the place of safety, they advised:

There is nothing to suggest this recommendation has been put in place with regards with people with dementia. We believe that it would be good not only for people with dementia, but also for other people with other mental health problems in inpatient facilities, if people with dementia had separate dedicated care facilities – with specialist, dedicated, experienced and dementia trained staff to care for them until an appropriate placement in a care home, or appropriate package of care at home can be provided.[181]

The Panel was interested by this comment and queried what consideration had been given to providing a specific place of safety for individuals suffering from dementia. We received a response in writing from the Minister for Health and Social Services, who advised:

The place of safety relates to a designated place where people can be safely held and assessed under Article 36 (or potentially when otherwise in crisis). It would be unusual for this to be required for a person with dementia, and – given the short term nature of the use of a place of safety, coupled with the function of this – there would be no requirement for a separate place of safety for people with dementia.[182]

The Panel is grateful for the brief explanation, however, has not had sight of any data to establish whether this is an issue. We note that there is commitment from the Government to develop a dementia strategy (as referenced in section 7.1 above), therefore suggest that this should be discussed further to establish that there is no requirement.

Crisis Team / Community Triage Team

As per recommendation 12 of S.R.4/2019, the Panel had highlighted that the Government should explore alternative options for dealing with people in crisis. Plans for a crisis treatment team were included as part of the Government Plan for 2020-23 and a trial had been conducted but, as detailed in chapter 4 the catalyst for its delivery became the COVID-19 pandemic.

The Panel took the opportunity to ask about the community triage team (CTT) impacted frontline mental health services in a public hearing. The Director for Mental Health and Adult Social Care advised that:

Director for Mental Health and Adult Social Care:

The community triage team is the team I have described earlier as the crisis team. It is impacted in that people can get a crisis assessment much more quickly. The feedback from the police has been positive in terms of they feel that they have had some less activity as a result of the triage team, although not anywhere near yet where we would want to get to. But certainly and where the police have got concerns about some on the triage team are able to respond quickly and undertake an assessment. The team also, I think during COVID, was offered as part of the offer to the prison.

[]

But moving forward crisis access and getting an assessment within a timely manner from the crisis team is absolutely essential as part of our services. People must know that they are going to be seen face-to-face for an assessment within 4 hours of the referral being made if a crisis assessment is indicated.[183]

In a letter to the Minister, the Panel requested confirmation of the process for the call out of the Triage Team and queried whether it could attend all requests for assistance:

What is the process for the call out of the Triage Team by the Police / Ambulance / Other Services?

Access to the triage team is via the switchboard – the duty worker is then contacted by bleep.

Is the Triage Team able to assist with all requests for assistance it receives?

Yes, although there are occasions when the triage team will not be available to respond immediately to a request for attendance / assessment (due to already responding to another referral). The team would note the request and indicate how quickly a response can be provided. As an urgent access component of our service, this is something that we would always seek to maintain and would consider any temporary closure of the triage team as a reportable incident.[184]

[185]States of Jersey Prison Service

The Panel noted the urgent access component in relation to a discussion it had on its site visit to the Prison on 6th April 2022, where it was advised that, on occasions, the response times for some requests for assistance from the crisis team had been days. The Panel has no specific data to refer to response times, however, in a letter on behalf of the States of Jersey Prison Service we were advised that:

Since mid-2019, we have direct referral routes through the Crisis Team and the Home Treatment team, however this does not work very well, and we rely on the CPN [Community Psychiatric Nurse] to escalate if a referral is being bounced' between teams.

[]

as mentioned above we have moved to a crisis team and home treatment team model at ADMH's (sic) however this does not have a significant impact on us, apart from slowing down referrals when we are without a CPN, on weekends for example.

186

Frontline Emergency Services

The Panel was interested to understand the demand for the mental health and crisis support from frontline emergency services and we learned from the data provided, both States of Jersey Police (SoJP) and States of Jersey Ambulance service (SoJAS) have recorded an increase in mental health related incidents.

In a letter submitted by the Minister for Home Affairs, on behalf of the SoJP, the Panel was advised that the SoJP continue to see a steady rise in the number of incidents that fall under the umbrella of Mental Health.'[186] There were 1,197 mental health incidents recorded by SoJP in 2021, compared to 1,022 in 2020. It was expected that there would be an increase in 2022 and noted that January 2022 alone had seen 66 mental health incidents, which compared to 56 in January 2021.[187] It was specifically noted that there is no evidence to suggest this increase in demand is down to Covid.'[188]

The submission from SoJP also highlighted to us that Repeat incidents are a regular occurrence and indeed a cause for concern',[189] it was indicated that during the period of June to December 2021:

six individuals were (on average) the subject of at least two mental health logs each month; and
388 individuals were the subject of mental health logs and 120 of these were repeat parties.[190]

We also received data from the SoJAS in relation to the average number of calls they attended each month where mental illness and / or mental health issues were the primary reason for the callout [191]:

Nb (The above data covers the full year 2018 until the end of February 2022) Whilst the data captures calls logged in these two categories of incident, it must be noted that these figures are taken from the Ambulance Services Computer Aided Dispatch (CAD) system. This data is captured from the caller and triaged according to their answers to triage questions, these figures may differ to actual clinical presentation on arrival of a clinician. In addition, it should be noted that in some cases the call may be categorised according to other presentations, e.g., if the patient has attempted suicide through traumatic means, the call may be registered as a trauma call. In some circumstances it may not be clear at the point of call that it relates to mental health.

The Panel wanted to understand the interaction between the SoJP and SoJAS services and the CTT. We understand that the SoJP has a regular operational meeting with the CTT and Police Officers were used to engaging the CTT service as early as possible, if required. We were also advised that:

We know that when we engage the Community Street Triage Service there are less Article 36's and most importantly it sees the right service' dealing immediately with those people who need support at that time.

The current protocol states that a member of the Community Street Triage Team will be on site within the hour.

Further conversations are planned between the two services to discuss further enhancing the Community Street Triage Service as well as undertaking joint training.[192]

The submission provided on behalf of the SoJAS provided details of the relationship between the ambulance service and the CTT:

During the trial period we [SoJAS] worked closely to develop processes with clear guidance for when to call out the CTT. There was a limited number of calls where due to the speed of response and the demand levels placed on the ambulance service, the CCT team were [un]able [193] to respond and assist in a timely manner. Therefore, in the majority of cases whereby we currently work together, the Police are often involved and either the CTT are already on scene when ambulance crews arrive, or the police make the arrangements, freeing up ambulance crews until a decision is made to transfer a patient to more definitive care. There is opportunity to review these arrangements, in order to see if improvements in the system and processes could allow for a timelier response, allowing the ambulance service to use the CTT to assist in more cases.[194]

The Panel notes that submissions on behalf of both emergency services made reference to further discussion and review arrangements for enhancing the partnership working between the services. The Panel asked SoJAS for a breakdown of the number of incidents that it has been called to that have also involved the Community Triage Team (CTT), however were advised that they held insufficient data to provide a response.

Resources provided by AMHS for crisis response

The SoJP advised that providing the CTT with further resources would be beneficial to patients and be more efficient:

A fully resourced Triage Team who are able to deploy as a pair should be the aim (following a suitable risk assessment), coupled with a 24/7 help line. This would mean that the police would only be required when absolutely necessary, this might be in regard to any risks that are linked to the individual. The Police want to avoid putting officers on the ground unless absolutely necessary – we are not the professionals that someone suffering from a mental health episode need to see.[195]

We were also advised by SoJP about challenges that arose following the detention of a person under Article 36 of the Mental Health (Jersey) Law (the MH Law) and required an assessment to be carried out by an authorised officer (as per Article 6 of the MH Law):

The police can evidence occasions where there have been significant' delays whilst waiting for an Authorising Officer. These delays are almost exclusively whilst Police Officers are with a person who has been detained under Article 36 and remains at the Emergency Department. Very often these delays are for hours at a time which causes stress and frustration to the individual and all concerned.[196]

In a public hearing the Director for Mental Health and Adult Social Care confirmed that work around timescales and expectations of the crisis team was underway:

Director for Mental Health and Adult Social Care:

We are putting some measures around that in terms of timescales and expectations, so I am hoping that within 3 months' time anyone that is referred in a crisis will be seen for a face-to-face assessment within 4 hours, because that should be our standard. [197]

Children and Young People in crisis

The Panel also wanted to understand the situations for Children and Young People in crisis. In a public hearing the Panel was advised that:

Director for Mental Health and Adult Social Care:

the crisis team provides a quick response for anyone that is in crisis and at the moment that is predominantly people who are either referred into the community services, people who are referred by the police, particularly around things like Article 36 but also other folk that the police are concerned about; anyone where there is a crisis and it is felt that we need to undertake an assessment quickly to work out what is happening. That team is available 24 hours a day, 7 days a week for adults and our plan at the moment ... we are having conversations with C.A.M.H.S. (Child and Adolescent Mental Health Service) as to how we start to develop in the C.A.M.H.S. arena and possibly work the 2 services together in some way.[198]

The SoJP identified the lack of a triage service for children as a gap in the service:

The triage team need to be able to assist in dealing with young people who are suffering with Mental Health challenges. The police deal with young people daily and very often these young people would benefit greatly from the triage service. This is absolutely seen as a gap in service.[199]

Transport of people in crisis

The Panel was also made aware by the SoJP that individuals who were detained under Article 36 of the Mental Health (Jersey) Law 2016 (the MH Law) were often transported in inappropriate conditions to the place of safety:

The other issue that needs to be considered is how people who are detained or indeed taken to a specific location are transported. Currently the only way to transport an individual suffering from a MH episode is in a police van where they sit within a small cage. It would be the position of the SoJP that to transport an individual who is suffering a MH episode in a caged van is inappropriate for a number of well documented reasons.[200]

Furthermore, we understand that the SoJAS are utilised to transport people to the inpatient facilities at Orchard House:

The Ambulance Service are routinely asked to convey individuals detained under the Mental Health Law from the Emergency Department to Orchid (sic) house. This may involve a number of Services.[201]

The Panel notes that the police cannot delegate the power or responsibility relating to the detention of an individual under Article 36. However, in order to facilitate a better environment for the patient / individual suffering from mental health crisis, there should be a better system established for transport which will require collaborative working between different services. KEY FINDING 52: Frontline emergency services, such as the States of Jersey Police and the States of Jersey Ambulance Service, are often called to attend incidents which are later logged under the umbrella' of mental health. Further work to enhance and review the relationship with the Community Triage Team has been suggested by both those emergency services.

Parity of Esteem

Original Recommendation

Current position

Evaluation of progress

13: The Government should adopt the parity of esteem concept and develop a plan for how it will be integrated into health and social care services. This concept should be reflected in the Mental Health Improvement Board's terms of reference.

This recommendation was accepted by the Minister in 2019.

The Mental Health Improvement Plan had referenced a government wide commitment to parity of esteem for mental health.

Parity of esteem remains a key concept to aim for, but further embedding of this concept in practical approaches is required.

S.R.4/2019 highlighted:

108

Key Finding 15: Parity of esteem, treating physical and mental health equally, has benefits for patients and staff. It allows health and social care services to take a "whole person" approach to people's care.'

In 2019, the Minister had anticipated (in the ministerial response to S.R.4/2019) that the parity of esteem concept would be incorporated into the work of the Mental Health Improvement Board, but that there would also be advocation across different sectors of Government. As discussed in section 7.3 of this chapter, the Mental Health Improvement Board will be replaced by the Mental Health Strategic System Partnership Board (MHPB).

The Panel was provided with a copy of the (unpublished) Mental Health Improvement Plan (dated November 2019) and notes that this referenced that there was a government wide commitment to parity of esteem for mental health. Work will be undertaken by the MHPB to assess progress against the actions identified in the MHPB.

The Panel notes that parity of esteem has been considered as part of the new Children and Young People's Emotional Wellbeing and Mental Health Strategy. Its first priority is that everybody promotes good well-being, mental health and resilience by thinking about mental health in the same way as physical health and making it as simple as possible to get help early'.[202]

The Panel received submissions, including confidential submissions, from organisations which highlighted that the mental health of patients was a key part of their interaction and service.

We received a submission from the Maternity Voices Partnership in relation to key finding 15, which stated:

We find this to be especially true in the perinatal period where birthing people are going through a huge life transition. Many don't have extended families on island and are especially isolated during a period of immense upheaval. The mental health support should have at least equal esteem with physical health and that is far from the situation currently.[203]

The Panel was also advised about parity of esteem was important to ensure that the physical health needs of patients in AMHS were addressed. The Director of Mental Health and Adult Social Care advised that:

Director for Mental Health and Adult Social Care:

We are particularly focusing on physical health of people with exactly as you described, serious mental illness. People with serious physical health needs, long-term physical health needs, are likely to die 15 to 20 years more quickly than the average member of the population for a variety of reasons. So we are making sure that we are doing some interventions around that from a physical health perspective to monitor and support people's physical health needs.[204]

Other areas to be addressed

Co-production

Original Recommendation

Current position

Evaluation of progress

14: The Government should adopt a genuine co- production approach to the design and ongoing delivery of Jersey's mental health services. People with lived experience should be empowered and involved in all aspects of mental health strategic and operation development including having a voice at corporate management level. These people should also be remunerated for their contribution.

This recommendation was accepted by the Minister in 2019.

We have been advised that there has been some effort to undertake a co-production approach in the provision of mental health services, for example the Expert by Experience (EBE) meetings, but it has been acknowledged that there is the opportunity and desire for AMHS to do more.

The Jersey Recovery College deliver a course in co-production.

The Panel is pleased to hear evidence that co-production is used in AMHS and would encourage further development of this across mental health services.

In the Panel's original review, we found that there was evidence to suggest that empowering service users was a good way to deliver services. Delivering mental health services in partnership with service users and mental health professionals helps to achieve this. As detailed in section 7.2 of this chapter, the Panel learned that there are a range of ways for service users to provide feedback and wanted to understand how this was practically utilised in the design of and proposed change to services.

In a public hearing, the Panel heard from the new Director of Mental Health and Adult Social Care that:

Director for Mental Health and Adult Social Care:

there has been real progress around co-production, for example, so you referenced that earlier. There is now a regular meeting between the mental health services and I am going to say experts [] people who use services and their carers and it was superb. I was so impressed by the peer support workers in Mind, for example, who were saying: "We really want to be more involved in stuff. There is a real opportunity for us to do more jointly with services." Steps have been made, good steps have been made; there is just more to do. We need to have more aspiration to do more, I think.[205]

The Panel received a number of submissions from organisations that referred to the importance of co-production. The Service Lead at the Listening Lounge advised of the progress they had seen made towards co-production:

There has been some momentum towards a greater emphasis on the value of lived experience, with Equals by Experience having more involvement in the design and delivery of a growing number of services. Our Peer team at the Listening Lounge occupy integral roles within the service, working alongside qualified counsellors in a client facing capacity. This has proved incredibly successful and has been well utilised, with over 40% of those visiting us choosing to access this type of support. There is huge scope and opportunity to adopt a genuine co-production approach and ensure that meaningful engagement with those who have lived experience of poor mental health or mental illness exists across all services. The introduction of a Lived Experience Engagement Framework would support this movement.[206]

When asked about what, if anything could improve the patient experience of Mental Health Services?' one of the responses from charity Focus on Mental Illness was:

Returning to the very basics of those aspects of service delivery that will support recovery.[207]

They quoted a member of their user participation group to support this statement who said:

existing services should be reviewed for basic quality of life improvements: e.g., Doors in the ED consultation room; better bedding for inpatients; repair of equipment used for therapeutic activities. There should be a renewed commitment to the emphasis on recovery that emerged from the 2015 consultation, with particular emphasis on the *genuine* (sic) involvement of service users as equal partners.[208]

In response to the same question from the Panel about improving patient experience, Jersey Recovery College (JRC) advised us that:

Co-production needs more focus and investment, including the development of an engagement strategy so that any organisation engaging service users can do so in a guided way. There needs to be greater understanding of the co-production model across the system and how to do it well, JRC offers training in this area. In order for co-production to become embedded it needs to be supported with suitable timeframes and budgets.[209]

The Panel asked he Executive Officer of the JRC for some further information about the co- production course and delivery and were advised by email that there is an Introduction to co- production course' and a Facilitating co-production course' available from the JRC.

Partnership working

Original Recommendation

Current position

Evaluation of progress

15: If the Government wants the community and voluntary sector to provide what are essentially frontline mental health services then it needs to provide realistic support to these organisations. The Government should provide adequate funding to, at the very least, cover the cost of delivering services, as well as longer-term contracts to these organisations (which could still be reviewed intermittently) in order to ensure that these services can provide the services required.

This recommendation was accepted by the Minister in 2019.

The Panel was made aware of seven contracts with third party organisations in relation to mental health services. We have not analysed the value of these contracts but note that the majority of contracts were for a period of 12 months.

The Mental Health Network is an operational meeting of mental health providers and other key stakeholder and also refers to an online platform that provides information and support in relation to mental health & wellbeing.

The Hub of Hope network is an online platform that signposts people to potential support.

The Panel is pleased to note greater transparency in elements such as the public HCS Board, however, suggests that there should also be greater transparency about the services procured by third sector organisations on behalf of mental health services where possible.

The Panel has noted evidence from submissions which indicate that voluntary and community organisations desire more joined-up' and coherent working with the public sector in relation to mental health services.

In a letter to the Panel dated 25th March 2022, the Minister for Health and Social Services confidentially provided a table of the current contracts with third sector organisations, together with the contract value. There were seven organisations listed and six of these had a 12-month contract and one organisation had a contract for 36 months. As per S.R.4/2019, the Panel is concerned that commissioning short term contracts does not provide the partner organisations with certainty that they need for continuity of service.

As an example, Dementia Jersey advised us that the charity costs over £420,000 to run and that they received £35,000 from Government. This funding is specifically for one of their services for people with a recent diagnosis of dementia.[210]

AMHS has recognised the importance of the voluntary sector as part of the wider system of care. In a quarterly public hearing the Director for Mental Health and Adult Social Care spoke to the Panel about this and said that:

Director for Mental Health and Adult Social Care:

So it is not just about the things that we do in Health as part of Government, it is about all of the assets around us, the third sector providers, volunteers. There is a whole raft of people who contribute to the mental health structure as a whole. That just needs to be co- ordinated and drawn together in a bit of a more coherent way.[211]

The Panel references minutes of the HCS Board of 8th November 2021, where it is recorded that:

[The Minister for Health and Social Services] noted it was disappointing to hear that the close connection between public & voluntary sector is missing & hopes that the structure can be put in place to improve this. [CEO of Mind Jersey] in agreement & noted that there is so much good practice & learning to share. There is also the risk of duplication where work is not joined.[212]

At the same meeting the HCS Board was presented with a View from the Bridge', which included reports from a number of voluntary organisations, including Mind Jersey's update on the Reconnecting with Hope Conference. A copy of the consultation feedback was also provided to the Panel as part of Mind's submission to this review. With regards to the accessibility of services, the consultation feedback had highlighted the theme that "there should be no wrong door":

We need a more joined up mental health service where there is rapid improvement and integration between statutory adult mental health services and cams (sic) and the community and voluntary sectors. This would need the development of a protocol to make maximum use of sectors expertise and for both sectors to learn from each other.[213]

The Panel is pleased that, in the case of MIND Jersey, this information has already been directly presented to the HCS board.

The requirement for a clearer and more coordinated system for connected services was reflected in a submission to the Panel by the Service Lead of the Listening Lounge:

Improved communication between services and clients is essential, along with improved communication between individual services. There are multiple electronic patient systems being used and a lack of coherent information sharing processes in place, which can hinder the quality of client care. There needs to be a sustained focus on partnership working to bolster improvements made to date.[214]

Similar comments were provided by the Jersey Recovery College:

There needs to be much more joined up thinking between the third sector and statutory services. The Island has a number of excellent, self-referral, accessible services that people can access themselves but there is a lack of awareness of these and signposting to them. The Mental Health Network project during the Pandemic raised some awareness but a lot more needs to be done to create one system where service users can move seamlessly between services, and where there are alternatives offered when a particular service cannot support an individual. Staff in all services across the system should be made aware of what else available and should actively be signposting.[215]

The Panel queried the Mental Health Network with the Minister and was advised that:

The Mental Health Network is an operational meeting of mental health providers and other key stakeholders / partners. It also refers to an online platform that provides information and support in relation to mental health & wellbeing. The Hub of Hope Network is an online platform that signposts people to potential service / support providers based upon their self-identified areas of need.[216]

The Panel is also aware of the newly established Health and Care Partnership Group, which aims to increase health and wellbeing outcomes for Islanders.[217] This group is not focussed on mental health services but incorporates a wider collaboration of stakeholders. Also, as referenced in section 7.14 of this chapter there is work being undertaken on the co-ordination of care model.

The Panel has found through this review numerous references to different committees and groups, service lines and departments, however, there is no clear picture or structure chart of how these all fit together. Without this, the Panel query how networks and signposting – both within HCS and with third party organisations / the voluntary sector - can be effective. As referenced in chapter 5 relating to the Independent Review of Mental Health Services, the Panel points to the Comptroller and Auditor General's Report into Governance Arrangements for Health and Social Care – Follow Up' (C&AG HSC Report) which was published on 13th September 2021 and recommendation 4 of this report.

Role of General Practitioners

Original Recommendation

Current position

Evaluation of progress

16: The Government should offer to all Jersey's General Practitioner (GP) practises, training on mental health and information about Jersey's mental health services.

This recommendation was accepted by the Minister in 2019.

The Panel was advised that the pandemic has interrupted this work. It is anticipated that the development of the Jersey Care Model will involve GP practices in about mental health support.

GPs play a role in early intervention physical or mental illness. More needs to be done to support them with both early intervention and in crisis situations.

17: The Government should Patients seeing their GP for Further work should be done review the fees charged by consultations about mental to review this as part of the General Practitioners GPs in health are not provided with sustainable healthcare relation to mental health. It different fees to those who funding review by Health and should explore, in close present with a physical Community Services. consultation with GPs, problem.

whether a different funding

method could be used if a Since S.R.4/2019 was

patient presents to a GP with published the Government

mental health problems has introduced a Health

rather than physical Access Scheme to subsidise

problems. GP visits for Income Support

households, or those in

This recommendation was receipt of Pension Plus.

accepted by the Minister in

2019. A review of sustainable

healthcare funding is being

undertaken in 2022.

Training for General Practitioners (GPs)

The Panel is aware that GPs can play a critical role in any early intervention for health concerns, whether they are mental or physical. In the Panel's 2018 survey 61% respondents had been referred to Mental Health Services by their GP.[218] However, the Panel had also collected evidence that suggested people's experience of GPs in relation to mental health was inconsistent.[219] Furthermore, it was highlighted that a key insight from the Government's Mental Health Strategy was that communication between primary and secondary care was poor.[220]

In the Ministerial Response to S.R.4/2019, in relation to key finding 19, it was advised that:

Supporting primary care colleagues is central to our plans for improving access and early intervention and providing assistance to develop their knowledge and information about good mental health care in the Island. We have already started an initiative that allows GPs to gain instant telephone advice from a psychiatrist.[221]

Furthermore, the Minister's response to Recommendation 16 of S.R.4/2019 stated that:

Enhancing the capacity at a Primary Care level to develop better mental health care is important to recovery, as early intervention is a key enabler to prevent further deterioration of mental health problems. Some practices are already providing access to mental health support funded from the Health Insurance Fund. We will continue to promote the Jersey Online Directory amongst Primary Care colleagues, and invite them to contribute and become involved in co-produced peer training at the Recovery College. GPs also maintain their own professional development relating to mental health.[222]

In order to establish how this aspect had progressed since the Panel's previous review, the Panel questioned the Minister in a public hearing:

Deputy M.R. Le Hegarat :

Please, could you provide us with an update on what support the Government has provided to G.P.s to assist with early interventions?

[]

The Minister for Health and Social Services:

I think it is just say that if we had not had the pandemic we would be further along this route but the pandemic has affected the development of this piece of work and the G.P.s have had other duties that we have asked them to do. But as the Jersey Care Model develops we will be engaging with G.P.s about enlarging their practices and taking on primary care work in mental health for which they are well suited.

Deputy M.R. Le Hegarat :

What you are saying is basically that in the future there is an anticipation that we will be providing the training for G.P.s to be able to provide that first line opportunity.

The Minister for Health and Social Services:

Yes. It may well be, I am sure, there would have been some discussion with G.P.s around it but I am not aware of any huge initiative at the moment. But this year we will see progress being made with the various work streams and the Jersey Care Model, G.P.s are involved in that. This is definitely one of the areas where we believe G.P.s can help and can address primary needs, rather than bringing people into secondary care services.

Both the COVID-19 pandemic and the States Assembly's decision to adopt the Jersey Care Model (P.114/2020) have significantly impacted the role of GPs in Jersey.

The Minister's 2019 response had referred to peer training and this was mentioned in the submission to the Panel from the Jersey Recovery College which indicated that, locally, this aspect should be developed further:

More credibility needs to be given to peer working and the important role peers can play across the mental health system. We should be working towards co-produced service delivery which involves peers being embedded in services. JRC is working with The Peer Network to bring in a training course to Jersey for anyone wishing to be a peer in health services. We are looking at a course designed by ImROC [Implementing Recovery through Organisational Change] that is requested by the NHS for it's peers. This would provide a skills benchmark.[223]

Role of GPs in early intervention and challenges to service referral and access for patients

The Panel is aware of the importance of early intervention for people suffering with mental health problems and was concerned to learn of the challenges faced by some in accessing services. The Primary Care Body (PCB) (which represents GPs in Jersey) advised us that:

Generally referral systems are poor and seems to be designed to filter out patients rather than assess them first and then provide appropriate care: more proactive approaches are needed.[224]

In relation to the Jersey Talking Therapies (JTT) service, the PCB noted that whilst overall accessibility had been increased through the self-referral process, there were concerns that without the option for referral from a GP (as well), certain groups could face difficulties with access:

Having previously been a health professional referral-only/gatekeeping service it [JTT] now only accepts self-referrals which can increase access, but there are concerns that not accepting GP referrals and requiring specific opt-in' reduces access to people with learning difficulties, communication difficulties (e.g. autism), non-English speakers and many with anxiety and depression where the conditions limit motivation and confidence to approach services directly.[225]

However, a submission from the Listening Lounge advised that there had been positive changes relating to accessibility:

A greater focus on early intervention and accessibility has been a positive change, along with self-referral options and more choice to help prevent problems escalating and empower islanders to be leaders in their own wellbeing and/or recovery.[226]

The Maternity Voices Partnership also highlighted the benefits of the self-referral system:

JTT is self referral through the gov website but this is not widely known and should be promoted as it cuts GPs out of the provision of services.[227]

The Director for Mental Health and Adult Social Care advised that he had been made aware about accessibility challenges and provided the Panel with assurances that the issue was being addressed:

Director for Mental Health and Adult Social Care:

People consistently, since I took up post, have talked to me about challenges with access, that people feel that they often get passed around the system and that they are not quite sure where to get into it or how quickly they are going to get a response, how to get their needs met quickly. So we are redesigning our access points into the service so that that is much clearer and everyone, whether it is someone in their home, whether it is the police, whether it is someone in the general office, knows exactly how to get a referral in, how to get seen. We are putting some measures around that in terms of timescales and expectations, so I am hoping that within 3 months' time anyone that is referred in a crisis will be seen for a face-to-face assessment within 4 hours, because that should be our standard.[228]

As per section 7.10 of this report, there has been reference to "joined-up thinking" and the ability for signposting across different organisation and sectors. The Panel believes that GPs need to be part of this process.

The Panel noted that in response to a question about What, if anything, could improve the patient experience of Mental Health Services?', the PCB, made a number of points which related to the support that was available to patients (and GPs) in crisis situations. We were advised, inter alia:

Both in-hours and out-of-hours crisis responsiveness and provision: it is often difficult to get hold of the right person at the right time and willingness/incentive to get involved is variable. Refusal to visit patients at home because "we don't do home visits" even when patients feel unable to leave their house. Relying on telephone assessments when face-to-face is more appropriate or has been specifically requested. Patients end up at the Emergency Departments which is less than ideal. There are some examples of good practice, but unfortunately seem to be too rare.

[]

Improved communication from mental health to GPs especially around crisis situations when it is vital GPs know what has happened in a timely manner. Lack of appropriate communication across the service is a recurrent complaint.[229]

In addition to the provision of further support and training for GPs in relation to early intervention for mental health the Panel also note the need for helping GPs in crisis situations or, consequently, providing timely updates to GPs about patients who are in mental health crisis.

Fees

The Panel is mindful that Jersey GPs are run as private businesses and patients are therefore required to pay at the point of use for this service. In S.R.4/2019 the Panel found that the cost of a GP visit did influence some people's decision to seek help for, or discuss, their mental health.

The Panel asked the Minister to reflect on this in a public hearing. He advised:

The Minister for Health and Social Services:

Since your review, Deputy , there have been changes in that easier access to G.P.s is available to families where there is somebody on Income Support in the household and to pensioners who are on Pension Plus and of course for children. Children now have free consultations and adults at a very much reduced rate of £12. My understanding is that - I will be answering a question on that tomorrow - that has been well received and there is evidence that people are responding and have been attending to a greater extent. I am very pleased we were able to introduce that.

[]

It may be that the next Government will want to investigate what further steps might be taken, but it is not just a question of fees and payment. It is a question of how G.P.s fit into the overall system really. Insofar as we have to fund that this year we are beginning a review of sustainable funding for health across the board, across the whole Island, and not just in Government.[230]

The Panel noted that the Minister's response refers to the Health Access Scheme, launched in December 2020, which provides a further subsidy to GP visits for all members of an Income Support household and people in receipt of the Pension Plus' scheme. The cost of the Health Access Scheme is met by the Health Insurance Fund, which is controlled and managed by the Minister for Social Security.[231]

The schedule of fees for the subsidised visits is:[232]

In comparison, as per S.R.4/2019, as at 1st September 2018 we identified that an adult consultation ranges from £43 to £33. The price of a consultation for 5 to 15 years old ranges from £27.50 to £5. The price of a consultation for under 5 year olds ranges from £27.50 to £0. Finally, the price of a home visit (in surgery hours) ranges from £95 to £70.[233]

The Panel notes this change, however highlights that the Health Access Scheme only targets those on lower incomes, rather than assessing any particular fees charged for services or support in relation to mental health. It has been secured by a decision from the Minister for Social Security until early 2023.[234]

Furthermore, the Panel re-highlights the issue of consistency, particularly as different GP practices may offer different support, and the treatment that patients receive might depend on their GP or GP practice. In its submission, the PCB advised us that an area that would improve the patient experience of Mental Health Services would be:

Consideration of better engagement between lower level psychology services and GP practices. At least one practice has a mental health practitioner providing immediate care for mild to moderate disorder but funding for this is not guaranteed for the long term - sustainable funding for such schemes would be beneficial.[235]

The Panel is aware that the Council of Ministers is supporting a review of sustainable healthcare funding in 2022 per the Government Plan. Decisions made as a result of that review will impact the future of the Jersey Care Model and provide clarity for services.

In a submission to the Panel from Focus on Mental Illness, we were advised that:

"As we continue to move towards the changes implemented through the Jersey Care Model for Health and Community Services (HCS), the challenges this presents for mental illness service is becoming more and more apparent. It is difficult to ascertain what resources in the Jersey Care Model are, or will be, ring-fenced for preventative and proactive schemes supporting people affected by severe mental illness.[236]

As reflected in the Independent Review, AMHS needs to develop in line with the context of the Jersey Care Model which will include GP practices and a wider network of services.

Moving from CAMHS to Adult Services

Original Recommendation

Current position

Evaluation of progress

18: Until mental health services are better staffed it will be challenging for them to provide appropriate transition arrangements between CAMHS and AMHS. However, we believe that CAMHS should start sharing a person's file with adult services once they have reached a certain age – even if that person isn't referred to adult services when they leave CAMHS.

This recommendation was accepted by the Minister in 2019.

A draft transition policy for service users who are moving from CAMHS to AMHS.

Preparation for the transition between services starts when a patient is 17.5 years old.

Recruitment of staff will be key to this, for both CAMHS and AMHS.

The transition policy should be shared and ratified by both CAMHS and AMHS.

[237]The 2018 Assessment of Mental Health Services Review (2018 Review) made two key recommendations about Child and Adolescent Mental Health Services (CAMHS).238

The recommendations focused on the transition of CAMHS service users to AMHS, service user information sharing and the transferal of CAMHS from Health and Community Services (HCS) to Children, Young People, Education and Skills (CYPES).

In addition to dealing with the challenges created by the outbreak of COVID-19 in Jersey in 2020, CAMHS has made a number of operational and organisational changes in the years since the Panel published its first report on mental health services in March 2019. The changes include the development of a draft protocol for transitioning service users, improvements to the quality of CAMHS data collection and the transferal of CAMHS from HCS to CYPES.

Service user transitions from CAHMS: Staffing and Information Sharing

The Panel's 2018 Review cited staffing and information sharing issues as a key challenge faced by CAMHS in making the appropriate transition arrangements for service users between CAMHS and AMHS.

The evidence received from key stakeholders during the 2018 Review, was analysed in detail by the Panel, which noted issues relating to: a need for more robust procedures; a lack of additional support for service users; a lack of communication during periods of off-Island treatment; a need to listen to the views of children and young people and the need for a transition period between the ages of 16 to 25.[238] This analysis led to Recommendation 18 of the 2018 Review, in relation to staffing and service user information sharing:

Assessment of Mental Health Services Review (2018):

RECOMMENDATION 18: Until mental health services are better staffed it will be challenging for them to provide appropriate transition arrangements between CAMHS and adult mental health services. However, we believe that CAMHS should start sharing a person's file with adult services once they have reached a certain age – even if that person isn't referred to adult services when they leave CAMHS.

CAMHS in 2022: information sharing/transition arrangements and staffing

As part of its 2022 follow-up review to determine the current position of CAMHS against the recommendations of the 2018 Review, the Panel decided to receive the Minister for Children and Education for a public hearing on 25th February 2022 and asked how the transfer of CAMHS from HCS to CYPES worked in practice, and whether any significant changes to mental health services for children and young people had taken place. The Panel found that at least 30 young people aged 18 and over continue to receive support from CAMHS and that young people aged from 17.5 years old, are now involved in monthly transition meetings with mental health management and practitioners:

Deputy Mary Le Hegarat :

Please can you describe how the move worked in practice and highlight any significant changes that have taken place as a result?

Assistant Minister for Children and Education:

At this point in time there are some 31 people - I believe it is 31, low 30s anyway - who remain supported by C.A.M.H.S., albeit they are over the age of 18.[239]

The Panel later clarified with the Department that the total number of individuals supported by CAMHS aged 18 and over was 50, and that this is due to a constant transition from CAMHS to AMHS. The Panel note that the recent increase to 50 individuals supported by CAMHS was due to capacity issues within AMHS.

Head of Children's Health and Well-Being:

I understand there was issues with transition historically, so in terms of the working arrangements to address that, there is now a monthly transition meeting between C.A.M.H.S. management and senior C.A.M.H.S. practitioners and adult mental health management and practitioners. So every young person that is of 17 and a half years that is open to C.A.M.H.S. is 9 taken to that transition meeting and discussed and transition arrangements planned. So all planning involves that young person and their families and both departments to make sure that that transition is smooth and works. There is a draft transition policy now in place which we are going to be ratifying in the coming months and I do believe that that has improved the process. It is not without its challenges in terms of capacity to move through, but we are responding to that.[240]

However, the historical issues with the CAMHS-AMHS transition and the need for a smooth transition process, was echoed in a submission the Panel received from Mind Jersey, about the need for more joined up mental health services in Jersey, and the development of a protocol to make the best use of mental health sector expertise:

Submission – Mind Jersey Reconnecting with Hope Conference Consultation Feedback/Report' – 28th February 2022

We need a more joined up mental health service where there is rapid improvement and integration between statutory adult mental health services and cams and the community and voluntary sectors. This would need the development of a protocol to make maximum use of the sectors expertise and for both sectors to learn from each other [241]

The Panel also received the Minister for Health and Social Services for a public hearing on 28th February 2022, and requested information about oversight of the formal, written transition process for service users. The Panel noted that conversations were ongoing between CAMHS and AMHS to strengthen governance of the CAMHS-AMHS transition process:

Is there a formal oversight and audit of the transition process so that it is clearly written down about how that structure works?

Director for Mental Health and Adult Social Care:

How the process works is written down. I do not know if there has ever been an audit of it, frankly. I think I said earlier we are currently having conversations about how we work between adult mental health services and C.A.M.H.S. to kind of strengthen the governance around some of that. The relationships are good and certainly I have met with a C.A.M.H.S. consultant on a couple of occasions and we have had conversations about some stuff we could do differently. I think there is an opportunity for us to do some of that in a different way moving forward. But at the moment what I am told is it is generally working well.[242]

During a public hearing, the Panel also requested information about possible legal obligations on CAMHS and AMHS, to treat service users within a specific age range. The Assistant Minister advised that whilst there was no legal requirement for CAMHS to treat a service user over the age of 18, the cut-off period for transitioning from CAMHS to AMHS was flexible:

Deputy Mary Le Hegarat :

Depending on the age of the service user, are there any legal obligations to carry out services specifically within the remit of C.A.M.H.S. or adult mental health services?

Assistant Minister for Children and Education:

There is no law enacted that requires C.A.M.H.S. to move with a client over the age of 18 There is a law that says that ... it is clear that it is said that for the purposes of treating mental illness and mental health problems there is that age cutoff of 18, but the age cutoff, as you have just heard, is flexible.[243]

The Panel was keen to understand more about the process used by CAMHS to collect feedback from service users in relation to the transition process from CAMHS to AMHS, and what the feedback indicated about the transition. The Head of Children's Health and Well- Being opined that, historically, the quality of data collected by CAMHS had not been good:

Deputy Mary Le Hegarat :

Do you collect feedback from patients about their transition and the process and, if so, what has this indicated?

Head of Children's Health and Well-Being:

So, I guess as I started the role one of the focuses that we have had to address is the data that C.A.M.H.S. collects, the data we have on outcome measures and the data that we have on feedback, and I do not think it has always been particularly good.[244]

The lack of data on outcome measures and service user feedback was also noted in the Performance Management Review undertaken by the Public Accounts Committee (hereafter the PAC Review), which looked at recent changes to the overall structure and performance management processes within Government and non-Ministerial Departments.

The PAC Review found that Government had not taken steps to measure the experience of service users transitioning from CAMHS to AMHS, and this led the PAC to produce the following Key Finding:

Performance Management Review – Public Accounts Committee – 8th March 2022:

KEY FINDING 5: There has been no measurement to assess the patient experience of the transfer of the Child and Adolescent Mental Health Service out of Health and Community Services into Children, Young People, Education and Skills.[245]

During a public hearing, the Panel then learned about the steps being taken to improve the quality of CAMHS data collection and feedback, which includes the recent appointment of a Data Officer and a Quality Assurance Manager in 2021. The Panel also learned that from early 2023, a performance report will be provided to CAMHS that describes service user casework, transition performance and feedback:

Head of Children's Health and Well-Being:

The service is going to be much better at this, about listening to what people say about our service and learning from it and making plans on the basis of what people are telling us. To date, that has not been great and substantial so I cannot give any review of what data are showing to date. We only established a data officer last year to begin this and we established a quality and assurance manager last December, whose task is to develop our outcome and our feedback measures. So from early next year we will have an annual report to C.A.M.H.S. which will describe all our performance with casework, all our performance with transition, and some clear feedback and clear summaries of feedback from all those areas, as well as the compliments and complaints we receive.[246]

During a public hearing, the Panel took the opportunity to question whether CAMHS service users were facing delays being transferred from CAMHS to AMHS and whether capacity in AMHS was insufficient. The Panel was advised by the Director for Mental Health and Adult Social Care, that there had been particular issues with regards to demand in relation to neuro- developmental disorders, such Attention-Deficit-Hyperactivity-Disorder (ADHD) and Autism:

Do you have any delays, do you know, in terms of patient transfers, if there is any insufficient capacity within adult mental health services?

Director for Mental Health and Adult Social Care:

There has. There is a particular issue around neuro developmental disorders, so autism and A.D.H.D. where the demand has shot up in adult services and, consequently, there are some folk who are still sitting with C.A.M.H.S. while they are waiting to move into the adult service.[247]

The Panel was keen to understand whether the delays related to staffing issues within AMHS, and learned that the delays were a result of AMHS capacity' and, in particular, noted that psychiatry had experienced issues prescribing medication:

Senator S.W. Pallett:

Is that down to staffing issues?[248]

Director for Mental Health and Adult Social Care:

It is capacity, so that it is about the capacity of the service, particularly for A.D.H.D. is prescribing particularly. The nature of the medication that is prescribed for A.D.H.D., there is a limitation currently on the Island as to who can prescribe. Consequently, it is psychiatry and of course they are overloaded currently in terms of prescribing need [249]

The Panel noted concerns about the amount of time spent by CAMHS clinicians prescribing medication and that the process was often frustrating for patients. The Panel learned that the primary barrier to improving the process of prescribing medication for CAMHS service users, was the requirement that a consultant or general practitioner make the prescription under Schedule 1 of the Misuse of Drugs (Jersey) Law 1978, which would need to be amended:

Deputy Carina Alves :

We have been advised that C.A.M.H.S. patients who are on long-term medication often have to receive monthly prescriptions through the C.A.M.H.S. clinicians. We understand that this takes up a considerable amount of clinical time and also the process has been frustrating for patients. How could this process be improved?

Assistant Minister for Children and Education:

The fact is that this has been a real issue, especially as most of the problems are with those drugs that are considered to be schedule 1 drugs that can only be prescribed by

a consultant and not by a general practitioner. That does cause difficulties. The other side of the coin is that those drugs can only be dispensed by the hospital pharmacy, not by a local pharmacy. I was in discussions with the pharmacist at the general hospital about what would prevent these prescriptions being fulfilled in local pharmacies and there was not a solution to the problem because of the way that the law is drafted. It is a ridiculous situation in which a family presented evidence, living out in the west with 2 children requiring medication, both of them receiving medication prescriptions at different times, and the parents had to travel into town on each occasion. It is not a satisfactory system at all and it would be very helpful for the panel to mention that and to get something done about it. But it will require a change in the drugs law to allow that to happen.[250]

The recently published Children and Young People's Emotional Wellbeing and Mental Health Strategy 2022 to 2025 set out the Government's model of care for children and young people in Jersey. The Strategy is based on "assessment of local need, stakeholder feedback, and takes a whole system approach; from promoting prevention and early intervention with the aim of reducing escalation of need and improving outcomes for children, young people and their families to the intensive support required for more complex cases being available over a seven-day period".[251]

The Panel notes the Strategy is comprised of 16 actions to achieve these results, which are grouped into four main priorities: "We want everybody to promote wellbeing, good mental health and resilience, so people aren't embarrassed to get help; We want it to be easy for everyone to find help and support; We want people to get the right help and support, at the right time and in the right place; We want to listen to people about what works and helps them, because this improves our services".[252]

KEY FINDING 61: A draft transition policy for CAMHS service users is in place and is due to be ratified by Children, Young People, Education and Skills.

Separation of Adult and Child Services

Original Recommendation

Current position

Evaluation of progress

19: CAMHS should remain part of the Department for Health and Community Services.

This recommendation was rejected by the Minister in 2019.

CAMHS forms part of the department for Children, Education, Young People and Skills (CYPES). It was transferred from under the responsibility of Health and Community Services in 2019.

The Panel has not analysed the success of the transfer of CAMHS from HCS to CYPES as that would increase the scope of this review, but we have collected information about how this transfer has impacted the service.

The Panel supports the PAC recommendation that a service level agreement should be introduced between HCS and CYPES to ensure consistency of service.

Transferal of CAMHS from HCS to CYPES

During its 2018 Review, the Panel highlighted that as part of a programme of Government reforms to Jersey's civil service, CAMHS was to be moved from HCS to CYPES.

The Panel also highlighted a number of concerns raised by key stakeholders about the transfer of CAMHS to CYPES, which included: a need for CAMHS to remain part of the HCS medical fraternity'; missing detail about how the support provided by HCS under a new organisational structure with CYPES would be replicated; a possible widening of the gap between CAMHS and the mental health system making it harder for service users to transition; a lack of service user trust in social workers and issues with the location of CAMHS and the design of the building. The Panel's analysis of this evidence led to Recommendation 19 of the 2018 Review, that CAMHS should remain within the remit of HCS:

Assessment of Mental Health Services Review (2018):

RECOMMEDNATION 19: CAMHS should remain part of the Department for Health and Community Services.[253]

On 7th February 2019, a Ministerial Decision was taken to transfer responsibility for CAMHS from the Minister for Health and Social Services, with responsibility for HCS, to the Minister for Children and Education with responsibility for CYPES.[254]

CAMHS in 2022: HCS to CYPES Transfer

As part of its current follow-up review, the Panel asked the Assistant Minister for Children and Education at a public hearing for his assessment of the impact of the CAMHS transfer from HCS to CYPES. The Assistant Minister expressed support for the transfer of the CAMHS service to CYPES, and highlighted that this had resulted in closer working relationships between all the children's services:

Deputy Mary Le Hegarat :

Please could you provide an assessment of how the move from H.C.S. to C.Y.P.E.S. has impacted C.A.M.H.S.?

Assistant Minister for Children and Education:

But over time, and we did ask that question in the report [S.R.4/2019], but over time it has become apparent that integrating C.A.M.H.S. into C.Y.P.E.S. has had its distinct advantages in the sense that there is now a very much closer relationship between all of the services providing for children.[255]

The Head of Children's Health and Well-Being also expressed support for the transfer of CAMHS to CYPES, and provided the Panel with more detail about the HCS-CYPES Memorandum of Understanding governing the working relationship between the two services, and some of the perceived advantages of the transfer of CAMHS to CYPES:

Head of Children's Health and Well-Being:

There was an original memorandum of understanding about how the 2 services would work together and collectively. There were 2 meetings last year chaired by team meetings between directors of Health and C.Y.P.E.S. and all the lead practitioners to clarify these arrangements and address any ongoing issues and it continues to be really close work in terms of several areas where both services are involved in terms of inpatient admissions, out of hours development and the neurodevelopmental pathway. I have seen much better working relationships in here between C.A.M.H.S. and social care, being based in the same building. Only last week all C.A.M.H.S. referrals began going through the Children and Families Hub, which now we have a unified and very clear front door for all referrers about where children and young people's referrals go through, and already by us having a C.A.M.H.S. nurse in that setting has enabled much better triaging of referrals and much quicker allocation to right services from being in there. We have also seen improvements over the last 12 months in terms of waiting times and feedback from casework, so I am seeing progress in the service by being part of C.Y.P.E.S.[256]

However, the PAC Review found that the transfer of CAMHS from HCS to CYPES, created ambiguity about which Government Department was ultimately responsible for CAMHS:

Performance Management Review – Public Accounts Committee – 8th March 2022:

KEY FINDING 4: The transfer of the Child and Adolescent Mental Health Service out of Health and Community Services has created a lack of clarity about which Department has ultimate responsibility for CAMHS.[257]

At the public hearing, the Panel also discussed governance and oversight of HCS and CYPES in relation to CAMHS. The Panel pointed out that the Ministerial Response to its 2018 Review had indicated the establishment of a Joint Peer Group' (Group) between HCS and CYPES in relation to CAMHS and asked for an update on this work. The Panel learned that the work of the Group involved renewed governance and oversight of HCS and CYPES, that Terms of Reference and workshops for the Groups board have been developed and would involve a substantial 4-year work programme:

Head of Children's Health and Well-Being:

So, work has been done by [name], who is head of commissioning, to reinvigorate the governance and oversight group and to develop a board on that, which is going to deliver some effective governance around both H.C.S. and C.Y.P.E.S. as both departments currently have some money to invest in children and young people's mental health service. So terms of reference for that board have been developed. There have been workshops around that and board members have been identified to develop and to sit on that. So for the next 4 years there is going to be a substantial programme of work being overseen by that board going forward.[258]

However, at a separate public hearing between PAC and the Directors General for HCS and CYPES on 29th November 2021, the PAC discussed line management challenges related to the CAMHS transfer and how the two Departments collaborated to deliver the service. The PAC learned that the lack of a CYPES representative on the Board of HCS had been highlighted as an issue by the Comptroller and Auditor General, and that this would be addressed in 2022:

Director General, Health and Community Services:

That has been highlighted as an issue by the work that was done by the C.A.G. (Comptroller and Auditor General) and it is something we are seeking to address next year.[259]

The PAC recommended that a formalised agreement between HCS and CYPES be introduced to ensure consistency with regards to the service provided by CAMHS:

Performance Management Review – Public Accounts Committee – 8th March 2022:

RECOMMENDATION 3: A service level agreement should be introduced between Health and Community Services and Children, Young People, Education and Skills to ensure consistency over the level of service expected between the two Departments.[260]

The Panel notes the PAC's comments about the consistency of CAMHS, which was echoed by a recent Improvement Notice issued by the Jersey Care Commission in relation to the Greenfields Secure Care Unit, that found that the support provided by CAMHS had not been consistent:

Improvement Notice – Jersey Care Commission – 28th March 2022:

Support offered by CAMHS has not been consistent and specific plans are not in place in situations where there is a need to meet mental health needs of young people.[261]

In addition, the PAC Review also recommended a formalised review of the transfer of CAMHS from HCS to CYPES, as part of a wider review of the Target Operating Model programme, to determine the benefits of the transfer:

Performance Management Review – Public Accounts Committee – 8th March 2022:

RECOMMENDATION 4: Given the concerns regarding the transfer of CAMHS between Departments, a formal review of this specific TOM driven transfer should be included in the Government's overall review of the programme to determine whether the anticipated benefits have been realised.[262]

Comptroller & Auditor General (C&AG) Review of CAMHS

During a public hearing, the Panel noted from a statement made by the Head of Children's Health and Well-Being, that the C&AG was undertaking a separate review of CAMHS, and that CYPES would be contributing towards this:

Head of Children's Health and Well-Being:

"We are also about to have another review as well with the Comptroller and Auditor General and we are doing some work towards that."[263]

In order to understand more about the nature of the C&AG's review, the Panel considered the C&AG review project specification', which was published on 21st February 2022. The project specification set out the objectives of the C&AG's review, and the Panel note that this includes a number of objectives relevant to the transition of CAMHS service users and the impact of the transferal of CAMHS to CYPES. A non-exhaustive list of these objectives is summarised as follows:

C&AG Review of CAMHS – Project Specification:

Governance arrangements: "whether responsibilities and accountabilities are clearly set out and agreed, including in transition services between CAMHS and adult mental health services".
Service design: "the design of transition services between CAMHS and adult mental health services".
Service resourcing/decisions:

"work across States of Jersey departments".
"ensure a joined-up service for children, young people and their family and carers".

Performance management/oversight:

"how the services are monitored and reported".
"whether the targets and measures being monitored are designed to ensure better outcomes for children and young people".
"the current and planned performance against key indicators".
"how performance and targets compare with best practice".
"how services are benchmarked".
"how partnership performance indicators are measured, managed and monitored".[264]

The full list of objectives for the C&AG's review of CAMHS can be found on the C&AG's Project Specification. The C&AG Project Specification also confirms that its review of CAMHS has a broad scope:

C&AG Review of CAMHS – Project Specification:

"The review will consider all aspects of CAMHS provision including services delivered by partners both on and off Island."[265]

KEY FINDING 63: A Child and Adolescent Mental Health Services performance report will be available in early 2023, that describes service user casework, transition performance and feedback.

Models of Care

Original Recommendation

Current position

Evaluation of progress

20: The Government should review the model of care that is used in Jersey's mental health services. As part of this, the Government should define the model of care that it uses. This definition should include elements used in Open Dialogue including collaborative and joined up approaches to care. This should be published in Q2 2020.

This recommendation was accepted by the Minister in 2019.

Since the Panel's last review several new services have been established for example a Listening Lounge' has been established (through an outsourced contract) and home treatment team / community triage team has also been established.

As evidenced by the findings of the Independent Review, a coherent model of care has not been put in place.

The Panel has been advised that different mental health services have different models of care, however, the final community model for mental health services will be agreed by the end of April 2022. This model of care will describe the overarching structure / delivery and objectives for community mental health services.

When a new community model of care is adopted there will be an implementation period that will include staff training and transition.

Work is also being done on model of co-ordination of care framework which will assist with the care for individuals with complex and multiple needs from different services.

To date, changes to services have been described as piecemeal' and it is hoped that a new community model will establish services as part of a joined-up system. This relates to findings that the Panel has made in sections of this report relating to the mental health strategy and partnership working.

It appears that staff and service users will be involved in the development of the new models of care.

132

Previous focus on a medical model'

In S.R.4/2019 the Panel highlighted that there was a suggestion that mental health services relied on a medical model' for treating people with mental health problems, rather than alternative non-medical therapies. At the time, the business case for the Listening Lounge was in development.

The Minister had indicated that the recommendation to review and define the model of care would be addressed when the Mental Health Strategy was created for 2021 onwards. As per our findings in section 7.1 of this chapter we note that no successor strategy was drafted due to COVID-19 pandemic.

Prescriptions

As part of the Panel's 2019 review it was made aware of concerns relating to the number of prescription drugs being prescribed for mental health in Jersey. It was suggested that GPs were prescribing because of the waiting times to access psychological therapies. This was reflected in the recent submission to the Panel on behalf of the PCB, who stated that something that would improve the patient experience was:

More immediate provision of psychological treatments to improve mental health more speedily and effectively, reduce the risk of deterioration and avoid overprescribing of antidepressants.[266]

As detailed in chapter 6 of this report, we have been advised that there will likely be a consultant pharmacist role created in order to assist with the management of long-term illness and particularly the relationship between medicines management and physical health issues for AMHS patients. This also relates to key finding 37 (in section 7.4) which references that the workforce model will be reviewed for appropriateness and needs to be aligned with the community model of care and the Jersey Care Model. We also point to finding 62 and recommendation 24 in section 7.13 of this chapter which refers to the issues faced by clinicians in relation to the prescription of medication for CAMHS patients.

In a public hearing, the Panel heard about the importance of the home treatment team as part of a community model, as this allowed patients to receive medication at home rather than an inpatient setting:

Director for Mental Health and Adult Social Care:

The other component part of the service model is home treatment and that is really important for a couple of reasons, firstly because we know that lots of people who historically were admitted to hospital did not need to come into hospital and do not want to come into hospital. They can be treated at home and I will give an example. Historically people were admitted because they needed to receive medication twice a day but now the home treatment team can go out and administer medication twice a day if required, so you can maintain people at home if it is clinically safe to do so and that is terribly important because, of course, we do not want to take people to hospital unless we absolutely have to.[267]

Jersey Talking Therapies (JTT) and Psychological Assessment and Therapy Service (PATS)

As referenced in chapter 4, JTT was closed during the initial pandemic lockdown in 2020 and this created a backlog which, together with the high levels of demand and reduced staff capacity, have impacted the waiting lists [268].

Health and Community Services now reports various indicators in its quarterly Quality and Performance Report. An extract from the December 2021 report displays that many of the indicators for JTT and the PATS remained high across 2021. The full report can be found here.

The Listening Lounge

The red RAG (Red, Amber, Green) categories are provided with exception reports [269]:

Whilst numbers reflect that the backlog for JTT is reducing after a focus from staff on this area, the numbers for PATS referrals remained high throughout 2021 due to increased levels of demand and reduced staff capacity. As evidenced in the graphic above, the Quality and Performance Report advised that a recovery plan is in development.

The Listening Lounge

When the Panel undertook its previous review, it was advised that there were proposals for a "Listening Lounge". This service was introduced as a pilot initiative in November 2019 as a partnership between L.I.N.C Mental Health & Wellbeing and the Government of Jersey in order to support Islanders with their mental health and wellbeing. In a submission to the Panel, Lucy Nicolaou, Service Lead at the Listening Lounge advised that:

demand has been far greater than originally anticipated, with 3,500 islanders accessing 11,500 appointments since the service launched.[270]

The Panel is aware of the importance of early intervention services, such as those provided by the Listening Lounge, as this will ease pressure on other services that require further interventions from AMHS.

Community Model

In a public hearing the Panel was advised that the community model for mental health services was being revised in order to make it clearer and where services sat in relation to each other and also to prevent people from entering in-patient care unless absolutely necessary:

Director for Mental Health and Adult Social Care:

We have started a piece of work, which we started 2 weeks ago and will complete at the end of March, redesigning our community model so that we are much clearer about what crisis does, what home treatment does and how we make sure that wherever possible we maintain people in the community unless they need to come into hospital and then of course they will come to hospital.[271]

[]

We are currently in the process of reviewing that community model because one of the things that has happened, I think inevitably, is that as services have developed particularly quickly they have not necessarily tied in well together. We have the services but we do not have a service that works in a coherent way all together as one system. I described it the other day as it is a bit like having a jigsaw where the pieces just do not quite fit together.[272]

Following a public hearing the Panel wrote to the Minister for Health and Social Services to get some clarity about the redesign of the community model' for mental health services. We were advised that since the publication of S.R.4/2019 there had been a number of changes and developments to the service, however, it was acknowledged that these changes did not sit into a well-defined system:

Whilst a number of service developments (such as triage / crisis and home treatment) have been introduced, these have tended to develop in a piecemeal' way which has created some disconnect and barriers between different aspects of our community mental health services – rather than developing integrated, coherent pathways & service offers across a single system.[273]

The Independent Review of Adult Mental Health Services in Jersey – which are part of the Health and Community Services' provided a recommendation that a clear model of care for Mental Health Services be developed in context with the plans for the Jersey Care Model. Actions to implement the recommendation have been undertaken since the appointment of the new Director of Mental Health and Adult Social Care:

Upon appointment of the new Director of Mental Health & Social Care, an initial assessment was made of priority actions required. A key priority area related to the design, delivery and development of the community mental health model. This was based on the external review findings, feedback from staff, direct observation, a review of recent concerns, and feedback from service users and carers. This was therefore determined as a priority action requirement, to be addressed within the first few months of 2022. In particular, this work intends to address repeated concerns that have been expressed in relation to ease of access to services (particularly in crisis), clarity of what is provided and for whom, consistency of service offer, clear expected outcomes, and the skills / training / development required by staff to effectively deliver this. The redesign of the community model will articulate clearly what is provided, how this is delivered, what the range of interventions available are, and what the anticipated outcomes are (and how these can be measured / monitored).[274]

As explored in chapter 5 the staff workshop, held in February 2022, heard feedback from a service user and carer conference on what matters to them, and what good care would look like considered models of care:

The workshop specifically focused on developing proposed future models in 3 key areas:

• Access to care in a crisis and home treatment as an alternative to admission

• Community Mental Health team function

• Transitions

Draft outlines of proposed models were developed through the workshop, and these are now being further developed / refined by the senior leadership team in advance of a follow up session and further consultation – including with service user groups - in early April. It is anticipated the final model will be agreed by the end of April, with an implementation period that will include staff training and transition.[275]

The Panel received submissions from other organisations which emphasised the importance of a system of care. The Service Lead from the Listening Lounge advised that:

At times there is rigidity in terms of applying thresholds and criteria as a priority over client care, rather than a whole systems approach which considers the whole person. Services should be organised in a way that prioritises dialogue and relationships.[276]

Model of Co-ordination of Care

The Panel heard about introducing a model of co-ordination of care' and the Panel queried how this differed to the community model of care that had previously been discussed. We were advised that whilst the community model of care described the overarching structure, delivery and outcomes for our community mental health services, the co-ordination of care framework referred to care for individuals who had complex needs:

Regardless of the delivery model of community mental health services, a key required component of this is an effective system of planning & coordinating care for those with complex needs, which also ensures the involvement and support of the service user and their carers in the planning and delivery of care. This is particularly important where people have complex needs that require a number of different interventions from different agencies, to ensure that care is comprehensively planned, delivered and coordinated and that a collaborative assessment of risk is undertaken (resulting in a clear, joint risk management plan). Within the UK the mandated national system of care coordination is called the Care Programme Approach (CPA) which was introduced in 1991 (and is currently in process of a national review). A number of reviews – including the Independent review of 2021 – have identified the need for such a system to be in place in the Jersey mental health services. Therefore, as part of the redesign process, we have included the development and implementation of a Jersey-relevant framework for effective care coordination that will replicate the core components of the CPA framework. Again the further development of the workshop outputs is currently being completed, and this will be incorporated into the final model alongside an associated implementation plan.[277]

There will be a role for the Mental Health Strategic Systems Partnership Board in the model for the co-ordination of care. This is referred to further in section 7.10 which refers to comments on Partnership working. Whilst this references relationships with third party / charitable organisations, the relationship of the mental health system and network will be vital. The Panel was advised that:

Director for Mental Health and Adult Social Care:

I hope the Mental Health Partnership Board is a place where people around the table collectively hold responsibility for the mental health system so there is an ability for people to challenge are we doing the right thing, are we developing the right models, are we spending our money in the right way, but also really thinking about how do all of the bits of the jigsaw fit together. How do we make sure, for example, that health and clinical staff particularly are doing the right tasks that clinical staff should be doing and that where other parts of the system, particularly third sector and voluntary agencies but also increasingly people who use services, can provide work and support and help the system move along that they are doing that?[278]

Other models of care

The Panel sought clarity about what models of care would be used in AMHS:

Please could you provide further details about any other models of care used by Adult Mental Health Services?

Different mental health services have different models of care, dependent upon their function and the wider context in which they operate. For example, some services have a primary diagnostic focus (such as the autism or ADHD services) whilst others have a primary treatment model focus (such as our psychological therapies services). How well these are articulated currently is variable across our system – it is a longer-term objective to standardise our approach to describing this, through service descriptions and local operating policies. An example of a new and different model of care that is being developed currently (with a plan to operational delivery in October) is the Perinatal & Maternal Health model, which is a virtual team' that comprises members from a variety of health, social care and third sector agencies all collaborating together to deliver a comprehensive perinatal mental health and maternal health service for Jersey across the levels of prevention, primary care and specialist secondary care.[279]

Transgender Pathways

Recommendation	Current position	Evaluation
21: The Government should commit to meet with Liberate Jersey to discuss their concerns and proposals in relation to pathways for transgender people. It	The Government has met with Liberate Jersey (Liberate), and other relevant organisations.	The Government has fulfilled the Panel's recommendation that it meet Liberate Jersey and review the pathway for transgender Islanders.

should also review the A business case has been There is also evidence that current pathway for developed and discussed work has been undertaken to transgender people and between HCS and a London- improve and develop the consider if it would be based Gender Identity Clinic. pathways for transgender possible to improve the Islanders.

process. This work should be The business case for a pilot

made public. gender clinic partnership However, whilst Liberate between Liberate, the Jersey Jersey has publicised an

The Minister accepted this Youth Service and HCS is overview of some of the work recommendation from the yet to be signed off by HCS. undertaken with Panel in 2019. Government, it is not clear that Government has made

details about this work

publicly available yet.

In addition, details about the pilot gender clinic partnership between Liberate, the Jersey Youth Service and HCS and the new pathway have been made available on the Trans* Jersey website.

The Panel's 2018/9 Review also addressed the provision of mental health services for Jersey's transgender community. In particular, the Panel noted the length and complexity of mental health pathways for transgender Islanders and the need for Government to engage with Liberate Jersey (Liberate) and review existing pathways.

As the Channel Island's "equality and diversity charity", the Panel's engagement with Liberate as part of its 2018 Review, provided key evidence about issues affecting transgender individuals access to mental health services in the Island, such as: complex assessment processes, lengthy wait times for access to gender transition services and the default treatment of all transgender Islanders via mental health services.[280]

Mental Health Services in 2022: Jersey's Transgender Community

As part of the evidence gathering process for its current review, the Panel received the Minister for Health and Social Services for a public hearing on 28th February 2022 and asked for an update on the Government's work on mental health pathways for transgender Islanders. The Panel learned that work on transgender pathways had taken place between HCS, the third sector and voluntary agencies, and that a contractual relationship between HCS and a London-based Gender Identity Clinic was in place:

Deputy Mary Le Hegarat :

"Please, can you provide an update on the Government's work in relation to pathways for the transgender people, please?"

Director for Mental Health and Adult Social Care:

"There has been a number of meetings between members of H.C.S., the third sector and voluntary agencies that are involved in this work. There is currently a provision that is a small provision, that is part of the community service, that is overseen. We have got a contractual relationship the Tavistock and Portman Clinic in London who provide gender services. I understand the lead clinician there provides significant support [to the Commission on Islanders [281]] doing that work. But we are meeting this afternoon to look at a business case that has been developed, a draft business case to expand the pathway for people with gender issues and we are looking to talk about that this afternoon to see about where is that going, what are the next steps and understanding how we might implement the next stage with them?"[282]

The Panel wished to clarify that HCS had engaged with Liberate in respect of transgender mental health pathways, and was informed that a number of meetings between HCS and Liberate had taken place:

Deputy Mary Le Hegarat :

"Can I just clarify that you or your officers met with Liberate?" Director for Mental Health and Adult Social Care:

"Yes, indeed. I understand there has been a number of meetings between health officers and Liberate."[283]

This was echoed in a submission the Panel received from Liberate, which advised that reforms for transgender and non-conforming Islanders are now in progress. It was advised that the reforms include a service user group involved in developing a new pathway, and that the business case for a pilot gender clinic partnership between Liberate, the Jersey Youth Service and HCS is due to be signed off by HCS:

Submission – Liberate Jersey – 28th February 2022

"The Government has met with Liberate and other relevant organisations. Reform of the pathway to care for transgender and gender non-conforming Islanders is in progress and involves a service user group in shaping the new pathway. As of this month, a pilot gender clinic that will run as a partnership between Liberate, Jersey Youth Service and Jersey Health Service has been launched and the transgender community informed of the pilot. The business case for the pilot is still sitting with Jersey Health Service for sign off. Once sign off has happened the pilot will be shared with the wider community of health professionals, such as GPs. Training for key Government practitioners and Third Sector partners has been organised by Liberate and is happening in April."[284]

Other Areas

8.1 Off-Island Placements

During the course of this review the Panel has been made aware of the use of off-Island placements for certain mental health services that cannot be provided on the Island.

In a public hearing with the Minister for Children and Education, the Panel was advised by the Head of Children's Health and Well-Being that specialist support was occasionally sought with off-Island placements:

Head of Children's Health and Well-Being:

The only other occasion is if we would have to seek potential off-Island specialist support and for any issue. We currently have one young person off-Island for specialist eating disorder treatment and that has been the first during my period in post here, so that does not happen particularly often.[285]

The Panel questioned this further and asked about whether the services could ideally be provided in-house':

Senator S.Y. Mézec :

is the arrangement by which you would refer some young people to those organisations the one that you think meets best practice or are there any referrals that are made that in an ideal world you might prefer them to be services that are done in- house?

Head of Children's Health and Well-Being:

... No. The off-Island provider, we have found one of the best places in the U.K. for treatment for the young person, and both the young person and their family were delighted that we secured that, so that has been appropriate.[286]

The Panel wrote to the Minister for Health and Social Services to ask for details about the total number of off-Island beds commissioned by Health and Community Services for Islanders with mental health issues since 2018. We were provided with the following table:

Year	Total Commissioned Beds	Total cost £	Average cost per bed £	Average length of stay (days)
2018	22	2,629,187	120,909	254
2019	24	3,388,341	138,804	277
2020	19	3,434,789	184,449	312

2021 25 3,316,721 135,278 229

The Panel also asked about the age range of patients who had been sent off-Island since 2018 and whether this number included any prisoners. We were provided with the following table:

Year	Working Age Adults (18-65)	Older People (65+)	Children & Young People	Prisoners
2018	19	0	3	1
2019	21	0	3	2
2020	18	0	1	0
2021	24	0	1	5

In the Minister's response to the Panel, it was advised that the rationale for outsourcing some mental health care off-Island was in cases where specialist treatment could not be provided on the Island:

Due to the specialist nature, population size and volume of demand for many of these specialised clinical services, it would be impossible to provide these on island (as a comparator, many specialised services are not provided in all areas of the UK and NHS providers rely on regional arrangements or contractual relationships with neighbours to access these). Therefore whilst we are able to provide core mental health service provision on island, there will always be a requirement to outsource some of this. [287]

The Panel also asked for more details about the commissioning process for an off-Island beds for Islanders with a mental health issue. We were advised that:

We are currently in the process of reviewing the off-island commissioning and oversight arrangements, with a view to implementing some changes in the process from April.

Currently, all decisions around off-island placements are made at a panel (this will continue) which comprises members of senior clinical and operational management staff, a finance officer (to support and record financial decisions & forecasts) and an officer from CLS (to link to wider Government financial processes and policies).

The clinical rationale for referral is made by the referring clinician, and alternative options to an off-island placement are explored. The panel also considers a quality assessment of the proposed placement (including the regulatory CQC rating & recent reports if in the UK) and discuss the pathway that will be required on completion of the placement to effect a safe transition of care back to Jersey. Generally the proposed placement will be required to complete a clinical assessment and confirm that they are able to offer a bed.

All patients that are placed off island are allocated to a named professional from within the mental health services who has responsibility for monitoring the placement and maintaining contact.[288]

The Panel notes that the process commissioning and oversight of off-Island placements is being reviewed with a view to change this from April 2022, however, considering the considerable cost of the off-Island placements to Health and Community Services the Panel believes that the commissioning and oversight process for the off-Island beds should be reviewed for appropriateness.

In the Panel's visit to H.M. Prison La Moye we were advised that, in Jersey, the decision to send prisoners off-Island to a secure hospital was made by the courts – rather than as part of a clinical process as in the United Kingdom. It was suggested that the court could be provided with some compelling reasons of why an individual needed to go to a secure hospital, however, it was suggested that, in some cases this could be done in Jersey if the prison was provided with additional support.

KEY FINDING 69: £3,316,721 was spent on a total of 25 off-Island bed placements for Islanders with mental health issues in 2021. 5 of these beds were for prisoners.

Conclusion

The Panel acknowledges that Health and Community Services (HCS) and Adult Mental Health Services (AMHS) have faced significant challenges during the COVID-19 pandemic. It is recognised that it has been a particularly difficult time for staff in this sector, as they have had to incorporate new ways of working and managing heightened infection control measures, in addition to the business-as-usual frontline requirements of AMHS.

The Panel has found that there has been some limited progress against the recommendations of S.R.4/2019 and had concerns that a more recent Independent Review, published in November 2021 also highlighted a number of severe concerns about the AMHS.

The Panel has also recognised that there are a number of factors within our findings that are beyond the remit of AMHS alone. For example the issues for recruitment that are impacted by Jersey's cost of living. However, the idea of joined-up systems for mental health services and networks of communication between government departments, services, as well as the private and charitable sectors have become apparent themes of this review.

The Panel has made a number of recommendations to reflect the importance of getting the governance for AMHS structures right. Transparency and clear lines of accountability will help to make the coherent networks more accessible for all parties and accountable for the patients who need them.

145

Appendix 1: Panel Membership and Terms of Reference

Panel Membership

Deputy Mary Le Hegarat (Chair) Deputy Kevin Pamplin (Vice-Chair)

Deputy Carina Alves Senator Steve Pallett (Co-opted for Review)

Senator Sam Mezec

Monitoring for Conflicts of Interest

Senator Mézec was Minister for Children during the period 21/07/2018 – 08/11/2020.

Senator Pallet was Assistant Minister for Health and Social Services with responsibility for Mental Health during the period May 2019 – November 2020.

It is not anticipated that this will be a major conflict of interest in terms of the focus of the review, however, the Panel will manage any potential conflicts of in an appropriate manner.

146

Terms of Reference

To assess progress against the recommendations from the Panel's review 'Assessment of Mental Health Services (S.R.4/2019) that was published on 6th March 2019.
To determine the impact of COVID-19 on the provision of mental health services.
To assess how the £500,000 of additional funding for Mental Health Services, as approved by Amendment 9 to the Government Plan 2022-2025 (P.90/2021), will be used.
To consider the impact and outcomes of the 'Independent Review of Adult Mental Health Services in Jersey', published on 19th November 2021.

147

148

[1] Comptroller and Auditor General, Governance Arrangements for Health and Social Care – Follow up', 13th September 2021, p.34

[2] Submission – Mind Jersey – 28th February 2022

[3] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.7

[4] Letter - Minister for Health and Social Services – 25th March 2022

[5] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.3

[6] Assessment of Mental Health Services (S.R.4/2019): Response of the Minister for Health and Social Services, 1st May 2019

[7] Government of Jersey, Government Plan 2022-2025', page 43

[8] Health and Community Services, 2022 HCS Business Plan 2022, 10th February 2022, p.20

[9] Submission – Jersey Recovery College – 17th March 2022

[10] Submission – Focus on Mental Illness – 1st March 2022

[11] Submission – Mind Jersey – 28th February 2022

[12] Transcript – Quarterly Public Hearing with the Minister for Health and Social Services – 4th February 2022, p.21

[13] Submission – Mind Jersey – 28th February 2022

[14] Draft COVID-19 (Mental Health) (Jersey) Regulations 202- (P.46/2020)

[15] Letter - Minister for Health and Social Services – 25th March 2022

[16] Submission - Mind Jersey Lockdown Stories'

[17] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.3

[18] Ibid

[19] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.4

[20] Submission – Dementia Jersey – 28th February 2022

[21] Submission – Primary Care Body – 13th February 2022

[22] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.5

[23] Submission – Liberate Jersey – 5th November 2018

[24] Submission – Focus on Mental Illness – 1st March 2022

[25] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.3

[26] Submission – Mind Jersey – 28th February 2022

[27] Submission – Maternity Voices Partnership – 10th March 2022

[28] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.3

[29] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.4

[30] Ibid, p.5

[31] Submission – The Listening Lounge – 9th March 2022

[32] Ibid

[33] Ibid

[34] Submission – Primary Care Body – 13th February 2022

[35] Covid-19 Response: Impact on Children and Young People, The Children's Commissioner for Jersey, October 2021, page 12

[36] Transcript – Public Hearing with the Minister for Children and Education – 25th February 2022, p.22

[37] Submission – Jersey Recovery College – 17th March 2022

[38] Submission – Focus on Mental Illness – 1st March 2022

[39] Dare to Care: From Strategy to Action: Road Map for Carers 2022-24', Carers Jersey, published February 2022

[40] Submission – Focus on Mental Illness – 1st March 2022

[41] Submission – Mind Jersey – 28th February 2022

[42] Submission – The Listening Lounge – 9th March 2022

[43] Submission – Jersey Recovery College – 17th March 2022

[44] Letter – Minister for Home Affairs – 18th February 2022

[45] Ibid

[46] Ibid

[47] Letter - Minister for Home Affairs –29th March 2022

[48] Letter – Minister for Home Affairs – 18th February 2022

[49] Minute of the Health and Social Security Panel, 6th April 2022

[50] Letter – Minister for Home Affairs – 18th February 2022

[51] https://www.gov.je/Government/Pages/StatesReports.aspx?ReportID=5476 (accessed on 22/03/2022)

[52] Professor P. Lepping and S. Pyke, Independent Review of Adult Mental Health Services in Jersey – which are part of the Health and Community Services (HCS)', 19th November 2021

[53] Ibid

[54] https://www.gov.je/News/2021/Pages/AMHSReview.aspx (accessed on 22/03/2022)

[55] https://www.gov.je/News/2022/Pages/MentalHealthAppointment.aspx (accessed 22/03/2022)

[56] Transcript – Quarterly Public Hearing with the Minister for Health and Social Services – 4th February 2022, p.22

[57] Ibid p.21

[58] Comptroller and Auditor General – Governance Arrangements for Health and Social Care – Follow up' - 13th September 2021, p.13

[59] Transcript – Quarterly Public Hearing with the Minister for Health and Social Services – 4th February 2022, p.20

[60] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.19

[61] Letter - Minister for Health and Social Services – 25th March 2022

[62] Transcript – Public Hearing with the Minister for Health and Social Services – 28th February 2022, p.18

[63] Letter - Minister for Health and Social Services – 25th March 2022

[64] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.48

[65] Professor P. Lepping and S. Pyke, Independent Review of Adult Mental Health Services in Jersey – which are part of the Health and Community Services (HCS)', 19th November 2021

[66] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.19

[67] Professor P. Lepping and S. Pyke, Independent Review of Adult Mental Health Services in Jersey – which are part of the Health and Community Services (HCS)', 19th November 2021

[68] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.17

[69] Government of Jersey, Government Plan 2022-2025, p. 43

[70] Ibid

[71] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.11

[72] Letter - Minister for Health and Social Services – 25th March 2022

[73] Submission – Focus on Mental Illness – 1st March 2022

[74] Ibid

[75] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.10

[76] Assessment of Mental Health Services (S.R.4/2019): Response of the Minister for Health and Social Services, 1st May 2019

[77] Health and Community Services, 2022 HCS Business Plan 2022, 10th February 2022, p.20

[78] Letter - Minister for Health and Social Services – 25th March 2022

[79] Assessment of Mental Health Services (S.R.4/2019): Response of the Minister for Health and Social Services, 1st May 2019

[80] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.44

[81] Assessment of Mental Health Services (S.R.4/2019): Response of the Minister for Health and Social Services, 1st May 2019

[82] Letter - Minister for Health and Social Services – 25th March 2022

[83] Submission – The Listening Lounge – 9th March 2022

[84] Submission – Jersey Recovery College – 17th March 2022 During the fact-checking process the JRC highlighted to the Panel that "While this statement was true at the time of submission, we have seen real improvements in this space in the past month or so".

[85] Submission – Mind Jersey – 28th February 2022

[86] Assessment of Mental Health Services (S.R.4/2019): Response of the Minister for Health and Social Services, 1st May 2019

[87] Letter - Minister for Health and Social Services – 25th March 2022

[88] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.9

[89] Letter - Minister for Health and Social Services – 25th March 2022

[90] Transcript – Quarterly Public Hearing with the Minister for Health and Social Services – 4th February 2022, p.20

[91] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.17

[92] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.43

[93] Letter - Minister for Health and Social Services – 25th March 2022

[94] Letter - Minister for Health and Social Services – 25th March 2022

[95] Assessment of Mental Health Services (S.R.4/2019): Response of the Minister for Health and Social Services, 1st May 2019

[96] Ibid

[97] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.46

[98] Ibid

[99] Submission – Focus on Mental Illness – 1st March 2022

[100] Ibid

[101] Comptroller and Auditor General, Governance Arrangements for Health and Social Care – Follow up', 13th September 2021, p.37

[102] Health and Community Services, Quality and Performance Report, December 2021, p.15

[103] Assessment of Mental Health Services (S.R.4/2019): Response of the Minister for Health and Social Services, 1st May 2019

[104] Ministerial Decision - MD-HSS-2019-0027 – 28th May 2019

[105] Ministerial Decision - MD-HSS-2019-0036 – 24th July 2019

[106] Ministerial Decision - MD-HSS-2020-0092 – 25th November 2020

[107] Ministerial Decision - MD-HSS-2021-0043 – 23rd December 2020

[108] Transcript – Quarterly Public Hearing with the Minister for Health and Social Services – 17th November 2021, p.19

[109] States of Jersey Law 2005: Delegation of Functions – MHSS – Mental Health Services – June 2019 (R.79/2019)

[110] States of Jersey Law 2005: Delegation of Functions – MHSS – Consolidated Schedule December 2021 (R.193/2021)

[111] Health and Community Services Business Plan 2022, p. 20

[112] Health and Social Security Scrutiny Panel, Assessment of Mental Health Services (S.R.4/2019)', 6th March 2019, p.29

[113] Transcript – Quarterly Public Hearing with the Minister for Health and Social Services – 4th February 2022, p.21

[114] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.15

[115] Ibid, p.15

[116] Ibid, p.16

[117] Ibid, p. 16

[118] Letter - Minister for Health and Social Services – 25th March 2022

[119] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.34

[120] Submission – The Listening Lounge – 9th March 2022

[121] Submission – Jersey Recovery College – 17th March 2022

[122] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.17

[123] HCS Board Minutes

[124] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.13

[125] Transcript – Quarterly Public Hearing with the Minister for Health and Social Services – 4th February 2022, p.27

[126] WQ.396/2021

[127] Public Accounts Committee – Performance Management Review (P.A.C. 2/2022)' – 8th March 2022, p.35

[128] Ibid, p.35

[129] Ibid, p.35

[130] Transcript – Quarterly Public Hearing with the Minister for Health and Social Services – 4th February 2022, p.27

[131] Submission – Mind Jersey – 28th February 2022

[132] Transcript – Quarterly Public Hearing with the Minister for Health and Social Services – 4th February 2022, p.26

[133] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.25

[134] https://www.gov.je/news/2021/pages/mentalhealthnursingdegree.aspx (accessed 01/04/2022)

[135] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.21

[136] https://www.gov.je/Working/WorkingForTheStates/NursingJersey/Pages/MentalHealthNursingDegreeProgrammePreRegistratio n.aspx (accessed 01/04/2022)

[137] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.20

[138] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.21

[139] Transcript – Quarterly Public Hearing with the Minister for Health and Social Services – 4th February 2022, p.28

[140] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.21

[141] https://www.gov.je/Working/WorkingForTheStates/NursingJersey/pages/relocatejerseynurse.aspx (accessed 01/04/2022)

[142] Assessment of Mental Health Services (S.R.4/2019): Response of the Minister for Health and Social Services, 1st May 2019

[143] Letter - Minister for Health and Social Services – 25th March 2022

[144] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.26

[145] Submission – Jersey Recovery College – 17th March 2022

[146] Submission – Focus on Mental Illness – 1st March 2022

[147] Ibid

[148] Letter - Minister for Health and Social Services – 25th March 2022

[149] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.26

[150] Public Accounts Committee – (Follow Up) Review of Estate Management 2021 (P.A.C. 3/2021)' – 15th October 2021, p.74

[151] Letter – Minister for Infrastructure – 16th March 2022

[152] States Assembly, 8th September 2020, (OQ.216/2020), Hansard record, p.67

[153] Letter – Minister for Infrastructure – 16th March 2022

[154] Ibid

[155] Ibid

[156] Ibid

[157] Ibid

[158] Ibid

[159] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.27

[160] Letter – Minister for Infrastructure – 16th March 2022

[161] Ibid

[162] Letter - Minister for Health and Social Services – 25th March 2022

[163] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.31

[164] Ibid

[165] https://www.jerseylaw.je/laws/enacted/Pages/L-29-2016.aspx#_Toc470684256 (accessed 28/03/2022)

[166] Letter – Minister for Home Affairs – 18th February 2022

[167] Health and Social Security Scrutiny Panel, Assessment of Mental Health Services (S.R.4/2019)', 6th March 2019, p.38

[168] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.36

[169] Ibid, p.37

[170] Transcript – Public Hearing with the Minister for Children and Education – 25th February 2022, p.21 171 Letter – Minister for Home Affairs – 18th February 2022

[171] States Assembly, 8th October 2019, Hansard record, p.85

[172] Ibid

[173] Submission – Focus on Mental Illness – 1st March 2022

[174] Ibid

[175] States Assembly, 22nd October 2019, Hansard record, p. 63

[176] Letter – Minister for Infrastructure – 16th March 2022

[177] Letter – Minister for Home Affairs – 18th February 2022

[178]Minutes of the Scientific and Technical Advisory Cell, 21st June 2021

100

[179] Transcript – Quarterly Public Hearing with the Minister for Health and Social Services – 19th August 2021, p.36

[180] Letter – Minister for Health and Social Services – 25th March 2022

101

[181] Submission – Dementia Jersey – 28th February 2022

[182] Letter - Minister for Health and Social Services – 25th March 2022

102

[183] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.37

[184] Letter - Minister for Health and Social Services – 25th March 2022

103

[185]186 Letter – Minister for Home Affairs – 18th February 2022

[186] Letter – Minister for Home Affairs – 18th February 2022

[187] Ibid

[188] Ibid

[189] Ibid

[190] Ibid

104

[191] Letter – Minister for Home Affairs – 29th March 2022

[192] Letter – Minister for Home Affairs – 18th February 2022

105

[193] Letter – Minister for Home Affairs – 29th March 2022 – During factual accuracy checking the Panel was advised that "able" (as per the original submission) should read "unable".

[194] Letter – Minister for Home Affairs – 29th March 2022

[195] Letter – Minister for Home Affairs – 18th February 2022 (emphasis added)

[196] Letter – Minister for Home Affairs – 18th February 2022

[197] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.13

106

[198] Ibid, p.5

[199] Letter – Minister for Home Affairs – 18th February 2022

[200] Ibid

[201] Letter – Minister for Home Affairs – 29th March 2022

107

[202] Children and Young People's Emotional Wellbeing and Mental Health Strategy 2022-2025

[203] Submission – Maternity Voices Partnership – 10th March 2022

[204] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.13

109

[205] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.34

110

[206] Submission – The Listening Lounge – 9th March 2022

[207] Submission – Focus on Mental Illness – 1st March 2022

[208] Ibid

[209] Submission – Jersey Recovery College – 17th March 2022

111

[210] Submission – Dementia Jersey – 28th February 2022

112

[211] Transcript – Quarterly Public Hearing with the Minister for Health and Social Services – 4th February 2022, p.21

[212] Minutes of the Health and Community Services Board, 8th November 2021

[213] Submission – Mind Jersey – Reconnecting with Hope Conference Report – 28th February 2022

[214] Submission – The Listening Lounge – 9th March 2022

113

[215] Submission – Jersey Recovery College – 17th March 2022

[216] Letter - Minister for Health and Social Services – 25th March 2022

[217] https://www.gov.je/news/2022/pages/hcpgmeetingheld.aspx (accessed 28/03/22)

114

[218] Health and Social Security Scrutiny Panel, Assessment of Mental Health Services (S.R.4/2019)', 6th March 2019, p.46

[219] Ibid, p.49

[220] States of Jersey, A Mental Health Strategy for Jersey (2016 - 2020): Planning together, for our future, November 2015, p50

[221] Assessment of Mental Health Services (S.R.4/2019): Response of the Minister for Health and Social Services, 1st May 2019

115

[222] Ibid

[223] Submission – Jersey Recovery College – 17th March 2022

116

[224] Submission – Primary Care Body – 13th February 2022

[225] Ibid

[226] Submission – The Listening Lounge – 9th March 2022

[227] Submission – Maternity Voices Partnership – 10th March 2022

117

[228] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.13

[229] Submission – Primary Care Body – 13th February 2022

118

[230] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.47

[231] Article 21 (1), Health Insurance (Jersey) Law 1967 (accessed 01/04/2022)

[232] https://www.gov.je/health/doctordentist/doctors/pages/healthaccessscheme.aspx (accessed 01/04/2022)

[233] Health and Social Security Scrutiny Panel, Assessment of Mental Health Services (S.R.4/2019)', 6th March 2019, p.49

[234] States Assembly (OQ.46/2022), 1st March 2022, Hansard record, p.59

119

[235] Submission – Primary Care Body – 13th February 2022

[236] Submission – Focus on Mental Illness – 1st March 2022

120

[237]238 2019 Assessment of Mental Health Services Report

[238] Assessment of Mental Health Services – Panel Website

121

[239] Transcript – Public Hearing with the Minister for Children and Education – 25th February 2022

[240] Transcript – Public Hearing with the Minister for Children and Education – 25th February 2022

[241] Submission – Mind Jersey – Reconnecting with Hope Conference Report – 28th February 2022

122

[242] Transcript – Public Hearing with the Minister for Health and Social Services – 28th February 2022

[243] Transcript – Public Hearing with the Minister for Children and Education – 25th February 2022

123

[244] Transcript – Public Hearing with the Minister for Children and Education – 25th February 2022

[245] Public Accounts Committee – Performance Management Review (P.A.C. 2/2022)' – 8th March 2022, p.28

[246] Transcript – Public Hearing with the Minister for Children and Education – 25th February 2022

124

[247] Transcript – Public Hearing with the Minister for Health and Social Services – 28th February 2022

[248] Transcript – Public Hearing with the Minister for Health and Social Services – 28th February 2022

[249] Transcript – Public Hearing with the Minister for Health and Social Services – 28th February 2022

125

[250] Transcript – Public Hearing with the Minister for Children and Education – 25th February 2022

[251] Children and Young People's Emotional Wellbeing and Mental Health Strategy 2022 to 2025

[252] Children and Young People's Emotional Wellbeing and Mental Health Strategy 2022 to 2025

126

[253] Health and Social Security Scrutiny Panel, Assessment of Mental Health Services (S.R.4/2019)', 6th March 2019, p.56

[254] Ministerial Decision - MD-C-2019-0016 – 7th February 2019

127

[255] Transcript – Public Hearing with the Minister for Children and Education – 25th February 2022

[256] Transcript – Public Hearing with the Minister for Children and Education – 25th February 2022

128

[257] Public Accounts Committee – Performance Management Review (P.A.C. 2/2022)' – 8th March 2022, p.27

[258] Transcript – Public Hearing with the Minister for Children and Education – 25th February 2022

[259] Public Hearing - Director General's for HCS and CYPES – 29th November 2021

129

[260] Public Accounts Committee – Performance Management Review (P.A.C. 2/2022)' – 8th March 2022, p.27

[261] Jersey Care Commission – Improvement Notice – 28th March 2022

[262] Public Accounts Committee – Performance Management Review (P.A.C. 2/2022)' – 8th March 2022, p.28

[263] Transcript – Public Hearing with the Minister for Children and Education – 25th February 2022

130

[264] Comptroller and Auditor General, Jersey Audit Office, Child and Adolescent Mental Health Service Project Specification'

[265] Ibid

131

[266] Submission – Primary Care Body – 13th February 2022

[267] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.6

133

[268] Health and Community Services, Quality and Performance Report, December 2021, page 4

[269] Health and Community Services, Quality and Performance Report, December 2021, page 14/15

134

[270] Submission – The Listening Lounge – 9th March 2022

[271] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.6

[272] Ibid

[273] Letter - Minister for Health and Social Services – 25th March 2022

135

[274] Letter – Minister for Health and Social Services – 25th March 2022

[275] Letter – Minister for Health and Social Services – 25th March 2022

[276] Submission – The Listening Lounge – 9th March 2022

136

[277] Letter – Minister for Health and Social Services – 25th March 2022

[278] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.15

137

[279] Letter – Minister for Health and Social Services – 25th March 2022

138

[280] Submission – Liberate Jersey – 5th November 2018

139

[281] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.44 During the factual accuracy checking process the Panel was advised that this should say "to the clinician on the island doing that work". A review of the audio recording was not clear enough for us to amend the original transcript to reflect the change requested.

[282] Transcript – Public Hearing with the Minister for Health and Social Services - 28th February 2022, p.44

[283] Ibid, p.45

140

[284] Submission – Liberate Jersey – 28th February 2022

141

[285] Transcript – Minister for Children and Education – 25th February 2022, p.30

[286] Ibid

142

[287] Letter - Minister for Health and Social Services – 25th March 2022

143

[288] Ibid

144

Report - Follow-up Review of Mental Health Services - 22 April 2022