Letter - From Minister for Health and Social Services re Bridging Island Plan Review - 15 October 20

19-21 Broad Street | St Helier Jersey | JE2 3RR

Connétable Mike Jackson

Chairman

Environment, Housing and Infrastructure Scrutiny Panel

15 October 2020

Dear Connétable

Thank you for your letter of 1st October. I will answer your questions in the order posed.

1  (Answer to Q1 is from Senator Pallett, Assistant Minister for Health and Social Services)

Sustainable wellbeing now lies at the heart of all government decision-making as the wellbeing of our Islanders is strongly intertwined with our environment, our economy and our society and culture. As one of its five strategic priorities, the Common Strategic Policy is committed to supporting Islanders to live healthier, active and longer lives. The Government Plan and the recently lodged revision of the plan includes considerable levels of funding to support this strategic aim to improve the physical and mental wellbeing of all Islanders. Preventing ill-health rather than treating it has to be the longer term objective of government and the proposal for a shorter term Bridging Island Plan (BIP) should meet both the government's aim of overall sustainable wellbeing and, in particular, the objective to improve the physical and mental wellbeing of islanders.

The BIP comes at a crucial time in the development of a long term Sports Facilities Strategy for Jersey that looks to address the lack of investment in facilities that has seen our public sports facilities poorly maintained and in need of major refurbishment or total replacement. The BIP should, I suggest, take into account the identification of any current and new sites and provide a process for development on these sites that takes into account the importance of physical and mental wellbeing on our population and gives comfort to owners / developers that if clear criteria are met, then planning permission would be supported. Moving forward, it is likely that projects will include public / private partnerships which would be beneficial to both government and islanders, but private investors need to have confidence that planning guidelines are clear and transparent and unnecessary hurdles are not put in the way of developing key infrastructure to support islanders' wellbeing.

The new sport and physical activity strategy for Jersey: Inspiring an Active Jersey 2020 – 2030' also sets ambitious targets to reduce inactivity in the Island's population and to achieve the necessary success it is vital that opportunities to exercise are encouraged and increased. To reduce the burden on Health and Community Services over coming decades ,especially with the increased number of islanders who are over the age of 65, the new strategy takes a whole systems approach' to increasing physical activity that will require all States departments, the private sector and islanders of all ages to work collaboratively. Physical activity will be defined in different ways for each and every Islander - for some it may be walking to the shops rather than driving, and for others it will mean taking up a new sport such as cycling or walking to work.

It is the last point that needs careful consideration by a new BIP to ensure that opportunities to become more active through cycling ,walking or running can be achieved safely throughout the island. The provision of more and improved cycling routes that connect the main areas of population in Jersey are vital if we are to grow the increasing numbers who have taken up cycling during the pandemic. Improving cycling routes across the island cannot wait any longer and it's important that any development in town, for example, includes provision for both cycling and walking routes to encourage people out of their cars, therefore both improving their activity levels and helping our local environment. Planning applications for larger developments, especially those in town, need to seriously consider how those who will live in such accommodation will travel to and from work and provide or contribute towards improving cycling and walking routes. By putting children first', we also have to consider how cycling and walking routes to schools can be made safer and some consideration should be given within residential planning applications as to how children will access their local school safely. Another aspect of planning that has been overlooked in the past is the provision of play space within urban developments, an issue that is key to ensuring both the physical and mental wellbeing of children.

The natural environment also has a key role to play in encouraging islanders to stay fit and active so it's vital that any new BIP protects key elements of our environment, such as the Jersey National Park, our local park portfolio such as People's Park and our many cliff paths, while our incredible heritage infrastructure is protected and enhanced with a new BIP. Our sense of wellbeing often originates from our cultural, sporting and national identity which is why it's crucial that our Bridging Island Plan commits to enhancing that identity and looks to support and enhance key elements that make up that identity.

2. Health and social care is reliant on expertise from outside the island and I don't anticipate this situation will ever change. Whilst greater emphasis is rightly being placed on local recruitment, it will never provide for all our needs. We also need to recruit all manner of staff to the island from consultants to care assistants and it is important to ensure this is recognised in government policies in order to maintain the quality and viability of our health and social services. To this end, a submission was made by HCS to the Migration Policy Development Board. It is attached to the e-version of this letter.
3. I am not aware of any specific assurances which have been provided but neither am I aware of anything that might hinder. I think this question would be better directed to the Environment Minister or to the Deputy Chief Minister as chair of the Our Hospital Political Oversight Group.
4. Theoretically there are downsides because we are operating under a 10 year old island plan which makes no provision for a hospital facility. However, I believe there is an overwhelming acceptance that a new hospital is needed and must be provided despite the lack of specificity in the current island plan. Supplementary guidance has therefore been produced and to all intents and purposes, I hope this will serve to overcome this issue. The guidance demonstrates that we have done as much as possible within the limitations of the current island plan to address the issues around a hospital build and I cannot conceive that a planning inspector would recommend refusal of an application due to the lack of a specific policy in a plan that was compiled some 12 years ago.

Thank you for seeking my comments and I wish the panel well in its deliberations on this important issue.

Kind regards

Deputy Richard Renouf

Minister for Health and Social Services Tel: 01534 442891 | email: r.renouf@gov.je

Migration Policy

Feedback response from HCS

1.Introduction

The following is a response to the Migration Policy Development Board (MPDB) Interim Report. It also takes into account the information which has been previously presented to the Migration Policy Board, as published on the gov.je website.

This high-level response sets out the changes in demand for care, the national workforce pressures experienced in health and social care, the current impact on Jersey recruitment and retention, and the local picture in relation to pressures across both the registered' and trained' health and social care workforce in Jersey. It also examines what is currently being done to address these pressures and provides the MPDB with context to ensure that any changes made to the CWH legislation does not create unintended consequences for a labour market sector which is already under pressure and which will need to grow to meet the predicted demand for care in Jersey.

2.Key factors to consider in relation to the sustainability of the health and social care workforce in Jersey.

Health and Social Care in Jersey faces a number of challenges now and in the future, particularly relating to an increase in demand for care with the number of islanders over the age of 65 predicted to double by 2040. At the same time, the ratio of working adults to older adult ratio is expected to fall from 3.9. to 1 to 1.8. to 1 by 2040 (extract from the Health and Social Services White Paper – Caring for Each other Caring for Ourselves Public Consultation Document).

This is clearly understood and is referenced in the draft document - Section 3.5 Jersey resident population estimate which states:

"The number of people over 65 will increase steadily over the next 30 years whatever migration controls are in place. With no inward migration this will lead to a reduction in the number of working age people as more older people leave the workforce compared to the number of younger people joining"

This increase in the over-65 population will increase the demand on health and social care services and care needs. It is estimated that 75% of 75-year olds in the UK have more than one long-term condition, rising to 82% of 85-year olds (Barnett et al 2012). This increase in demand will be a challenge for health and social care systems if there is not an appropriately skilled workforce available to meet the demand. The delivery of health and social care throughout the island is dependent on the availability of a workforce – both at the registered professional level (such as doctors, nurses, social workers, pharmacists etc) and at a trained level (such as healthcare assistants, support workers, home care support workers). The issues of availability and sustainability were concerns shared and expressed by members of the public during the public events on the Jersey Care Model, which took place during Nov/Dec 2019. At every parish event, there were questions about growing, attracting and retaining the workforce.

3.Current position regarding recruitment of registered professional staff and factors affecting recruitment

3.1 General UK labour market context

The majority of our registered health workforce is recruited via the UK labour market.

The current workforce position across the UK health and social care labour market is challenging with an estimated 1 in 12 or 8% of posts vacant in hospital and community services. The highest percentages of vacancies exist in the Thames Valley, near London, where the vacancy rate is c.12%. The lowest rates, at c.4%, are in the North East.

40,000 vacancies exist in nursing and midwifery in the UK. Concern about nursing workforce numbers has been evident since 2015, when nurses were added to the list of shortage occupations by the UK Migration Advisory Committee. This list was refreshed as recently as October 2019 and nursing still features.

In terms of medical staff, whilst there has been inward investment in the UK directed at medical staff and hospital consultants between the years of 2004 to 2019, it is estimated that 1 in 10 speciality postgraduate medical training posts go unfilled resulting in demand outstripping supply.

Mental health staff – in 2015, concern about this specialism was also considered and added to the list of shortage occupations by the Migration Advisory Committee. In 2019 when the list was refreshed, it cited all mental health medical practitioners as a profession experiencing workforce gaps.

Community Health Nurses – this sector has experienced significant pressure and since 2009 there has been a steady decline in the number of district nurses, health visitors and school nurses. This decline relates to loss of posts and a lack of people entering the sector.

When the Migration Advisory Committee (Migration Advisory Committee Full Review of the Shortage Occupation List May 2019) invited a response from the health and social care sector about the reasons for the workforce gaps, the following points were made:

- a low number of people available with the required skills

- too much competition from other employers and

- the offputting nature of shift work and unsociable hours. 4.Impact of these gaps

Across the NHS it is estimated that 80% of the nursing vacancies and 90% of the medical staff vacancies are being filled by locum/agency staff. Whilst this is costly, it also leaves gaps in staffing levels.

It is estimated that the NHS is looking at a workforce gap of 250,000 by 2030.

EU nationals and the restriction of movement has already impacted on the number of nurses registered with the Nursing and Midwifery Council (NMC) and therefore available to work in the UK or Channel Islands. The latest report from the Health Foundation indicates that the number of nurses from overseas registering has fallen in 2018 from 8,800 to 3,500; this has particularly been driven by the fall in the number of EU nurse registrants – a fall of 87% from 6,400 to 800.

The Interim Report states: "The UK Government intends to remove the right of EU nationals to live and work freely in the UK and requires EU nationals to apply to get immigration permissions to do the same. These changes will be mirrored in Jersey. The impact of these changes upon the full flow of EU migrants to Jersey is not yet clear however they will be treated the same as 3rd country nationals and will require immigration permissions to enter Jersey and be able to work".

Whilst Jersey has not been part of the EU, in health and social care labour market terms this change will have an impact on Jersey's recruitment of registered health and social care professionals as all of the staff working in roles such as adult social work, nursing, physio, midwifery, pharmacy, medicine, biomedical scientists etc are registered through the UK professional regulators (NMC, GMC, HCPC). This is the professional regulation requirement to work and practice in the UK and Jersey. When the UK leaves the EU, it is predicted that the number of professionals registered on the UK register, and therefore eligible to apply for roles in Jersey as well as the UK, will continue to fall.

5. Jersey position re-registered workforce

Jersey typically experiences the same health and social care workforce pressures as elsewhere. Whilst we have had some relative success in some areas of service through developing different roles and sponsoring training ourselves, there are undoubtedly areas experiencing similar pressures to that of the UK.

Mental health nursing in HCS – this is an area of focus for Jersey and a priority in the recently published Government Plan. Whilst we are currently developing an on-island mental health nurse training programme, we will continue to look outside Jersey for experienced staff in this field. At the moment, this area of service is very reliant on temporary staff and in some areas up to 48% of the substantive posts in nursing are filled with agency staff. Whilst the geographical position of Jersey means that agency staff in Jersey do not move around as they do in the UK and they do become a part of the substantive team for a period of time, this is an expensive way of staffing.

Adult nursing in HCS – approximately 75% of registered nurse and midwifery vacancies are filled with agency nurses and midwives. Additional staffing needs are topped up by the local nurse bank, run through HCS.

Pressures experienced in other parts of the sector – last year, HCS supported two provider organisations to source temporary registered staff as they had experienced difficulties in attracting registered nurses to Jersey. HCS has been able to assist by sourcing agency nurses and providing HCS temporary staff accommodation. Without this support, capacity within the sector would have reduced, as beds would have had to close due to lack of staff and this would have impacted across the whole health and social system.

Community Nursing – this is an area which requires expansion within Jersey as part of our ambition – as set out in the Jersey Care Model – to offer islanders more choice about their place of care, and to keep people well and cared for at home for longer. This is also a sector under pressure in the NHS for reasons cited above and, again, while Jersey will be able to grow some of its own community nurses through our UK university provider, we will also need to supplement this by bringing in experienced staff from elsewhere.

6. The trained workforce – these are typically roles such as Healthcare Assistants, Support Workers and Home Care Support. This workforce is generally recruited from within the island, and is recruited on variable rates of pay, terms and conditions. Many in the private sector are recruited onto zero hour or part-time contracts and in many instances are paid only for the time in which hands on care is delivered, ie not between visits when they are driving from one client to another. It is of concern that other jobs in Jersey, such as admin and clerical work, attract better pay and terms and conditions than these roles involving the most intimate caring work supporting some of the most vulnerable people in our island.

This workforce is key to the current and future delivery of health and social care in the island and is a sector that is expected to, and needs to, expand. This sector is experiencing difficulties now with demand outstripping supply. The impact of this on the whole island healthcare system means that more people are being cared for in places that do not best meet their care needs. So, for example, within the general hospital the number of patients aged 65 and over who get stranded in hospital beds whilst waiting for their ongoing care needs to be met is increasing. At any one point in time, this can affect up to 35 patients, which is the equivalent of the capacity of two wards. The impact of this increased demand and issues with workforce supply in the home care market sector means that the residential sector becomes the default discharge destination. As a result, capacity within this sector is now becoming challenging.

Discussions with the sector during the engagement events for the Jersey Care Model revealed a number of factors that are impacting on this sector, namely the increased regulatory requirements linked to the Regulation of Care, such as the increased workforce training requirements. In the Board's Interim Report, reference is made to Bermuda, but Jersey has no central ie "national" training resource for this sector. This means training needs to be sourced from a variety of providers which range in cost and quality. Time staff spend in training needs to be backfilled by other colleagues to ensure care continues, which puts double running cost pressures on the organisations.

Providers can and do apply for work permits under the current system. However, even with permits there are limits as to what they are able to do. One care agency explained that although they have five permits they do not use these as being the only agency recruiting staff from outside the island would mean they would have to source accommodation for this workforce on a temporary basis and possibly contribute to the cost of rentals. Short-term leases in Jersey are expensive and are not in huge supply, particularly for those without housing permits.

We also heard from carers, ie family members about the difficulties they are experiencing as a result of pressures in this sector. For example, a family was told at the last minute that there were no staff available for the forthcoming weekend and the family was left to make alternative arrangements.

7. Jersey's recruitment sourcing position for health and social care professional staff Currently, Jersey recruits from three main sources:

• From outside Jersey – experienced qualified registered professionals. All of these staff have to be registered via the UK regulatory body in order to legally practice as a locally registered professional in Jersey. The UK regulators are the General Medical Council (GMC), Nursing and Midwifery Council (NMC) and the Health and Care Professions Council (HCPC).

• Home grown in Jersey – from the local population – this currently happens for nursing, midwifery and social work. The programme is a degree programme delivered in Jersey and awarded by a UK university. It has an annual intake. The programme takes three years and we train to employ'. There are consistently around 54 students in total on the nursing and midwifery programmes who will qualify over the next few years. The first intake for the social work programme commenced in September 2019.

• Return to practice – in nursing and midwifery we are able to offer an opportunity for those who have left the profession to pursue other opportunities to return to nursing and get back onto the register and enter the local labour market. Some six people have taken up the opportunity so far.

Recruited from outside of Jersey – In the case of registered nurses and midwives, doctors, and those professions registered with the HCPC, all staff are currently recruited onto permanent contracts. This was not always the case, specifically in relation to nursing and some of the allied health professional posts (employed on civil servant contracts). For them, employment used to be offered on a non- permanent basis, typically under five-year contracts.  

However, as attracting staff became more difficult, barriers to recruitment were removed and permanent contracts have been offered for a number of years along with an improved relocation package. This has had a positive impact and undoubtedly assists in retaining this valuable workforce.

The average age of nurses and midwives on qualifying has changed with 60% being above the age of 27 when they enter the workforce. This means we would typically be looking to recruit those with experience in post before appointing to Jersey (as we have our own supply of newly-qualified nurses). In our experience, this has meant that many nurses and midwives are 30+ and have family commitments by the time they consider relocating to Jersey for work.  

The interim report suggests four types of work permits. In summary they are:

1.Low skilled employees – permission for 9 months in any 12. Must leave island for at least 3 months before reapplying. Will never achieve settled status.

2.Skills shortage at medium level – permits to be granted for no more than 4 years. Must leave island for at least 1 year before reapplying. A limited number only will be granted settled status after 4 years on grounds of significant work record.

It isn't exactly clear which of the categories above would apply to the trained workforce who provide homecare, healthcare assistant and support roles – however, clearly there is a need for a co-ordinated island-wide response to the growing demand in this sector to ensure that Jersey is able to deliver and sustain as much as it can in relation to this workforce. There needs to be a strategic needs analysis and a labour market strategy to address this issue and to fully understand the risk and options to address gaps in the workforce. This includes addressing the skills gap, addressing terms and conditions, and pay.

Finally, if we are to make health and social care an attractive career choice and recruit into this labour market from outside Jersey then it is not an attractive prospect to be able to offer only four years of work and then expect employees to leave for a year before returning. This is not a viable and cost effective approach, given the knowledge, skills and experience developed by those individuals during the time they have lived and worked in Jersey. It does little for continuity of care and would mean a revolving door that is unlikely to meet need or sustain services.

3.Skills shortage at high income/critical skills level – permits to be granted for no more than 4 years but employee would gain settled status at the end of 4 years subject to remaining in employment.

If this category is applied to the registered workforce then, bearing in mind the national context, there is a risk that this will have a negative impact on recruitment and retention.

At present, registered professionals recruited from outside Jersey are appointed to permanent posts. This has had a positive impact and actually puts Jersey in a stronger and more attractive position than our counterparts in the other islands. Discussions recently with colleagues in Guernsey about recruitment revealed that it has extended the permit time on appointment for nurses to 8 years, with permanency at this point. Guernsey is currently considering a further review of its rules with a view to extending it further for this workforce.

The proposed impact of offering a permit for four years with the promise of permanent status after four years will impact on our recruitment as it creates another barrier for registered professionals relocating to Jersey and does not recognise that they are bringing valuable much needed skills to the island.

4.Demonstrable significant contribution to the island since arrival on permit in 3 above or (more strictly controlled), 2 above. Permanent settled status.

To conclude

Whilst we can increase efforts to source local staff or reassign existing staff into community work, the health and care sector will always need to recruit off-island for a range of skilled jobs. The direction of travel that the report suggests is not dissimilar to the present arrangements for licenced and entitled workers, but suggests that the grant of permits will be more strictly controlled. Under the proposed arrangements, employers will still assess their skill needs and apply for a certain number of permits to be held by their business. There is a need for an island-wide "workforce strategy" which covers the whole health and social care sector's total need for off-island staff, with recruitment focused on meeting that need. This would remove the need for individual employers in the sector to recruit off- island staff into specific posts who cannot thereafter work flexibly in other parts of the sector.

January 2020