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STATES OF JERSEY
Health, Social Security and Housing Scrutiny Panel Income Support Sub-Panel
FRIDAY, 27th FEBRUARY 2009
Panel:
Deputy G.P. Southern of St. Helier (Chairman) Deputy D.J. De Sousa of St. Helier (Vice-Chairman) Deputy T.A. Vallois of St. Saviour
Connétable S.A. Yates of St. Martin
Reverend G. Houghton (Adviser)
Mr. E. Le Quesne (Adviser)
Ms. C. Le Quesne (Scrutiny Officer)
Witnesses:
Ms. P. Massey (Family Nursing & Home Care)
Ms. J. Le Ruez-Lane (Family Nursing & Home Care) Ms. J. Hinks (Family Nursing & Home Care)
Mr. A. Cook (Family Nursing & Home Care)
Deputy G.P. Southern of St. Helier (Chairman):
Good morning. Welcome to this meeting of the Income Support Scrutiny Panel. We are here to investigate the effectiveness of Income Support on the ground and how well it is being delivered. I will just introduce my panel first, if I may, just so we can identify ourselves on the record. We are being recorded but feel free ... I know it is a fairly formal setting but it is not meant to be formal. Do have a chat, tell us what you like. If you would then introduce yourselves following that, just to identify yourself on the tape. So I am Geoff Southern . I am chairing this panel. This is my Vice-Chairman, Deputy De Sousa, and the other members are Constable Silva Yates and Deputy Vallois from St. Saviour . My 2 lay advisers are Ed Le Quesne and the Reverend Geoff Houghton. If you would just like to introduce yourselves, and then we have got one formal item to go through and then we can kick off.
Ms. P. Massey (Family Nursing & Home Care):
Thank you. My name is Pam Massey. I am the acting Chief Executive of Family Nursing & Home Care. I have brought with me some colleagues that obviously are in touch with frontline staff workers and also representatives from the business side of our organisation. So, if we start with you, Andy.
Mr. A. Cook (Family Nursing & Home Care):
Yes, I am Andy Cook. I am Finance Manager for Family Nursing & Home Care.
Ms. J. Hinks (Family Nursing & Home Care):
I am Jean Hinks and I am the team leader for the home care support team of Family Nursing & Home Care.
Ms. J. Le Ruez-Lane (Family Nursing & Home Care):
I am Jane Le Ruez-Lane and I am a district nurse team leader.
Deputy G.P. Southern :
Thank you. If I could just draw your attention to the notice that is in front of you. It tells you about the conditions under which we are meeting. Basically it says almost whatever you say you cannot be sued. You have got parliamentary privilege. So feel free to speak as frankly as you like. Here we are a year into Income Support and we are trying to find out how effective it has been on the ground. So do kick it off and tell us what is happening.
Ms. P. Massey:
Okay. First and foremost, the charity that our organisation serves, serves the whole of Jersey and we have 3 core businesses. It is around child and family services; we have district nursing services; and we have social care. The social care is split into domestic care and actual social care, providing washing, getting people up, et cetera. In order to deliver these 3 core services we have a business unit and we also have a unit that supports education, training and H.R. (human resources). So that is a view of the organisation that we are. We have an estimated budget of around £8 million, and £6 million of that comes from the States and £2 million we have to fund raise and that is by fund raising, donations and legacies. We have a total staff of around at this moment in time about 234 staff, with 4 of them part- time, and out of that we have about 70 healthcare professionals that are qualified in either district nursing or health visiting. What we have done is, my colleagues here, we have tried to get a snapshot from our frontline workers about their sort of gut feelings around the system that is in place now and that has also come from their experience of dealing with clients and having to go through the forms. We have some case studies that we have written that might be useful for you, if you would like to take those and take some copies of those. We have got a couple of case studies. So I think to start off, the first question that we were asked was about what impact you believe the change of the income support system has on the welfare of clients. I think what we saw was when we had the parish system we felt that the parish system was very reactive. So it was quite an immediate sort of response, or could be quite an immediate response, and also that it was quite flexible as in that you could really apply for most things and see how you got on. So there was not a sort of screening of what you could and what you could not apply for. However, on the back of that I think that the healthcare professionals that we have spoken to did feel that the actual criteria for getting these sorts of grants was not very well registered and when we have got families that are in chaos and live chaotic lifestyles they sometimes were discriminated against, or that was the general feeling. So some lifestyles could have been discriminated against and that was the feeling from our professionals that we have talked to. So from that change to our new system I think our general feeling has been that clients have felt less well off.
Deputy G.P. Southern :
Can I just pick you up on that? Felt less well off?
Ms. P. Massey:
Felt less well off with the new system and I think Jean may have some --
Deputy G.P. Southern :
I think we might explore that.
Ms. J. Hinks:
We do not do financial assessments of the clients. There is no kind of means testing at Family Nursing & Home Care but the general impression from all the disciplines is that people are reporting back to us that they feel less well off. In fact, we were copied into an email - I cannot share that with you today because I want to make sure it is completely anonymised - that there was a widow, a 75-year old widow, and we were copied in by her son who was emailing Social Security because he presented the maths of what was happening before and what was happening after, and it was a deficit of £44 a month. So that is the sort of evidence that the clients are giving us and sharing with us.
Deputy G.P. Southern :
Has that case been resolved since?
Ms. J. Hinks:
No. In fact the nurse who emailed it to me from the social care assessment team has actually written on the email: "This was never acknowledged", the email. I want to be very careful here because we do understand that there are enormous pressures on the new system and so it is not a reflection on individual members of staff. We realise they are under enormous pressure.
Deputy G.P. Southern :
They have taken on a big load and that is one of the things that we are recognising.
Ms. J. Hinks:
Yes. So we would not want to go down that line of criticising them.
Ms. P. Massey:
We want to be balanced. It is about what is being reported into us really. I think the other thing is clients have felt that the medical component has been sort of averaged out and that high users find themselves less well off and to identify changing needs and further needs it is quite difficult because they have to go through the whole system again. So if they have got high needs and they get even more problems it is quite difficult about having to go back and get re-assessed and apply for further --
Deputy G.P. Southern :
Certainly. Again, we have already got evidence of that to a certain extent. You could be receiving monthly visits or you could have the doctor monthly, 12 visits are taken up. You fall ill in that year ... and I am not sure that the system does not cope but that people are not confident and aware that the system will cope. So if I fall ill what happens? That worry goes into the equation.
Ms. J. Le Ruez-Lane:
When someone had an H.I.E. (Health Insurance Exemption) card we knew quite happily that this patient could get free G.P. (general practitioner) visits so there was no concern in calling the G.P. Now, we are totally unaware of how many allocated visits the patient has and the general population, the ones that have not had massive G.P. input, get 4 visits a year. Suddenly if they need one home visit that will wipe out their total H.M.A. (Household Medical Account).
Deputy D.J. De Sousa of St. Helier :
Are you saying as a corporation that you are not aware of how it works?
Ms. J. Le Ruez-Lane:
No. We know that there is an H.M.A. account but obviously we do not know who has got what. We are totally unaware of how much is in a person's H.M.A. account, how the fees have been allocated, and the patients do not understand themselves.
Deputy D.J De Sousa:
If you do not understand how can you explain to them so that they understand as well.
Ms. P. Massey:
If there is a clinical need for a G.P. visit it is very difficult if the client is afraid to call a G.P. because they are not sure if they are going to get this account paid or not.
Deputy G.P. Southern :
That is the key. The key is the information may not be there.
Connétable S.A. Yates of St. Martin :
I am recognising what you are saying and in regard to your H.M.A. accounts we are learning as well. In fact, I was going to ask the Chairman when we have come to some meeting of consensus, as we mentioned before we have got to sit down and decide where we are ... we have interviewed Dr. Ince and I think I am seeing Family Nursing & Home Care in the same position as we were in before. I think we know a little bit more about it now and I think we must actually go through Dr. Ince's transcript and pick out what he said. I would think that it would be the time to feed this back to Family Nursing & Home Care because obviously they do not know what the situation is at the present moment and what it might be after our report to Social Security.
Deputy G.P. Southern :
The first point is we are meeting the Minister on Tuesday. So whatever is said today is going to be on his plate.
The Connétable of St. Martin :
I am very interested in what you are saying because I recognise exactly the situation as I feel. I have a gut feeling and I cannot put my finger on it but under the old system I know that we would get an application for assistance and it would be dealt with under a supplementary grant or something or other and it was fairly simple and fairly immediate because generally speaking if I did not know the client personally I am sure that somebody in the municipality did and the reaction was almost immediate. I can see that what you say about the rather hit and miss situation as applied before but it was a reaction and you got it immediately.
Deputy G.P. Southern :
Sorry, you were about to come in. I am concerned that we listen more than ...
Ms. J. Hinks:
I do agree. I think the only comment I wanted to make was that it is confusing about the top slicing of the benefit. So people who are in receipt of benefit cannot get their heads around the fact that it is top sliced and moved over into a different pot. I think particularly for our client base, which is mainly an elderly frail population, they find that difficult to understand. That is all I wanted to say.
Ms. J. Le Ruez-Lane:
Certainly the population who were not too disabled were just getting like the transport allowance. Their money for the doctors in the H.M.A. has come out of that transport allowance. I do believe they have had a supplementary amount given, starting from 1st February, which has helped that.
Ms. P. Massey:
I think that is why people feel less well off, to be perfectly honest.
Deputy G.P. Southern :
The reality is that if you top slice what is in a pot you would be less well off. The fact is that a certain section of people, rightly or wrongly, got free access to G.P.s in the past and that does not happen, that comes out of your money. It is put in a little pot for you but it still comes out of your money. The extra visits come out of a separate pot, that is extra money, we are told, into the pot. So if you fall ill seriously
you are not worse off because that money will come into your pot from a fresh source as extra money.
Ms. J. Le Ruez-Lane:
But we do not know how that happens. We have no idea of that decision and we have got now a crisis with hospital beds. The G.P.s are forced to keep people at home. So the patient might need a visit daily.
Deputy G.P. Southern :
So that then puts the load on to you.
Ms. P. Massey:
Certainly you think about New Directions work and trying to keep people in the community, we are looking at trying to keep dying patients more in the home. Patients will probably require a G.P. visit at home on a daily basis over that week or last week of life, and certainly for chronic disease management people are too sick when they are chronically ill to get to a G.P. So it is that difficulty and the trajectory of disease is so difficult to predict that we would be always behind in the assessment because we would need the G.P. visit when you need the G.P. visit not by the time you have filled out the forms.
Deputy G.P. Southern :
Has that been a serious problem this year? I am aware there has been lots of flu type things going around and with the elderly and frail it must have been particularly serious for them this year.
Ms. J. Le Ruez-Lane:
Yes, it has been because obviously people are being kept at home for as long as possible and having early discharges, therefore they are in a much worse state at home, requiring more frequent G.P. visits.
Ms. P. Massey:
I think our nurses do spend quite a lot of time reassuring patients that: "Yes, you do need a G.P. visit and do not worry about the funding" but it is a worry to them and we can only advocate for them. We cannot actually make them call the G.P. out if they have that real fear. I think those are sort of the key points. Do we want to go on to your third question which is: "Please give an overview of how you see Income Support one year on"? I think Jean has got some quite ...
Ms. J. Hinks:
Yes, I have just sort of précised some information from the staff. We do understand it is a new system and it is a work in progress and it is going to change and evolve but we have identified some gaps. I think it has under-estimated the amount of work the parish system used to do. I think that is one of the things it has flagged up: a great deal of work was done by the parish system and I do not think that that necessarily is easily transferred over to the new Income Support system. The main areas that clients report problems include the application form is lengthy, confusing and takes a great deal of time to complete. Many people need help completing the form and that often falls on Family Nursing & Home Care staff, particularly the social care assessment team. That is a group of nurses who are non- uniformed, do not provide a task-based, the specialist nursing system, but they work within the social care field.
Deputy G.P. Southern :
Sorry, I am disturbing you again.
Ms. J. Hinks: It is okay.
Have you noticed that particular admin load has --
Ms. J. Hinks:
Yes, we have. In fact, the increased workload is something that the staff have identified. I was reflecting on the way here about whether we could provide you with any evidence of that and we probably could maybe choose 2 members of staff and ask them to do a diary analysis for last year. We might be able to provide some evidence, if you thought that that was appropriate.
Deputy G.P. Southern :
It is enough that you have flagged it up. You are aware there has been an extra admin load, you have been assisting in filling in that 26-pager which even I would baulk at, and I am quite used to helping people with application forms.
Mr. E. Le Quesne (Adviser):
Is it ongoing if their circumstances change? Is there a new form or is it very easy to just update?
Ms. J. Hinks:
It is very difficult to get hold of the forms because in fact the forms are kept behind at Income Support. So you cannot sort of practise either and get used to the forms because they are individualised, they are personalised, and there is a date stamp put on them. In fact, I am not sure if the system is still the same but you used to only have a 2-week window to get that form, all the supporting evidence and everything back to the department. If you did not succeed you got another form with another date stamp and your payment was backdated to the latter stamp, not the first stamp. For a lot of elderly people it is just not possible to complete something in a 2-week turnaround time.
Ms. P. Massey:
It takes us 2 weeks sometimes to cajole them into applying.
Deputy G.P. Southern :
Yes, these are real people, not automatons.
Ms. J. Le Ruez-Lane:
For patients who are not H.I.E. there will be 2 forms. There will be the main form, which is massive and highly intrusive, and then they will have a medical component form to fill out which is then another form on top of the --
Ms. J. Hinks:
A personal care component form. In fact a lot of people think that the first form is the whole form and the whole assessment will be made on that form but of course that is not true, and then they have other forms to complete as well. The other thing that staff have identified though is that there was a perception, particularly from the people who did the community work with the parishes, that there would be some home visiting and people would be supported at home and that has not happened. So that is another burden on the staff. We have had it reported that the pack is so overwhelming that people will just not fill it out at all. They will not go down the road at all because the pack is too much for them, they cannot face it. They particularly find the letters that change the payments to them very confusing, so they will not understand the language that is written in there, particularly about the H.M.A. system, and they just cannot understand that. They are fearful about revealing personal information. They find that very intrusive and find the questions about personal assets the most difficult to answer. They find it difficult sometimes to provide the supporting evidence, as Pam previously mentioned. People who have quite chaotic lifestyles or may be in the early start of memory loss leading to some form of dementia find it very difficult to get their supporting evidence together and they need a
lot of extra help. At the moment it appears that the minimum time to access payments is 11 weeks, so people are finding that gap difficult, thinking about pain levels and things.
Deputy G.P. Southern :
I have got to pick my jaw off the ground. Eleven weeks?
Mr. E. Le Quesne:
Eleven weeks from putting the form in to getting the payments?
Ms. J. Hinks: Yes.
Deputy G.P. Southern :
That is horrific. That is almost a quarter of a year. We are talking 2 months plus.
Ms. J. Hinks:
Do not forget these are just perceptions from the staff though that the clients are reporting to them. The accuracy, we have got no way of knowing that.
Mr. A. Cook:
I will pick up a little bit on that further in just a moment.
Ms. J. Hinks:
There is a perception that the claims will only be successful if the need for care is to exceed 6 months. But in fact a lot of people would need shorter periods of help but they would need it quickly. So, for example, a simple fracture, if somebody falls, has a fractured wrist, they will need a short amount of care from either the private agencies or Family Nursing, but they would need it quickly and it would not be going long term. There is a perception that in fact that you have got to be ill or needing care for longer than 6 months. It is reported, and I do not want this to be criticism of the staff, that Social Security staff give conflicting advice and this can result in numerous visits to the department and the clients will feel quite distressed and upset about the fact that they have to go back and get conflicting advice and then go back again. There is an expectation that as health professionals, particularly of the social care team, that the staff will have a working knowledge of the system and that they will influence the decisions that are made. I think that comes from the parish system because, of course, we could give a lot of evidence to the parish system about individual people but that system does not apply any more. I would suggest we do not have the greatest working knowledge of the system anyway but we certainly do not have any influence on the decision making which previously I think we might have had with the old parish system.
Deputy D.J De Sousa:
So they never approach you for supporting information?
Ms. J. Hinks:
We do give the supporting information for the form, but we would have direct face-to-face contact often in the old parish system.
Ms. J. Le Ruez-Lane:
We used to meet at home often with them as well. With the doctors that came out to do the assessments we used to meet with them and we had the notes, we could go through things, because clients underestimate the care. They deliberately minimise what is wrong with them, especially the elderly. They do not want to say that --
Ms. P. Massey:
They are fearful they are going to be taken out of their own home so they are motivated by lots of different things.
Deputy G.P. Southern :
Exactly, and with reason. Just a natural human thing, when people ask you how you are you say "Fine". You might be awful but you say "Fine". Again, when you are doing an assessment you tend not to play it up, you tend to cover up. It is intrinsic, especially if there is the danger you might be thinking about being taken to hospital or taken out of your home.
The Connétable of St. Martin :
Mr. Chairman, could we pursue this massive delay?
Deputy G.P. Southern :
I think we will come back to it. It is already flagged up, do not worry.
Ms. J. Hinks:
I have got a little bit on question 4 about the impact the system has had on supporting individuals in the community. That was the 4th question that we were given and we have outlined a lot of the problems already. There is that general impression from the staff that the clients feel worse off under the new system. We do have another little case study where a daughter was caring for her elderly father. She is the sole carer and under the old system she had been able to purchase in some private support to help her manage the 24-hour care but in fact she had then to turn to Family Nursing to get subsidised care, because the care that we deliver is subsidised by the charity, because she could not afford the private care any more. So that is just one little vignette really about how that has been happening. We do have evidence that clients have declined the service. They have gone through the assessment with our social care nurse, they have been allocated a care assistant to care for them, but then they have been refused the support, the Income Support payment, so they have declined the service and that puts us in quite a difficult position when we have assessed that care is necessary.
Deputy G.P. Southern :
So that is an identified need which in the new system is hitting the button and the computer says no.
Ms. J. Hinks:
Yes. Now, we have, of course, no evidence. That person who has declined care may be a wealthy person, because we do not do the means testing, but they have made the decision to decline the service because the support has been refused.
Mr. A. Cook:
Sorry, for the sake of clarity, just so we are all clear: Family Nursing has charges, makes charges for some items of care and not for others. So district nursing is not charged, home care is, the supply of goods is. Having said that, just so we are also clear, a typical rate of home care charge is under £2 an hour, so it is not huge numbers but if you were a heavy user it is actually surprising how large some of these accounts can be. So that is why you know in advance you are going to get a bill.
Ms. J. Hinks:
The final comments on question 4 that I have is that it has increased the workload for the social care assessment team at Family Nursing & Home Care. We have increased the amount of referrals we make to Social Services and although the Social Services adult team have tried to support us, in fact they say it is not strictly within their remit to be helping people make application for Income Support. But they have taken cases from us and we have increased the referrals that we have made to the adult team.
Ms. P. Massey:
I do know that the pressure is on adult social work team and I think part of their increasing workload is due to the Income Support system.
Deputy G.P. Southern :
Certainly. I have anecdotal evidence from them that, "Yes, those bloody forms. Take them away from us, please." You were going to elucidate a little on the 11 weeks and the timescale.
Mr. A. Cook:
Indeed. It just helped to keep those questions running in order. You will find it is the next one up.
Deputy G.P. Southern :
In that case, anything more you want to add on those areas we were talking about in 4 and 3?
Ms. P. Massey:
I think Family Nursing & Home Care are still supporting financially the total cost of safety equipment, which is we have a charity that supports fire guards, safety equipment, those sorts of things. I think previously the parish did help out with those sorts of things. At this moment in time we have got child accident prevention set-up within our system and it is supported by other charities as well. It is a sort of a third split and we are supporting those sorts of things that do not fall into the remit of the Income Support system at all. So these are families that are in hardship that cannot really afford the safety equipment to keep their children safe.
Deputy G.P. Southern :
In the past there had been a special payment from Welfare, from the parish.
Ms. P. Massey:
Yes, you would apply to the parish.
Deputy G.P. Southern :
You would just go along and knock on the door and say: "This is the amount of gear. Are you going to fund it?" It used to happen. It is not happening now?
Ms. P. Massey:
It does not happen now so, as I say, the organisation has joined together with other charities to try and block that gap really.
Deputy G.P. Southern :
Again, it is has put a greater load on the charitable arm.
Ms. P. Massey:
Yes. All the assessments come through the health visitors so they will know the families and know those families that are in difficulty and they will come through with me again to be able to apply for those sorts of equipment pieces.
Ms. J. Hinks:
I think the staff are making applications from our charity to other charities to try and find payment for special items.
Deputy G.P. Southern :
Which means a different scramble around whereas there used to be a mechanism.
Mr. A. Cook:
And time, because the sort of thing that might get involved, it is amazing how much time you do sort of think might be better utilised in the community doing the job we are very good at rather than chasing ... and it is now, even over the months I have been there I am seeing an increase in talking about: "Can we get this from someone else? Can we get this from that someone else?"
Deputy D.J De Sousa:
Surely that is an added cost to you as well, trying to sort this out?
Mr. A. Cook:
It is a consumption of time and ultimately, no matter how many hours you have in the pot, you can only get so much out of it and that is putting pressure on at time where we are also having to be extremely firm with our own management of resources. This pot has got very tight and therefore time, we want to put that into our clients, the people in the community.
Ms. P. Massey:
These are not high cost items. These are £5, £10, £15, £20 but clearly if you have got a family that is struggling ... again, with car seats that is going to be something else, particularly if we start looking at car seats, those are the things that make a big difference to families that are really just struggling and right on the breadline. So they are not high cost things but they are small items that make a big difference and keep people safe.
Deputy G.P. Southern :
It was part of your task, it used to work a lot smoother than it does now, and the demand, the need, is still there
Ms. P. Massey: Yes, it is still there.
Deputy G.P. Southern :
Again, this comes back down -- you mentioned I think in your opening, inflexibility, flexibility of the old system.
Ms. P. Massey:
I think it is and it is these small cost things really that can make big differences to people. I think the other thing that we wanted just to flag up was elderly people living in families. The whole system is worked out on a family income so that the families are assessed but the actual individual ... it is a whole package really and that does influence the care giver. They do not seem to get supported, the care giver that is looking after their elderly relative or not, because the whole income is taken into account that is living in the house.
Deputy G.P. Southern :
My understanding of what constitutes an Income Support unit, for want of a better word (it is their word), is that that individuality can be maintained and that you can do that. Certainly that is what I have heard from the ex-Minister.
Ms. J. Hinks:
Our perception is that if you are within the family home then it is a household assessment, so the income of the whole household. You are not seen as a person making the claim; it is the household. That is our perception of it.
Ms. P. Massey:
That is our perception.
Deputy G.P. Southern :
Then you are into a balance between income and medical or caring need and where does that boundary stop and start.
Deputy D.J De Sousa:
It is putting added pressure on the family unit because if their income and expenditure is going to be taken into account when they are looking after an elderly relative then they are less likely to invite that elderly relative to come into the household.
Ms. J. Le Ruez-Lane:
That is certainly what the form implies that if they are actually living in your home then you and your family have to declare what assets you have.
Ms. P. Massey:
Very often the family members will be working but they will be working and incorporating that caring and enabling that person to live with them. It just feels so unfair that they feel as if financially they are at a disadvantage because of that.
Deputy D.J De Sousa:
They are actually helping the State because they are saving money by having them there.
Ms. P. Massey:
I think those were the key areas.
Mr. A. Cook:
On the finance side, there are a number of finance questions there, I think I have to say the fundamental change was that in the past Family Nursing & Home Care dealt directly with the parish and we dealt with the parish on behalf of the client. Under the new system, not getting into the rights or wrongs or anything, the client deals with Social Security or Income Support and some of the changes that we have just mentioned here. There are things that we do not know anything about. You have heard it on the clinical side what they do and do not know. This is because now the onus is on the client rather than Family Nursing. Now, that may be very good for lots of different reasons but what it does mean is we have no idea whether they are getting Income Support or not getting Income Support, whether they are quite confused about what they have asked for and we would understand it better. Certainly as I understand it with the parish system it was all about relationships, everybody, the parishes knew Family Nursing, Family Nursing knew the parishes, it worked and when they spoke about a certain thing they could communicate that well. That element, that fundamental change, I believe impacts both on clinical and certainly on the finance side. However, to start with good news, there is a question here which asks us whether the billing issues of client membership and medical supplies have now been resolved and that implies obviously former problems. I have not been around since the beginning but from my point of view now I would say that those initial problems in transferring H.I.E. clients in to the Income Support system are now mostly resolved. Key to this has been stopping and creating relationships. So my finance guys now, we have just stopped and said: "Right, who are we talking to at Income Support? We need a name, we need to keep going back to the same people." That building of relationships has started slowly but we are getting there, the development of relationships where the person on the other end of the phone has some idea of what we are talking about and we have started to have some idea of what they are talking about. That was the good bit; the rest of it moves on. However, other issues have arisen and this is in respect of your 11 weeks. In particular there were different time periods to settling home care accounts to medical supply accounts. So they are clearly processed differently. We raise those invoices separately because the mechanisms for recording them are different. So we raise an invoice for supplies and an invoice for home care. Home care accounts are settled 2 to 3 weeks after being sent out and this is exactly what we would wish for, for it means that if there are any queries they are current and easier to sort out. Medical supply accounts may take up to 4 months to settle, at which point the queries that we are trying to resolve are months and months old and simply become much more difficult to resolve. At the current date we are still waiting ... the last settlement of ... I will explain a bit more about the settlement but Family Nursing, the number of accounts we deal direct with there, for Family Nursing the last settlement was November 2008. We are just about in March 2009. The prior one to that was a full 4 months. We got settled 4 months of accounts in one go and that is because I allowed the Chairman to intervene.
The Connétable of St. Martin :
Just for clarification, the lady with problems who lives alone and has daily visits from you or maybe 3 times a week from you and needs special bandages and care which might be costing something of the order of ... I am just trying to remember from memory, £50 a week, you are supplying those bandages and stuff but you are waiting a long time for the money?
Mr. A. Cook: Yes.
The Connétable of St. Martin :
What I am trying to say is that you are not withholding the care and the supplies? You are building a debt up because there is a 4-month delay.
Mr. A. Cook:
We are. Let me just remind everyone that on the transfer from the parishes to Income Support there was effectively an agreement made that those clients that were receiving H.I.E. support at that moment in time, it would continue that we would bill Income Support directly. Then you have anyone who was not receiving it at that moment in time, they now will go through Income Support themselves personally, if you like. Let us just assume it is agreed, Income Support say: "Yes, they need our support" now we bill those individuals directly. Those individuals take their bill to Income Support, Income Support give them the money and they pay us. The mechanisms of which, in all honesty I can see it is 6 of one and half a dozen of the other, but we currently have a situation where we ourselves, if you like, are a client of a large number of patients or clients and therefore, because those accounts are settled direct to us, it would be reasonable to assume that we are receiving the same processing time because they are all done individually and then ultimately they do get sorted, so those accounts are getting processed, no different whether we happen to be representing those clients. We believe it is exactly the same as if Joe Bloggs' individual client foots the bill. We send them an invoice and they pass it on to Income Support. There is some fundamental difference in Income Support between their processing of healthcare invoices and medical supplies invoices and I am ...
Deputy G.P. Southern :
You have no reason to think that the accounts are any different for you than they are to any other individual?
Mr. A. Cook:
No, and we know our timescales, and I can put a specific date on them and we have anecdotal evidence
to suggest that that is in line with individuals.
Deputy G.P. Southern :
You may be able to live with that, just, as it were. You may not like it but on an individual basis it may be a very different issue.
Mr. A. Cook:
Indeed. I mean just for the sake of clarity we internally ... I have now been able to ... about 6 months and we internally have simply had meetings and said that from a finance point of view I think they are not that bad a debtor, I am hoping that the States of Jersey will not go bust, and therefore we can live with that. It is not clever, you would not think it would be the norm, but what we have not done at all ever, and I do not think is conceptually possible for us, is to say no in terms of supplying either services or products. We fundamentally could not. We do have one or 2 cases where we start off by knowing we are going to absorb the cost.
The Connétable of St. Martin :
Again, because I am a bit shocked that you have this delay in reimbursement for your supplies and I know one particular client that lives in my parish who I think was having to look at the cost of ... I think it is probably £30 or £50 a week which seemed quite excessive but on the Isle of Wight scale can you give us some indication of the cost of medical supplies that really are on a 4-month delay of payment rather than they should be on a 30-day payment?
Mr. A. Cook:
Yes. These figures are not accurate however I would say that they are broadly correct. We supply approximately £35,000 worth of clinical supplies per month. The Income Support debtor for us, i.e. which I can tell you at the current date consists of 351 clients, costs about, give or take a yard, £10,000 per month. So Income Support that we are dealing with, i.e. those ones that were on the H.I.E. when they transferred. If you have come off that and then come back on it you would now come back in.
The Connétable of St. Martin :
So ultimately they would all come through directly.
Mr. A. Cook:
But of clients that are receiving Income Support my estimate or guesstimate would be that many do pay it themselves prior to receiving funds on that particular issue. The reason why I make that guesstimate is that our debtors are not growing proportionally with the Social Security side of it, therefore some must ... one way or another, whether a friend pays it for them, we do see all these things, or it is picked up through charities, from my point of view that cold bit of the number cruncher, it is clearing off my book. But obviously that is not the overall case. I mean, one comment we have here, there is a question here on debtors, and do we notice this lengthening of debtors and all the rest of it. You will find that in a few minutes we will be making a number of confessions as well today, but also Family Nursing & Home Care went through a phenomenal change in its finance department and finance systems and, from moving to a very simplistic, almost home accounting approach, we are now on the beloved J.D. Edwards, which is the States accounting system, but what it does do is it is a harsh little system that lets you not get away with anything, so you have to record everything. So I think straight comparisons from our books of today and yesterday are unreasonable. There are changes, our debtors have grown, but I could not tell you that it is specifically to do with this.
The Connétable of St. Martin : You know who they are now.
Mr. A. Cook:
Yes. With dates and all the rest of it, it was a rolling type debtor, it was not so hot.
Ms. P. Massey:
We have to say and you have had some evidence, Andy, have you not, that there have been clients that have received their Income Support individually and have spent it and have not paid their bill.
Deputy G.P. Southern :
That will happen more and more as the client base becomes individual rather than your collective responsibility; there is a risk of that happening.
Ms. P. Massey:
It is about setting systems, about trying to enable people to pay, but I suppose for them there has been a big cultural shift in that they have got their own money and they have to manage it.
Deputy G.P. Southern :
Again there will be a difference between you dealing on their behalf with more of their issues, more and more of the total package of issues which they have to deal with by themselves because you will not be the interface even on that area, as you are not now on other areas.
Mr. A. Cook:
The questions, running through them here, we have a more specific question how are the clients coping with invoices and such like. Of the receiving of their bills, receiving bills we are not seeing that as a particularly big issue. The reason why I say that, basically we do not know which clients receive bills relative to Income Support. We cannot track them, but what we can say is that our finance department has not noticed any undue rise in the number of queries about the invoices. So simply receiving the invoice, which was the question, does not appear ... they do not like our invoices and we do not like our invoices because it is a J.D. Edwards thing but receiving them and that side of it has not been a big issue. How they pay for it may well be a big issue. But receiving it ... "What is our total client base and how many clients do you have that are paid for by Social Security?" We record clients under 3 principal categories: district nursing, child and family and home care. Each category is further analysed to produce a statistical report that has been made public each year. You may recall this, this is a 4 or 5 page "do you in by statistics" report that Family Nursing has always produced year-on-year: "Initial review of the processes involved in compiling these statistics at the end of 2008 revealed that there were some fundamental process errors. These errors appear to have been longstanding and are likely to have overstated the number of Family Nursing & Home Care clients, particularly in respect of Home Care. The Committee of Family Nursing has charged its finance department to review these processes and to bring forward recommendations in order to ensure the integrity of our data and its usefulness. We are required to report back to the committee by April 2009." So to convert that into plain English, we have been sending out a bunch of stats for the last decade that I would suggest are overstated. This is now clear. I have done a review of these things and I am far from happy that the way in which we did things was appropriate and we will not continue to do the same and therefore I cannot give you the answer to what is our total client base at this moment in time. However, in respect of the number of clients that are paid for by Income Support, you will appreciate that we are not aware of the total number as Income Support deals directly with the client, after which the client settles their account with us. However, what we can state is that under the H.I.E. structure we recorded circa 1,000 H.I.E. members on our membership database, i.e. the parish paid for their membership. Currently we have 301 individuals for whom Income Support make a payment directly to us for membership. It is important to recognise that we do not know the number of individuals who they themselves receive funding from Income Support
on which they then pay Family Nursing & Home Care.
Deputy G.P. Southern :
Got that, and I am aware of where the question came from.
Mr. A. Cook:
So we would not be able to say what ... to answer that question what Income Support could do is say how many people do they pay directly to Family Nursing & Home Care membership. If you add those to our number then you could see ...
Deputy G.P. Southern :
Yes, it is more the size of that issue and that presumably you are sorting out your numbers.
Mr. A. Cook:
Very much so and it is ... but I mean internally we were quite devastated with ... basically it is trying to be too clever, too much and the more simpler approach ... we lost accuracy along the way.
Deputy G.P. Southern :
But then presumably that is between you and Health and Social Services, your main funder ...
Mr. A. Cook:
The reality check is nothing has changed. It is the number that we publicly stated that we had was miscalculated but the number of clients has not changed a jot. The real legal bit has not changed; it is the numbers.
Deputy G.P. Southern :
Two things really. The questions must be more or less right because we have an awful lot of information and you are addressing them. Can we just to go back on to the issue to finish off with as to what has been delivered and what has not been delivered and where the pinch points are? We have about 6 or 7 minutes left and I do not know if you want to add some more or where you want to go?
Ms. P. Massey:
Yes, there was just one area that I had not mentioned which my colleague that works with the health visiting services, child and family services, wanted me to highlight and that was she has some mothers who are working the night shift and in fact because they are home during the day that they do not get the benefit for the child benefit system because they are there during the day even though they are working at night. That has been challenged, I think, but still there has been no outcome from that so she has asked me to raise that as an issue.
Deputy G.P. Southern :
What is not being delivered to these people?
Ms. P. Massey:
It is the childcare component. They are missing out on that.
Deputy D.J. De Sousa:
A lot of them cannot sleep because of that.
Deputy G.P. Southern :
So when do they sleep if they work at night?
Deputy D.J. De Sousa:
Exactly. They do not. I know so many of them and they do not sleep. They get maybe one or 2 hours
on the sofa and then go and do another 12-hour shift. I know an awful lot of them.
Deputy G.P. Southern :
They are not getting the childcare component? Just as vital.
Ms. P. Massey:
They are not getting the childcare component. Westmount Nursery have raised this as well, so it is just ...
Deputy D.J. De Sousa: It really is a big one, that.
Deputy G.P. Southern : Interesting.
Ms. J. Hinks:
If we are just looking at pinch points can I just mention about the appointment system, well, the lack of appointment system. People have to attend the department or they are really encouraged to attend the department but there is not an appointment system, so they end up queuing and the queuing ... staff who have accompanied clients have queued between 45 minutes and 2 hours to see one of the staff members there.
Deputy G.P. Southern : Recently or ...?
Ms. J. Hinks:
Recently, that is recently, so in fact it is really looking at is there a system that could have an appointment system and could the frail elderly person be helped to attend, because in fact we had a gentleman from Grouville who had to incur ... because the form has to be returned, it is difficult to post because it is large, so you need to attend a Post Office and get that to the department. He had a £26 taxi fare round trip and that was ... he could not claim that back. So it is just those processes about accessing the department, having an appointment system, having a named person as your member of staff who will support you through the process, you know, looking at home visiting. It is those sorts of issues.
Ms. P. Massey:
It would make a big difference.
Deputy G.P. Southern :
I can almost hear the officer saying, "Oh, and if it is really difficult we will come to them" and I am thinking of a great deal of them going out.
Mr. E. Le Quesne:
It is a private interview as well, some people have raised the issue whether they can have the interview in private rather than the other way around. The fact is Welfare had privacy issues sorted. The assumption was you will have a conversation because you are talking about a family situation in private. Only rarely would it be done publicly. That has reverted now to sitting within 3 yards of the queue exposing your entire family history.
Ms. J. Hinks:
But interesting that confidentiality the staff now have to fill out a form. If they wish to support somebody through the system they have to go and get a form, so that the person can agree for disclosure of information but then they are in that sort of situation, whereas all the nurses work to the N.F.C. (Nursing and Family Care) guidelines about confidentiality and the healthcare staff have access to as well, but with the old parish system you could support someone through the process without having to go through the ... I am not saying the bureaucracy is wrong, but there is that bureaucracy now.
Deputy G.P. Southern :
But it should be a very straightforward process. It should not be a problem. The central issue you are talking about there is not only perhaps an elderly frail person sitting there for three-quarters of an hour in a queue, which is wrong, but from time to time a professional is twiddling their thumbs doing ditto and that is not effective.
Ms. J. Hinks:
It is not effective, it is not good results management.
Ms. P. Massey:
I think the other thing is when catastrophic things happen to people it is about that immediate response, because sometimes these things happen to families and that is a big issue, is this flexibility and this immediacy really.
Deputy G.P. Southern :
So the time of response has been an issue that has been brought up by several witnesses.
Ms. J. Le Ruez-Lane:
There are just a couple of things that previous clients with H.I.E. they were entitled to a lot of benefits through the parish such as free caselon(?), free membership, free meals on wheels, there was a whole range. We have no idea now where ... if the person on Income Support is given that money. So all these things are just refused because the cost seems so horrendous to the client and they do not seem to understand or we do not understand how much is going into their account to assist them with the payment for these vital ...
Deputy G.P. Southern :
On top of which you used to have free scans, free G.P., free transport, free access to the health ...
The Connétable of St. Martin :
We are coming to the end I think of this session, but I have found this extremely illuminating and I do concur and I understand and I recognise what you have said. I just wonder whether the witnesses here could perhaps sum up. Do you have any gut feelings about an idea that would say: "This is what we should be working towards"?
Mr. A. Cook:
Chairman, could I just ask, we do have that item as item 20 and I think to leave without just very quickly making some comments there about ... it would be ...
Ms. P. Massey:
The first thing, as Jean has alluded to, is to have some sort of benefit community worker that can go out and do the home visiting. I think that was something that was promised to us when we had initial discussions that those things would be looked at. As far as I am aware and talking to the staff that has not happened, so certainly something like that, particularly when you are looking at our clientele, mainly the elderly and frail and those in crisis. The worst thing they want to do is go and queue for up to 2 hours. So that is one of the things. I think it is about the information and the forms for Income Support need to be in a language that all people understand, including myself I have to say in that. It is the
language that it needs to go through some sort of testing system where elderly people read it and see if they understand it, because the majority of information that comes to them they do not understand, and whether that be the application of the form or any changes within that form on the system.
Deputy D.J. De Sousa: That was flagged up in 2007.
Deputy G.P. Southern :
We did send them a good, plain form from the U.K. (United Kingdom).
Ms. P. Massey:
It is not just the form as well, it is those changes and the outcome of the form, when you read some of those letters you will know what we mean. I think that is one thing. In the short term it is about the turnaround, it is about having that speed of turnaround. Certainly some of our clients are very reluctant to take up the care before they know the outcome of whether they are getting Income Support or not, and so if it is that 11 weeks terrible things could happen to people in that time and we could be moving on from enabling people to picking up a crisis and that is a different form of care. I think the risk of debt needs to be addressed and I think we will be in a better place probably to assess that and it is about is there going to be some help around for those people that are failing to meet the bills even though they have perhaps had their Income Support. I know in-house we will be looking at that but ultimately it will be very hard for us to withdraw services so how do we meet that, and that will be an added pressure, not only on to us but also I am sure on to other organisations as well. The particular thing that I am concerned about is this medical account, because particularly if we are looking at trying to keep people in their own homes in a more chronic position then we have got to have access to good medical cover and not have the fight: "We can get the G.P." and to agree to have a G.P. because of that fear. So I think that is crucial. I think it is about training and education and we will hold our hands up too, we do not have the greatest knowledge in the world of the system. We need our colleagues from Social Security to come and give us some pointers around education and developing our skills around the process and I think they need to come and listen to us and learn from us the experience that the patients are experiencing in a real fashion, so it is about that shared learning approach too.
Ms. J. Hinks:
It is simple things about the department really. If there was reception staff who were able ... we have a triaging system for referrals and queries and questions that come into Family Nursing and if some kind of system like that could be there, so that the frequently asked questions, the picking up of leaflets, simple discussion about information could be done by reception staff rather than having to queue, because all you may need is one of the leaflets and a little bit of information and one of your queries or questions answered quickly. So it may be that they could look at a process where that was ... we call it triaging in healthcare, I am not sure what they would use, but it is that processing of people as they come in immediately so that quick things can be dealt with.
Ms. P. Massey:
I think we can learn from each other and it may be that is the other thing, it is about having some multi- disciplinary groups where you can learn from each other, because I think what tends to happen is obviously Social Security have gone off and developed this and it is not an easy process and it is very difficult and the principle that people should have their own money I suppose is a good system to have but it is about how we work together to enable that.
Deputy G.P. Southern :
Ultimately again it comes back to this balance between there is a need and that might be medical, it might be social, and there is a means, and we can talk about financial assessment until it comes out of
our ears but that does not take away the physical need for delivery of a service. Now, what we do not have, and it is coming increasingly into the picture, is we have an effective bureaucracy that deals with the financial aspects; it has not yet taken in the social and health need. That does not go away if you have one group or more who fall outside the realm and that issue I do not think has been properly addressed. But certainly I think we have come on in leaps and bounds and I am very impressed by your presentation today. You have obviously done a lot of thinking about it and I thank you very much.
Reverend G. Houghton (Adviser):
You have clearly been working from notes there. I take our question plan very seriously. Would you be prepared to leave us a copy of that?
Ms. P. Massey: Certainly.
Deputy G.P. Southern :
Thank you and when you have sorted out the issues around services if you could let us have them that would be great.
Ms. P. Massey:
I must admit we appreciate being listened to too, because I think we have an awful lot of information and sometimes you feel as if you are not listened to, so thank you for listening to us too.
Ms. J. Le Ruez-Lane:
I would quite like to know about where the parish fits in with all of this. We seem to have lost the parish involvement with their people and it would be nice if there could have been some ...
Deputy G.P. Southern :
Yes, we were told that there would be something to deal with this interface issue, about who is negotiating on behalf of people. I remember hearing quite the opposite, that maybe at a different time, that fell out of the system: "No, we are Social Security, we are about dealing with benefits and that is what we will do." The community service workers we are about to hear from later in the day were taken into the system, were not taken into the system to do what they were doing previously, they are all over the system now and it did not happen.
The Connétable of St. Martin :
From memory in the years coming up to the transfer of Welfare to Income Support there was quite a lot of planning that the parish back office would be linked to Social Security and we were expecting to have training on the computer systems and to be able to interact with Social Security and right at the last minute they decided that it was much too complicated and we did not receive any training. So that was basically ...
Ms. J. Hinks:
I think that is a sadness because Jersey is quite unique. I am not from Jersey but Jersey is quite unique and what you want to do is hold on to the best of the parish system and incorporate it into an efficacious service from Social Security. So you are looking to have a local solution that gives you the best of both worlds.
Deputy D.J. De Sousa:
You have really hit it on the nail there.
We must get on. Thank you very much for that, that is very interesting and slightly depressing.