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Health, Social Security and Housing Scrutiny Panel
Full Business Case - Hospital Review
FRIDAY, 11th APRIL 2014
Panel:
Deputy J.A. Hilton of St. Helier (Vice-Chairman) Senator S.C. Ferguson
Deputy J.G. Reed of St. Ouen
Witness:
Chairman of the Medical Staff Committee
[12:01]
Deputy J.A. Hilton of St. Helier (Vice-Chairman):
Welcome to the Health, Social Security and Housing Panel. We are holding a public hearing with Dr. Howard Gibson, who is Chair of the Medical Staff Committee, this morning. We will all start by introducing ourselves for the benefit of the tape. I am Deputy Jacqui Hilton, Vice-Chair of the panel.
Deputy J.A. Hilton:
Thank you for that. I would like to draw the members and public attention to the notice on the wall and on the chairs. I would like to start by offering the apologies of our Chairman, the Deputy of St. Peter , who is currently unwell. Thank you for coming this morning, Dr. Gibson, and I would like to start by asking you if you could briefly outline your involvement in the Future Hospital Programme and that of the medical staff more generally.
Chairman of the Medical Staff Committee:
So the Medical Staff Committee is a committee that meets about 6 times a year, so we spend 3 or 4 hours discussing current topics as a group, trying to come to a consensus as to the way the consultants think about particular things. The management also come down to that meeting, so it is a great opportunity to meet with everyone and talk the issues through, people air their concerns and hopefully get some answers with regard to that. With regard to the new hospital, we get a regular update on the hospital as an agenda item, so Helen O'Shea will come in and talk to us about that and also where we are up to in terms of the planning. I was also involved in the initial review of the multi-site options, so there were 30-something original sites whittled down originally to something like the 5 sites. I was involved in the discussions on that, what ins and outs might be required, so they consulted me on that.
Deputy J.A. Hilton:
Was that in your role as Chairman of the Medical Staff Committee or as a consultant?
Chairman of the Medical Staff Committee:
As Chair of the Medical Staff Committee, yes, I think so.
The Deputy of St. Ouen :
Those meetings, you said you have an agenda for each of the meetings. Is there an official record of ...
Chairman of the Medical Staff Committee:
There is an official record, yes. I think they probably are on the intranet. I suspect they are.
Deputy J.A. Hilton: Right, okay. Thank you.
The Deputy of St. Ouen :
So you say that you were involved in sort of looking at the multiple or the large number of potential sites that a hospital could be provided on, and then you were involved in part of the process of whittling down that number. More specifically, what discussions have taken place between the Medical Staff Committee and management and others around single site versus dual site?
Chairman of the Medical Staff Committee:
That obviously comes up at our meetings, so that was raised. Obviously it was presented as the options originally and the costings and what was available with the budget provided et cetera, so it was explained why a single site was significantly more expensive than a conjoined twin site, really, I suppose is how I would look at it. Obviously, I think you have to go within your budget. There was an acceptance that that was the budget, and not only presented a substantial amount of work that had been done, various groups looking at the logistics and so on.
Senator S.C. Ferguson:
So really it was a kind of an updating of the Medical Staff Committee rather than an asking for input from them?
Chairman of the Medical Staff Committee:
No, I think that has gone on consistently through the process, so I think - well, I hope so - that obviously I will comment on a variety of issues that we would like reassurance on, whatever, then it is taken back to the decision-making body which then takes that into account when they are making a decision, so I think that has been throughout the process, so it has not just sort of appeared at the end as a decision but as a consistent process over more than a year.
The Deputy of St. Ouen :
How does that work link with the development of the White Paper initiatives?
Chairman of the Medical Staff Committee:
I think they are integrally linked, are they not? I do not think the new hospital system is a standalone project. I think it is part of the White Paper project, so I think they go together, so there is an update on the White Paper as an agenda as well, so we are kept informed as to where we are with that and so on at least.
The Deputy of St. Ouen :
So has the Medical Staff Committee been more involved with the developments of the improved community services that were identified within the White Paper?
Chairman of the Medical Staff Committee:
Yes, because we had meetings according to our specialties, so I think there are certain areas which tie in very, very strongly to particular areas within the White Paper, so I met with Richard I think to discuss neurological services and chronic neurological conditions particularly and how he would look to develop that, push that forward with closer integration with primary care, for instance, and how to manage people with these kind of conditions without them needing to come into a hospital. We have run that system in neuroscience for quite a long time, I think, the sort of Neurocare Project, which is a multi-disciplinary system for people with chronic neurological conditions. So I think from my point of view, in that sense the White Paper has not radically altered the way I do things perhaps, certainly for those kind of conditions, but I think it brings an opportunity to do things slightly better or change things a little bit or formalise the arrangement.
The Deputy of St. Ouen :
Sorry, I just want to ask the question, what is your view with regards to the impact or not, as the case may be, about the development of the improved community services and the requirements placed on the hospital?
Chairman of the Medical Staff Committee:
I think one of the issues there has been has been the relatively lesser-developed community services, which have put extra work into the hospital, I think, and not particularly for anybody's benefit. I think that people do not particularly want to be in the hospital with it and it does use up resources in the hospital that would be used for people who have to be there, so I think there is a quality issue with regard to it, so if you improve community services, it is a much better quality for the people who have the conditions and then there is a resource usage thing, because those resources are no longer being consumed by people who really ought to be in the community, where they want to be.
The Deputy of St. Ouen :
So is it your belief that there will be a positive benefit on the resources required within the hospital because of the ...
Chairman of the Medical Staff Committee:
Yes. I think with well-developed community services, you will need a smaller hospital, because I think really what has come out of this project is that the hospital you finish up with will be smaller than if you did not do the White Paper, and therefore cheaper.
Senator S.C. Ferguson:
You talked about reviewing the way you do work. Have you been doing much in the way under the Lean Project?
Chairman of the Medical Staff Committee: Not personally.
Senator S.C. Ferguson: Why not?
Chairman of the Medical Staff Committee:
I suppose the way we look at it is I would review my project, my work, continuously as part of audit, so from that point of view, my clinical practice is constantly reviewed.
Senator S.C. Ferguson:
Yes, but I thought the essential part of Lean was for everybody, from the sort of manager/consultants at the top down to the frontline staff, who get together and assess what is being done and how it is being done.
Chairman of the Medical Staff Committee:
Right. What I am saying is that we do that with anything as part of standard clinical practice, so that we would review our clinical practice as part of audit, find out whether there any issues regards clinical practice, both in terms of patient safety, treatment options, cost, throughput, mechanisms of care, audit it, see if there are any gaps or places that do not work well and change the practice and then re-audit, so that is standard medical practice.
The Deputy of St. Ouen :
So currently there has been no specific emphasis placed on reviewing practice within a defined area and more generally across the ...
Chairman of the Medical Staff Committee:
There have been specific things with regard to the new hospital project, so obviously we are now looking at that and drawing up things as to how it may be different under the new hospital, so that is a different thing altogether.
The Deputy of St. Ouen : Right, okay.
Deputy J.A. Hilton:
Can I just take you back a little bit, because I just wanted to ask you a question? In an earlier question, you told us that the Medical Staff Committee met 6 times a year, and the hospital and the White Paper is an agenda item each time you meet, so you have not met on a more frequent basis to discuss the new plans for the hospital?
Chairman of the Medical Staff Committee:
Within the hospital they have had workshops with regard to the White Paper, so they run separately from the Medical Staff Committee, because they are then open to all members of the hospital, rather than just the consultants and the senior medical staff.
Deputy J.A. Hilton:
Can you just tell me who sits on the Medical Staff Committee?
Chairman of the Medical Staff Committee: All the consultants.
Deputy J.A. Hilton:
All the consultants, so it is just the consultants and not anybody else, so it is all the consultants?
Chairman of the Medical Staff Committee:
But the senior management team come to the Medical Staff Committee, but they are not really technically part of it.
Deputy J.A. Hilton:
Okay. But they come to each of your meetings ...
Chairman of the Medical Staff Committee: Every meeting.
Deputy J.A. Hilton:
... so is that the Hospital Director at each meeting or the Chief Executive Officer?
Chairman of the Medical Staff Committee:
They both have a slot and obviously Julie is not able to attend all of the time, partly because I think we have had meetings that have clashed with meetings here, but she comes otherwise and does a report, so we have a Chief Executive's meeting and a Hospital Manager's meeting and the Finance Officer and Rachel comes to talk about the White Paper developments.
Deputy J.A. Hilton:
I think you mentioned also earlier on in answer to a question about the decision to switch to the 2- site option. Can you recall when the Medical Staff Committee was told that that was going to happen and were you part of that decision?
Chairman of the Medical Staff Committee:
Not directly in terms of the decision with regard to the 2 sites, so I suppose that began to come up sometime last summer as an option or a potential option. It was there as developing the Overdale site in conjunction with the current hospital has always been one of the options, because it came out, I think, into the sort of last 5. I think when I first got involved, they had whittled off, I do not know, 15 of them or something, it was down to about 14 or something, and then the others dropped out fairly quickly.
Deputy J.A. Hilton:
How was that decision presented to the Medical Staff Committee, because a lot of work had been done around all the sites and whittling it down to 3 and I am just interested to know how it was given to you.
Chairman of the Medical Staff Committee:
I think they went: "These are the constraints in terms of the financial constraints, these are the options. In the budget, this is what can be achieved" so they presented the different options and can explain why they had come to this conclusion.
Deputy J.A. Hilton:
Right, okay. What was the initial response of the Medical Staff Committee to that decision?
Chairman of the Medical Staff Committee:
I do not think people were particularly surprised because I think we have increasingly used the Overdale site. I mean, I have always used the Overdale site, so I have always worked on a 2 site, because my original neurological clinics were at Overdale, but I also had clinics at the General Hospital, my rehabilitation beds were at Overdale, my acute beds were at the General Hospital, so I have always done it that way. About 10 years ago I moved all my clinics up to the Overdale site, because as a place to do outpatient work, it is much nicer. The access, I think, for people to go there is much nicer. It does not quite so hospital-like. The access for any kind of disabled person is massively better, so I have a fair number of patients with a disability, it was much easier to move them there.
[12:15]
So I was a kind of convert to that, so I have no real problem, but I think it was quite a nicely well- kept secret for a while, but more and more people have gradually moved up there. Pain moved, I think, first, then Urology moved, Diabetes moved, so it is ever-increasingly, so people are not really surprised by it and they are not surprised now, because they know a lot of people who do it that way, who do their clinics up there and enjoy doing it, and I think they get very nice comments from people coming up to the clinics as well, so I think that the feedback is generally that it is a good place to do clinics, so there was no sort of: "Oh, crikey, that is terrible, I cannot do that."
Deputy J.A. Hilton:
Yes, so I think it would be fair to say from what you have just said that you are confident, you are happy with that decision because that is how you have operated yourself for the last 10 years.
Chairman of the Medical Staff Committee:
I am very happy with the decision. I think there is also some advantages in moving more services up there, you get a sort of more critical mass of people in one area, so I think instead of being a large hospital with a side on, you then get something, as I say, sort of more sort of conjoined, a pair of complementary hospitals.
Deputy J.A. Hilton:
Okay. When you were given the decision, was the opinion of your fellow consultants the same as yours or what was the reaction generally?
Chairman of the Medical Staff Committee:
Yes, I think generally positive. I think there are always people who will have a concern about: "Do we need 2 things or should my department be in this place or that place?" and I think there is work to be done to look at exactly what should go where and in conjunction with the clinicians, I think.
Deputy J.A. Hilton:
Was there anybody who was ...
Chairman of the Medical Staff Committee:
We have had nobody who has just gone: "I am not doing that."
Senator S.C. Ferguson:
But presumably there are departments which will have to be in both places, like pharmacy, cath lab and those sort of things, so that there will have to be a bit more thinking about those, presumably.
Chairman of the Medical Staff Committee:
Yes, I think there will have to be a sort of central area and I think there will have to be then a ... I mean, one of our problems I suppose when we do clinics at Overdale is the lack of any kind of pharmacy, so of course I write a prescription for somebody who is 85 or whatever and then tell them they have to go down to the General Hospital to get it. It is not great. That is one of those advantages of having that kind of critical mass, you have those things, the sort of basics in both places so people will not be yo-yoing backwards and forwards.
The Deputy of St. Ouen :
In your view, what do you think are the most significant challenges in what I call the overall redesign of Health and Social Services, taking into account the development of the community services alongside the ...
Chairman of the Medical Staff Committee:
Yes. I think demand will be the primary challenge, so I think you are going to have an older population which needs more services, will have more things wrong with them, but who now know that they really ought to be in their homes, being looked after. They do not want to be in an institution particularly, they want to be at home. They are aware that that is an option for them and I think there is that sort of public awareness now. It is something that will drive the need for services, and I think it is essential that those services are out in the community, otherwise people will be drawn in, because the quality of medical care and so on should be out there for all of those people.
The Deputy of St. Ouen :
So you say that the challenge will be to make sure that those improved community services are delivered; is that what you are saying?
Chairman of the Medical Staff Committee: They need to be delivered, yes.
Deputy J.A. Hilton:
With regard to the Health White Paper, I am not sure that your speciality has been particularly targeted in the first 3 years.
Chairman of the Medical Staff Committee: No, I think we are the second wave of that.
Deputy J.A. Hilton:
The second tranche, 2016 to 2019.
Chairman of the Medical Staff Committee:
Yes. We looked a little bit in terms of acute stroke care, because it was very similar to that related to cardiovascular, in the sense that the risk factors or the health message really in terms of smoking cessation and diet et cetera and blood pressure control are all exactly the same, so we share common risks, so what the cardiology team and so on put in place in terms of reducing the risk of heart attack will reduce the risk of stroke without needing to do anything, which is good.
Deputy J.A. Hilton: Yes.
Senator S.C. Ferguson:
Have you had a look at the work that has been done in Plymouth in approving the throughput of the stroke department?
Chairman of the Medical Staff Committee: No.
Senator S.C. Ferguson:
Oh, it is worth looking at, I think.
Deputy J.A. Hilton:
Are you confident that ... we had a public hearing this morning with the Chief Nurse and we know that there are going to be significant pressures on the hospital and the services we provide because of an ageing population and high expectations from people as well that they are going to be treated.
Chairman of the Medical Staff Committee: Absolutely.
Deputy J.A. Hilton:
Are you confident that Jersey is well-placed to provide those services that need to be provided with regard to staffing, for instance?
Chairman of the Medical Staff Committee:
Firstly, I think Jersey has an ideal opportunity because of its size to react very rapidly to changes, so I think we can adjust it reasonably quickly. This is quite an exciting project. I think it is the sort of thing that will attract people to come to Jersey I think in terms of nursing, and so I think these are quite exciting times. You know, there is clear commitment which has been made by this Island to improve its healthcare and compared to some places where things seem to be tailing off a little bit and there is not a drive forward, Jersey is not like that. We have taken it by the horns here and we are going to improve matters and I think that is quite exciting, so I think that is the sort of thing that will drive recruitment. I think people want to work in that kind of environment where they feel that they can develop their services to improve the healthcare of the Island.
Deputy J.A. Hilton:
With regard to your staff, some of whom I believe work in the community already, have they expressed an opinion about the 2-site option or the additional investment in care in the community?
Chairman of the Medical Staff Committee:
In terms of the 2-site option, my specialist nurses obviously are based largely at Overdale, but go regularly down to the General Hospital, so again, they are already on a 2-site option. Obviously the development of better community services is something they can then bring forward to the people they are looking after and improving their care, so they are quite excited by that.
Deputy J.A. Hilton: Yes, okay.
The Deputy of St. Ouen :
So generally, in your view, staff are supportive of the proposed ...
Chairman of the Medical Staff Committee: Yes, I think staff are supportive, yes.
The Deputy of St. Ouen :
Are there any greater risks to patient safety from moving towards a 2-site option rather than a single site?
Chairman of the Medical Staff Committee:
Personally, I do not think there are. I mean, I think obviously the General Hospital site will remain the acute hospital site, so that patients who are acutely ill will be taken there, as they are now, so I do not think that is radically different. I think in terms of the people in Overdale then there will be more people there providing a greater range of services than they have at the moment, so in fact, if anything, I think it might reduce the risk of something occurring unforeseen at the Overdale site, because now obviously we scoop and take them to the General Hospital and it may not be necessary to do that. We, for instance, could not do an x-ray at the Overdale site because we have no x-ray facility.
The Deputy of St. Ouen :
Are you aware of similar practising dual sites that are in operation in the U.K. (United Kingdom) or elsewhere?
Chairman of the Medical Staff Committee:
I think there have always been dual-site operations in the U.K. Many, I suppose, standard towns in certainly the north-west of England have 2 hospitals, usually traditionally a Royal Infirmary in the centre of a town and a general hospital, which is just outside, which used to be a workhouse, largely. That is how it is set up that way. Now, quite often the A. and E. (Accident and Emergency) department would be in the Royal Infirmary and some of the more long-term conditions would be in the general hospital, although what you are tending to see is that that has been shuffled around a little bit because the population no longer lives in the town, they live out of the town, so they are beginning to move those services out of the town, so it has always been done that way. There is nothing particularly radical about it, I think, so it does not bring this sort of terror, really.
The Deputy of St. Ouen :
Mention has been made of the development of an acute hospital strategy - I hope I have got the title right - or plan. Are the Medical Staff Committee involved in developing or considering that acute hospital strategy?
Chairman of the Medical Staff Committee:
Yes, because what is required for our particular specialty and our particular range of conditions and what resources may be required and so on, and then obviously there are potential staff implications in terms of making sure there are adequate numbers of doctors or nurses or specialist nurses available to manage those conditions when they come in, so that has really got to be clinically-driven.
The Deputy of St. Ouen :
What stage are you at in that plan?
Chairman of the Medical Staff Committee:
We are just at that point where we are looking at it from the point of view of what do we need at the moment, so we are filling in documents just to look at what services we think would be required in each place and so on.
The Deputy of St. Ouen :
So is it likely that running a dual-site hospital will require additional resources, manpower and general resources?
Chairman of the Medical Staff Committee:
I think if you did it entirely without the White Paper community service thing, then you would certainly need to do that. I think there may be some initial duplication while one site is being changed and the other site is not, so I think there will be a bit of that and certainly there will be a sort of bump in it, and then as the White Paper community service is developed, then you may not necessarily need to do that.
The Deputy of St. Ouen :
Do you or your committee have any concerns about sort of being able to recruit individuals, nurses, other professionals with the appropriate skills to support a dual site?
Chairman of the Medical Staff Committee:
I mean, we have had very good recruitment in the last year or so. We have recruited a fair number of young, extremely talented consultants to the hospital and to the Island who are bringing lots of new skills. Now, obviously those new skills occasionally will bring in new technology, so there is initial set-up, but I think that was worked into the business case for their arrival and their job descriptions when they came, so I think that was all worked through. But some of those, there is then some gain with regard to that, because they are bringing skills that currently or previously would necessitate a person going off the Island for that treatment, and now they are no longer needed to do that, so we are bringing those patients back into health and keeping them here, which firstly, most patients would prefer to do, and secondly, it is significantly cheaper to do that if we do it.
The Deputy of St. Ouen :
So you have no major concerns about the Island being able to recruit the appropriate staff and deliver this?
Chairman of the Medical Staff Committee:
I think what we have got to note is with this kind of development, what we can say to people is that we are committed to healthcare on this Island. We are developing this as an exciting place to come and be in health and I think that is a very attractive thing.
The Deputy of St. Ouen :
We were also told that obviously because of the acknowledgement that there is quite a big financial constraint on the overall cost of providing a new hospital that a prioritisation process has taken place around what services are going to provided and so on and so forth. Have the Medical Staff Committee been involved in that?
Chairman of the Medical Staff Committee: In terms of?
The Deputy of St. Ouen :
Discussions and that prioritisation of how a hospital can be provided within a much lower figure than what was initially identified.
Chairman of the Medical Staff Committee:
I think we have already been consulted on things that have to be provided, so there are certain things that absolutely have to be provided and I think there are things that ideally you would provide and I think in many ways that is a clinical decision. You can say: "Well, we can do this, but the numbers may be quite small and therefore you may say that is ... we could use that money better to do that" so I think there are always those. In healthcare, there is always the ability to spend limitless amounts of money and I think we could always spend the money you give us, but anyway, I think there is increasing understanding in the real world that there is not a limitless amount of money and therefore you have to look at where you get your best results and your best value for money.
Deputy J.A. Hilton:
Within your speciality, are you the only consultant?
Chairman of the Medical Staff Committee: I am.
Deputy J.A. Hilton:
Have you got a problem with your waiting list?
Chairman of the Medical Staff Committee: Have I got a problem with my waiting list?
Deputy J.A. Hilton: Yes.
Chairman of the Medical Staff Committee:
My attitude to my waiting list is it is longer than I would like, but significantly better than it was a year ago, so my waiting list is smaller than it was a year ago, significantly smaller, so we have moved that smaller. I would hope that that would come down further as these developments begin to kick in, because obviously part of my patient load, I suppose, are people with chronic neurological conditions. Now, some of those conditions, with better-developed services in the community, would not then need to maybe attend hospital quite so often. If we can remove the number of follow-up patients who come, then we can see more new patients, then the waiting time will come down, so I am hoping for positive effect on my waiting times from this whole project.
Deputy J.A. Hilton:
Can you tell us what the waiting list time is now from referral from a G.P. to yourself?
Chairman of the Medical Staff Committee:
Not absolutely accurately, in the sense that when I get a referral from a G.P. and I prioritise it to urgent, in which case they could well be seen later that week; a routine, which could be, I suppose, about 18 weeks at the moment - or probably somewhere around that figure - and then a soon, which would be sort of 6 to 8 perhaps or a bit less.
[12:30]
Deputy J.A. Hilton: 6 to?
Chairman of the Medical Staff Committee: 8 weeks.
Deputy J.A. Hilton:
Weeks, okay. So generally speaking, for just a routine appointment, about 18 weeks, and you have spoken that your waiting list is shorter than it was a year ago ...
Chairman of the Medical Staff Committee: Oh, yes.
Deputy J.A. Hilton:
... through improved working practices.
Chairman of the Medical Staff Committee:
Well, we redesigned the clinics so that they are longer and then we adjusted them slightly to reduce the impact of recurring events, sort of audit meetings or management meetings or things that tend to rotate through a month or a week, so it takes out a particular session. Some of those tended to occur on the same day, and therefore pulled out a clinic on a regular basis. We adjusted the clinics so that it will not work that way, so ...
Deputy J.A. Hilton:
The reason I asked that question is because a lot of concern has been expressed in general about waiting lists at the hospital, and with an ageing demographic, I am wondering, in the future, realistically how you would manage as a single consultant speciality.
Chairman of the Medical Staff Committee:
I think this is the reason you have to have the White Paper, so this is why you could not, I think, have business as usual, because I think eventually you would drown in the demographics, but I think you have to be able to develop your community services, the option for people to be managed in their homes, in their communities and largely overseen by primary care. They may need to touch into the specialist service periodically for a review but substantially less than they do at the moment, I think.
Deputy J.A. Hilton:
So I think from the previous answer we said that your particular service will be looked at in the Health White Paper in the 2016 to 2019 period.
Chairman of the Medical Staff Committee: Yes.
Deputy J.A. Hilton:
So that is a couple of years away yet. Are you confident that you are going to stay on top of the waiting lists in the next couple of years, which are bound to increase?
Chairman of the Medical Staff Committee:
Yes, I think waiting lists have come down, so they are not going up, they have come down, so I think we have at least moved it in the right direction and as long as we can keep ... you know, it is vigilance, really, I think on it so that it does not drift.
The Deputy of St. Ouen :
Given that the initial cost of the new hospital that was identified by a team of experienced U.K. consultants was £450 million and that subsequently a sum of £300 million has been determined to be the appropriate amount that the Island can afford, what actual impact will the reduction in that capital spend have on the Island and the hospital services we provide?
Chairman of the Medical Staff Committee:
I think the way it has worked out, because we are using the sites we already have, and that is a substantial amount of that difference, is it not, rather than a completely fresh site. It is one of the reasons. I mean, obviously we do own the 2 sites.
The Deputy of St. Ouen :
So you are saying it is basically making use of existing, albeit ageing, buildings rather than starting with a clean sheet of paper and having a complete new build?
Chairman of the Medical Staff Committee: Yes, that is one of the reasons, certainly.
The Deputy of St. Ouen :
There is no other impact apart from that?
Chairman of the Medical Staff Committee: I am not quite sure what the question is.
The Deputy of St. Ouen :
If the consultants say to provide the hospital services you require a hospital that will cost £450 million, and certainly an individual says or a group of ministers determine that the money available is only £300 million, we are just trying to understand what impact, if any, the reduction in the funds available make to the services that we actually will benefit from.
Chairman of the Medical Staff Committee:
Well, what I would hope is that it would not affect the services that we deliver, that by doing it differently in terms of the way it is built, in terms of where it is built, then the services can be provided, but the cost of putting them into a building is much cheaper.
Senator S.C. Ferguson:
Do you have any conversations with your Medical Staff Committee colleagues as to services that we do not provide in the Island that you think we could provide with advantage, or alternatively, services that we are providing that would be better provided on the mainland?
Chairman of the Medical Staff Committee:
We would not normally discuss that at the Medical Staff Committee. That would normally be raised through the clinical directors, so if we wanted to develop a service, for instance, that we do not currently have, then we would either ... we would go the Clinical Director. If there are cost implications, then we would be required to provide some kind of business plan as to how that would be funded, how it would be delivered, what is the likely number of people and what extra resources may or may not be required, and then that would go forward to a committee of clinical directors, which I am not part of, I have to say.
Senator S.C. Ferguson:
Yes. I was going to say, okay, if ...
Chairman of the Medical Staff Committee: But that is how I would do it, certainly.
Senator S.C. Ferguson:
Yes. Let me put it another way: from your sort of personal and professional point of view, are there services that we should be looking at and we do not have or ...
Chairman of the Medical Staff Committee:
I think they are looking into the feasibility of radiotherapy on Jersey, so that is, I suppose, the other service I occasionally would use which we go off the Island would be radioisotopes imaging, but with the numbers I certainly would use, I am not sure that would be justifiable to keep it here, to provide it here.
Senator S.C. Ferguson:
There is not anything you think: "Gosh, we need that desperately"?
Chairman of the Medical Staff Committee: No, I do not think there are.
The Deputy of St. Ouen :
Again, I am just trying to get my head round how we can end up with a hospital which provides all the things that we want to at two-thirds of the cost that the consultants believe it needs to be, and also whether or not any ... I mean, are we going to be experiencing more or less off-Island treatment as a result of having a lesser hospital than perhaps we otherwise would have had?
Chairman of the Medical Staff Committee:
I am not sure we will get less of a hospital. I think you get a hospital that costs less, but it is not necessarily a lesser hospital, so personally I do not think we are going to send more people off the Island. I think, if anything, we are likely to send less. That is really to do with changes in staffing and new people coming in doing different things, particularly in the surgical specialties, where new expertise comes in and brings new talent and does new things. I think some of those people are currently travelling to the U.K. for that expertise and now we have got the expertise here and they do not need to travel. I am not privy to the build costs of the hospital, so I do not know how much saving is from going from ... the sort of £450 million was the single-site option, but I think included things like buying a site, did it not, and things like that? I am not privy to that information, but I think that has a big impact on the overall cost, so I do not think the services are being cut to cut the cost. That is not my understanding. I am not expecting services to be cut, I am expecting enhanced services from the new hospital rather than reduced services.
The Deputy of St. Ouen :
Do we currently have visiting consultants who come and attend the Island on a regular basis to see patients on the Island rather than sending patients off-Island for treatment?
Chairman of the Medical Staff Committee: Yes, we do. Yes.
The Deputy of St. Ouen :
Is it planned to extend that sort of service, we have looked at introducing more off-Island specialists to come and treat or see people on-Island, rather than send a patient off-Island to them?
Chairman of the Medical Staff Committee:
I think it depends on the numbers. Generally, I do not think it is anticipated that we bring more people to the Island. Generally, the specialties in which numbers would go off are the ones where we have visiting people. I think that as you drop below a certain point, it is much better to send the person, if necessary. So I do not think we are going to see a lot more visiting. It has its complications, having visiting, not least of which are weather disruption and a variety of things like that, and supervision of those people when those people are not here, so ideally that people - from talking to people - would be prefer to be looked after on the Island by somebody who is on the Island because what they want to know is if something does not work or they get a funny reaction to something, they can ring up the secretary or whatever and then you can get hold of them or bring them up to a clinic or whatever, but if you are not coming back for 3 months, then that is a problem, I think. So there is an issue with that, and obviously for specific expertise, the numbers that we would see here would be too small to justify having a specialist in a particular area, and to keep their skills up, and some of those specialties are only provided in central hospitals in any case. So many, many hospitals, smaller hospitals in towns rather than in cities, would not have one of those either, they would send those people into a central hospital.
The Deputy of St. Ouen :
Is there much collaboration between our hospital and the one in Guernsey and the medical staff?
Chairman of the Medical Staff Committee: Absolutely not, as far as I know.
Deputy J.A. Hilton:
Are you surprised at that?
Chairman of the Medical Staff Committee: I am, yes.
Deputy J.A. Hilton: Why is that?
Chairman of the Medical Staff Committee: I do not know.
Deputy J.A. Hilton: Have you asked?
Chairman of the Medical Staff Committee:
We used to. When I first came here, which was 18 years ago, we used to go over twice or 3 times a year, or they would come over, we would come over, and just meet, and we would present some cases or interesting cases and they would do the same, but increasingly, certainly in Guernsey, they were never able to come because they do not have junior medical staff in Guernsey, so it is entirely ... so we would go over there and we would not meet anybody because they would be stuck in the A. and E. department or with a case or this or that or the other, and it just stopped. So I think it sort of fizzed out by demand. I think our islands are very close together and I think there are certain things potentially that they have that we do not and we have that they do not.
Deputy J.A. Hilton:
So do you believe there should be greater collaboration between the 2?
Chairman of the Medical Staff Committee: Potentially it could be done. I do not know whether ...
Deputy J.A. Hilton:
Is there one area you think we could do more that you would like to share with us?
Chairman of the Medical Staff Committee:
I mean, for instance, I do nerve conduction studies here. They do not have anybody who does nerve conduction studies in Guernsey, so nerve conduction studies in Guernsey go to Southampton, so potentially ... I mean, I have done nerve conductions on people from Sark and from Alderney who have to go to Guernsey and then come here as a transport hub. So there are things where potentially there is shared synergies, I suppose, between the 2 islands.
Deputy J.A. Hilton:
Whose responsibility do you think it is for that type of situation to be brought up for discussion?
Chairman of the Medical Staff Committee: I think that might be a political one.
Deputy J.A. Hilton: Okay.
The Deputy of St. Ouen :
I need to ask one question, and it is no disrespect to your colleagues, but are there a sufficient number of cases on the Island to sustain high-quality, safe treatment, whether it is not or it will be provided in the new hospital?
Chairman of the Medical Staff Committee:
Yes. I mean, it depends on the condition, obviously, so there are certain conditions which are stabilised here and then they would go off. If you say neurosurgery, for instance, we do not provide neurosurgery here, but we do see neurosurgical patients here. They come here, we stabilise them and then we transfer them, so it is important when we do not have those facilities that we have a link and a smooth link to enable those people to come through and back out again without delay.
The Deputy of St. Ouen :
Who would make that judgment? Who is responsible for making those decisions about what cases are better and less risky to be ...
Chairman of the Medical Staff Committee: That is a consultant decision.
The Deputy of St. Ouen :
It is a consultant decision? Right, okay.
Chairman of the Medical Staff Committee: Absolutely.
The Deputy of St. Ouen :
If we do not have a local consultant, then we would rely on the consultant, the visiting one, to determine that?
Chairman of the Medical Staff Committee:
Well, it would be when the person comes in with whatever they have got, there will be a local consultant who will take ownership of that person when they come in and they will be their patient until such time as that patient goes somewhere else, so everybody who comes into the hospital has a consultant.
The Deputy of St. Ouen :
Regardless of what their condition may or may not be?
Chairman of the Medical Staff Committee:
At the moment they are in the hospital there will be a consultant who is in charge of that patient, and it is up to that consultant to sort out that patient or find somebody else to sort it out if it is outside their area of expertise.
Can we move on to the issue of single beds and what consultation took place between hospital management and the Medical Staff Committee?
Chairman of the Medical Staff Committee:
Yes. When we discussed the issue of single beds and whether the new hospital would be entirely single-bedded ...
[12:45]
... I do not think there is an absolute answer to that one. I think there are big pluses with regard to single beds in terms of efficiency of usage, in terms of infection risk, in terms of the fact that many people, but not all, prefer single rooms. I think there are a proportion of people who do not want to go in single rooms, they feel uneasy in single rooms and feel a little bit cut off, and you certainly see that in patients with infections or whatever, they have to be in a single room, so some of the older people, for instance, feel more comfortable in rooms that are not single, so it is very much a personal thing. Personally, I suspect you need most of your beds to be single, in an ideal and efficient way, but probably you need a small number of high-dependency or areas where people do not necessarily have to be in a single room, perhaps because they need very close monitoring. It would give just a degree of choice.
The Deputy of St. Ouen :
What implications would having 100 per cent single-bedded rooms have on general resources?
Chairman of the Medical Staff Committee:
I think, as I say, you have to have access so that you can be seen and trade it off against their privacy. At the moment, there are advantages to single rooms in the sense that you go in to talk to a person in a single room, you can have a very detailed discussion of their personal intimate details in complete privacy. At the moment, we draw some curtains around which means people cannot see what is going on, but it does not do much for sounds, so if I want to sit down and tell somebody some pretty bad news, 3 other people in the bay are likely to be privy if we are not very careful. We try to get people out of bays in many ways; we have got some individual rooms with comfy seats where you can go through, provided people are fit enough to go into them, which is not always the case, so there is going to be people who are confined to the bed that they are in because it is not safe to move them. The single rooms are better in many ways for that kind of thing, in addition to which I think if you want to undertake procedures on a person, that is much easier in an individual room, otherwise you are tangling yourself up in the curtains and this, that and the other. So there are great advantages to it. Obviously I suspect they take up a bit more
room and things like that, so generally there are less beds in an individual ward than there are in open-bay wards.
The Deputy of St. Ouen :
You do not think it would require extra nurses and other staff to support patients in a single- bedded room?
Chairman of the Medical Staff Committee:
Personally, you have to be able to see people to make sure that they are not deteriorating, so there is importance with regard to that and that is looking at different designs of the way the rooms might be provided so that people can be seen. We do look after sick people in single rooms at the moment, so we do it. One problem at the moment we have, obviously because of the limited numbers, we tend to have to move people around, so if somebody develops an infection then suddenly they will be in this bed and then they will be moved here and there, then they will stop having an infection, but somebody will, and they are moved again, which of course is what people absolutely hate in a hospital, is being moved from one place to another. It brings with it risk, clinical risk and infection risk, by moving people around, which you avoid completely with single rooms, I think.
Deputy J.A. Hilton:
Are you aware of the views of your colleagues on the Medical Staff Committee?
Chairman of the Medical Staff Committee:
Yes. I do not think anybody would object to single rooms. I think that there will be those people who think they would probably like a small area where they would have 3 or 4 people who they really ought to keep a very close eye on, and that would be directly opposite where the nurses sit, ideally, which is what you tend to do at the moment with single rooms, obviously where the nurse station is, you put them in the rooms that directly face so you have some idea of what is going on, but it is likely to be that kind of thing, but you can open that up a little bit, so you see people a bit more accurately.
The Deputy of St. Ouen :
You have spoken about sort of ageing demographics and so and so forth. We are also well aware that there is quite a significant percentage of our population that currently has private health insurance. Has any consideration been given to how that group of people will influence or take advantage or utilise hospital services here, when in some cases people tend to go off-Island to receive specialist care?
Chairman of the Medical Staff Committee:
I think in terms of the new hospital, there appears to be the consideration of developing a private facility within that area, both for consultation and for treatment, the idea being, I think, to negate the need for people to go off the Island. Some people go off-Island because they think they should and they can, but other people would not necessarily want to go off the Island for a particular treatment, I do not think, if it was available.
The Deputy of St. Ouen :
Is it no longer the case that insurance companies encourage their clients to identify a particular hospital for treatment?
Chairman of the Medical Staff Committee:
I think certain insurers insist - or try to insist - that their clients go to one of their hospitals. Now, obviously in the case of an Island offshore, when it is pointed out usually to the insurer that that would necessitate them flying et cetera et cetera, they go: "Oh, that is fine" because they then incur the cost of the travel, so it negates any saving there might be from going to whichever hospital they would like you to go to. I think sometimes they forget or do not quite know the geography, which I think influences the decision. Usually you ring them up and go: "Do you really mean this? This would not require this to happen" then they go: "Oh, no, we did not realise that."
The Deputy of St. Ouen :
So it is your belief that currently a lot of people even that have private health insurance still look to be treated on-Island?
Chairman of the Medical Staff Committee:
Yes, I think the vast majority of people want to be treated on-Island. I think what we have is good quality healthcare here. This is where they live, this is where their families are.
The Deputy of St. Ouen :
So with an improved building/services, would you anticipate perhaps an increase in the number of people covered by private health insurance seeking to be treated or not?
Chairman of the Medical Staff Committee:
I am not sure whether it would make dramatic differences one way or the other. I think the vast majority of people who have insurance are treated here. That would be my impression. I suspect there will be a small number who feel they need to go to London or wherever for it, but I think they are in the minority and I am not sure you would necessarily change it one way or the other. I think it is a personal choice thing, which is one of the reasons they have private insurance, I suppose, that they can make the choice, and I would defend their right to do that.
The Deputy of St. Ouen :
So you do not see the private provision growing within our Island?
Chairman of the Medical Staff Committee:
I think it could be grown, I suppose. I think if you provide a facility that people really want to use, then there will be more people potentially that would use it, but I think in terms of what we are aiming for with the hospital is to give everybody a better experience really rather than a few.
The Deputy of St. Ouen :
The intention then is not then to encourage health tourism?
Chairman of the Medical Staff Committee:
No, I do not think so. I think that would not be my idea, anyway.
Senator S.C. Ferguson:
KPMG reckoned that about 60 per cent of people in the Island have private healthcare, private insurance. What is your impression of it as a sort of ...
Chairman of the Medical Staff Committee:
I think it is a bit less than that. I think they must have been talking to accountants, but I think it is less than that. There is a significant proportion, but it cannot possibly be 60 per cent, I do not think. We do have patients who will be privately insured who still elect to come to the hospital, for instance, for certain conditions.
Senator S.C. Ferguson: Well, if is acute then ...
Chairman of the Medical Staff Committee:
Yes, the acute patients do anyway, but many of the patients who ... if you have a chronic condition, your insurers cease to insure you anyway.
Senator S.C. Ferguson:
As you get older, you get chronic, yes.
You acquire more things that they will not cover you for, yes.
Deputy J.A. Hilton:
Just one last question to finish off the hearing: what evidence is available from the Intermediate Care Pilot to demonstrate that it can replace any parts of a hospital stay and by how much?
Chairman of the Medical Staff Committee:
Wow, that is a question, is it not? I mean, in terms of impact at the moment, I think the clinics team has been the thing that certainly for me has made the big difference, it has palpably changed things very quickly. We now just have that option of just going: "There is new this or that." Now, previously that would have been we will have a look at them and go: "Yes, we will keep them in hospital another week or 2 weeks or whatever, because they are not safe to go home like that." Those people are going home now. The other way, which I do not see quite so much, I think the G.P.s (general practitioners) have been much more aware of the ones where that team has gone in and stopped them coming in. I mean, I do not know who they are, really. I presume there are those people where that service is contacted, put in place and admission is avoided. But I think for the people I tend to see, they come in with an acute problem, but also have 3 or 4 disabling conditions, which when everything is perfect enables them to go home, but when any of those things ... it just destabilises them and they are just non-functional for a period of time and then it just takes that little bit, and you get them over their pneumonia or whatever else when they came in, but they are just weak or just a bit unsteady or not quite able to get to the shops or upstairs or whatever, and those people are now going home and being cared for in their home, so I think that is the thing that has made a real difference, because some of those people were in hospital for an extra 2 or 3 weeks. Some of them acquired a new infection while they are in the hospital, which is inevitable, because you are bringing sick people into the hospital all the time, and then they stayed longer, so I think that has made a demonstrable difference, so that is the big one for me.
Senator S.C. Ferguson:
Yes, because if you are not careful, they get institutionalised, do they not?
Deputy J.A. Hilton:
There is just one last question that fell out of that answer, and I was interested to know with regard to the Medical Staff Committee what contact you had with the G.P.s, if any at all, as a body, especially the hospital resource.
Chairman of the Medical Staff Committee:
There is the Jersey Medical Society, so all doctors on the Island belong to the Jersey Medical Society or certainly all the permanent doctors, so all the G.P.s, all the consultants, so we meet reasonably regularly. I present, usually some people give a talk on a particular issue and they will discuss issues, joint issues, so there has been talk, for instance, about the server project, the I.T. (information technology) and so on and how that might work better. I mean, the nice thing about Jersey really is that we know a lot of G.P.s very well. I speak to them quite a lot on the phone and sort of try and encourage people if they want to talk to me about one of their patients, they give me a quick ring, or have any concerns, and then they do not need to come. They will say: "Well, I do not think they probably need to see you in the clinic, but what shall I do with this?" and I go: "Well, you could do that" or we will give them a ring and say: "We are about to discharge this patient, but there is just this issue. Could you possibly do this next week just to make sure everything is okay?" or whatever. So I think there is already that kind of liaison. I think the White Paper brings it into a bit more of a formal setting and brings in extra resources on the outside that people can pull into it to enable it to work, so I think it is quite an exciting time, really.
The Deputy of St. Ouen :
Have you been involved in looking at how we can sort of identify the benefits and improvements, the real outcomes, if you like, that will flow from the improved community services?
Chairman of the Medical Staff Committee: I have not been directly involved in that, no.
The Deputy of St. Ouen :
Has the committee been asked to comment at all, do you know?
Chairman of the Medical Staff Committee: Not that I am aware of.
The Deputy of St. Ouen :
Would you think it would be ... I mean, is it something that the committee would like to be involved in or should be involved in?
Chairman of the Medical Staff Committee:
I think ultimately, if you are giving us lots of money, we need to be able to demonstrate that what we are doing makes a difference, so certainly in terms of clinical audit, which would be the way to do that, I think, which is a regular programme, obviously when we put in a new provision or a new
service then we would audit to see whether that makes a difference in terms of our clinical outcome in terms of quality.
The Deputy of St. Ouen :
What data do you capture, because if the community services are keeping people away from the hospital, one would hope that you would see it being reflected in ...
Chairman of the Medical Staff Committee: Reduced numbers.
The Deputy of St. Ouen : ... the numbers that ...
Chairman of the Medical Staff Committee:
Yes. So we do know the numbers that come into the hospital, for instance, we do know the numbers that we take in on a daily basis, for instance, and we certainly know the admissions certainly have risen steadily over the last 10 or 15 years, as they have everywhere else in the Western world, so that is again related to demographics.
[13:00]
I think in terms of services, we do not currently audit outpatients, outpatient work, because we have not had the infrastructure to be able to do that, so one of the advantages of the joint I.T. is that we ought to be able to firstly access what the G.P.s are seeing and they can access what we are seeing. At the moment, that requires some kind of letter to go backwards and forwards, which is a fairly clumsy and entirely related to ... they may not necessarily know exactly what you would like, and equally, you do not know exactly what they would like, so there is always a bit of filtration that goes on there, and I think that joint service thing would enable that sort of exchange of information and sort of pan-Island auditing to go on, so I think only by putting those kind of systems in would you really be able to tell what a lot of these changes would actually do. That is straight number counting. In terms of the quality of issue, that it is a slightly more difficult one to do, because that requires you to ask people about their impressions and so on, so it can be done, but it is not quite so ... you cannot just push the buttons on the computer and bring it out. It is a slightly different thing.
Deputy J.A. Hilton:
Just one final question - and it is the final one - have any of your patients expressed a view on the 2-site option?
Chairman of the Medical Staff Committee: No.
Deputy J.A. Hilton: Not a single patient?
Chairman of the Medical Staff Committee:
No, but for me, that would be quite difficult because my patients are already on a 2-site option so they would not do it. I would say that patients do say that they really like coming to clinics at the Overdale site.
Senator S.C. Ferguson: Parking is easier, for a start.
Chairman of the Medical Staff Committee:
I think it just has a ... it does not feel quite so hospital-like, you do not feel like you are about to be admitted to the hospital at any moment.
Senator S.C. Ferguson: You can escape.
Chairman of the Medical Staff Committee:
There is a sort of safe distance between you and a hospital bed and I think people just feel a bit more calm. They certainly feel more relaxed, I think.
Deputy J.A. Hilton:
Thank you very much indeed, Dr. Gibson, for coming today, it has been very interesting.
Chairman of the Medical Staff Committee: Okay, many thanks.
[13:02]