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Health, Social Security and Housing Scrutiny Panel
Full Business Cases and Hospital Review
MONDAY, 12th MAY 2014
Panel:
Deputy J.A. Hilton of St. Helier (Vice-Chairman) Deputy J.G. Reed of St. Ouen
Senator S.C. Ferguson
Witness: Chief Nurse
[10:30]
Deputy J.A. Hilton of St. Helier (Vice-Chairman): Good morning.
Chief Nurse: Hello.
Deputy J.A. Hilton:
Welcome to the Health, Social Security and Housing Scrutiny Panel. This is a review into the full business cases and the hospital review. We will start by introducing ourselves. I am Deputy Jacqui Hilton, acting chair of this panel.
Deputy J.A. Hilton:
Thank you. I would like to start by offering the apologies of the Deputy of St. Peter who is unwell at this time. I would like to draw the public's attention to the notices on the chairs, thank you. I would like to start by asking you, following the States of Jersey decision of the implementation of a Health White Paper, what challenges have you or are you facing in recruiting appropriate staff to support the hospital services and services in the community?
Chief Nurse:
There are similar challenges that have been historically noted as a matter of record, both through the media and at various other meetings I have attended in the past. We still face issues with nurses in terms of the affordability to move with Jersey in the main and it, again, relates to the cost of rental accommodation in the Island particularly. We do attract some staff who see the opportunity of exciting changes that are happening in Jersey and see that as a real positive to come here. Unfortunately, when they do their sort of pounds, shillings and pence calculations they tend to withdraw. We have had some good successes in pockets of areas of recruitment but the problems with nurse recruitment remain, as they have been for some time.
Deputy J.A. Hilton:
How many vacancies are you currently holding?
Chief Nurse:
We are not holding any. We are actively recruiting to them all. At this moment in time we are sitting at around 45 registered nurse vacancies and that will be a mixture of some new staff waiting to come into post that we have offered contracts to and some posts that are still up for advert.
Deputy J.A. Hilton:
Yes. Are some of these posts attached to the Health White Paper reforms, the additional funding to provide services in the community?
Chief Nurse:
Some of them potentially but the majority are existing posts within the hospital services and within community services as well.
Deputy J.A. Hilton:
How does that compare with a year ago, 45? My recollection is that they are possibly in the high 20s.
Chief Nurse:
Yes, it varies because since last year we have obviously gone to recruit more staff than we had, so we have been increasing the bottom line of our workforce. As we have made the changes to critical care, for example, we have invested again in some additional nursing posts, so a chunk of those posts and new posts that are coming on board as a result of that. We have had, for example, 8 critical care nurses that we have been able to recruit this year, this is additional to the posts that they have already got.
Deputy J.A. Hilton:
That is 8 additional critical care nurses.
Chief Nurse:
Additional on top of their posts.
Deputy J.A. Hilton:
What has brought those additional posts about?
Chief Nurse:
Changes that we made to critical care to modernise it within current building practices in terms of room space around beds. We did a refurbishment to the Critical Care Unit, so there were greater bed spaces, greater privacy and dignity. It was in keeping with infection control standards and we have also got a High Dependency Unit down on one of the wards as well. We have basically made the unit bigger, critical care services.
Deputy J.A. Hilton:
Okay. As a result of making the unit bigger, and is it following best practice in the U.K. (United Kingdom) that these additional posts have been created?
Chief Nurse:
Yes, we have done some work with Professor Keith Hurst from the University of Leeds who is a well-known workforce expert across the U.K. but also internationally. We did some work with him some time ago that was around looking at acuity independency as to how sick our patients were, what level of care needs that they had but also within Critical Care Units there are some standard guidelines set out for staffing levels as well in terms of nurse to patient ratios.
Deputy J.A. Hilton: Okay.
Senator S.C. Ferguson:
What is the nurse to patient ratio then on the critical care?
Chief Nurse:
We usually have one nurse per patient on critical care, it is one-to-one care.
The Deputy of St. Ouen :
Are you managing to sustain it at the moment?
Chief Nurse:
We are but we sustain it at the moment through movement of staff around the organisation on a shift-by-shift basis. What we have done with the critical care posts, as an example, is we have gone to a recruitment agency to source the nurses that we require to fill those 8 posts. We have gone through a traditional method of recruitment that has been put out to advert, invite people over, interview them and we have not been able to fill all the posts. Our next line was to go down the recruitment agency route where you pay a small fee and they will headhunt the nurses for you. This is a similar approach that I know our colleagues have taken in other Islands.
The Deputy of St. Ouen :
How many nurses are employed through the recruitment agencies currently?
Chief Nurse:
Through this particular route this is about recruiting for substantive posts, so this is not about what you would consider to be an agency nurse. This is about a substantive recruitment. This is our first attempt at using this particular approach. This will be the first 8 that we will have recruited this way.
The Deputy of St. Ouen :
Right. Are they nurses with particular skills that are harder to recruit than others?
Chief Nurse:
Yes, yes, yes, they are critical care nurses who will come with the skills of looking after somebody who is on a ventilator, for example, and who is trained in use of all the technology that you would see on a Critical Care Unit. They are difficult to recruit, full stop, critical care nurses.
Senator S.C. Ferguson:
Is that because they are older and they have been training longer and, therefore, they are older and, therefore, they have got families?
Chief Nurse:
I think definitely from our experience of recruiting nurses and the problems that we have had, definitely the age plays a factor into that because they are then looking at relocating their entire family.
Senator S.C. Ferguson:
Yes, but if you are looking for somebody who is more skilled, do you normally find that they are
Chief Nurse:
No, it is not specific to age. You could qualify as a nurse and then go into critical care nursing as the area of your specialty. It does not necessarily mean that you would only work in critical care when you reach a certain age or time in your career. You could specialise in that area fairly early on. But in the general recruitment sense we do see an effect of nurses who have families, partners who want to come to Jersey and if their partner cannot find fulfilling work it is generally a no go.
Deputy J.A. Hilton:
What steps has the hospital taken to make it more attractive for these hard-to-fill posts, to attract those staff to Jersey?
Chief Nurse:
We have made some changes to our relocation package so that previously, after we had agreed that nurses would be able to claim the same amount that civil servants could when they relocated to Jersey, which was up to £8,000, when we did some work and looked at what nurses were claiming of that relocation package it was fairly small, it was in the region of £3,000 to £4,000 for their removal costs. But we did get agreement from the States Employment Board was that we could, within that £8,000 envelope, offer nurses an additional incentive. Say, for example, if they spent £4,000 on their relocation costs we could give them a one-off payment of up to £4,000 when they came to the Island and this invariably to help nurses, particularly with deposits on rental properties. That was one of the things that we did to try and change the package for them.
Deputy J.A. Hilton:
What is the biggest barrier to getting trained nursing staff to the Island at the current time? Is it accommodation or is it because they are coming with families and there is difficulty around employment with regard to their husbands and partners?
Chief Nurse:
It is a mixture. It tends to be a mixture of things because it generally relies on the individual and their circumstances. We did see a particular problem a couple of years ago if we had nurses that we recruited who owned properties in the U.K. that they then either could not sell or they could not rent out because the market was just saturated and not moving at that time. They just could not afford to pay for a rental property in Jersey and also continue their mortgage on their property at home. We see the effect of the accommodation on all different levels. Some nurses will choose to sell up and move to Jersey lock, stock and barrel. Some will try and keep their property on in the U.K. to see how it works out and they will look to rent. We had got to a particularly good position when we had the old (j) cat scheme with regards to nurses, particularly with partners who were seeking employment. There seems to have been a bit of a change since we have gone to residential status in that some of our nurses' partners have experienced a bit more difficulty and we have shared those with the Chief Minister's Department. I do know of cases where we have had nurses get married when they have come here to make it easier for their partners to source work.
Deputy J.A. Hilton:
Generally, has the Chief Minister's Department been sympathetic to the problems that the hospitals face in the recruiting of qualified staff and the way they treat their partners?
Chief Nurse:
Yes, we made it very clear in the run up to the changes that they were making to the residential and work-permit status about the pressures that we would particularly have in recruitment. They tried to help on an individual basis but certainly at the moment it does not seem to be as easy, it just does not feel as easy as it was for our nurses previously but that is something that I know we are having ongoing conversations with the Chief Minister about that.
Deputy J.A. Hilton:
Is the Minister for Health and Social Services aware of that difficulty?
Chief Nurse: Yes, she is, yes. Deputy J.A. Hilton: She is aware.
Senator S.C. Ferguson:
Would it be helpful if, for instance, the 2 hotels that are up for sale were converted into apartments for nurses?
Chief Nurse:
I think any accommodation that is appropriate and affordable would be helpful. I would not want to pick on any in particular but, yes, I certainly think it would make a difference if we had some better affordable accommodation. As I said, when I came last time, we are still doing ongoing work with the Housing Department and the Minister for Housing.
Senator S.C. Ferguson:
Because you have got the nurses' home across the Parade, have you not?
Chief Nurse:
Yes, it is mainly medical staff that live in there, the junior doctors.
Senator S.C. Ferguson:
I thought that was meant to be for nurses.
Chief Nurse:
Yes, the one opposite the park.
Senator S.C. Ferguson: Yes.
Chief Nurse:
Yes, this tends to be the junior doctors that live in there. We have got Peter Crill House that is attached to the hospital and our temporary nurses or our agency nurses will stay in there and our locum doctors will stay in there. Then our nurses, if they choose to stay in our accommodation, will be in various properties around the Island, so they could be up at the St. Saviour site or they could be in other properties that we own.
Deputy J.A. Hilton:
How much progress have you made with the Minister for Housing? I know we have spoken about this before. Do you feel that any real progress has been made on addressing the issue?
Chief Nurse:
I think there is a will there but I think that there is the issue around there is the complexities added in around nurses' pay in terms of making sure that their pay is commensurate with the equal work pay of equal value. So that when we move into a new programme of accommodation for nurses, which would be the programme that we talked to the Minister for Housing about, that we do that at a time when the issues around the pay have been addressed. It is difficult to do one before the other.
Deputy J.A. Hilton: Yes, okay.
The Deputy of St. Ouen :
Apart from the critical care nurses are there any other particular nurses that you find difficulty in recruiting, the types of nurses?
Chief Nurse:
Some of it tends to be predictive, critical care is a well-known specialty that is hard to recruit. Neo- natal nurses are very similar. Where you have got the highly specialised roles there tends to be a demand for them everywhere, globally as well as in the U.K. Our general nurses are difficult to recruit now. There is no sort of rhyme or reason particularly, whether it is a specialist nurse or a general nurse. There tends to be pockets of problems and you will get one area will fill up their vacancies and then you will start to experience problems in another area. It does not necessarily need to be specific to a speciality. I am aware that they have announced in the U.K. that they are launching minimum staffing guidelines today, which I have not had a chance to read yet. I certainly saw in the media that they are predicting there is going to be a significant shortfall of nurses in the U.K., as hospitals start to move their nurse staffing levels up. Again, this issue around nurse recruitment is going to be a problem probably across the U.K. I would suspect, as well as here and we feel the effect of that.
Deputy J.A. Hilton:
This is fallout from the staffing at the hospital.
Chief Nurse: Yes, yes.
Deputy J.A. Hilton:
I think we heard in the media that they are talking about one nurse per 8 patients.
Chief Nurse: Yes.
Deputy J.A. Hilton:
But it is not a statutory ... it is a recommendation, is it not, it is a guidance?
Chief Nurse:
No, it is a guidance of the minimum staffing level.
Deputy J.A. Hilton:
How is that likely to affect us if we adopt the same guidance?
Chief Nurse:
Yes, we have done quite a lot of work around nurse staffing levels, particularly in the general hospital and we have made significant inroads in increasing the number of posts. I think at last count it was up to about 120 additional posts that have come in over a period of about 4 or 5 years as the demand changes across the wards. I think one of the benefits that we have is we are small and we do have a workforce that has very generic skills. They are able to move around safely on a shift-by-shift basis, whereas some of the bigger hospitals in the U.K. that are very specialised nurses, like doctors, find it difficult to move to other clinical areas to help out. I would say that during our working day, particularly because some of our wards are so small, our staffing levels will benchmark well against the standard that has come out today. I do need to read the detail of it because I will be quite interested to see what it says about night duty, for example.
Senator S.C. Ferguson: What are our ratios then?
[10:45]
Chief Nurse:
I would say on some wards on some days we would have at least one nurse to 8 patients, maybe less patients, it depends on the size of the ward. For example, Rayner Ward is a much smaller ward and so you would probably have a ratio of about one nurse to 6 patients on that ward. But, as I say, our workforce is very used to moving around, so they are looked at on a shift-by-shift basis. If there is a particular surge of demand in one ward and they are struggling they will move some nurses from a quieter ward to another ward to help out.
Deputy J.A. Hilton:
Would you say that today we are operating it not to that guideline of 8 patients to one nurse? If you take a picture of what is happening in the general hospital today, are you confident that we are or do you think there are areas where we are probably falling a little bit short?
Chief Nurse:
Without having read the guidance because I do not know how far beyond the hospital walls it goes in terms of applicability to our services, such as elderly care but I would say with regards to the general hospital we probably meet that standard during the day shift. As I say, I do not know what it says about night shifts.
Deputy J.A. Hilton:
One of the other recommendations they were talking about this weekend was to inform patients and their family what the guidelines are by posting up at the entrance to the ward what the guideline is and what staff are actually on at that particular shift. Is that something that you would consider implementing at our hospital?
Chief Nurse:
Yes, it is something that we have been talking about, myself with Helen O'Shea and some of the senior nurses in the hospital. They already do publicise activity data on the hospital wall, so as you go into wards you can see certain sort of measures up there, sort of number of complaints, patient falls, that sort of information. To put staffing levels up there is something that we are looking at. What I would say is that nurse staffing is just one measure around quality of care and nurses are part of a multi-professional team. While we may fix it in one aspect, in terms of our nurse staffing levels, there are other aspects with the wider team that contribute to that patient's outcome.
Deputy J.A. Hilton:
I think they were talking about care assistants as well.
Chief Nurse: Yes.
Deputy J.A. Hilton:
It was not just qualified nurses, it was care assistants as well because, as you have just said, care assistants are an important part of the daily running of a hospital.
Chief Nurse: Yes, yes.
Deputy J.A. Hilton:
I think it was a little bit broader than just nursing.
Chief Nurse: Yes, yes.
The Deputy of St. Ouen :
Currently, is all of that data captured by the department, hospital?
Chief Nurse:
In terms of the shift patterns and who is on duty.
The Deputy of St. Ouen :
Yes, and nursing and the ratios.
Chief Nurse:
Yes, that is all captured on the rotas. It is all monitored by the heads of nursing in those particular areas. The head of nursing for inpatients, for example, if I rang him up this morning he would tell me where the ward-staffing levels were on each of his wards and where the lists are.
Senator S.C. Ferguson:
Could he do it easily or is it all on paper?
Chief Nurse:
Some of the rotas are electronic. When you say easily he would be able to do it easily because he gets that information already but he is probably reliant on the ward sisters telling him. We have not necessarily got the I.T. (information technology) system that would automatically give us that information, that is sort of fantasy.
The Deputy of St. Ouen :
But currently, am I right in saying that none of this information is published?
Chief Nurse:
Not in the ward areas at the moment and we were waiting for the N.I.C.E.(National Institute for Health and Care Excellence) guidance to come out in terms of the staffing levels before we considered what we did.
Deputy J.A. Hilton:
Could you just tell us what difference will the changes make to the role of nursing staff in hospital and primary care, particularly in relation to the job role and also if the 2-site option is approved?
Chief Nurse:
Yes, where to begin. There are so many different levels and so many different ways of working.
Deputy J.A. Hilton:
Would you like to start by telling us what you think of the 2-site option, whether you think it is a good idea, bad idea?
Chief Nurse:
Yes. I can see from their plans in terms of their future visioning for the dual-site option that having all of our outpatients and ambulatory care services in one place is a real positive, particularly for patients because they only have to go once and the plan is that they will get all of the investigations and tests all done at that same time in that same place. From my point of view, I have worked in organisations where they have more than one site. It has not necessarily been particularly problematic, provided you have got your rota sorted, you have got your right staff in the right place and people have the appropriate access to the services that they need to support them to carry out their treatment.
Deputy J.A. Hilton:
To enable that to happen, do you think it is going to require more staff if we have got the 2-site option?
Chief Nurse:
I think, potentially, there will be some challenges with the very small specialties where perhaps you have one consultant and their very small medical team and a small team of nurses, potentially that could be a problem. But, again, it depends on how we foresee services will be delivered in the new model of care. For the larger specialties I cannot see that that is a particular problem, provided your workforce plan is appropriate.
The Deputy of St. Ouen :
What discussions have taken place around dealing with some of the issues that you have just spoken about?
Chief Nurse:
There has been quite a lot of meetings, some that I have been to, some that I have not been to. But certainly with clinicians, with nursing staff, we had one at the Town Hall , which was quite a large group and then we have had smaller meetings with clinical directors, heads of nursing, hospital management and also groups of the inpatient sisters as well and some of the nursing staff that would be directly affected.
The Deputy of St. Ouen :
Are you saying that all of the issues that you have raised have now been dealt with satisfactorily?
Chief Nurse:
I think there is ongoing discussions. I am not aware that there is a final plan of what is going where yet. I think the discussions are still being had. My understanding is that through the expert advisers they will help facilitate these discussions to bring them to some sort of conclusion in terms of what is clinically best for patients.
The Deputy of St. Ouen :
In these discussions, does it extend out into looking at community services that are planned to be delivered, regional community services?
Chief Nurse:
Yes. The discussions tend to flow from one to another, so the same people who were originally involved in some of the discussions around the White Paper and what sort of community services we were going to look to expand, it is all the same group of people. Those were the same people who then started talking about what the future hospital would look like and the connectivity between the 2. You cannot have one group talk about one and not the other because it is all interrelated.
The Deputy of St. Ouen :
Potentially, because of the improvements and the enhancement of the community services, obviously that is going to increase their demand for additional staff, nurses and the like.
Chief Nurse: Yes, yes.
The Deputy of St. Ouen :
How do see that impacting on the larger hospital on the dual site?
Chief Nurse:
In relation to what, the ability
The Deputy of St. Ouen :
Including, being able to physically have efficient people to run both of those 2 sites.
Chief Nurse:
If we cannot recruit the staff then we cannot run the services basically. I know from conversations I have had with Julie before that they are struggling at the moment to recruit to certain posts and hospice went through a similar issue last year but they have managed to pull up their way through that one. I think we are looking at different options as well for training staff locally to do some of the jobs that are required and certainly I know, potentially, it is the same staff moving through the labour market in Jersey. Nurses who had previously worked in the hospital make fantastic nurses for rapid response because they have got those acute skills but obviously they have moved from one role to another role and we need to backfill those particular posts. But the work that we are doing around home-grown nurses will help plug some of the gap.
Senator S.C. Ferguson:
Forgive me, I am probably off on a wild-goose chase here but are you telling us that the concept of the 2-centre hospital was formulated without doing any sort of assessment of the staffing requirements?
Chief Nurse: No, but I
Senator S.C. Ferguson:
The assessment of the staffing requirements is being done now, rather than before the exciting, we are going to have a 2-centre hospital.
Chief Nurse:
Yes, I think it is difficult. I think the 2 things are separate and I apologise if I have misled you there. The issues around the future hospital, it is difficult to determine the staffing requirements until you know exactly what the service is going to look like, what the wards are going to be configured like and what exactly is going to be at Overdale. Until that is clear it is difficult to build any workforce planning model around that to say whether or not we will need any more nurses particularly. In relation to the community services the workforce modelling around those services has been done. I am sorry if I have misled you on that one.
Senator S.C. Ferguson:
The concept of having single-bed rooms, is that going to increase the workload and require more staff as well?
Chief Nurse:
Until we know what the design is going to be like it is difficult to say what the workforce demands will be. It is certainly, from the literature that I have read, not clear that more single rooms mean more staff. It does not always equate to that, it depends on the design, it depends on the layout of the ward, how it is configured, how your nurses work, what sort of pathways the patients are on. It is not a case of saying that we are going to have, say, 100 per cent single rooms, therefore we need to increase our nurse staffing by 10 per cent. But we would need to have a look at that, absolutely, once we know what the model is going to look like, what the physical environment is going to look like for nurses and patients, then you can calculate your staffing around that.
The Deputy of St. Ouen :
As we have parts of the hospital that currently provides some single-bedding units, is it possible for you to provide to us, not now, the ward staffing levels with running the single-bedded wards, as against an open-ward system?
Chief Nurse:
Yes. Yes, you want the
The Deputy of St. Ouen :
We would like to draw a comparison.
Chief Nurse:
If it was 100 per cent single-bedded.
The Deputy of St. Ouen :
We have the private wing, which is all single-bedded.
Chief Nurse: Yes, yes.
The Deputy of St. Ouen :
It would be useful to know what staffing levels are currently provided in those wards against what is provided in an open ward.
Chief Nurse:
Okay. Yes, that is fine, yes, yes.
The Deputy of St. Ouen : That would be really handy.
Deputy J.A. Hilton:
We have not asked you whether you believe that all the rooms should be single en-suite rooms.
Chief Nurse:
Personally, my preference would be, and this is my own personal belief, that 100 per cent single rooms are the way forward. I just cannot imagine building a new facility with mixed bays.
Deputy J.A. Hilton:
Would you just like to explain for the record why you believe that?
Chief Nurse:
I think that 100 per cent single rooms would give us better efficiency with the use of beds. It would be better from a patient safety point of view because once you are in your room you would not need to move, so, potentially, unless your clinical condition deteriorated or, potentially, you would be in a room for the duration of your stay and that if there was an infection issue in any particular area that would be managed within the confines of the room, you would not need to close beds down. You would not, potentially, have people walking up and down the ward corridors to use the bathroom as well. From a privacy and a dignity aspect I would support single rooms as well.
Deputy J.A. Hilton:
Do you think that is an essential must do or do you think it is desirable?
Chief Nurse:
I personally would like to see it as an essential, provided they have got en-suite bathrooms.
Deputy J.A. Hilton:
Okay. My understanding is that the design was drawn up with slightly smaller single rooms, the space. I think one of the models they were looking at was Hillingdon and the single-unit size was below the recommended size. Have you got any comment you would like to make on that, if the rooms were going to be delivered below the recommended size?
Chief Nurse:
Yes. I do not know about that particular case but I would suggest from a moving and handling perspective that you do need an appropriately sized room in order to be able to move an individual around. I know single rooms give you the option then, which creates more flexibility around visitors, so you can have your family with you, much more than you can at the moment and, potentially, people could stay overnight if they wanted to stay with their relative.
The Deputy of St. Ouen :
Would you expect to be involved in determining the size of the rooms if they were all single beds?
Chief Nurse:
Not necessarily, not if they have got the appropriate advice, people who are better placed than I am, to talk about the H.D.M. (Healthcare Data Management) standards and the modern building regulations around ...
The Deputy of St. Ouen :
Even though it has been suggested it might be under the U.K. minimum standard, you, as head of nursing, would be happy to operate within that sort of decision.
Chief Nurse:
You are suggesting that our rooms would be smaller than the minimum standard.
The Deputy of St. Ouen : Well, they would be.
Chief Nurse:
Right. If that was to be debated and questioned I would be expected to be involved in that conversation, yes.
[11:00]
The Deputy of St. Ouen : Right, great.
Chief Nurse: Yes, sorry.
Deputy J.A. Hilton:
Can you just, for the record, tell us which groups that you sit on because we are aware that there are a lot of groups operating in them and we are getting completely confused about who does what?
Chief Nurse:
Yes, I know. Yes, I personally sit on the Transition Steering Group, which is the group that is chaired by Julie Garbutt and attended by all the exec directors of Health and Social Services, also joined by the Treasurer, Social Security Chief Officer and representatives from the primary care body and also from the community and voluntary sector. That group, initially, was the White Paper Steering Group, it has changed its name to the Transition Steering Group and they talk about obviously all of the White Paper initiatives but the future hospital project is becoming part of the agenda for that group as well now. That is the sort of steering group for all of the changes in the way care is delivered. Then alongside that there is a group called Clinical Directors and Heads of Nursing that meets on a monthly basis on a Wednesday evening and much of the discussion around that is in relation to future hospital plans. The most recent one I attended, Bernard and Helen led the discussion. The medical director was there, the clinical director of the specialties and the heads of nursing for the individual specialties were also present.
Deputy J.A. Hilton:
You are part of that group as well.
Chief Nurse:
I am part of that group.
Deputy J.A. Hilton:
Are you aware of any concerns from the medical directors or clinical directors at the moment with regard to the hospital and the delivery of service?
Chief Nurse:
Not particularly. In relation to the future hospital
Deputy J.A. Hilton: Yes, the 2-site option.
Chief Nurse: Yes, yes.
Deputy J.A. Hilton:
We have heard from Peter Southall last week.
Chief Nurse: Right, yes.
Deputy J.A. Hilton:
Obviously there is going to be a duplication of services and they had expressed an opinion about Pharmacy and I did not know .., I just wanted to ask you whether you had picked up on that or any other concerns from the clinical directors or the medical directors.
Chief Nurse:
Peter is certainly a member of the Wednesday evening group. I do know that at the last meeting that I was at there were some general discussions about what was going there, similarly from microbiology's perspective as well. I was not aware of any specific issues, though I think there was going to be some further meetings with Peter with Bernard and Helen after that one, rather than it being in a big forum with lots of people with ideas.
Deputy J.A. Hilton:
Yes. I think that is our understanding that the hospital director had agreed to review the pathology services to address their concerns.
Chief Nurse:
Yes, yes. I think the main message that comes out of those meetings is that everybody has the opportunity to talk about any concerns that they may have but nothing is a done deal at this moment in time and that as much as possible they are encouraging people to share with them their thoughts and their concerns about any aspect of the future hospital.
Deputy J.A. Hilton:
Okay. Those are the 2 groups that are currently operating at the moment.
Chief Nurse:
They are the formal groups that I am part of. There are obviously conversations within other meetings where people are being backed
Deputy J.A. Hilton:
Yes. We understand there is a Ministerial Oversight Group as well, is there?
Chief Nurse: Yes, yes, okay.
Deputy J.A. Hilton:
Okay, that is lovely, thank you.
The Deputy of St. Ouen :
Given the comment you made regarding the availability of nurses and, to a certain extent, to determine what can and cannot be provided on the Island, what involvement have you had personally in the prioritisation of services and the discussions about exactly what the hospital is going to provide or provide in the hospital?
Chief Nurse:
That was mainly done at the big meeting I referred to that we had in the Town Hall last September where we all ran workshops with groups of clinicians and we talked about potential for services that could be provided off the acute service site, the reasons why they could be provided off site, the reasons why it would not be appropriate for those services to be provided off site. We discussed the risks and the potential issues.
The Deputy of St. Ouen :
Sorry, I was not talking about the dual-site approach.
Chief Nurse: I am sorry.
The Deputy of St. Ouen :
I was talking about what clinical services we provide on-Island rather than off-Island.
Chief Nurse: I see.
The Deputy of St. Ouen :
Yes, from what you have already said, it is difficult. We have a number of services that are provided off-Island for all sorts of different reasons and I just wanted to understand what discussions have been taking place around future services, which will be by the on-Island versus off-Island, and some of the challenges that they would bring.
Chief Nurse:
I think from my personal perspective I have not been involved in those particular discussions. My understanding is those take place with the clinical directors and the hospital management team with the senior nurse involvement in that. Potentially, I would only be involved if they asked my particular opinion on something.
The Deputy of St. Ouen : Right, so you would be
Senator S.C. Ferguson:
Just looking at services and so on, would you not expect to be involved?
Chief Nurse:
Not in the initial discussions, no, not when they are potentially talking about their specialty and activity, I would not necessarily be involved in that. I am aware that they are taking place because I see Helen O'Shea on a regular basis but I would not necessarily be in the room in the same discussion, no, mainly because my job is not particularly operational within the hospital.
The Deputy of St. Ouen :
Would you get involved in the expansion of services provided on the Island?
Chief Nurse:
Yes, potentially, from a nursing point of view.
The Deputy of St. Ouen :
Right. Have any discussions of that sort taken place?
Chief Nurse:
Let me just think. Certainly, I would be involved in, for example, when we increase staffing in oncology, for example, to meet the demand. Anything that requires any workforce input from a nursing perspective I would be involved in that.
The Deputy of St. Ouen :
Right. Is there any paperwork that you could direct us to that would confirm some of the work around looking at the on-Island/off-Island provision, demand on services and the impact that it would have on those of recruitment and nursing region?
Chief Nurse:
I could, potentially. I do not necessarily have anything to hand but I could find out for you.
Senator S.C. Ferguson:
I am sorry, I am probably a little dumb on this, you do not get involved with the operational stuff.
Chief Nurse:
No, no, the operational services are all under Helen O'Shea.
Senator S.C. Ferguson: What does the chief nurse do?
Chief Nurse:
The chief nurse's role has an Island-wide role in terms of professional adviser but also a role across Health and Social Services, not just the hospital but also within that there is the elements of governance that sit within the post as well. On a day-to-day basis I do not deal with the operational side of running services, that is left to the hospital. My role is about making sure that we have the appropriate support for nurses within Jersey to enable them to do the jobs that they do. For example, I have responsibility for nurse and midwifery education, nursing workforce planning, governance, practice development and wide infection control. Those are my sort of operational areas, if you like, in terms of my line management responsibility. But my role is not so much as you would expect a director of nursing role, it is a much more broad role than that.
Senator S.C. Ferguson: All right, thank you.
Chief Nurse:
The hospital deal with the operational issues.
Senator S.C. Ferguson:
No, because the title chief nurse ...
Chief Nurse:
I know, yes. It is a bit different from that, yes.
Senator S.C. Ferguson:
So that the matron of the hospital is actually Helen O'Shea, it is the equivalent.
Chief Nurse:
Yes, in effect, yes. I do not think she is registered any more but, yes.
Senator S.C. Ferguson:
Sorry, I am probably coming from James Robertson Justice days.
Chief Nurse:
It is all right, do not worry. It is confusing because you think it does what it says on the tin but it does not necessarily.
The Deputy of St. Ouen :
I would just like to explore a little bit about the potential risks with regard to running a dual site. Can you just maybe guide us a little bit on what those potential risks might be and what would be required to address that risk?
Chief Nurse:
Yes. In terms of setting up the dual-site working we do operate on more than one site at the moment and in terms of the future vision, for what we are looking at, potentially providing or put over them in terms of the one-stop shop. Some of the risks are fairly obvious in terms of making sure that we have got the right equipment, we have got the right I.T. support, we have got electronic prescribing, all of those enable us to support people to do the job that they need to do. The other only potential risk would be around those small specialties and how we would manage that or where those small specialities would be based or how they would work differently and it would require them to work potentially differently if they planned to move them across the 2 sites. From a risk from a patient point of view I think it would be safer for patients to go for a one-stop shop instead of coming to an outpatient appointment one day and then having to come back for a scan another day and then something else. Because every time you have transition in a process you potentially put a layer of risk in, whereas if you are able to attend one appointment all of your investigations are completed, then not only do you get a very quick and efficient response to whatever your condition may be there is less transition and hand-off of the patients' care in between that. I think, from that point of view, it would be better.
The Deputy of St. Ouen :
Picking up on the sort of key building blocks that are required to support a dual site, how far advanced are we in delivering the I.T. and having those other matters dealt with?
Chief Nurse:
I am not really up to speed on the I.T. aspect. I know Graham Prince has been leading on it but I would not like to mislead you by giving you an incorrect quote.
The Deputy of St. Ouen :
Okay. In your general opinion, yes, we are not there yet.
Chief Nurse:
Yes, yes. No, no, no, and we are not there with the prescribing yet.
Deputy J.A. Hilton:
Can I just ask you a question, you mentioned the one-stop shop and people just going to one location and having various tests that they need to be done, presumably on the same day.
Chief Nurse: Yes.
Deputy J.A. Hilton:
How would the M.R.I. (Magnetic Resonance Imaging) scan and C.T. (Computed Tomography) scans fit into that equation because we only have one, I believe?
Chief Nurse: Yes, yes, yes.
Deputy J.A. Hilton:
I was just sat here thinking about that and I was thinking, how is that going to work?
Chief Nurse:
Yes. Presumably the M.R.I. scanner and the C.T., they would need to come down to the general floor but there is a whole range of other tests that people would routinely have such as the bloods, some of the cardiology tests that they do. There are things that they would be able to do up at Overdale without them needing to come down to the general hospital.
Deputy J.A. Hilton:
Okay. We have just got one M.R.I. scanner now?
Chief Nurse: I think so, yes.
Deputy J.A. Hilton:
Have you heard of any discussion or plans to increase that to 2?
Chief Nurse: No.
Deputy J.A. Hilton: No. Okay, thank you.
The Deputy of St. Ouen :
You talk about the one-stop shop but I am struggling to understand how 2 sites are better than one because obviously the initial proposal was to have one single site. Is it still your belief or preference that a single-site hospital would have been the better option?
Chief Nurse:
My personal belief would be if you had the option that you would build from scratch but we do not have that option and we have to do what is affordable and what is doable within the resources that we have been given to maximise the best use of that money.
The Deputy of St. Ouen :
Are you concerned that we seem to have reached the position where the service in the hospital that is being provided is being limited by money perhaps rather than necessarily focusing on what the future needs of the Islanders might be?
Chief Nurse:
No, not necessarily. I think it is both. I think, certainly, in terms of the mapping of the future needs of the Island and certainly the 100 per cent single rooms really plays into that because the evidence shows that if you have 100 per cent single rooms you do not need as many beds. It is when you do not have 100 per cent single rooms potentially it costs more money because you need more beds because you need more capacity.
The Deputy of St. Ouen :
Single rooms, one might argue, it is important but it is the medical care that is provided to the patient.
Chief Nurse:
It is the most important, yes, yes, yes.
The Deputy of St. Ouen :
It is far, far more important than whether you are all single beds or wards, would you not agree?
Chief Nurse:
Yes, I would agree with that but I would say that a good working environment for staff does improve outcomes for patients as well. There is clear evidence around that that supports that. The concept of having single rooms and the way care is delivered in those rooms comes hand in hand. What we struggle with at the moment is an environment that is not conducive and it is very difficult for people to work in and they do their best.
The Deputy of St. Ouen :
I will come back to that and just parking that aside, the single-bedded rooms because, as I say, the whole aim is to have a new hospital with all the wards and the operating theatres and all the rest of it that is necessary for the Islanders to enjoy a good health service.
Chief Nurse: Yes.
[11:15]
The Deputy of St. Ouen :
Bearing all of that in mind, are you confident that a patient's needs will be properly provided for within the current proposal and within the current budget?
Chief Nurse: Yes.
The Deputy of St. Ouen :
Why do you come to that conclusion?
Chief Nurse:
Because one reason is if, as we are having to rebuild on the site that we have currently got, to manage a site within a building site for a long period of time is quite difficult to manage in a clinical setting. To go for the dual-site option that enables you to phase your building work is one positive. I think from the option of having a dual-site service from other experiences it has not proven to be problematic by having your services split across 2 sites. We do not have a lot of option within the footprint that we have got at the moment in terms of the current hospital sale. Overdale is a beautiful site, it is to make the best use of the resources that we have got and the estate we currently have.
The Deputy of St. Ouen :
But we would end up with less services being provided currently on the hospital site than we now have, is that not true?
Chief Nurse:
The outpatients will be up at Overdale but it would not be less services, it is a dual site, so services will still be provided.
The Deputy of St. Ouen :
No, but I am talking about on one site.
Chief Nurse: Yes.
The Deputy of St. Ouen :
We would have less services that we would be able to access from one site than we currently have.
Chief Nurse: On one site, yes.
The Deputy of St. Ouen :
I am struggling to understand why doing that might be a positive rather than a negative.
Chief Nurse:
You would not have all of that footfall of people coming through the general hospital building. They would be cared for and attending in a different environment and different places more appropriately suited to the needs for outpatients than we currently have.
The Deputy of St. Ouen :
You are saying that what we have now is not appropriate.
Chief Nurse:
It is very cramped and not a particularly nice environment.
The Deputy of St. Ouen :
Yes, it is to do with size though, is it not?
Deputy J.A. Hilton:
Could I just ask you a quick question around the shortage of nursing staff? Do you believe that the current shortage of nursing staff and possibly thinking forward to the future has an impact on waiting lists?
Chief Nurse: No.
Deputy J.A. Hilton: None at all.
Chief Nurse: No.
Deputy J.A. Hilton:
What do you think has the greatest impact on waiting lists?
Chief Nurse:
Some of it will be increased demand, some of it will be appropriate referrals, some of it will be access to specialist clinicians and ... those are probably the main ones I can think of.
Deputy J.A. Hilton:
Do you think at the moment that the Island is well served by its specialist clinicians, that we have enough in post to serve all the people who require assistance at this time?
Chief Nurse:
Yes, I think it is well served by the individuals but that is not the same question and I think
Deputy J.A. Hilton:
No, it is all about numbers and capacity.
Chief Nurse:
Yes, I think certainly there is probably opportunity for primary care in relation to developing pathways so that they could support patients more in the community than rather referring them in. There is also opportunities for nurses working at an advanced level to take some of the caseload of the patients off the clinicians and, again, we have been doing that in some of the specialty areas, which has had an impact, certainly on containment of increased demand. There are opportunities in the way in which we can address it differently, which do not always mean you bring in another consultant in terms of the same level that you have always had.
Deputy J.A. Hilton:
Is that a piece of work that is ongoing? Is it a piece of work that is being looked at with each of the specialities, how you can actively reduce the waiting list by
Chief Nurse:
Yes. I know there is a piece of work at the moment going on across all the specialities with service reviews and also the work that we do around supporting nurse prescribers and the scoping work we do at the beginning of that programme that makes sure that those nurses that come forward to do the training work in those specialities where they will be able to use their skills and it helps the organisational pressures that we have got.
Deputy J.A. Hilton: Okay, thank you.
Senator S.C. Ferguson:
Where is Lean in all this then? Where are the reports showing how Lean is getting on?
Chief Nurse: In relation to
Senator S.C. Ferguson:
We are talking about looking at service provision and so on. I would have thought that this is exactly where we need to be looking at the way we do things. Are all your nurses involved with Lean? How low is the level going? It should be the frontline staff who are involved with it.
Chief Nurse:
Yes, yes, no, absolutely. We do have a lot of nurses involved in Lean. I could not give you the exact figures but they are available if you want them. It is an ongoing process in terms of embedding that as a way in which we deliver change within the organisation. Lean is just a methodology and a way of doing things and how we apply that to what we do should be inherent in most of the things that we change.
Senator S.C. Ferguson:
Yes, because it is very new for men, so she would be totally sexist. But is nobody keeping track of it? Where is the report going to be saying what we are doing, how we have done it, where we have done it?
Chief Nurse:
Yes, yes, absolutely. Yes, the responsibility for the Lean programme sits with the director of H.R. (Human Resources) and there are reports for each project that has been commissioned is under way. There is lots of information available around Lean in relation to the prioritisation of projects, lots of
Senator S.C. Ferguson:
No, no, it is the outcomes we are interested in.
Chief Nurse:
There are reports completed at the output
Senator S.C. Ferguson:
If you look at, for instance, the orthopods and so on, have we looked at Lean with that to see where we can improve the service delivery and so on? Those are the sort of areas we need to be looking at surely.
Chief Nurse:
Yes, yes. No, I agree. I could not tell you the vast array of projects that we have got in place about Lean at the moment.
Senator S.C. Ferguson:
Yes. You do not get much coming back to you from your staff, from your nurses.
Chief Nurse:
What I get from nurses is they have brilliant ideas and some of them get on and do them and some of them would like some support from Lean, people who have been Lean-trained, to help them kick start the projects. There is a lot of interest and lots of good ideas about how we can do things differently. Nursing documentation is one at the moment that we are looking at, streamlining that particularly to reduce the time nurses spend on paperwork.
Senator S.C. Ferguson: Which is rubbish, yes, I agree.
Chief Nurse:
Yes, which is something that we are looking at as a Lean project. That is just another example of one that I would be involved in, similar to the nursing appraisal one which are organisation-wide.
Senator S.C. Ferguson:
Are they getting the support they should get?
Chief Nurse: Yes.
Senator S.C. Ferguson:
They are obviously getting it from you.
Chief Nurse:
Yes. No, I would say they are getting the support that they should get.
Deputy J.A. Hilton:
Can I just ask you a question around transport on the 2-site option? Have you been involved in any discussions in how we are going to move patients from one site to the other and how that might happen?
Chief Nurse:
No, not personally, no.
Deputy J.A. Hilton: Not at all.
Chief Nurse: No.
Deputy J.A. Hilton: Okay.
Chief Nurse:
In terms of the sort of the detail of the proposals I have not been involved in the level of conversation that gets down to that sort of detail, yes.
Deputy J.A. Hilton: Yes.
The Deputy of St. Ouen :
Who would be responsible for dealing with that matter?
Chief Nurse:
It would probably sit with, as well as with Helen as managing director, Nick Cunningham who is responsible for all facilities and portering and all the estate side of things from that aspect.
Deputy J.A. Hilton:
Just one thing I wanted to clarify with you on the Transition Steering Group, were all the options presented to your group on the preferred hospital sites? Were you privy to all that work?
Chief Nurse:
Yes. I am just trying to remember which group it was presented at but, yes, definitely we saw all the options appraisals and certainly when we were at the Town Hall meeting, that was the start of the sort of sharing of the information that had come back and Helen gives regular updates to the Transition Group.
Deputy J.A. Hilton:
But the Transition Group was not actively involved in the decision around the 2-site option.
Chief Nurse:
I am just trying to recall who was there. A lot of the members of the Transition Steering Group were at the Town Hall event. As you know with Jersey we all go to lots of things.
Deputy J.A. Hilton:
Yes. Okay. I wanted to talk to you about the acute services strategy and what involvement you have had in the development of that, if any.
Chief Nurse:
Probably just some high-level involvement in terms of some of the initial discussions that we had had around the acute services strategy and I have seen a draft for me to comment on and that is probably about it. I do not think I went to a workshop on that one but I believe there was one.
Deputy J.A. Hilton:
Who is leading on that piece of work?
Chief Nurse:
It will be Helen and Bernard and Martin Chudlar(?) I think.
Deputy J.A. Hilton: Okay.
The Deputy of St. Ouen :
Are you aware that that work has been completed?
Chief Nurse:
I do not think it is finished. I think it is still in draft, it is still a work in progress I think, the last copy I saw. Bernard was recruited by me as a head of nursing, so I still see Bernard on a very regular basis because of being the professionally phased role. We have a lot of contact through that route as well. Things like the acute services strategy Bernard will come and talk to me about it.
The Deputy of St. Ouen : Does Bernard report to you?
Chief Nurse:
No, no, he reports to Helen for the future hospital project because he
The Deputy of St. Ouen : Right, do you report to Bernard?
Chief Nurse:
No, because he is a nurse and I am the professional lead for nurses. He meets with me on a fairly regular basis because he is in this job on a fixed-term basis, so potentially
The Deputy of St. Ouen :
Right, but there is no direct line of reporting between the 2 of you.
Chief Nurse: No, no.
Senator S.C. Ferguson:
His line manager, presumably, is Helen.
Chief Nurse: Yes.
Senator S.C. Ferguson: His professional manager
Chief Nurse: Is me.
Senator S.C. Ferguson: Yes.
Chief Nurse: Yes.
The Deputy of St. Ouen :
There is one last matter, it is around transport and, again, perhaps you might not be able to comment but it is to do with the ambulance service and the support that the company provides. Have you been in any discussions around how that will work with the 2-site option?
Chief Nurse: No.
The Deputy of St. Ouen : No.
Chief Nurse: No, no, not yet.
The Deputy of St. Ouen :
Is that an issue that needs to be addressed or is it just taken as a given that the ambulance service will just fit in to whatever is decided?
Chief Nurse:
No, I think it needs to be looked at in terms of how it currently operates and how it will need to operate in the future to make sure it meets the needs of population.
Deputy J.A. Hilton:
The ambulance service comes under Helen because she is director of operations.
Chief Nurse:
Sits under Helen, yes. Yes, it is part of acute services.
Deputy J.A. Hilton: Okay.
The Deputy of St. Ouen : Okay, yes.
Deputy J.A. Hilton:
Thank you very much for coming along and speaking with us this morning.
Chief Nurse: Thank you.
Deputy J.A. Hilton:
I will close the meeting.
Chief Nurse: Thank you.
The Deputy of St. Ouen : Thank you.
[11:26]