Redesign of Health and Social Services - Minister for Health and Social Service - Transcript - 16 June 2014

Health, Social Security and Housing Scrutiny Panel

MONDAY, 16th JUNE 2014

Panel:

Deputy J.A. Hilton of St. Helier (Vice Chairman) Deputy J.G. Reed of St. Ouen

Senator S.C. Ferguson

Witnesses:

The Minister for Health and Social Services Assistant Minister for Health and Social Services Assistant Minister for Health and Social Services Chief Executive Officer

Director of Finance and Information

Deputy Director of Commissioning

[10:30]

Deputy J.A. Hilton of St. Helier (Vice Chairman):

Good morning and welcome to the Health, Social Security and Housing Scrutiny Panel. We'll start by introducing ourselves. I am Deputy Jacqui Hilton, Vice Chair of the Panel.

Deputy J.A. Hilton:

Welcome to you all and thank you for coming this morning. I would just like to start by offering the apologies of our Chair, the Deputy of St. Peter , who is currently unwell. We would like to start by asking you questions around sustainable funding for primary care. Would you explain the process that you have followed in gaining the support of G.P.s (general practitioner) for the changes that you are taking forward.

The Minister for Health and Social Services:

All right. So we are starting with primary care, all right. I think it goes back to quite a number of years and that is why we have the Deputy Commissioner here who is leading on the primary care of consulting with the G.P.s and, not only the G.P.s, because it is primary care, so we are looking at opticians, pharmacists and dentists because they provide the care. There was some consultation last year, which did not quite get off the ground, so we have all, everyone together, sat back around the table at the end of last year, I think it was, and worked a way forward of everyone now engaged and going to take that next step forward of looking at the primary care with Jo leading it and getting expert advice, whatever, as needed, as we go through/

The Deputy of St. Ouen :

Are you confident that all the main key stakeholders are involved now in the process?

The Minister for Health and Social Services:

They always have been involved and I think it is unfair to say that they were not involved. They might not have agreed perhaps the way that things might have gone, but they have been involved and were listened to and I am very positive that we have a very good way forward under the leadership of Jo.

The Deputy of St. Ouen :

Does that include opticians and dentists and pharmacists?

The Minister for Health and Social Services:

It does. Very much so, because they are part of primary care, and also there is the wider one of family nursing services too.

The Deputy of St. Ouen :

When do you see the work being concluded?

The Minister for Health and Social Services:

I think some sort of paper will be available towards the middle of this year, or we're in the middle of the year now, towards the end of this year. But it is a big piece of work.

The Deputy of St. Ouen :

So are you saying that it will not be concluded by the end of this year?

The Minister for Health and Social Services: It all depends what you mean by "concluded".

The Deputy of St. Ouen :

Well, I mean the States agreed, and you supported the delivery of a primary care model by the end of 2014. Is that still the case?

The Minister for Health and Social Services:

It will not. By the end of 2014 something will be available to States Members. I think there will be a report. But regarding it being completed, no, it will not be completed, because it is a huge, as we said at the time, it is a huge piece of work, not only looking at the G.P.s, but also looking at opticians, dentists and pharmacists too.

The Deputy of St. Ouen :

So when would you expect it to be concluded?

The Minister for Health and Social Services: I would not like to say.

Deputy Director of Commissioning:

The plan at the moment is that we would have a strategy put forward by around April 2015, but prior to that there will be a number of publications that we hope will come from the Sustainable Primary Care Project Board and looking at some policy and principle issues that would help us to frame future strategy around primary care. So we are expecting the first document to come out

around the autumn time. So the Sustainable Primary Care Project Board was launched officially in April and has now met formally twice, and that has all the key stakeholders around the table. We have agreed terms of reference. We have agreed what the key milestones for delivery of the project will be. Also we have agreed what the role of each of the constituent members is and how they are going to communicate with the wider stakeholder group throughout the process. So, so far so good. We have really good sign-up and participation, and we are just in the process of preparing for a workshop in July where all of the members of the stakeholder board are coming together to have a look at the international evidence base around the different types of models of primary care and what we are all committed to is to find out the things that we all agree on so that we can come out from that workshop with a sort of a clear sense of where the areas of consensus are and where there is more work to be done around where people are different. So it feels quite positive and constructive at the moment.

The Deputy of St. Ouen :

One last question from myself, can you tell us whether the strategy will be supported by a funding option?

The Minister for Health and Social Services:

I would have thought there would be some mention there of financial resources.

Chief Executive Officer:

The plan for the project is for us to co-design, with primary care practitioners, a new and sustainable way of providing primary care. That will also be costed and we will look at the way the money flows around the system because, as you know, at the moment there are some perversities in the way funding flows, which does not necessarily help the delivery of the type of primary care that, for example, we know general practitioners want to provide, which is a much broader and holistic set of services in their practices. But at the moment the way the funding goes into practice from the Health Insurance Fund does not necessarily support that. So we will be both co- designing the system, but also in looking at how we fund the system, and then, if there are issues around the levels of funding, obviously that would be an issue that comes back to the States for further consideration.

The Deputy of St. Ouen :

Are those 2 streams of work happening in tandem or in parallel?

Chief Executive Officer:

Yes, they will all go forward at the same time.

The Deputy of St. Ouen :

So, just to be clear, April 2015 we can expect, or the States can expect, to be able to consider a strategy together with the funding options that will need to be required to take forward the new primary care model?

Chief Executive Officer: Yes.

The Deputy of St. Ouen : Thank you.

Deputy J.A. Hilton:

Thanks very much. I know we were aware of problems earlier last year. Are there any challenges that you still feel that you are facing or do you feel that you are all working with the various stakeholders, working collectively together, and you are confident that this is going to happen when you say it is going to happen?

Chief Executive Officer:

I think the difference between last year and this is last year were working with primary care practitioners through a route that would have seen a significant piece of work being done with us, but with external support, and we required a procurement process in order to find that particular partner. I think the learning for all of us, primary care practitioners and ourselves, is that we do need to design something, which is right for Jersey, and the best way to do that is to use the resources we have on the Island and supplement that with expertise as and when we need it. It was as part of joint discussions between the department and, firstly the primary care body, but then other practitioner groups, that they identified with us that if we could create the time for Jo to take the role of project director and give her some support and give her some money to access specific expertise if she needed it, that would create more of a sense of us co-designing the new system on Island and for the Island, and that does seem like a much more positive way to go forward.

Senator S.C. Ferguson:

But surely the whole basis is that, with the changes that will come with the primary care system, is that G.P.s are going to see their income very much affected. Now, surely the whole basis of this is negotiating a new contract with G.P.s as well as looking at a long-term sustainable funding mechanism?

Chief Executive Officer:

Absolutely, yes, I absolutely agree with you, and that is part of the project. I think ...

Senator S.C. Ferguson:

That is something that surely should have been started with.

Chief Executive Officer:

I do not think you can decide on what you are contracting for until you know what it is that you want to have in place as a service, so that is what they are doing, describing the services, looking at how the money flows around the system currently, and looking at how we would want it to flow differently. That new way of funding might well be a contractual mechanism, so that is the piece of work that we are engaged in doing.

Senator S.C. Ferguson:

Well, like best practice in other countries, such as Singapore. When was the KPMG report?

Chief Executive Officer:

The original KPMG report that kick-started it was in 2010/11.

Senator S.C. Ferguson:

We are only just starting to discuss it?

Chief Executive Officer:

The discussion at the States was taken in October 2012 and that was when the proposition was put forward that suggested we needed to do a sustainable piece of primary care work. Primary care is a complex part of the system and it would take some time to do and, as part of the overall KPMG work we were looking at the total system, not the individual parts, which is why we have developed business cases around community services, we have developed business cases around our acute services, and within the next year we will be developing business cases around our primary care services.

Senator S.C. Ferguson:

I am sorry I am possibly sliding into detail here, but the primary care surely should centre on the G.P.s ...

Female Speaker:

It should centre on the patient I would have thought.

Senator S.C. Ferguson:

... and the G.P. is the main co-ordinator of treatment for the patient, and yet that side of it has not really been started until just now with Jo.

Chief Executive Officer:

That is not strictly true, because some of the services that we are developing as part of the rollout of community services are based in G.P. practice. So, for example, the outreach of antenatal care is in G.P. practices working with G.P.s and they are being funded through a contract in a different way. So we are piloting those approaches but the whole system has to work and it is a complex system, which is why we have embarked on the piece or work we have embarked on.

Senator S.C. Ferguson: All right, thank you.

Deputy J.A. Hilton:

Thank you very much. I would just like to move on to talk about services in the community. Concerns have been raised about the extent to which the white paper development in out-of- hospital care has been taken forward successfully. While there have been some stories of things working well, it has been difficult to see developments as positive overall. The report on community intermediate care services of February 2014 was quite damning of progress since 2012. To quote the report: "There is insufficient outcome data to determine the effectiveness of inputs. Less than half of the patients, 43 per cent, had an outcome scoring, but for those who did the results were positive. Further consideration needs to be given to the appropriate use in future to determine achievement of outcomes. The provision to preventative services may not all be intermediate care or ablement(?) and in some cases may be duplicating mainstream provision, which raises questions about value for money of the current model and approach. This will need to be carefully worked through as the out-of-hospital system develops to ensure that intermediate care is ring-fenced." To what extent has the development of out-of-hospital services, as agreed in the white paper, been successful in the period to April 2014?

Deputy Director of Commissioning:

Having written that report, I did not think that it was damning at all. I think that what we have learned from that has been hugely influential in helping all of the stakeholders to work together to think about what the future looks like. It is really important to remember that what we were doing was piloting, we were testing out some ideas about new ways of working to keep people at home

when it is clinically appropriate for them to be at home and to help them to get out of hospital when they were clinically and medically fit to be at home. We have got a huge amount of learning about the things that we have done really well and the things that we could do better and one of our big system issues is a lack of objective data that helps us to measure outcomes. Where the teams were able to do that, we had some really good evidence of some really strong outcomes. What we are doing, taking this forward, is where I am establishing a strategic partnership of the key organisations who are providing out-of-hospital care, which includes the primary care body and family nursing and home care and our own in-house providers, plus the voluntary and community sector. Together we are going to agree what are the things that we are going to measure that will help us all to know whether what we are doing is value for money in the future. So, having had all of the wealth of information from the pilot, it has really helped us to know what are the things that we have to focus on from day one as we move forward and rollout the whole system. So the pilot was a small part of the eventual out-of-hospital system and the learning from that has been invaluable in helping us to design something that will take us to where we need to go perhaps much quicker than we might otherwise have done.

The Deputy of St. Ouen :

You mentioned the issue of a lack of objective data. What is being done to address that?

Deputy Director of Commissioning:

We have created a new data set that all the providers are contributing to. We are having monthly, thick detail here, but we are having monthly performance review meetings where we are looking at the data and we are validating it as we go through. So that, if we've got any issues or concerns, we can deal with it at that point, so I have got one of those meetings tomorrow.

The Deputy of St. Ouen :

So when will we have (overspeaking 10:44:16)

Senator S.C. Ferguson: (overspeaking 10:44:16) the data?

Deputy Director of Commissioning:

The data is kept in various databases and in clinical management systems.

Senator S.C. Ferguson:

So, but, you know, is it easily accessible by all people involved in it?

Under information governance rules, it is accessible by people who need to know. So, an example would be I wouldn't see the information about any individual; it would be anonymised, because it would be a breach of confidentiality for me to know. But, in terms of the numbers, I can access the numbers because I need to know how the services are doing. So the (overspeaking 10:44:51)

Senator S.C. Ferguson:

(overspeaking 10:44:51) thinking in terms of the whole data system for the hospital where it is not perhaps where we would like it to be.

[10:45]

Deputy Director of Commissioning:

As we go forward, we are going to be monitoring the system and we will be looking and agreeing a set of high-level indicators for the whole system and an example of that, one would be the number of unplanned admissions for older people into hospital and we would say that is a system measure. Then we will be expecting the services in the community to give us a view as to whether they think they have avoided a hospital admission or not and we will be then bringing those together. So we have to look at it at a number of different levels. There will be system measures and then there will be service measures. We can only extrapolate a connection if we were able to prove that this activity in the community created this change in the system. We would be well sought after internationally because every health and social care community is trying to make connections between cause and effect. But the work that we have done with the stakeholder group, which has been highly influenced by the G.P.s, which has been really helpful, is helping us to get a list of what we think the sensible measures are that will help us as a system to know whether or not we are making a difference to the whole system by the things that we are doing in the community.

The Deputy of St. Ouen :

Can I ask, when will reliable data be readily available and relied upon?

Deputy Director of Commissioning:

We are building it all the time. I would say that, as we go forward into 2015, I think we will have really robust data collection systems that will enable us to know what difference we are making in the system based on the things we have just described.

The Deputy of St. Ouen :

Will that apply to data that is collected within the hospital?

Hospital Managing Director:

The hospital is (overspeaking 10:46:42)

Senator S.C. Ferguson:

Is it going to be part of the data of the patient record system?

Hospital Managing Director:

It is already part of the record system. TrakCare is our administration system and also an electronic patient record in the A. and E. (accident and emergency) Department and in Maternity. So already have that data. It was only implemented I think in 2011, so our data has been robust since then, and so that is already in place.

The Deputy of St. Ouen :

So you are saying that you are confident that the data that you can now obtain from the systems that you have in place can be relied upon and can act as a base for tracking and monitoring the improved out-of-hospital services versus the demands that the hospital will have to meet?

Hospital Managing Director:

As Jo has just said, it is what is cause and what is effect. I know last year I saw less people come to the E.D. (emergency department) and we admitted less emergencies. That may well have been because of some of the pilots the out-of-hospital teams were delivering. So it is that cause and effect. So, yes, we can measure the data, but it is connecting it.

Female Speaker:

I (overspeaking 10:47:51)

Senator S.C. Ferguson:

Yes, because this is something that, if you will excuse me, this is something that has come out in the review of patient records, the patient record system, that the public accounts people have been doing, where we are going to spend another goodness knows how many million in order to have a records system that is appropriate, which is why we are questioning if you are going to have enough information to make proper decisions.

Perhaps I can help with that. I know we have had some of these conversations before. The development of information systems across all the services is in train and the implementation of hospital patient administration system was a major element of that. As you will have seen from the department's information strategy, which the P.A.C. (Public Accounts Committee) has said the think perhaps is primitive, there is a programme of work that extends forward into the future to support some of the things that Jo and Helen and the Ministry have been talking about. In some areas, we have very advanced systems, which are collecting robust data on which clinical decisions are made and management decisions are made here and now today. In other areas, there is more work to do, and that is what the information strategy sets out, how we are going to do that and what they are. As we are implementing various new services and processes, looking at the overall services and looking at the overall system, we are implementing I.T. (information technology) system solutions to back it up at the same time, and integration to the main patient databases, one of the big issues that we are dealing with all the time.

The Minister for Health and Social Services:

Can I also take this opportunity, kind of perhaps on a side issue, to give an example of having done it when I went to family nursing and midwifery services A.G.M. (annual general meeting), they are doing the rapid response and collecting all the data, as Jo mentioned there, and they have been running that for 6 weeks and the dramatic effect just in those 6 weeks has been amazing. So, from the other end of the scale, you can see it working in the community and voluntary sector. Obviously a part of it was making sure that they had the right data to feed into Jo, and it was very impressive I must say.

Deputy J.A. Hilton:

Can I just ask a question around I.T., we had your I.T. lead here in a hearing back in April and he talked about the requirement for additional investment over the next 4 to 6 years and I think he was talking about needing to spend somewhere in the region of £3 million per year to have an I.T. system in place in the hospital that was set up to do what it needed to do. Has money been set aside to fund a comprehensive I.T. programme?

Director of Finance and Information:

It is probably worth saying that is more than just a hospital I.T. system. It is developing the existing hospital I.T. system and it is working to do likewise in the community services and making sure that the systems all talk to each other, including enabling the G.P. systems to talk to the hospital systems and so on, all of which are crucially important elements. The funding of that

strategy is within our bid into the long-term revenue plan and medium-term financial plan.

Deputy J.A. Hilton:

So you have made allowances for all of that, because he did speak about: "If the dual site option went ahead, how important it was that the electronic system was more robust." I am quoting what he said: "because obviously you do not want to be moving excessive numbers of paper notes up and down the hill." That was a comment that he made and obviously, if the dual site option goes ahead, Westmount Centre would be going live in 2018, so we really just wanted an assurance from you that the I.T. system would be up to speed and doing what it needs to do.

The Minister for Health and Social Services:

But it needs to be across the whole system and that is why it is important that part of the primary care review is that, and E.M.I.S. (Egton Medical Information System) is now in the G.P.s, and making sure that E.M.I.S. is in family nursing, or the equivalent of family nursing services, and hospice, so that it is a continuous pathway rather than using all different systems.

Chief Executive Officer:

I think our answer would be in terms of the money, we have made provision within the current medium-term financial planning process that we are in year 2 of, we have money set aside to keep this moving forward, and we have bid for the next tranche of money as part of our bid into ...

Deputy J.A. Hilton: Is that the 2016 2018?

Chief Executive Officer:

2016 onwards; would be the long-term revenue plan that is being worked up at the Treasury at the present time. Of course there is no guarantee of that money as yet because we are not in that phase of the financial planning and you have not yet been, as States Members, asked to approve those sums of money.

Deputy J.A. Hilton:

Do you know if the G.P. central service project has gone live yet?

Deputy Director of Commissioning:

It is going live as we speak, I think it is this week is the first go-live bit happens and E.M.I.S. are over. I am talking to broad stakeholders, as the Minister just explained, because there is a commitment in principle for all other organisations to buy into the central server product, which is fantastic, and those conversations are happening this week.

Deputy J.A. Hilton:

Can you also tell us, because it was mentioned earlier, this again, this is about 3 senior roles in I.T. in the hospital, a business support group manager who I believe started work in I.T. recently and the second role was for a director of information for in the hospital as well. Do you know if those posts have been advertised and filled?

Director of Finance and Information:

The posts you are describing, one is an I.S.D. (Information Services Department) post, which has been advertised, recruited and filled, and the incumbent is there today, has been there for a good few weeks now. The other post is the Head of Informatics post for the whole of the department, and that is out to advert at the moment.

Deputy J.A. Hilton:

What about the post of programme manager?

Director of Finance and Information:

I think we may have identified somebody to do that who is an existing States employee through the I.T. department. We have a meeting about that Wednesday this week.

Deputy J.A. Hilton:

Thank you. Just moving on, how have you monitored the use of budgets allocated under the white paper to ensure the stream of funding is not used to support shortfalls in existing service provision?

Director of Finance and Information:

Forgive me if this sounds repetitive, because I think we have probably had some of this conversation before. In terms of the white paper funding, we hold it separately, identify it separately and allocate it separately to specific services and initiatives as they are approved to go forward. I think I have described the approval process in some detail before, but in terms of new services the end point is that the Minister signs off on a new service being initiated, then the budget is established, and the exact process depends on whether it is a service that we are providing internally or whether it is a service that the voluntary or community sector are providing or that we are contracting with a private sector party. But, whichever one of those scenarios it is, the budget is allocated and held on separate business units so that we can always identify what has been spent and where it has been spent. The process to arrive at the budget is either the result of a tender process, where we go through the bids as you would expect, or, if it is a service

that we are providing internally or one that one of our voluntary or community partners is providing,

we work through the budget at a granular level of detail with them, or with ourselves, to do a bottom-up approach to make sure that we are comfortable from 3 sides really. One that it is the service that we set out to deliver, so what was described in the white paper in P82; that the organisation providing it is comfortable that they can deliver it within those resources and deliver the outputs and outcomes that Jo has described earlier; and thirdly that the costing of the delivery of the service is reasonable and robust and that nothing has been missed. So we go through that process, all those sign-offs, the budget is then issued and set, and we report it to the Treasury on a quarterly basis and they ask us questions on it.

Deputy J.A. Hilton:

Can you just confirm that your 2 Commissioners, besides yourself, are still in post and doing that work? They are? Thank you.

Director of Finance and Information:

The budgets that are issued, it is worth just remembering that some budgets we issue to commission services from third parties, some budgets we issue to provide services ourselves, but there is a budget holder for each and every budget, be it white paper or be it anything else.

Deputy J.A. Hilton:

Is there any area of the additional health white paper funding to provide services in the community that has been delayed for any reason at all?

Director of Finance and Information: There is ...

Deputy J.A. Hilton:

I know for instance, although the money was granted in October 2012 for talking therapies, my understanding is that the posts were only advertised maybe a couple of months ago. So I was curious about where you were with that at the moment.

Director of Finance and Information:

The timing of the implementation of the various services that were described in the white paper is quite well documented in some of the other papers that we have provided I think. Where that has been a different timetable to that originally envisaged, has generated an underspend in that particular year, so primarily last year, that underspend, you will have seen in the States accounts, which have now been published, so the underspend that was generated we can relate back this

initiative that was forecast to start then and it started later, so that's all tied down to the last pound.

Deputy J.A. Hilton:

So, is there any of the work streams where funding was given in October 2012 that have still slipped significantly from the original timetable?

Chief Executive Officer:

I think it is probably worth noting that funding became available in January 2013 because of the funding cycle, but I understand the point you are making. A number of services initially slipped because I think, as the Panel is well aware, that in the early part of 2013 there were some concerns expressed by hospital consultants and G.P.s that they felt that perhaps things had moved a bit quickly and they wanted to just have some time to pause and reflect and re-examine the evidence, and we agreed that was the right thing to do, so we had that pause and reflection, we had a whole range of workshops involving hospital consultants, G.P.s, and a range of other stakeholders, where we re-examined the evidence and decided whether or not we wanted to continue with those services. I think I am right in saying every service was approved to carry forward, but of course that did result in a delay, which is why some of those underspends were generated. But, since that time, I think we have worked pretty much to the revised schedules we have had in place.

Deputy J.A. Hilton:

We became aware last year there was only one-half full-time employee, a psychologist for the over-65s, and I was just interested to know how you think we are doing the best by that particular group of people by only having one-half full-time employee?

[11:00]

Chief Executive Officer:

Drilling down into some quite considerable detail then, I know that we did discuss that at the time, it is important and of course as we examine all of our service departments we look to see where is the right investment, what gives us the best value for money. It is not really a service area that Jo deals with, but you might want to comment?

Deputy Director of Commissioning:

Yes. The dementia service has been expanded and the implementation plan is being delivered at the moment and I can only give you high level because I am not directly involved. But it includes an expansion of community mental health teams, of the memory service, and of support for carers

through short breaks. So it's quite a significant work programme and my colleague commissioners

are overseeing that in partnership with community and social services managers. So there is investment through the white paper going in to transform the service for older people. But there is also a significant review of mental health services that we are just embarking on, which is going to look at mental health services from cradle to grave, and a fundamental review that Andrew Halpin(?) is leading on and that will help us to review and revise the mental health strategy and there will be further implementation plans as we need to keep moving forward on mental health services.

Deputy J.A. Hilton:

So you are basically confirming that the post of psychologist for the over-65s, there will be an increased resource with regard to that in the short term, before the mental health review is completed?

Deputy Director of Commissioning:

What I cannot tell you is exactly what post the resource is creating, because I do not have that level of detail, but we can get it. But the increase in resource in the community is already taking place.

The Deputy of St. Ouen :

Can I just ask, Minister, we have been told about there is implementation plans that are in train or being developed to help deliver the priority areas of services that are identified in the first stage of the transformation programme. When will users of those services be able to access and benefit from those plans?

The Minister for Health and Social Services:

Some of them are doing it right now, and have been doing it for a little while. Julie mentioned the community midwifery and antenatal care. That has been happening for a little while. As I mentioned, it is very good going to the family nursing services A.G.M. they must have been successful for 2 areas, and one was the rapid response, and they had a presentation on that, and the other one was M.E.S.H.(?), someone will tell me what M.E.S.H. stands for because I cannot remember. There we are. So, coming from a service point of view, that was a presentation, and I thought that was very good to see because it is making a difference on the frontline staff. The other one is short breaks, that has made a difference, that has been happening for quite a while.

The Deputy of St. Ouen :

So you are saying that all those matters that you spoke about are fully implemented?

The M.E.S.H. is just beginning. The short breaks and respite, that has been in place for quite a few months I understand.

Deputy Director of Commissioning:

I think your original question was, when will people who use services see a difference, and I think what the Minister has explained is that people are seeing a difference already. Your second question was about, have we implemented everything fully? No, we have not. Because the process that we are going through is one of continually reviewing and learning, so we are going to be continuing to be implementing the changes as we go forward. What is interesting about it, there is quite a lot of information, which we can happily send you again, about the services that people have begun to see. So, for one we have, for example, where there was a very long waiting time, that has now been reduced down to a very short waiting time. So there is a whole range of different ways that people will see a difference. So people are not waiting as long as they might have done for the service, particularly carers through the short breaks, for adults and children, are getting more support than they had in the past. We are already seeing, through the Kicks(?) pilot and the rapid response service that people are getting out of hospital quicker than they were and some people are not ending up in hospital because we have alternatives in the community. We are seeing more people who are able to make a choice at end of life to die in their homes with their families and friends rather than being in hospital. So there are lots of different ways that people are benefiting. They might themselves not recognise that it is to do with the white paper because they would not necessarily know that the service was a white paper funded service, but we can certainly resend you some of that information (overspeaking 11:04:58)

The Deputy of St. Ouen :

I think it would be useful to have that information and to be clear about when users, general public, are able to rely upon and benefit from the full service, once it is fully implemented, because obviously there are expectations and people are looking to see the improved services. Also, it would be useful if you could provide us with how you are monitoring the improved outcomes, some of which you have mentioned, because one is aware that certain individuals have still got issues around end of life care, and so on and so forth, which is anecdotal I hasten to add, but it would be good to have some real evidence that we can point to, to say, although you are not experiencing all of the services and all the things that you would expect now, this is when you can. If you can give us that, that would be great.

The Minister for Health and Social Services:

But, as Jo said, there is not a white flag that says, "This is white paper money, you are going to access", it is improving of services and some people will not realise that it is white paper money, and in some ways they should not realise because it is the service that we provide on the front line that is the most important.

The Deputy of St. Ouen : Good.

Deputy J.A. Hilton:

Thank you. Have you agreed an acute services strategy for the hospital?

Hospital Managing Director:

We have agreed a high-level strategy in terms of what we are aiming to do, which we have shared with you before, it is about doing as much on-Island as is clinically safe and affordable. The work that is underway now and due for the first iteration of the paper is due this month, is the work that we are doing with individual specialties to say what does that look like for emergency and elective care. So we are currently looking at things like ambulatory care for elective patients and the whole ethos of the Overdale site. We are looking at ambulatory care for emergency patients, so patients can be rapidly assessed and turned around in an unplanned way, so they do not get admitted. We are looking at women's and children's type of centre, so that we combine appropriate services together so that we get better care for those patients. So they are the sorts of concepts coming out, and a cancer centre, those sorts of concepts are coming out of the work that is going on at the moment. The first draft of that is going to be ready by the end of this month.

The Deputy of St. Ouen :

Can you just remind us, sorry, there were 2 questions. When did work begin?

Hospital Managing Director:

The work began by my predecessor, so back in 2012, all the services did a S.W.O.T. (strengths, weaknesses, opportunities and threats) analysis of their services and that was documented. That has been built on since then. With Bernard going into post Christmas last year, he has been able to concentrate more fully on that and take that work forward more rapidly.

The Deputy of St. Ouen :

So, when will the strategy be completed and available for public or States Members?

Hospital Managing Director:

The first draft is going to be ready at the end of this month. The intention with that is then that it goes out to the clinicians, and obviously we are engaging the clinicians, but we want to engage everybody that is involved with that. So they need to have a good look at that strategy. Also the new health advisers who were just appointed as part of the feasibility study, they will have a look at it and they will be able to compare with what they have seen nationally, internationally, best practice and all the other things that they bring with all that experience, so they will review it as well.

Chief Executive Officer:

Sorry, could I just add something to that, I think it is quite important, the other thing that we are doing is we have our inaugural meeting with a joint forum with G.P.s commencing in a couple of weeks' time and they also are going to be looking at that in great detail and looking across the pathways to make sure that we are bringing out into primary care those things that should be done in primary care and that we are not just reinforcing a hospital-centric model.

The Deputy of St. Ouen :

Thank you. Could you just, my question, but just to pin you down a little bit, when are you aiming for this strategy to be completed?

Hospital Managing Director:

It will have going through all of its iterations by the time we get to outline business case, which will be January next year, so between now and January we will have to have nailed down all or that.

The Deputy of St. Ouen : Great, thank you.

Deputy J.A. Hilton:

That will be on the basis of a dual site option going forward; that is what the work ...

Hospital Managing Director:

Yes, some of the models of care will talk about how do you deliver from dual sites, but some of the models of care would be regardless of site.

Deputy J.A. Hilton:

Yes, I was just about to ask you that. So that piece of work would not be affected by any future decision on where the hospital might be based?

Hospital Managing Director:

No, these models of care ought to be able to deliver best quality care on the Island.

Deputy J.A. Hilton:

Thank you very much. Are you confident that your estimates of the future demand for acute hospital services are robust in the light of developments elsewhere in the world and given the developments in out-of-hospital care that you are introducing?

The Deputy of St. Ouen :

Minister. Maybe the Minister would like to comment first.

The Minister for Health and Social Services:

That is a very detailed question and we know for the future, going forward, that Health and Social Services, as in other jurisdictions, will require more funding, and that is a big piece of work that is happening within Treasury. But I am sure Helen has some comment on that further, the detail.

The Deputy of St. Ouen :

Just to pick up, I understand obviously there is a funding issue, but we really were wanting to understand and get from you whether you are confident that the estimates of future demand for the acute services are robust and can be relied upon?

The Minister for Health and Social Services:

Demand, patient-led demand, it goes back to what Julie was saying there about KPMG and the consultation that went on, and also what the Islanders said that they wanted their health service to deliver. But also the continuing work that Julie and Helen and the rest of the team are, not only doing within the hospital, but also within primary care. So it will all be fed into the future funding needs of health and social services.

Chief Executive Officer:

The assumptions around acute needs and bed needs and how many numbers are going to be flowing through the system was based on the levels of activity we had at the time, so it was based on the increased population living on the Island, it was not based on the population estimates that were known at that time, because we had not had the census. KPMG stress-tested those in terms of their knowledge base and they also, as you know, I think we have briefed you before, have created a model, quite a sophisticated scenario modelling system, that they could test out, if this

happens, what will happen if that happens, and all those numbers were churned through that and that is what led us to the system change that said, "If we do more services in the community, we can manage the growth in demand that we anticipate we will see looking at the way our population is changing with 300 beds". If we do not do these things in the community, or they are not successful for some reason, then the number of beds may well need to be higher at circa 400 beds. That was the piece of work KPMG did for us and it informed the green paper and the white paper and the P.82 report and proposition. When W.S. Atkins were appointed to start doing the pre-feasibility work, they again crunched all the numbers and tested out the KPMG assumptions, talked to the statistics office and other places, and they endorsed those numbers as being the correct numbers going forward ...

Senator S.C. Ferguson:

Was that based on the census figures?

Chief Executive Officer: No, that was based on ...

Senator S.C. Ferguson:

So, where are the assumptions based on the census figures?

Chief Executive Officer:

They based it on the usage we already had of services on the Island, so the figures that we were getting out of TrakCare by that point were showing what 100,000 people on this Island generated in terms of current workload, so that was our baseline. They then applied the new census data to project it forward, so that's the way they did it. So that was tested again with W.S. Atkins. What we have seen, looking around other jurisdictions, and we read it in the health press all the time, I am sure you have seen it as well, is that there are a number of jurisdictions where their push into the community has failed. Where it has failed and those services have not delivered or not been established due to lack of resources or whatever they have had to build more beds. So, for example, we heard, and some of our staff, Bernard and Will, have been visiting various hospitals currently. Edinburgh Royal Infirmary, beautiful new building, and they are having to in-fill and they have had to turn their patient hotel into wards, they have had to turn their management offices into wards, because their community strategy failed. If you look at Malta, I think we have shared some evidence with you that would suggest that island systems tend to need more beds anyway because they do not have the ability to just send patients down the road to the next hospital, for obvious reasons, and if you look at the system, they again have built a beautiful new hospital, but almost immediately they ran out of beds. And so you do have to make sure that the community services are robust and they are established in advance of your new hospital, otherwise the

number of beds will be too few, and I think I will pass on to Helen, but we do think we are being very prudent with the number of beds and for preference we would probably plan for a few more.

Hospital Managing Director:

I would agree with that. I think we are being prudent. The endcap(?) study that we have undertaken supports our view that we do have patients in the hospital that, if we can develop the community services, could move out. So we have evidence that could happen.

[11:15]

We have developed, with the finance team and the project team, a new model that is really detailed that talks about individual services down to sub-speciality level and how many patients they are seeing, what the new changes in service might do, so they all have scenarios in them so we can map it over 10, 20 years almost, so when a change happens, what happens to the demand for that particular service. That model we have developed ourselves and that has been worked through for every service. The health advisers will give us some robust review of that and make sure that they accept where our modelling is taking us. But the only one thing I would say is what you cannot do is horizon-scan far enough to see what technology is going to do. So we can only plan for what we know is around the corner and one of the comments somebody made the other day is: "iPads were not here 5 years ago." Technology is moving so quickly it will change the way we deliver care,

Chief Executive Officer:

So one of the big challenges for developing the future hospital will be to make the most flexible buildings we can so that, if changes of use are needed, it does not become we have to knock that down and start again, we can reuse the floor space differently.

Deputy J.A. Hilton:

Key to care in the community is having the appropriately trained staff. I was just thinking then, with regard to health care assistants, are we going to be able to meet that demand? Have you done any work ... I mean I know Hines(?) do courses specifically directed at training health care assistants, but are we going to have enough staff?

Chief Executive Officer:

I think one of the most challenging aspects we have of where we are at currently in this journey we are on for the 10-year transition is doing the workforce planning because it does need specific

skills and we are struggling to find those skills at the moment. So we are having to get on with 22

identifying the types of staff that we need, but we do need to inject some specific resource quite quickly now to help us with that.

Deputy Director of Commissioning:

That is one of the examples about how useful the intermediate care pilots have been in identifying where our skill gaps are and with the further pilots, so the Minister has talked about the rapid response pilot, that has specifically ... F.N.H.C. (Family Nursing and Home Care), supported by us, spent the first 6 months ensuring that the clinical nurse specialists who run the service have the right level of skills to be able to really function as a very effective hospital-at-home service. So we have learned, from having tried out things in a small way, that we do need to do some of those things. As we go forward and roll this out, we are going to be learning more about where those gaps are, so we have already identified that, while we do have quite a good range of health care assistants on the Island, providing different types of services, there are the independent and the voluntary and charity sector, as well as within our own sector, that what we will need to do is to refocus some of those skills into reablement type skills. So, rather than having people come to your home who will do for you, this is people who are trained to come alongside and work with you to help you do more for yourself. We know that is going to be a key component of the out-of- hospital service going forward. So we have already identified some quite significant workforce development issues and we will be taking those forward as we roll out the services.

Deputy J.A. Hilton:

How closely do you work with Highlands and what do you see Highlands role in providing the training for some of the staff that is going to be needed for community services, because it is not at the same high level as nurses and ...

The Minister for Health and Social Services:

I think that is fair to say that the education department, I think you have had roles, areas of responsibility for the education part, are working very closely with Highlands and doing exactly what Jo said. But also, as you know, they now have a contract with the University of Chester, so are able to do far more training on-Island, not only for health assistants, but across the board.

Deputy J.A. Hilton: Yes.

The Deputy of St. Ouen :

You mentioned earlier that the demands placed on the hospital are absolutely dependent upon what happens within the community setting. What concerns do you have that we will be unable to provide the necessary improvements within the community setting, given that we are all of the knowledge the cost pressures that are currently faced by the department and indeed the costs involved with providing the improved services?

The Minister for Health and Social Services:

That is a big question. I think finances would be an important one because across all health and social services we need to make sure that we are well funded going forward. I think, as Jo mentioned about the manpower, we have to make sure that we have the right skills in the community. It is not just one thing, it is going to be a multitude of different facets, trying to bring it all together. But also it is primary care, making sure that everybody, from G.P.s, practice nurses, are all kind of signed up to it and ready to take it forward. Because Health and Social Services cannot do it alone, that is why working with the G.P.s is important, working with the voluntary and community sector is important, because we all have a part to play to improve patients' lives in the community.

The Deputy of St. Ouen :

I hear what you are saying, Minister. But I am just thinking of the example of the Edinburgh situation that has just been described. You translate that to the Island and suddenly we have a big problem because, if a decision is made that we cannot afford, or we are unable to pay for the improved services in the community because of the cost to the public, and we find we have too small a hospital that has been limited because currently the size of the hospital is based on an affordable funding model, then what do we do?

Chief Executive Officer:

I think that there are issues there. Fundamentally, I believe that, if we can get the sizing of the resource available right, then we have a much better chance of developing a robust out-of-hospital system, a community-based system, than virtually any other jurisdiction you can mention, certainly in the U.K. (United Kingdom) situation, because the big advantage we do have is that we do not have the immensely fragmented system of care that they have in the U.K., particularly in England, but also to an extent in Wales and Scotland, where there are so many different separate organisations and groupings who, when they come together, will put the same vision on the table that we have to the States in October 2012 of wanting to develop services in the community, have a robust hospital as part of that whole system, have G.P.s at the heart managing the packages of care for their patients, we all say very similar things because those are the sorts of things that will work for patients. But then they fall down because their funding systems, money follows the patient sounds great, except money always follows the patient into the acute hospital, and trying to

get the patient out is not the hard part, it is trying to get the money out. We do not have those

systems here. We have what is virtually an integrated system and we have money, which does not come and have to follow people around as part of contracts, and therefore it is much easier ... there is no incentive for Helen and her clinicians to hang on to patients in the hospital, quite the reverse, they want those patients to be discharged easily and quickly, they want only the right patients to be admitted, because they want to get on with doing the things that only they can do. In the U.K. I think they have a system there where hospitals get money if more patients come in, so their incentive, although they know they want to put patients out again, the system works against it. So the big benefit we have is having far more integration and more ability to work together. The Island system, the Island culture, is much more conducive, family nursing and home care, the hospice, they wanted to come to the table and work with us. In the U.K. they want to come to the table and work but then all these ways that the money flows and the fact they are all independent does tend to mitigate against them making the changes.

The Deputy of St. Ouen : Thank you.

Deputy J.A. Hilton:

It sounds like we are in a much stronger position than most ...

Senator S.C. Ferguson:

Is this what happened in Edinburgh that the hospitals hung on to the money and the primary care could not get their hands on to it?

Chief Executive Officer:

There is an element of that and there is also an element of, whoever was responsible for implementing community services, they were not able to do it. So the services either were not being developed, or, where they were, they were developed insufficiently, or patients voted with their feet, because patients at the end of the day will still go to a hospital if that is where they have confidence. So you have to create systems and ways of delivering services that patients want. One of the good things about what we are doing on the Island is we may be going a little bit slower than the U.K. but we are getting it more right because we are getting patients saying to us: "We like this service. This is what we want."

Senator S.C. Ferguson:

We have a patient group, have we not?

Hospital Managing Director:

We have a patient group in the hospital following the listening post, yes.

Senator S.C. Ferguson:

Yes, so that you are listening to what they say?

Chief Executive Officer:

Yes, the voice of the patient is very important.

The Minister for Health and Social Services:

That is one of the strengths of Jersey, which you perhaps do not realise, is that we are health and social services, and I think we take it very much for granted, but when you hear, like you say, about Edinburgh, and other jurisdictions where it is fragmented, we have this opportunity to really provide very good services.

Senator S.C. Ferguson:

Surely some pressure on resources is being reduced by your lean programme. I hate to keep sounding like a broken record.

The Minister for Health and Social Services:

I think, Senator, if you did not bring it up, we would be most disappointed.

Senator S.C. Ferguson:

Well, as I said, John Seddon(?) reckoned 20 per cent out of our public services if we applied proper systems approaches.

Chief Executive Officer:

I think I would dispute the levels because I think you also have to look at where you start with your level of resources. If I was starting in the U.K., having had a decade of 8 per cent growth every year, I might well have thought I could take 20 per cent out. But I think if you look at the state they are in currently, on the back of 3, 4 years of real austerity measures, and you look at the pressures on their A. and E., you look at what is happening with their social services and their packages of care, I think that is a bit of a tall order. What "lean" does do, and what we are seeing increasingly is "lean" gives us a number of opportunities, not only to improve the service for patients, and that of course is the critical thing, by making their journey through much more streamlined, much more bespoke to what they need and taking all those delays and wastages out, it has allowed us to cost- contain and on occasion it allows you to make savings. But I don't see us getting anything like 20 per cent savings out.

Senator S.C. Ferguson:

I certainly question the austerity in the U.K. but I think that is an argument we can have elsewhere.

Chief Executive Officer: Yes, indeed.

Deputy J.A. Hilton:

Let us move on to healthcare financing now. What progress has been made in developing a sustainable model of health care funding for Jersey and what advice have you taken?

The Minister for Health and Social Services:

That is a Treasury question really. I am sure Treasury answered that for you on Friday.

The Deputy of St. Ouen :

We been lead to believe that you were a partner in the development of the healthcare funding, because obviously you are the one that knows the costs, is that not true?

Chief Executive Officer:

We can provide lots of information, and do, about what we spend our money on currently and where the pressures are and what we would like to spend money on in the future. Looking at the original KPMG work, they of course did present their estimate of what implementing the new system based on scenario 3 would cost, and over the lifespan of that project it was a considerable amount of additional money. The money that we bid for in M.T.F.P. (medium-term financial plan) one was consistent with the trajectory of their line of growth and the money that we hope to bid for in M.T.F.P. 2 is also consistent with that line of growth. It is a considerable sum of money. Clearly it is not the Health Department's responsibility to decide how much money and where it comes from, we are just the grateful recipients of it in order to put services into place.

The Deputy of St. Ouen :

Sorry, just be clear, you are saying that it is a Minister for Treasury and Resources' responsibility to develop and produce a model for healthcare funding?

The Minister for Health and Social Services:

As Julie said, we can provide all the data and all what he needs, but at the end of the day it is Treasury that have to work out sustainable funding going forward, putting that in the Council of Ministers, over the next long-term financial planning, and at the end of the day it will be a States decision.

The Deputy of St. Ouen :

How do we ensure that ultimately the funding that is produced or decided upon or named by Treasury Department will meet the needs of the Island?

The Minister for Health and Social Services:

I think it is because of all the information and all the data that Health collect, which feeds into Treasury.

The Deputy of St. Ouen :

So it is not a case of just you providing data, it is you playing a part in discussions or entering into conversations with the Treasury Department to ensure that whatever they propose you can be satisfied that will meet the needs of the ... all right, so it is not just a case of ...

The Minister for Health and Social Services: Yes.

Chief Executive Officer: Yes.

The Minister for Health and Social Services: It not just: "Here is the data," get ...

The Deputy of St. Ouen : So it is an involvement?

The Minister for Health and Social Services: Absolutely, yes.

Deputy J.A. Hilton:

Can I just ask you a question about that, I think you just said you had submitted your growth bids, are you able to tell us what sum of money that was for?

I cannot recollect off the top of my head. I think we have provided the papers to you previously, from memory, I think ...

Deputy J.A. Hilton:

My point is that you presumably submit growth bids for services that you believe Islanders need, but presumably there is a chance you are going to be knocked back for that money. So, it is you as management of the hospital, which decides presumably, with your clinicians, which services you are not going to deliver that you originally felt Islanders needed.

Chief Executive Officer:

If that was the set of circumstances, if we asked for sum A and we got sum B and sum B was less than sum A, obviously what we would do is a piece of work, as you have said, with clinicians and managers in the hospital or in community or in social services to say this is what we wanted to do all of these things, this is what we have, so where are the priorities in that and why? And then we take that to our Ministerial team and talk them through those decisions and those suggestions and ultimately of course the Minister would take the decision as to whether or not we would proceed in that direction or some other direction. But ultimately we have to stay within budget.

[11:30]

So, if we do not have enough, because we always look to see if we can do more with less, so we would not give up on a service until we had really looked through it and said, is there any way we could possibly still deliver this, or perhaps we can deliver part of it but not all of it, but that is part of the ongoing debate between the Treasury and ourselves, and the Treasury and every department, because every department will have its bids that it would like to develop services, but ultimately there is not a bottomless pit of money, so decisions have to be made.

The Minister for Health and Social Services:

So, when budget comes to Council of Ministers, it is important for me as Minister to say: "This is the money that we will need and the reasons." But ultimately, as Julie says, it has to be a fixed budget, which will come to the States.

The Deputy of St. Ouen :

Just following up on the comments that have just been made, what efforts are being made to ensure that you can demonstrate that you are providing best value for money relating to the individual services that the department provides?

Chief Executive Officer:

There is a range of ways that we would do that. I mean obviously in relation to new services that are subject to the business case development that goes to the (overspeaking 11:31:11)

The Deputy of St. Ouen : Forgetting about those for a minute.

Chief Executive Officer:

For services we are already giving, we are looking constantly across the department at where we can benchmark, where we can look and see how much does it cost for us to do that, can we get benchmarking information from somewhere else, does it look like it is too high, does it look like it is too low. So there is a range of things that we do but I do not know if you want to comment from the hospital's perspective?

Hospital Managing Director:

It is all about productivity and efficiency measures that you can benchmark as well, so, for example, what is your length of stay for each patient group, how many patients do you get through theatres, what is your theatre utilisation rate like, do we have delayed discharges. So it is all those productivity and efficiency measures that we can compare with other hospitals, as well as the pure costs, which I know some of Jason's team are working on to get the details.

Director of Finance and Information:

I was going to say perhaps I can add, there really is a myriad of different things that we do to make sure we get the best value of money that we can, ranging from the very obvious procurement processes where you go out to tender and so on to get the best value that you can, through to some potentially quite sophisticated benchmarking processes, something that the panel may be interested is we have literally just got together, myself and my colleagues from the Isle of Man, Guernsey, the Isle of Wight and Gibraltar, to look to see where we can compare, contrast and benchmark island or small jurisdiction services, where there are integrated services, to understand how each of those jurisdictions is working at a very low granular level to see whether we might be able to drive out improvements, efficiencies, where we can learn from each other, and all those jurisdictions, the finance directors have met recently, and we have all committed to work together to try and progress some of those issues, again the objective being can we learn from each other, can we identify some improvements that will improve value for money. That could be a new service that we are looking at or it could be something that one of the other jurisdictions is about to embark on but perhaps we want to see how that works, or it could be a service that we have all been providing for the last 50 years.

The Deputy of St. Ouen :

So, just sticking with existing services, just parking the new services to one side, because I know that there is slightly different attitude and view taken to how those are managed. As finance director, how confident are you that the information is available for you to be able to determine the forecast of individual services across the department?

Director of Finance and Information:

I am very confident that we know the full cost of all our services, we can account for every last penny that we spend. One of the things that we are trying to do to move forward and improve our understanding of the value for money that we are getting and how we can push that even further is to bring together the costs and the activity and the outcomes that we have been talking about, to try and squeeze more improvement for every pound that we spend. That does not happen overnight and it is a continuous process and it is something that we are looking at, everybody is look at. It would be wrong for me to say that we are ever going to a point where we say it is absolutely done, finished. It is something we need to continually check with ourselves to do.

The Deputy of St. Ouen :

In that case, if you have not got clear information about the cost of services, it is more difficult to make a case that it should be running.

Deputy Director of Commissioning:

We have clear information about the cost of our services.

The Deputy of St. Ouen :

So, when you make a bid to Treasury Department for additional money, you are confident that that bid is appropriate and should not be done down?

Director of Finance and Information: Yes.

Senator S.C. Ferguson:

So you have got it down to the level that if I asked you how much a hip replacement, standard version, costs, you could tell me?

Director of Finance and Information:

The way in which we cost services (overspeaking 11:35:15)

Senator S.C. Ferguson:

No, no, I just asked a simple question.

Director of Finance and Information:

I am trying to explain. The simple answer to hip replacements, for example, is yes, we have that both for private patients and for public patients, so we can answer those questions and we have done on a number of occasions. We are continually refining the way we do it and that relates again back to some of the work that we are trying to do with the other jurisdictions to understand the differences between here and the other jurisdictions to see if there is improvements that we can make.

Senator S.C. Ferguson:

So you can sit there and tell me how much a hip replacement would cost?

Director of Finance and Information:

Not this very second because I don't have the information. I could do if I went back to office.

Deputy J.A. Hilton:

I would like to move on to new hospital plans now. How confident are you that investing £297 million in new hospital facilities will provide for the Island's needs over the next 50 to 60 years?

The Minister for Health and Social Services:

I am very confident, as you well know that the hospital does need a revamp, it is past its sell-by date, and it does need to be looked at for a huge number of reasons. We know that we need to extend because of the capacity for the demand of services, which we have been discussing now. The poor condition of the hospital and the suitable space, bay walls, et cetera, which is not right going into the future. We also need to deliver a safe and affordable hospital for the next generations and it is something that we need to do and not doing it is not an option.

Deputy J.A. Hilton:

No, no one is questioning whether we should do it, Minister, so we will not go down that track today. But really we are interested to test your confidence in the present sum that is being suggested, which is £297 million, when, after engaging with experts in the field and in close discussion with the department, that a figure of £450 million was produced as an appropriate cost for a new hospital to meet the needs of the Island. Suddenly, we have a figure that is £150 million less and yet you are saying we can do it. I ask, and I come back to the question I asked earlier,

either we can rely on the information that comes out of the department or we cannot. If the

department is saying we need £450 million to deliver the services on the Island and the hospital to provide for it, how can you then turn around and say, forget about all that, we can do it for £300 million? Can you just explain some of the ...

Chief Executive Officer:

I will have a go at explaining that. If we were to build a whole new hospital in a one-off development where every single part of the hospital was new, built from scratch, then the pre- feasibility estimates that Atkins came up with, looking at all of the costing information they had at their disposal, health building notes, all the things they do to test and build a sum, they came up with sums that ranged between £400 million and £450 million. That is for a whole new build on a number of different sites. We spent, "we" being our department, Treasury, Property Holdings, everybody spent a good 6 to 8 months drilling down into those figures because they were big figures, saying what could we do differently, could we reduce this? Then there is an expectation that if you move into feasibility stage with a large sum and a large building you will, through value engineering and just firming up on your requirements, reduce the sum, but it would still be a big sum. Having tested and challenged and looked at schemes elsewhere to see who was building what and what it was costing them, there was a growing realisation that it seemed highly unlikely that it would be possible to deliver a sum of £450 million or £400 million to have a new build. At the same time, it was also proving extremely challenging to find a site to do that with. Whether you stayed on the current hospital site, which was fraught with risks and challenges and issues about rebuilding a whole hospital there, or move to any other site you could find, there were always issues. So it was at that point that we had to take I think a very prudent decision to say, what sort of money might we work with? So that figure was developed at that point. I do not know that there was any great science behind it, it was just, if we would talk about this sum of money, which feels much more doable, what could you do?

Deputy J.A. Hilton:

Can I just stop you there one moment? In the KPMG report there was a figure of £300 million mentioned. Is that where the figure of £300 million or the £250 million to £300 million came from?

Chief Executive Officer:

I do not know, because it was not a figure that we invented within the Health Department. They came to a figure, I think we have talked about this before, it was based on their very broad-brush

knowledge that generally speaking you work on a million a bed, so if you are going to have a 300- bed hospital you would have roughly £300 million, but that is at U.K. prices and we know there is a premium for building on Island. But I would imagine, and obviously it is for my political masters to say yay or nay to that, but I would imagine it is quite hard to understand why, if KPMG are saying

roughly £300 million, you end up with something that is sitting at £400 million, £450 million. So I think it is that sense of unease about this is an awful lot of money, could the Island really deliver that sum of money? So really the £250 million, it ended up at £300 million, was just a "let us see what we could get for that". Now, I think, if I am being honest, I went away thinking there is no way we can do that. But when the design champion came in and had a look at the whole situation, had a look at the work that Atkins had done, and just asked the basic question about how do you do it now? You happen to be working on 2 sites as it is, is there a model that involves that? Trying to maximise the benefit between some new build and some major refurbishment and do all the things we set out saying we wanted as benefits for Islanders to ensure that we were offering a safe and sustainable set of hospital services for the future. Obviously, as we have talked about before, Graham was able to come back within a couple of months and say, "You could do it like this", and we talked to our clinicians and there was a range of views but they broadly said, "If that is what we are doing, we could probably make it work", and we do get the bulk of the benefits that we wanted. The big compromise is twofold, one of which is, whichever way you do it, 10 years is a long time to be spending trying to develop new hospital services, and it does affect the site that we are working on, which does have an impact on patients and staff, and it does affect the overall cost, depending on how long you take, and obviously in an ideal world you would like a whole new build somewhere. But we are not in an ideal world, we are in a realistic world, so that is how we ended up where we were.

Deputy J.A. Hilton:

For our part, we are just trying to understand where that figure came from originally because, despite various hearings, we still have not really bottomed that out. I asked you that question last time and I said: "You do not personally have an idea how that sum of money was reached, how that figure was reached?" You responded: "I do not know, but I do not think anybody ever sat down and did a special sum with a formula behind it to say we think this sum is this."

Chief Executive Officer:

That would be ... I still think that.

Deputy J.A. Hilton:

That is fine, but as a scrutiny panel we are just still trying to understand where this figure came from and we are getting sort of conflicting advice.

Assistant Minister for Health and Social Services:

I think it was a concept figure really, it was like £400 million is quite an aggressive figure for the Island to have to find and I think it came out of a session: "Well, if we only had something like quarter of a billion, what could we do with that? Let us have a look at what could we achieve with something like £250 million (overspeaking 11:43:30)"

Deputy J.A. Hilton:

Did that figure come from Treasury initially?

Assistant Minister for Health and Social Services:

I think it came out of general discussion, from my recollection (overspeaking 11:43:37)

Assistant Minister for Health and Social Services:

We send to Atkins back to say, if that was the figure, what out of this gold star ... if you took some of the cost of the green field sites and having to have a dual carriageway to get to them, because the build was not just the build, it was when we build that, when we were presented with some of these green field sites they had tiny lanes, so it was a lot of the extra infrastructure that brought up the £450 million that then we said, "Right, go away, see what we can build for the main patient improvement, operating theatres and everything else, come back and let us see what we have". Basically they did come back, we were not very impressed in the oversight group, the Minister for Treasury and Resources, nobody was impressed with what they gave us for £250 million. So that is when we decided second pair of eyes and we seemed to have got a lot more for our buck basically because we are doing it on the 2 hospital sites, we have Overdale, it is there in town, it is ready to go.

The Deputy of St. Ouen :

We come back to the original question I suppose, and it is around about how confident are you that the £297 million will provide for the Island for the next 50 to 60 years, because from what you have just told us, and the fact that we are not having a complete new build, and we are going to be refurbishing, we are not going to be doing certain things, because of the compromises around the money, that it is potentially likely that there will be additional costs required over that 50 to 60 years as life of refurbished buildings comes to their end. Is that not the case?

[11:45]

Assistant Minister for Health and Social Services:

That is the case with any building though, James. There is always ongoing maintenance costs, even with a new build there will be ongoing maintenance costs, there will be settling in costs as well. I think the as far as the work that we have done, and we are looking at it as part of a

Ministerial oversight group as well, we have been challenging this all the way through, every single

element of the costing, and saying, is this viable going into the long term? And yes, it is. They are having to make some compromises about is it squeaky-clean new or something being refurbished. The refurbish will be, from the patients' perspective, like new. What the patient will see will be a new hospital; wherever they go, they will see a new hospital.

The Minister for Health and Social Services:

If you kind of ask me a question, would I like to see a brand-new site, leave the hospital, turn the key and walk to a brand-new one, yes, of course I would, nobody would not, but then also we live in the real world. We know that work that was done beforehand, that a greenfield site to take the size that the hospital needs, which is one and a half times the size it is now, I think, approximately, is a big site, and to include all the infrastructure that goes with it, it is just not feasible. Therefore a compromise has to come, because at the end of the day, we have to live in the real world and we have to make sure that this is funded right from the start to the end. That is the most important thing.

Senator S.C. Ferguson:

Did you look at the greenfield site with some of the assumptions that you have made with the £250 million, £300 million site? For instance, the size, I think you have reduced room sizes by 15 per cent or something on the U.K. standard. Have you gone back to the greenfield site and looked at that?

Chief Executive Officer: No, no.

Assistant Minister for Health and Social Services:

I think that is what we were hoping Atkins would do when we said: "Here is your £250 million budget." What they came back with were different things. It was not front up patient services like rooms, getting down to rooms. They were not in there.

Deputy J.A. Hilton:

I think in the previous hearing it was Will who answered this question. I was asking them questions around feasibility and my understanding is ...

The Minister for Health and Social Services: Feasibility or pre-feasibility?

Deputy J.A. Hilton:

It was all to do with the dual-site option and going ahead with the feasibility study, okay, and so the question I have is we have just talked about the 3 preferred sites, the Atkins options, which were priced between £440 million (overspeaking 11:47:53). Senator Ferguson has just mentioned the standard, and the dual-site option is based on the room standard being 15 per cent less than the U.K. best practice, which is fine, I do not think anybody has an issue with that, but what I was disappointed to hear - and I think Will confirmed this - that nobody had gone away and looked at the 3 models that had been put forward initially and reduced those room sizes by 15 per cent for a start. I think the Treasurer in the hearing mentioned to us ... when we asked about contingency, I asked her about a figure of something like a third for contingency on the new build, which is an astronomical figure, and you have just said yourself that when you go into a more detailed study, then you would expect that figure to reduce. I think as a panel, we are just disappointed that extra work was not done to test those figures, because we are talking about £300 million - £300 million, give or take - for a refurbishment on a dual site as opposed to a new build of £450 million, but the figures had not really been challenged.

Assistant Minister for Health and Social Services:

There are several aspects to the decisions when we looked at the £450 million. It was either 23 or 28 sites we looked at ... 27, something in that range. Thank you, Will.

Deputy J.A. Hilton:

But Atkins got down to the 3 sites.

Assistant Minister for Health and Social Services: Absolutely.

Chief Executive Officer:

Atkins got down to 3 and the M.O.G. (Ministerial Oversight Group) got down to one. The Ministerial Oversight Group had reached the conclusion that the preferred site was a redevelopment on the General Hospital site, so we had already made a decision within the Ministerial Oversight Group at that point that whatever was done would be done on the current hospital site.

Deputy J.A. Hilton:

But that was because it was bound by the £300 million envelope, was it not?

Assistant Minister for Health and Social Services: No, no, no.

Chief Executive Officer:

No, not at that point. The new build was going to be on the General Hospital site, because it was our site, and try as we might, we could not find the other site that did not have all these other problems associated with it, so although there are a lot of problems associated with doing a complete rebuild on the current site - and we have talked about them before and we can talk about them again - but the decision within M.O.G. at that stage had been that there was a preferred site and it was the General Hospital site, so when the point came of saying: "It is just that we cannot live with £450 million" which was the cost of the new build on the General Hospital site, then the test and challenge was around that preferred decision. What I would say is that I do not think the 15 per cent reduction applied to any of the other 2 options would have saved £150 million, nowhere near it.

Deputy J.A. Hilton:

No, I am sure it would have saved, but ...

Chief Executive Officer:

So I do not think it would have been a deciding factor in this.

Deputy J.A. Hilton:

I am not saying that it would have done, but I did not feel that we were comparing apples with apples and that was my concern.

Chief Executive Officer:

Because we were not doing a comparison.

Deputy J.A. Hilton: No, I know, I know.

Chief Executive Officer:

The decision was made that it would be where we were.

Deputy J.A. Hilton:

But can I just come back to you, Minister? I think your Assistant Minister said the decision about the £250 million came out of the Ministerial Oversight Group, which is yourself, the Chief Minister and the Minister for Treasury.

Chief Executive Officer:

And the Minister for Social Security.

Deputy J.A. Hilton:

Okay. So what is your recollection of how that decision was made that it was going to be £250 million?

The Minister for Health and Social Services:

I think it was putting a reality check on that. We knew £400 million, we could not afford that.

Deputy J.A. Hilton:

Who said we could not afford it?

The Minister for Health and Social Services:

It was discussed at that Ministerial Oversight Group.

Deputy J.A. Hilton:

But was there any one person just driving that argument that the Island could not afford the £400 million?

The Minister for Health and Social Services:

The money sits with Treasury to say how much can the Island afford and that is the figure. It was discussed at a robust discussion around that Ministerial Oversight Group, but also taking into account what we can deliver, which is the most important thing.

Deputy J.A. Hilton:

Okay, but on what basis was that figure ... just trying to understand the assumptions that were used, that if you are saying that Treasury said: "We can afford this figure" on what assumption we have used to arrive at that figure?

Assistant Minister for Health and Social Services:

Can I help you at all? Can I help at all, Jackie? Basically the decision, from my recollection of that time, we sat down and we spoke about the costings on those preferred sites, and as Julie just said, we came down to 3 sites, and essentially the hospital was the final preferred site. The question was posed with the sort of budget and the financial conditions we were in at that time: "£400 million is almost a bit too much to swallow in the current environment. How are we going to raise that funding?" The question was let us say we only had £250 million to spend going forward, how would you achieve that? So that was one of Will's early roles, to go out and have a look: "What could we do? Is it realistic to even look at a £250 million development?" That was worked around and they came back and said: "It is almost doable, but we need to stretch the budget a bit and we are going to some more work to stress test that." So it really evolved down to the figure that we are now at, basically a suggestion around the Ministerial Oversight Group saying: "If we were to say we would only put up a fund of £250 million, then what would we get for that money?" and what we have achieved now is a very good result, albeit with a stretched budget.

Deputy J.A. Hilton:

But taking into consideration ...

The Minister for Health and Social Services:

Sorry, you have got to bear in mind too that this money, there is no ... like kind of with the housing bonds or whatever, the rent from the housing will be going back to pay the £250 million, but with the hospital, there is no payback, because we have no income.

Deputy J.A. Hilton:

I know. Treasury have done an amazing job on ...

The Minister for Health and Social Services: They have done.

Deputy J.A. Hilton:

... investing the Strategic Fund and getting a return of £91 million in one year, which is absolutely brilliant. I just wanted to ... I have lost my train of thought. Oh, I know, I have read a figure somewhere that the additional cost of running the dual-site option I believe is something like £6.38 million per year.

Director of Finance and Information:

I think you are recollecting the figure from the strategic outline case.

The Deputy of St. Ouen :

No, it is written evidence that we were provided by the Treasury Department prior to our public hearing.

Deputy J.A. Hilton:

On that basis, I think that is probably new evidence that we have not had very long, but on that basis, when you take that figure and over a period of 20 to 30 years, it is one hell of a figure, and so that again has made us stop and ask the question, is the dual-site option the best option when you take into consideration concerns that have been raised about pathology being based at Overdale, transporting people, the additional cost of transporting people between the 2 sites? There is a whole myriad of reasons that are coming up that are causing us concern and we just want to be reassured that ... has anybody got a comment to make on that figure?

Chief Executive Officer:

It is a bit chicken and egg though, is it not? If somebody was to say you: "Would you like to have £450 million and build a brand-new hospital?" then yes, please. I still think there would be some real challenges about what you would do where, because I still have real concerns about a massive rebuild on a single site that is still trying to deliver services to patients over a period of time. I quite recently visited the Alder Hey Hospital, which is building a brand-new hospital currently. The current Alder Hey Hospital is here, and over the road is a big park and they are building their new hospital there, so they are getting on with delivering their services day in and day out to patients; the new hospital is going up and then one day they can lock the door and everybody else is over the road now, and then the park land will be re-provided back on the site. That is the ideal scenario, but we tried for at least a year. We looked at every site going on the Island, every geographical system was out, we worked with the planning people. There is not a place to do it and the issues of building a whole new building on the one site of the General Hospital I think would have had us tied up in planning for donkey's years.

Deputy J.A. Hilton:

Yes. My understanding is the 3 preferred sites was the Warwick Farm site, the General Hospital site and the waterfront.

Chief Executive Officer: The waterfront.

Deputy J.A. Hilton:

I believe that Atkins said they preferred either the Warwick Farm or the waterfront. That is my understanding.

Chief Executive Officer:

There was not a lot between them, but I think the waterfront site was the number one site.

Deputy J.A. Hilton:

Yes, that was my understanding also.

The Minister for Health and Social Services:

But I think also taking in context the size of the new building, yes, I think to get your head around it, it is what, 9 floors? It would be 9 floors.

Assistant Minister for Health and Social Services:

We are looking at possibly going up to 6 floors, or 6 clinical floors, equivalent to a 9-floor building. To give you an idea of what a 9-floor building looks like, have a look at Cyril Le Marquand House and imagine that 10 times larger but that height sat on the waterfront.

Deputy J.A. Hilton:

But does Cyril Le Marquand House fit perfectly there? We do not look at Cyril Le Marquand House and think: "Oh, my goodness. Why did we put such a tall building there?"

Assistant Minister for Health and Social Services:

Would you put something that size on your waterfront? The answer is no. We would never get through planning. Look at the issues we have got at the moment trying to get a 5-storey building on the finance area.

The Deputy of St. Ouen :

Anyway, we are not here to discuss sites. I still find it difficult that ... and I understand that obviously Ministers are electing to undertake certain responsibilities, but to make a decision around what price should we spend on a hospital without necessarily seeking the public's view, especially when we are talking still a considerable sum of money, whether it is £300 million or £400 million, is something that needs to be explained and then the public need to just understand, as we do, the process that is followed. I think that we will move on, but if you have evidence that you can provide us that shows us and explains to us the background behind the move from what was the Atkins proposal and figure and then this new figure being introduced of £250 million, it really would be helpful, because we are still struggling with that.

Chief Executive Officer:

I do not think we have anything beyond what we have said. I do understand the dilemma that you are expressing. The one thing I would say is that we desperately do need to get on with developing the future hospital, for all the reasons that I know you are all very aware of in terms of the challenges of the current hospital and its infrastructure and the state it is in. I think we, in our department, are pragmatists. We have spent now the best part of nearly 2 years looking through all of these various options. We believe - and we have looked at it very carefully now - we can deliver a very, very good option with the £300 million on the dual site and while the heart of me would love to have a brand-new build and have £450 million or £400 million to spend on it, my fear is we could still all be sitting here talking about it in 5 or 10 years' time.

Deputy J.A. Hilton:

That cannot be allowed to happen, so we fully understand a decision has to be made on this as soon as possible and we need to be moving on with it, delivering.

Senator S.C. Ferguson:

I am curious as to where the fag packet was that somebody worked out £250 million.

Chief Executive Officer:

There are no fag packets in our department.

Senator S.C. Ferguson:

But somebody has worked out £250 million on the back of a fag packet somewhere and it is where it is.

[12:00]

Deputy J.A. Hilton: Sorry, Minister.

The Minister for Health and Social Services:

Yes, about the consultation, we have been out to consultation, not only initially with KPMG, but with the dual site - and it is still ongoing - at the future hospital, we went out to consultation with our staff, clinicians, community stakeholder groups, as well as the general public. I know that Bernard is still continuing that process of engagement and it will continue for however long it is needed, so that the public understand the concept, because at the end of the day, it is the public money that is paying for the hospital.

Deputy J.A. Hilton:

Thank you. Moving on, we wanted to ask you a question around single-bed wards. Has a decision been made to have hospital facilities providing only single-bed wards with ensuite facilities?

The Minister for Health and Social Services:

I do not think a decision has been made, but I made it extremely clear that my preference is for, as far as possible, 100 per cent single rooms. You know the reasons why, and I am very much aware that there are some areas like critical care and perhaps the children's ward that are not conducive to single rooms, but however far as possible, it should be single rooms. I am happy to go down very many avenues for the reason why.

Deputy J.A. Hilton:

Yes. Has that decision been made yet?

The Minister for Health and Social Services:

Not completely, no, but I shall be very disappointed if for one reason or the other ...

Deputy J.A. Hilton:

Who is going to make that decision?

The Minister for Health and Social Services: I think it will be the Ministerial Oversight Group.

The Deputy of St. Ouen :

Just remind us, which Ministers sit on the Ministerial Oversight Group?

The Minister for Health and Social Services:

It is chaired by the Chief Minister, obviously I am there and my 2 Assistant Ministers, the Minister for Treasury and the Assistant Minister, the Minister for Social Security and his Assistant Minister and the Assistant Chief Minister.

The Deputy of St. Ouen :

So is it the Chief Minister that has overall responsibility for the Ministerial Oversight Group ...

The Minister for Health and Social Services: He is chairing it.

The Deputy of St. Ouen :

... and the delivery of the new hospital?

The Minister for Health and Social Services: Yes, he ...

Chief Executive Officer:

The delivery of the whole system.

The Deputy of St. Ouen : The Chief Minister?

The Minister for Health and Social Services: Yes.

Deputy J.A. Hilton:

Was this a condition given to Atkins in their earlier work? If no, then when was it decided as a key factor?

Chief Executive Officer:

No, it has always featured in our brief.

Deputy J.A. Hilton: Has it?

Chief Executive Officer: Yes.

Deputy J.A. Hilton:

From the beginning? Okay. Can you provide a figure for the additional cost to the build process associated with having only single-bed wards in absolute cost terms and as a proportion of the build cost?

Director of Finance and Information:

I do not know if you asked the Treasurer this question. There is a paper that Atkins were asked to prepare by the Ministerial Oversight Group somewhere back in early 2013, I think, to look at the single accommodation, single-bedded wards, and the cost of that. I think you have a copy of that document. That talks about what would the impact be if the total had 50 per cent single rooms and 50 per cent multi-bedded rooms and what impact would that have. That came out with a figure that suggested that could save up to £4 million, which is about 1.5 per cent of the total cost at the time. However, what it did not reflect was that the fact that you would need to make some other allowance in a build that was 50 per cent single rooms, 50 per cent multi-bedded wards for the same reason as now we have got an issue that if there is an infection in a multi-bedded ward and you have to close the whole ward, you lose a number of beds. You would have to make some allowance if you were going to take 50 per cent multi-bedded wards to cope with that, so you probably need some extra capacity build in there, which would mitigate against that £4 million too. That is the long answer. The short answer is it does not generate very much at all.

The Minister for Health and Social Services: You cannot put a price on dignity and privacy.

The Deputy of St. Ouen :

You say that, but you already stated that already compromises have been made, and one of those compromises is that bed spaces are going to be smaller than they should be. How do you respond to that, Minister?

The Minister for Health and Social Services:

I think a lot of work ... when Atkins or whatever - I cannot think who, which it was - went out and looked at the sizes of the rooms, we were going first, as I understand, by N.H.S. (National Health Service) guidelines, and quite rightly questioned: "Is that average across other jurisdictions?" asking the question, as you would expect, that we would do, and when more detailed work was done, it came across very clearly that the N.H.S. guidelines were on top of the scale compared to other jurisdictions, so therefore more work was done on if we reduced that size, is it still acceptable to the clinicians, to the managing staff?

Chief Executive Officer: We did test it, did we not?

Hospital Managing Director:

We did, and when we said there is a 15 per cent reduction, it is not across all areas, so we would be looking circulation space, we would be looking at certain areas that are perhaps not as critical clinically. If you take an intensive care unit, we did not want to reduce any space at all. If we were ending up with any multi-bedded wards - which I absolutely agree with the Minister we should not - but if we did, we would not compromise on that, we would not want that reduced in size.

The Deputy of St. Ouen :

You talk about the hospital needing to be flexible to meet potential demands, given that the out of hospital community services are not provided or do not happen in the way that you plan they would. How does a single-bedded hospital provide that flexibility?

Hospital Managing Director:

We get more flexibility from having single rooms from an operational point of view.

The Deputy of St. Ouen :

So you have got 2 in each room, is that the idea?

Hospital Managing Director:

No, but you do not have the issues of mixing sexes of patients in the same bay, so that you do not have to worry about: "Am I admitting a male or am I admitting a female?" You do not have the issues around infection control and having to make sure that you are separating different categories of patients, because they all have their own room with their own infection control measures. You get far more flexibility operationally out of single rooms.

The Deputy of St. Ouen :

But that is given that you manage within a certain number. You have already told us or we know that we are in need of an additional 50 beds now. Now, if that was the case and we only had single-bedded rooms, given all of the issues that you have already dealt with, how does that provide that flexibility to add another 50 beds to a totally single-bedded hospital?

Chief Executive Officer:

But if you went for 4-bedded and 6-bedded rooms in the new hospital and you needed more beds, you would not have any more flexibility. You would still have to build more beds.

Hospital Managing Director:

You would not put an extra bed into a bay.

Chief Executive Officer: No, you could not.

The Deputy of St. Ouen : Sorry, just ...

Hospital Managing Director:

If you built multi-bedded wards and you thought you were running out of beds, you would not put an extra bed into that multi-bedded ward. That would be a real clinical no-no.

The Deputy of St. Ouen :

Even if there was a need and that the alternative was that you would not provide for patients?

Hospital Managing Director:

You would not just put extra beds into a clinical room. I mean, that is really the wrong thing to do. What we mean by flexibility is that you build it in such a structural way that office blocks or admin areas would be able to be become clinical, so you do not restrict yourself to what is clinical and what is not clinical. We do not mean it is about where you put a bed.

Senator S.C. Ferguson:

Right, so if we had an epidemic, you just have made sure that the chief executive's office would take half a dozen beds and he would be out?

Hospital Managing Director: Yes, absolutely.

Senator S.C. Ferguson: Right. That is flexibility.

The Deputy of St. Ouen :

Yes, I will not challenge what you said, but certainly I will do my own work on trying to understand it, because - and maybe I have not expressed myself clearly - I was of the belief that a number of hospitals that are currently in operation, and new ones, had a mixture of single-bedded ...

Hospital Managing Director: Some do.

The Deputy of St. Ouen :

... and wards to allow for a greater flexibility than would be given to a complete single-bedded unit. Maybe I have got the wrong view, and if I am wrong ... I think we should test it.

The Minister for Health and Social Services:

You would expect, going down your line, if there was a need for more beds, by using a 4 or 6- bedded bay, whatever, what you mean by flexibility is that they would put another bed in that bay, is that what you are saying?

The Deputy of St. Ouen :

No. As I understood it, if you are going for multiple-bedded wards, you create the ward to be bigger than it would be, that it is absolutely suitable and large enough, up to modern-day standards, to cope with 4 or 6 beds or whatever and maybe build in some additional space so as and when need increases ...

Hospital Managing Director:

But then you are building more additional space than a single-bedded hospital.

The Deputy of St. Ouen :

... or demand increases, it does allow you to utilise that facility for ...

Deputy Director of Commissioning:

I can probably help a little bit here. I think what you might mean is that some hospitals will have what they call decamp facilities, so that when there is perhaps infection outbreaks, they have got ward spaces or single-room spaces that they can open up at different times of the year, which increases the capacity overall, so ...

The Deputy of St. Ouen : That could be it.

Deputy Director of Commissioning:

... I think that is probably ... you hear about that when you hear stuff on the news about hospitals in the U.K. when they are under pressure and they go to decamp facilities, and that is what they do, so they have a bigger space than they ordinarily need, and at different times of the year, they can staff the beds, and at other times of the year they will close them.

The Deputy of St. Ouen :

So my question is will we have that in the new hospital?

The Minister for Health and Social Services:

That would be the intention. Yes, that would be the intention, yes.

Hospital Managing Director:

With the addition of only 50 beds, I have said to you before I think we have been very conservative with our number.

The Deputy of St. Ouen : Okay.

Deputy J.A. Hilton:

Can I just ask you a question about the 50 beds? In P.82 it talks about additional 50 beds by 2017, I think. How are you going to deliver those 50 additional beds?

Hospital Managing Director:

We are not, by 2017. You are right, there was an early ... I have got it written in here somewhere. There was an early modelling that showed you needed, I think it was, 10 initially, then another 20 and then another 20. We have done some work. That was based on the assumption that some of the White Paper initiatives would not be in place and that demand would be managed not as effectively as it is today, so it was a worst-case scenario. What we have looked at, and Jo has helped me some of this, is how much of the White Paper initiative is working and if we can start with some of the end cap work sooner, could we manage for a longer period of time? Our plan at the moment between now and the complete new build would be that we put some additional beds into Samarès so that we can have a few extra beds there, but we might need to what we call spot purchase, but use some of the private sector beds to enable the discharge of patients more effectively, and we manage our own bed flow more effectively, so we are not planning to have 50 beds by 2017. We are planning some, but we will look at flexing that and how we get to ...

The Minister for Health and Social Services:

Yes, and making sure that services in the White Paper are in place.

Deputy J.A. Hilton:

Yes. So are you saying that those 50 additional beds that were previously mentioned in P.82 are not going to be delivered at the General Hospital site, but they are going to be delivered at other locations?

Hospital Managing Director:

Yes. There is no space at the General Hospital.

Deputy Director of Commissioning:

Just to add, we also think that we need 50 because of the work that we ... some of the learning from the intermediate care pilot, and it has helped us to have a look at some of that in a lot more detail and that is, for example, why the rapid response service that the Minister has referred to, we have accelerated implementation of that part of the hospital system because we know that that is going to have the biggest impact on reducing the beds, so there are a combination of different ways we think we can manage that transition capacity by doing things differently and using the whole system resources, rather than just the very simple idea was that it had to be hospital-based. We have just learnt a lot from the work that we have done through the pilots.

Deputy J.A. Hilton: Okay, thank you.

The Minister for Health and Social Services:

I think it highlights the importance that we are community and social services, and also the importance of working with our partners in the community.

Deputy J.A. Hilton:

Can I ask you a question around States approval of the dual-site option? We had the Minister for Treasury and the Treasurer here on Friday and there definitely seems to be a level of confusion around what was agreed by the States, and so I just wanted to ask you whether you intend to have any further debate on the dual-site proposal or will Members simply be asked to approve the funding in a future budget?

The Minister for Health and Social Services:

When I made a statement in the States about the 2-site using our current assets and also in the budget last year, the Minister for Treasury made it very clear that it was on the dual site as well after that, and we have had many presentations about that as well as, as I said, about consultation

with the general public as well. I think when States Members decided to go ahead with the funding

which was in the budget, it was on the understanding that it was a dual site, because all the work that we have explained here to get to this point had been done. There are going to be tough decisions next year of when we get into the proper feasibility ... there is a title for it and I cannot think what the phrase is, but the feasibility, and also I think there is going to be another request for money in the budget this year.

[12:15]

The Deputy of St. Ouen :

So just to be clear, is the Ministerial Oversight Group's intention - or your intention, in fairness - to come back to the States and seek approval for the dual-site option?

Senator S.C. Ferguson: And £297 million budget?

The Minister for Health and Social Services:

In some ways, we have already done that with the budget at the end of last year, but next year, I think in the middle of the year, it will be coming to the States, as I said, about the feasibility.

The Deputy of St. Ouen :

Are you able to direct us to where the States has been asked to approve a dual-site option?

The Minister for Health and Social Services:

As I said, the statement that I made, but also - and understand it was a statement - that within the budget, it was discussed that if States Members did not like this or did not want to approve the budget that they could have done that at that time.

The Deputy of St. Ouen :

Sorry, are you saying that within the proposition that accompanied the budget it made specific reference to a dual site?

The Minister for Health and Social Services:

Yes, the Minister for Treasury made that very clear at the time.

The Deputy of St. Ouen : Did he?

The Minister for Health and Social Services:

He did, and I made it very clear too before that, the statement I made.

The Deputy of St. Ouen :

So basically there is a significant question here that needs to be dealt with. Some would argue that the States are still yet to be given the opportunity to support the dual-site approach, because there has been no direct reference to the dual site in any proposition the States have approved. Yes, you may have made statements; yes, the Minister for Treasury may have included some reference to the dual site and other options in an accompanying report, but the question is - and it needs to be answered - that has direct States approval linked to wording included in a proposition, not in any link to any words in the report, been given?

The Minister for Health and Social Services:

As I have just said before, that the feasibility plan, whatever, on the dual site will be coming to the States in the middle of next year time.

The Deputy of St. Ouen :

Right, so you do believe that the States will be given the chance?

Chief Executive Officer:

I am probably straying into a political debate here, so I will tread cautiously, but Helen and I both briefed extensively to States Members as part of the budget debate so that there was clarity, that in asking for the £297 million, it was based on a 2-site model. I am not saying it ...

The Deputy of St. Ouen :

I am sorry, I have got to stop you, I have got to stop you, because I think you are straying into the political area, for the simple reason that States Members obviously and the way the States operate rely on agreeing propositions. Yes, reports and conversations happen and briefings are provided and so on and so forth, but ultimately, the only thing that the States and public can rely on is what is said in the wording of the proposition. I think that this is why we are specifically looking at how that has been dealt with and whether or not there is a way of creating greater certainty around the position that the Ministerial Oversight Group and others, including officers, have taken regarding supporting a dual-site approach rather than a single site, that is all again ... we are not ...

Deputy J.A. Hilton:

But my understanding is that you will not get anything until probably the spring, early summer of next year, which will be the product of the feasibility study, which is based entirely and only on a 2- site option.

The Minister for Health and Social Services: Which I have just said.

The Deputy of St. Ouen :

Just sticking with the dual-site option, but approaching it from a slightly different direction, do you believe that the public support the dual-site approach rather than a single-site option, and the refurbishment rather than a redevelopment of the General Hospital and the provision of it all on one site?

The Minister for Health and Social Services:

As I said, we have been out to consultation with the future hospital and there Will and Bernard have done various stakeholder groups, and from the legal friends to interested parties, to our own clinicians. Yes, there are some questions, understandably, and I would be very concerned if there was not any questions, and I think the main themes that are coming out are traffic, getting up and down from Overdale, more questions like that. I think if there had been really, really public concern about using the 2 hospital sites that we already own, I think we would have heard it before now.

Assistant Minister for Health and Social Services:

Because much of the public already use Overdale, so they know it. It is not an alien concept. You say Overdale Hospital, General Hospital and everyone knows where they are. Drilling down to more of the clinicians of course is different, but it has not been an outrage in the public and the public have been told where we are going to redevelop the new hospital, new build at Overdale, mainly refurbished and some new build at the General.

The Deputy of St. Ouen :

So are you saying that basically because of the lack of response to the suggestion that we should have a dual site rather than a single site, that is sufficient in determining that we go for the dual- site option?

Assistant Minister for Health and Social Services:

I think there is pragmatic realisation on behalf of the public that we are doing our best to deliver the best we possibly can at a reasonable price to the public purse, and I think that is exactly where we are. That is why the public are not screaming out about it being 2 sites. After all, if you recall (several inaudible words 12:21:24) and maybe you will recall when there was a lot of wards up at Overdale which have come back to the General, and we are really changing things back to reorganise what we are doing at Overdale and also the General Hospital at the same time. It is something which us older members of the community remember having to do in the past and what you remember the community will become conditioned to in the future, and at the best reasonable price to the public purse.

Assistant Minister for Health and Social Services:

Babies were born in St. Saviour 's Hospital, so we have worked on different sites over the many years and we have these sites to work with.

The Deputy of St. Ouen :

I am pleased you raised the issue of St. Saviour 's Hospital, because one of the matters that the States Members have been made well aware of is that Overdale had been identified as a site for new mental health services. We have recently been told - and maybe you can confirm this is true or false - that because of the latest proposals to deliver the hospital on 2 sites, Overdale will no longer be able to be used to provide the new mental health service type facilities that many thought were going to be delivered on that particular site. I suppose the question is what efforts and involvement are you having, Minister, in securing an alternative site that is desperately required to meet the needs of those suffering with mental health problems?

The Minister for Health and Social Services:

I totally agree with you, that is desperately needed, and that is why it has pushed forward the work, as you know, for the Mental Health Review, as Jo said, reviewing all services, mental health estates, because that has got to be included in that now, and also the Mental Health and Capacity Law, so those 3 pieces of work are being done as we talk now, and with the Mental Health Review completed the middle of next year, I think, if I am right. Is that right, Jo, middle of next year?

Deputy Director of Commissioning:

Yes, it is. The 3 pieces of work are essential to make sure that the mental health services on- Island are more than up-to-date with 21st century practice, so it is not just about the buildings, it really is about the whole approach, the philosophy and we already know that we need to update

our laws to come in line with standard practice in the rest of Europe.

The Deputy of St. Ouen :

But sticking with facilities for the minute, this is what we are talking about, are you telling us that the States will be able to ... or decisions will be able to be made around about the relocation or improved facilities being provided for mental health services this time next year? Is that what you are saying?

Chief Executive Officer:

The overall piece of work will report this time next year and I am sure it will be reported to the States. I would just want to comment on the starting point of that question, which alluded to Overdale previously being identified for use of mental health services.

The Deputy of St. Ouen : It was.

Chief Executive Officer:

It is certainly true within the department that we talked about Overdale as being a potential site for mental health services. I am not aware of any States decision saying that that would be so, and in fact the pre-feasibility study on whether or not Overdale would be suitable for mental health services was profiled for 2015, so it had not even started. Now, clearly, if there was an aspiration to put mental health services there, we cannot if we are going to use it. There may still be some scope for services to go on to the Overdale site. We will know that as part of the feasibility work that we are now doing for the General Hospital. We have, of course - as I know you are well aware, because you have gifted us the money - completely revamped and upgraded Clinique Pinel, so there is now at least 10 years' worth of life in those facilities, which is good, because it gives us the time to do the piece of work that Jo has alluded to. I think we have also commented in this forum before that we will be looking to see if we can accelerate a plan for Orchard House, because I think that is the part that we really do need to try and bring forward more quickly.

Senator S.C. Ferguson: It needs knocking down.

Chief Executive Officer:

Exactly, and the patients need to go somewhere else, yes.

The Deputy of St. Ouen :

I just want to come back to the compromises and the issue of the initial proposals around the hospital and the cost and then what is currently proposed. One of the areas that you were tasked, I believe, with undertaking what is sort of a reprioritisation of services linked to the lower budget. Can you just make us aware of what those key outcomes were, that prioritisation process?

Hospital Managing Director:

If we think back to the original process when we were looking for a complete new build, the only priorities were getting the right number of beds, the right number of theatres and single rooms with ensuites and that was as far as it had gone. Once we were starting to look at how we would reprioritise with an envelope of money, then the clinicians were involved to say: "What are the services that are in most desperate need?" and we came up with ... obviously we still needed the number of beds, the number of theatres and we still wanted the single rooms, but pathology and imaging were 2 departments that needed a complete overhaul, maternity needed to go and change into single rooms, the children's department. We wanted an A. and E. Department that had better flow through it, because at the moment we are mixing sort of minors with the majors, and we wanted a Critical Care Department that was going to be big enough for the future with the right space between beds.

The Deputy of St. Ouen :

Sorry, you say that the clinicians were involved at quite a late stage. Why were they not involved at the beginning?

Hospital Managing Director:

Because initially we had not asked them to clinically prioritise, because they were expecting everything to be new and renewed, so they had been involved in the design in the clinical adjacencies, but they were not asked to prioritise any of the facilities.

The Deputy of St. Ouen : What, so ...

Chief Executive Officer:

That does not mean to say they were not involved, because both Helen and I regularly briefed the Medical Staffing Committee and the senior nurses group and any other groups as to where we had got to in the pre-feasibility stage.

The Deputy of St. Ouen : Right, so the extent ...

Chief Executive Officer:

We could not give them specific information, because some of the issues about sites were commercial and in confidence, but we could tell them the broad thrust of where we had got to, that we were looking at 27 sites, it had narrowed down to 11, it had narrowed down to 3, that that involved a greenfield, brownfield and a rebuild, so they knew all of those things as we were going through. Once we said: "There is a preferred site and we are now looking at an envelope of money" we could then open up that debate very specifically, because it had to be clinically appropriate.

The Deputy of St. Ouen :

So when were the clinicians asked or were ...

Senator S.C. Ferguson: When were they consulted?

The Deputy of St. Ouen :

Were the clinicians asked to identify what was required to improve the services they were providing, and in fact, whether they could identify additional services that would be better provided on the Island or off?

Chief Executive Officer:

We have been doing that since 2011. As Helen said, our predecessors had engaged them in those pieces of work.

The Deputy of St. Ouen :

So all of that information was available when Atkins were engaged to look at the development of the hospital?

Chief Executive Officer:

Yes, and they spoke to our clinicians as part of that process.

Assistant Minister for Health and Social Services:

Sorry, can I just ask the Deputy there, I have been reading through quite a few of your transcripts, and this is political, and I do not know whether you are asking our officers to compare something that maybe I did not know that we had agreed to. You talk about in lots of your questions and answers about this on-Island and off-Island and why have we got this certain size of the hospital if

we may be delivering lots more off-Island. I just think politically we have never sat down and had

that decision of who would stay on-Island and who would go off-Island. It is just about critical care and how acute services like the heart or transplants we do we will do better at, so that is a theme that is seen running through from your questioning which I am quite concerned about, because you are going to make a report on this, and you may well be saying if we need to look at ... and you need to ask us now, do we need to look at sending the majority of our services off-Island and them maybe adjust the size of our hospital, but I do not remember politically we have ever had this discussion.

[12:30]

But maybe I am interpreting what I have read, what you said wrong.

The Deputy of St. Ouen :

I think our questions have been focused at the department around what decisions have been made and what consideration has been given to the continuation of providing services on-Island versus off-Island and whether or not there are opportunities to do more on-Island. Obviously we have asked questions, absolutely, around what is the cost of providing those services, whether it is in the best interests of Islanders to be treated on-Island when perhaps they could access higher or better-qualified professionals off-Island elsewhere in a specialist hospital.

The Minister for Health and Social Services:

Careful what you say. The care we provide by our consultants and the staff is extremely good.

The Deputy of St. Ouen :

Absolutely, but in England, let us face it, we are well aware if you happen to benefit from private health insurance, you will be directed to the specialist top-quality hospital in the U.K. ...

The Minister for Health and Social Services: Not necessarily.

The Deputy of St. Ouen :

... because there they are doing large numbers of operations on a regular basis, which obviously draws the top professionals in their area.

Chief Executive Officer:

That happens in tertiary hospitals in the U.K. and we send our patients to tertiary hospitals in the U.K. for those very specialist services, but I think what we have said quite consistently on this is Islanders have told us, and they have told us in the consultation on the Green and White Paper, that they wanted as many services on-Island as they could have, providing they were safe and providing they were affordable, and that has been our mantra all the way through this: safe, affordable, sustainable.

The Deputy of St. Ouen :

Right, so the question which I will come back to ... sorry, but the question that I did ask originally was when you prioritised the services, have you had to reconsider providing some services on the Island because of the limited budget that has been set?

Chief Executive Officer:

No. We would never compromise a patient who needed to go off-Island to access specialist services. They would be sent.

Deputy J.A. Hilton:

As a final question before we wrap up, and it leads on from just what we have been talking about, has a decision been made about delivering radiotherapy on-Island yet?

Hospital Managing Director:

No. We have commissioned a piece of work.

Assistant Minister for Health and Social Services:

We have made space for it. If it is safe and feasible, there will be space at the Overdale site for it, which we hope it will be. It will be brilliant for patients.

Deputy J.A. Hilton:

Thank you very much for coming this morning.

[12:32]