Staff Recruitment and Retention - Minister for Health and Social Services - Transcript - 7 December 2015

Health and Social Security Scrutiny Panel Quarterly Hearing with the Minister for Health and Social Services

MONDAY, 7th DECEMBER 2015

Panel:

Deputy R.J. Renouf of St. Ouen (Chairman) Deputy G.P. Southern of St. Helier (Vice-Chairman) Deputy T.A. McDonald of St. Saviour

Witnesses:

The Minister for Health and Social Services Human Resources Director

Hospital Managing Director

Head of Workforce and Planning

Head of Education, Learning and Development

[9:32]

Deputy R.J. Renouf of St. Ouen (Chairman):

Thank you, Minister, for coming to our panel meeting and bringing your team. As you will know, this meeting is being recorded, so we will do the formal introductions first. This is a meeting of the Health and Social Security Panel and this is in connection with our review on medical staff recruitment in the hospital service. I am Deputy Richard Renouf and I am the chairman of the panel.

Deputy G.P. Southern of St. Helier (Vice-Chairman): Deputy Geoff Southern , Vice-Chair.

Deputy T.A. McDonald of St. Saviour : Deputy Terry McDonald, member of the panel.

The Minister for Health and Social Services: Senator Andrew Green, Minister for Health.

Human Resources Director:

Tony Riley, H.R. (Human Resources) Director.

Hospital Managing Director:

Helen O'Shea, Hospital Managing Director.

Head of Workforce and Planning: Honor Blain, Head of Workforce Planning.

Head of Education, Learning and Development: Julie Mesny, Head of Nurse Education.

The Deputy of St. Ouen :

Thank you all for coming. Minister, staff recruitment: can you tell us if we have a problem in that area and how big it is if we do?

The Minister for Health and Social Services:

It is a matter of balance really. I will hand you over to colleagues in a minute if you want to go into detail. Recruiting nurses worldwide is a challenge, although we seem to do quite well in comparison to others. Recruiting consultants is very different to the way it used to be, when you used to be able to recruit a consultant to carry out 3 different areas of work, more generalist, and today they tend to be much more specialised. But in terms of attracting people to come and work in Jersey, which is why Julie is here, or to train and develop our own, I think we do quite well.

The Deputy of St. Ouen :

Okay. Can we ask what strategy and plans you follow to ensure we do recruit?

The Minister for Health and Social Services:

Let us talk about training first of all, training and staff development and recruitment for training ...

The Deputy of St. Ouen :

So you are talking about nursing?

The Minister for Health and Social Services:

Yes, nursing particularly, start with that. You might have seen on Friday and Saturday last we were running a programme to attract people to come and train with Chester University for what I would have called the registered general nurse. Is that correct?

Head of Education, Learning and Development: That is absolutely fine, yes.

The Minister for Health and Social Services:

Yes, adult nursing. While the process is yet to be followed, the result of that was 90 active leads, young people - young or mature people - wanting to come into the profession and train locally, 90 people there to follow up. But I will hand you over to Julie to talk to that.

Deputy G.P. Southern :

Before you do, Minister, the initial statement was: "It is a matter of balance." In what sense?

The Minister for Health and Social Services: "Have we got a problem?" was the question.

Deputy G.P. Southern : The answer is?

The Minister for Health and Social Services:

I said that is a matter of balance, but I do not believe we have a problem.

Deputy G.P. Southern : We do not have a problem?

The Minister for Health and Social Services:

I do not believe we have a bigger problem than anybody else worldwide. We seem to be able to attract people to come and work for us, and once we get them here we also seem to be able to keep them, because our turnover is considerably lower than the N.H.S. (National Health Service), for example. But as I say, we can talk about the programmes that we have, specifically nursing to start with, and then we can talk later on.

The Deputy of St. Ouen :

Can you talk about the programmes and then how we measure how well we are doing?

Deputy T.A. McDonald:

Before we move on, could I just ask a question? Recruiting now for nurses, while we are talking about nurses, is it all being done at that level or is there any other potential training courses?

Head of Education, Learning and Development:

Yes, it is a national standard. I manage nurse education and vocational training as well on the Island. Since 2004 we have been working with the Open University and we have been growing our own student nurses. When you look at the career trajectories, some of our students from 2004 are now managers in ward areas so there is a career for them on the Island. In 2011/12 we entered into a contract with the University of Chester, so I am pleased to be able to say we now have 12 third-year students, 9 second-year students and 13 first-year students, the first students to graduate with the degrees. It has been a graduate profession since 2011, 2012. Having said that, we also recruit to our healthcare assistant workforce as well and we also have a training programme for them, which is the vocational award route, Q.C.F. (Qualifications and Credit Framework) Level 2 and Level 3. Within that provision as well we also work closely with Highlands College, and by working with Highlands College then the people of the Island can access the Access course. So we are also saying you do not have to be young to come into nursing and midwifery and that you can have a change of career. We work closely with Mary Hubert and the team at Highlands College to ensure that people know that they can access a career on the Island.

The Minister for Health and Social Services:

But to answer, because I think you were asking really whether we had to go down the degree route, I think that is the question you were asking ...

Deputy T.A. McDonald: Yes, in many ways, yes.

The Minister for Health and Social Services:

... and there is no choice. If you want a qualified nurse, you have to go down the degree route. However, as Julie said ...

Deputy T.A. McDonald:

As you say, H.C.A.s (healthcare assistants) and so on.

The Minister for Health and Social Services: ... you do have H.C.A.s.

Head of Education, Learning and Development:

On top of that, our local workforce have been able to access degrees on the Island since 2000. We originally worked with the University of Southampton and we have over 150 of our own nurses on the Island who have accessed degrees. They also access the nurse prescribing programme, so we are growing advanced practitioners as well for our workforce to meet the needs of what is required.

The Deputy of St. Ouen :

What formal strategies do we have in place to ensure that we are recruiting as we should? Is there a plan? Is there a programme?

Hospital Managing Director:

Can I perhaps try and help with this? Are you talking about a workforce plan or a recruitment and retention strategy, because I see them as slightly different things?

The Deputy of St. Ouen : Could you explain?

Hospital Managing Director:

Yes. A workforce plan is what workforce do we need now and what workforce do we need in the future to deliver the sorts of care that we think we are going to need to deliver. That is something that we are right in the middle of doing a new one at the moment that fits in nicely with our out-of- hospital strategy and our acute service strategy. So we know where we are today, but where do we want to be in 2024, 2040 and what sort of workforce will we need? Once that strategy is developed - and it will be early next year sometime - we will then be able to say: "Do those sorts of posts exist? Do we need to grow our own? Do we need to put people in specific training? Where in the world will we recruit them from?" So one will follow the other. We are in the middle of writing the new one that will see us into the future hospital and beyond, but at the moment we have models of care that exist within the hospital, that we know how many people we need to work them and so it is a case of if we are fully established - which is highly unusual in a hospital, you always have a degree of turnover with that sort of volume of staff - we recruit whatever vacancies we have got. We have got a process in place. We have to make sure that the post is vacant; do we still need it; is it the right thing and get it signed off and get it advertised and recruited to. We have recruitment policies, so they are always followed. It is about the workforce. We are changing our models of care and deliberately changing our models of care. We want to do less in the hospital, and that that we do in the hospital we want to be done by the right person, so we are extending the roles of nurses: we have nurse endoscopists now, you have consultant nurses and you have dermatology specialist nurses and cancer specialist nurses. That changes the dynamics of the workforce.

Human Resources Director:

In recent years, we had of course the 6 outline business cases and full business cases that supported the White Paper, proposition 82, each of which included a recruitment strategy for each element of the White Paper, supplemented since then by the work that Helen and her team have done on the acute service strategy. So we have high-level strategic documents that give a shape and a balance to our recruitment efforts over the last couple of years and the next couple of years. We are now wrapping it up in the bigger piece of work that Helen has just described, a whole system workforce plan for Health and Social Services which will be reporting next year.

Deputy G.P. Southern :

But in terms of the immediate future, the next 2 to 3 years, as we develop this more care in the community, what sort of numbers are we talking about there, because we are talking about - what is the figure - 65 full-time equivalent nursing posts in family nursing, for example. That sounds like a relatively small number compared to the 1,000 or so in the hospital.

Hospital Managing Director:

We have got a plan over the next couple of years as part of the M.T.F.P. (Medium Term Financial Plan) 2, but obviously we have only 2016 signed off at the moment, so we will see where the next few years go. We are looking at developing what we are calling ambulatory emergency care within the hospital, so that is about how do we prevent people coming into the emergency system at all. That will be working with our paramedic teams and looking at how people can be treated in their own homes and not just brought to hospital; working with the rapid response team, which is the family nursing team; working with the E.D. (Emergency Department) team to say: "How do we get people seen in A. and E. (Accident and Emergency) and turned around much more rapidly, so we get rapid diagnostics, rapid support put in place, treating them at home and turning them around and not letting them get admitted?" So we have got some extra posts over the next few years that we are anticipating recruiting to strengthen that type of model of care. That will be radiographers, radiologists, it will be physios, it will be the rapid response team, it will be looking at the paramedic workforce, specialist nurses in A. and E., and some extra frontline physician posts. So we have got those sorts of posts planned in the next few years.

The Deputy of St. Ouen :

Okay, but at the moment, insofar as concerns a strategy, do we just wait until a vacancy arises and then decide where we are going to advertise or ...

Hospital Managing Director:

It depends on the group of staffing, so one of our hot spots - you asked if there is a problem and I do not think there is an overall problem, but we do have hot spots - is attracting theatre nurses and that is a U.K. (United Kingdom) issue. There is a shortage of trained theatre nurses. We almost have a rolling programme in theatres to continually recruit and so we are always in that process. In other areas where we do have a recruitment problem, yes, we just wait for a vacancy. Yes, there is sometimes a bit of a delay, because somebody gives 3 months' notice and you then have to quickly get out to replacement.

The Deputy of St. Ouen :

Mr. Riley has talked about strategies around the White Paper and the business cases that were produced. What was in those strategies about recruitment?

Human Resources Director:

Most of those 6 F.B.C.s (full business cases) were community and mental health based, from memory. The next big tranche of recruitment is in the middle of 2016, end of quarter one into the summer of 2016. I cannot remember the exact figure, but I believe it is 40-odd posts we will be looking to expand that part of the workforce on. We have a sequence of planned events to take us from the funding being released to carrying out recruitment campaigns, to inducting and expanding the workforce.

Deputy G.P. Southern :

What was that 40 you were referring to?

Human Resources Director:

I do not have the paper with me. I believe there is at least 40-odd new posts in community ...

Deputy G.P. Southern :

That is new posts in the community?

Human Resources Director: Yes.

But all this links together, does it not? You have the mental health strategy launching today or announcing, because we have done the work on it, and you have seen the acute services strategy as it is going forward.

[9:45]

All this is about doing things slightly differently, planning to ensure that we do have the staff with the skills to do the job that we want to do, but also about designing of the new hospital, because one thing is certain, if we carry on doing what we are doing and just transfer that to the new hospital without expanding the out-of-hospital service, then you are going to need a much bigger hospital, much bigger than we are currently planning for. That is not just about: "Let us design a hospital right for what we think it should be", it is also complying with what people told us when we went out to consultation. They said that they would, as much as possible, wherever appropriate, prefer to be treated at home and to stay at home for as long as possible. So we are designing our service around that and with that. You asked about do we just recruit when a vacancy occurs. Of course you have got the day-to-day business as usual, as you have got the planning, but we never just recruit. No good manager ever says: "I have got a vacancy and I am going to fill it." As Helen said, you always look at: "Do I need to replace this person? Do I need the same type of person? Do I need somebody with different skills?" All those questions you ask legitimately as part of the day-to-day stuff and then go out to recruit.

Deputy G.P. Southern :

When we were looking at figures before we started this meeting, we came across the figure of something like carrying 10 per cent vacancies, so about 100 vacancies. Is that normal?

Head of Workforce and Planning:

Sorry, that figure is not 10 per cent, it is under 10 per cent. It includes posts being filled, so it includes a percentage of nurses who have been offered posts and are waiting to come into post. The actual vacancy factor at the moment right across Health and Social Services is 6 per cent, which is significantly lower than the N.H.S.

Deputy G.P. Southern :

But nonetheless it is generally accepted that the figure that starts to be problematic is around 5 per cent, is it not?

Head of Workforce and Planning:

It is, but it is a seasonal trend that we see every year from October onwards, October, November and December. That is when we see most of our attrition of nurses either retiring or leaving the Island or leaving for whatever reason, so that is why the figure is 6 per cent at the moment. All year it has been sitting around 3 per cent to 4 per cent, so we have done very well this year.

Hospital Managing Director:

It does vary by service. I think the hospital is not at 6 per cent, I think it is lower.

Head of Workforce and Planning: No, it is not, that is across Health.

Hospital Managing Director:

Out of all the hospitals I have worked in, it has the lowest vacancy, lowest turnover I have worked with.

Human Resources Director:

It does compare favourably with every high-cost area in Great Britain, very favourably.

The Deputy of St. Ouen :

Does that include our Social Services or is it just the Health Service?

Head of Workforce and Planning:

No, right across Health and Social Services.

The Deputy of St. Ouen :

Social Services as well, so it includes the social workers, yes. Coming to specific areas now, so let us take consultant level. We have heard from some of the staff groups, and I think it is accepted that nowadays consultancy work is very specialist, you do not get the general consultants that we once had. How do we go about recruiting the consultants we need? I gather as well our consultants are generally at a certain age, so we can expect a batch of retirements soon. How are we planning to bring in new consultants with the specialisms we need?

Hospital Managing Director:

I am going to keep saying it depends on the specialty. It does depend on the specialty; it depends whether we are talking surgeons or physicians. We have got a surgical colleague that will be retiring later next year. We have already recruited 2 specialists to work with them and what we are now going to look for is a complementary set of skills that will work with the 2 that we have already

got. You are right to say that people sub-specialise these days, they highly sub-specialise. An Island this size, we cannot afford to do that, we do not have enough patients with each of those sub-specialties to keep them busy enough. We have found that bringing people over at 2 stages in their career, after they have done probably 10 years as a consultant somewhere and they are ready to look at taking a more generalist workload on, they can find the Island very attractive, or attracting somebody right at the beginning of their career, where they have just finished their generalist training, where they still have those skills - because it is not long ago that they were training - they come over and they retain those generalist skills in their specialty. We have done that a few times in the last couple of years and that has worked out extremely well. It depends on the specialty, and I know that sounds a bit vague, but, for example, the physicians all have a general acute knowledge of admitting patient in the middle of the night when they come in with a stroke or a heart attack or whatever it might be, but then they have sub-specialty training, whether it be cardiology, neurology, gastroenterology, that they will do their planned cases, so they will do their clinics in that sub-specialty. That is quite a normal model and that is the model that we have adopted here. So they still keep some of their specialism, but they have that generalist take ability to see the emergencies when they come in. The areas that might be more tricky would be areas like oncology, where people specialise in a particular tumour site, so they might be the bowel oncologist or the breast oncologist. We are talking to people in the U.K. and finding that we can attract some people that have got 2 or 3 sites as a specialism and that will work for us, if we have a 3-person team, and radiology, the x-ray department, people sub-specialise now in whether it is M.R.I.s (magnetic resonance imaging) or C.T.s (computerised tomography) or parts of the body that they are very skilled at reading those diagnoses. We are still working through that one. I think that might be an area where we have got to change some of our own models to accommodate new people.

Deputy G.P. Southern :

What is the extent of our reliance on locums at the moment, temporary contracts, short-term contracts?

Hospital Managing Director:

We have a reliance on locums when we have gaps in junior doctor rotas. Those junior doctors rotate through the system through the Deanery and if for whatever reason one of them leaves, we fill that for the 6 months that they are on rotation with a locum. We have a reliance on a locum for unexpected sickness, if it is going to be extended over a week or so. At consultant level, we are pretty much full at the moment. We have got a locum in oncology. That is about it, I think, at the moment.

Human Resources Director: I think so.

Deputy G.P. Southern :

How does that compare with nursing?

Hospital Managing Director:

It is lower. We are using less locums at the moment.

Human Resources Director:

Lower than I have seen in the U.K. in terms of percentage.

The Deputy of St. Ouen :

Is recruiting a person to come to Jersey the only answer? Are there other ways of dealing with ... using technology perhaps in dealing with issues if recruitment is difficult?

Hospital Managing Director:

In the workforce planning that we are talking about, that we are in the middle of now, we will discuss whether or not there are alternative models of delivering care. You can do joint appointments, we can do shared appointments with another organisation, but that organisation has to require part of that job plan as well. They are not as attractive, because people either want to live in Jersey or not and travelling backwards or forwards is not always a good use of their time. We already use technology. For example, every cancer patient is discussed in what we call a multi-disciplinary team, we link with U.K. specialist centres and we do that through teleconferencing. So we are already using skills in the U.K. to look at some of our images, to look at our tests, to talk to our doctors over a tele-link, so we already embrace some of that technology. There is not a lot of other ways that you could do that. I mean, a doctor needs to see their patient. They can do follow-ups and things possibly using technology, but they do need to see their patient face-to-face, so short of sending patients to the U.K., which we are trying to avoid if at all possible, no, we do really need to recruit here.

Deputy G.P. Southern :

In terms of the nurses, what is our reliance on bank or agency?

The Minister for Health and Social Services: There is a big difference between them.

Deputy G.P. Southern : Yes, I am aware.

The Minister for Health and Social Services:

Just to be clear about that, because bank are our staff, if you like, coming in on a zero-hour contract, because I think that is a legitimate use, but agency is very difficult. The actual detail I do not know.

Head of Workforce and Planning:

We have got about 15 agency in at the moment, nurses right across Health, so it is not just in the hospital, it is right across the community and Social Services as well. That has come down significantly from the beginning of the year.

Deputy G.P. Southern :

Has it come down by the mechanism of closing beds, like you have done with Beauport Ward recently?

Head of Workforce and Planning:

No, it was specifically to plug gaps. We have got a very long lead-in time when we offer posts. You made reference to the 10 per cent figure earlier that I said was slightly lower than that. At one point we did have a lot more nurses waiting to come into post than we did have vacancies. The agencies did help to plug that gap, where we have got about 4 or 5 months waiting for a nurse to start in post, because they cannot hand their notice into their employer in the U.K. until their clearance, their references and their police check has come back clear with us. So that lead-in time does cause gaps where we do use agency to plug that gap and they are used with that vacancy money available in that clinical area.

Deputy G.P. Southern :

One of the reasons that I was given in the States by the Minister was ... this is a closure of Beauport Ward , an orthopaedic ward, which I find completely strange, because waiting lists are going up in orthopaedics. I would have thought that is certainly an area that expands as we get older. Was there a requirement to avoid using agency nurses where possible for vacancies that are currently being advertised? It seems to me that the prime reason was that you were trying to cut down on the use of agency nurses by closing beds in orthopaedics. It seems strange to me.

Hospital Managing Director:

The reason the Beauport beds are closed - and there are 6 of them, it is a bay on Beauport Ward - was there has been a particular group of nurses there. We have got a couple of vacancies and we have got a couple of nurses on maternity leave and so rather than bring in nurses that are unfamiliar with the ward, we took the decision that for a period that has already started and will end in January we can close those beds and still manage our operating theatres and the patient throughput for that short period of time. We know that workload goes up in January and the beds will be reopened in January.

Deputy G.P. Southern :

There is no impact on waiting lists or throughput?

Hospital Managing Director:

There is no impact. We are not taking any theatre sessions now. We are still full going through the theatres, so what we will do is we just choose the patients that have shorter lengths of stay or ...

Deputy G.P. Southern :

So there is an impact because you are doing less serious work?

Hospital Managing Director:

We do that all the time, we make the lists appropriate to our facilities.

Deputy G.P. Southern :

So is there an impact on those waiting lists?

Hospital Managing Director:

More patients will probably get operated on, because we will do more of the minor procedures. If you are waiting for a longer procedure, then yes, it might have an impact, but that is normal ebbs and flows. It depends which consultant is on-Island, it depends which theatres are free, so we do theatre list management like that all the time.

Head of Workforce and Planning:

Running alongside that, the orthopaedic team developed an enhanced recovery package and what we have seen is patients coming in, they are being rehabilitated and they are being discharged a lot earlier with more intensive support at home rather than in the ward. That would have informed the decision and reduced the actual demand on beds.

Hospital Managing Director:

That has been going on for about the last year, and length of stay in the orthopaedic ward has dropped significantly, so we see more empty beds on that ward than we used to, so it is not full to gunnels every day anyway.

Deputy G.P. Southern :

So someone with a serious knee orthopaedic surgery who is waiting in pain is not going to see that wait extended?

Hospital Managing Director:

All patients with a serious need that is clinically urgent will be seen urgently and will continue to be seen urgently. All the other patients will be seen in date order.

Deputy G.P. Southern : Can I come in?

The Deputy of St. Ouen : Yes.

Deputy G.P. Southern :

The Minister said: "Nobody replaces just automatically. We look at the positions and say: Can we do this differently? Do we need this job?'"

The Minister for Health and Social Services: Yes.

Deputy G.P. Southern :

How many people have taken the voluntary release scheme? What is the impact of the over- arching policy?

The Minister for Health and Social Services:

I know 3 of our staff have, but Tony will take you through it.

Human Resources Director:

As part of the 2015 release scheme, 8 staff in total from Health and Social Services will be leaving and the preapproved ones that will be leaving in 2016 are 15. Of that, I think 3 other nursing qualification.

Deputy G.P. Southern :

So 3 nurses. The rest, was there a trend?

Human Resources Director:

Widespread of roles, job titles, divisions, departments, site locations.

Deputy G.P. Southern : Okay. Can we have that list?

Human Resources Director:

No, I do not think it is appropriate to give a list of names and financial amounts. I can give you a list of job titles.

Deputy G.P. Southern : Yes, sure.

Human Resources Director:

I will need to edit it. I will need to review that. Some of the job titles are so specific the individual is identifiable.

[10:00]

The Minister for Health and Social Services: We will give the department rather than the title.

Human Resources Director:

I will ask our comms people to sense check it for me and see whether it is appropriate.

The Minister for Health and Social Services:

Because I know one or 2, there is only one person in the whole service at that time. We are happy to sort of say it is support services or in nursing or whatever.

Human Resources Director:

There are no doctors. There is a spread of civil servants, manual workers and a small number of people with a nursing qualification. They tend to be nurse managers rather than hands-on practitioners. It is part of the management restructuring; they happen to be nurses as well.

The Deputy of St. Ouen :

I want to come back to our recruitment strategy and try and understand exactly how we recruit, so I want to talk about advertising. Do we go to the U.K. exclusively and seek new members of staff, consultants down to nursing levels?

Hospital Managing Director:

I might let Tony answer as well, but depending on who you are trying to recruit, whether you are talking nurses, doctors, physios, sonographers, we try and target it to where we know they look when people are looking for roles. The U.K. have something called N.H.S. Jobs, which we cannot access, but we do put things out on the internet so that we try and get as wide a field as possible. Doctors will go in the B.M.J. (British Medical Journal) and that is the doctors' go-to publication when they are looking for jobs. Nurses we use the nursing publications, The Times and Standard. Sonographers you would go through the radiographer-type press, so it does depend.

Human Resources Director:

There tends to be one or 2 journals for each profession. We advertise online and in paper format, depending on the audience, because some audiences have shifted almost entirely to being online job searches. We are in the process of engaging a new recruitment advertising agency with a great track record in healthcare recruitment.

The Deputy of St. Ouen :

That would be a professional website for, say, radiographers or anyone ...

Human Resources Director:

Yes, absolutely. The B.M.J. has its own website, and junior doctors in particular do not read magazines and newspapers, they just go straight to the B.M.J. website and see what is around.

Deputy G.P. Southern :

We are still largely recruiting from the U.K., are we, from an English-speaking market?

Hospital Managing Director:

Largely, because our registration requirements are the same as the U.K., so we expect doctors to all be G.M.C. (General Medical Council) registered and nurses to be N.M.C. (Nurses Medical Council) registered, so we tend to attract from that market.

Deputy G.P. Southern :

But you mentioned earlier when you think about 20 years' time as to where in the world you might be recruiting from. Can you expand on that?

Hospital Managing Director:

It may well be that we will attract more from Europe. We have already had some interest from some European doctors wanting to relocate to Jersey. They have contacted me and said: "What is the situation here?" so I explained to them that they would have to be registered with the G.M.C. in the U.K., which is relatively straightforward for somebody that has trained and worked in Europe. So we would not dismiss anybody from other parts of the world if they have got the right qualifications and skills and we can get them appropriately registered.

Human Resources Director:

The trend in the U.K. is to start to look to Portugal rather than the Philippines. For many years it was the Philippines, for nurses in particular. Portugal is now the top destination for N.H.S. recruiters to go to. Greece has become very fashionable in the last year or so. We have not seen any particular activity from those areas, although we have had some positive conversations with Madeira and the nursing school in Madeira, which we would see as a very good fit going forward to do more work with them. I know Rose and her team are continuing to explore that and see what merit that has.

Hospital Managing Director:

I was invited to Madeira to go and specifically look at their nurses. They are over-training their nurses. They cannot recruit as many as they are training. I went and had a look: they have got 2 nursing schools and I looked at their syllabus. It compares very favourably with what we do. They tend to then learn a language at the same time as they are learning their nursing and they sometimes pick German, they sometimes pick English. Those picking English are saying: "What are the opportunities to come to Jersey to work?" and we have formed some quite good relationships with Madeira, have we not? Although we do not have a flow of people coming through yet, we have now got all the contacts, we understand their training, their registration processes and that would be a good source of recruitment.

Human Resources Director:

In terms of the demographic of the Island, that is very positive as well. A country I forgot to mention is Poland, and increasingly the N.H.S. is looking to Poland. Of course there is a strong logic for Jersey to look to both Poland and Madeira in terms of our workforce reflecting the community that lives in the Island.

The Deputy of St. Ouen :

So why do we not yet advertise in Europe?

Head of Workforce and Planning:

We do not need to advertise in Portugal at the moment. Following a successful intensive care unit recruitment campaign, where we did speak to Madeira - this is part of what Helen was talking about - we recruited into all of those posts, and since, because of word of mouth, we get quite a lot of interest from nurses in Portugal, who come with husbands and partners who are also nurses, and because of the links that they have got with nurses that are here and the family that they have got, I get quite a lot of people enquiring about opportunities in Health and Social Services. So we have not felt the need to advertise in Portugal, because we do get quite a lot of enquiries and they are able to apply for the posts online in the same way as any other nurse; the same as the Polish nurses, we are starting to recruit more nurses from Poland. I do not have any numbers for you, but there is a sense, you know, that they are there and they are coming into the organisation. So we are reflecting our local community more now than we did do before.

Deputy G.P. Southern :

In terms of recruitment and retention especially, what sort of package are we offering employees in the Health Department in Jersey compared to the rest of Europe?

Human Resources Director:

Our pay generally compares reasonably well. We usually look to high-cost London prices to pitch our pay, and apart from at the very, very top of the nursing scale, which tends to be senior nurse leadership roles, we compare pretty favourably with most of our pay and terms and conditions. The one that tends to stick out, that people comment on, is what U.K. nurses would probably describe as quite a modest approach to annual leave entitlement. Jersey tends to be much lower in the public sector - either social workers or nurses - on annual leave, but on pay and pay rates we are generally comparing reasonably well, except at the very top of the scale, where that needs some assessment, because that is all being swept up under the workforce modernisation programme now, which was originally driven by nursing. It came out of a project we did in 2011 in Health. That was the catalyst for the whole workforce modernisation programme, with nurses at its heart. So we will continue to improve the overall package of terms and conditions and pay, but I think Honor can probably confirm my experience, and my feedback is we very rarely have recruitment problems or retention problems where pay and conditions are the principal reason for the recruitment not working or that drives the attrition. There tend to be other factors. So on the simplest level, our pay is okay, our tax is fine.

Deputy G.P. Southern :

Can you show us figures that show that comparison with high-cost areas?

Human Resources Director:

Yes. That is putting the scales like that, but on the other side of the scale of course is property prices and child care. Those 2 can often balance each other out, so the high pay and low taxes are wiped out by that or balanced by that. Again, my experience and anecdotes from my team in the recruitment crew, probably the biggest single factor that tips the scales against us if we are trying to recruit can be the population laws. They make it very difficult for the professional's partner or grown-up children to get the work that they want, so if we find the most wonderful clinical nurse specialist whose husband is a train driver and whose daughter is a secretary, it is difficult for Jersey to provide the train driver a job and the secretary a job for that family unit.

Deputy G.P. Southern :

Certainly we do not have mountaineers.

Human Resources Director:

Well, indeed. So we do find that. That is as problematic as anything, in my experience, the family employment issue; because nurses will rarely be the sole or major breadwinner in many, many families and they come with a husband, wife, partner and now often with grown-up children. Many years ago Jersey's nurse recruitment I am told was predominantly very young nurses, single nurses were the large volume that were coming in. Because we are growing our own now, more and more of our nurse recruitment is an older more mature person who has a family unit and that is more difficult to transplant into Jersey and get gainful employment for the whole family unit. That is a bigger problem for us than pay.

Deputy G.P. Southern :

But you said conditions, for example, about holiday. That is an ongoing issue, is it? Are you working on this?

Human Resources Director:

Annual leave entitlement is being looked at as part of the overall workforce modernisation programme, as part of the package that we have brought together.

The Minister for Health and Social Services:

I think Tony was saying it was commented on more than some of the other ...

Human Resources Director:

It is the one that raises the most comments. It is the one bit of our T.s and C.s (terms and conditions) that is further adrift from the U.K. than others. Pay generally is favourable, our hours of work are the same, 37.5 hours, so most of the things are the same. We are very similar to the N.H.S. I honestly think annual leave is the one that always comes back: "Why are you so mean?"

Deputy T.A. McDonald:

Why can we not - the royal "we" - address that? Is it purely a financial restraint or is it something else?

Human Resources Director:

I think it is historical and I think it is being addressed and reviewed very closely, working with all the trade unions as part of workforce modernisation. I have been at meetings - not on Health meetings, but on the whole States workforce - recently, and more planned for early 2016, where reviewing the annual leave entitlement is something that is very much on the radar.

Deputy G.P. Southern :

Have those discussions not broken down?

The Minister for Health and Social Services: No, they have not. I think they are still ongoing.

Human Resources Director:

The nursing and midwifery unions have never disengaged from workforce modernisation at all.

The Deputy of St. Ouen :

So when is this whole workforce modernisation programme to be concluded so that we will know what terms and conditions the nurses should have?

Human Resources Director:

I think, as Deputy Southern suggested, some unions are finding it difficult to engage with as much positivity as they have for the last couple of years, until we can get through the 2015/16 pay round. But I think we are hopeful that is back on track, and if that comes back on track, then workforce modernisation will pick up pace, then we should see it flourish 2016/17. It is a completely new set of pay terms and conditions for something like 70 per cent of the States workforce, including Health and Social Services, obviously.

Deputy G.P. Southern :

You say you think that is back on track now?

Human Resources Director:

I hope it is back on track. We have got meetings planned with the unions this week and next week to hopefully have constructive discussions about pay 2015 and 2016, which is the key to re- engaging the non-nursing unions with the rest of the workforce modernisation agenda. That is our intention and expectation.

The Deputy of St. Ouen :

Coming back to the other difficulties, you have spoken about families, bringing families over. Have you any initiatives or steps that can mitigate those difficulties?

Human Resources Director:

We do what we can within the law. The Population Office ...

Deputy G.P. Southern :

Meaning, sorry? "Within the law" meaning ...

Human Resources Director:

Well, we are constrained by Jersey's population laws. I cannot promise a train driver a job or promise a 20 year-old girl she will be given a secretary's job the day she arrives on the Island if she is not suitably qualified and what have you. But the Population Office are very, very supportive. They are very flexible across all of our clinical professional roles. I forget the phrase ... a letter of comfort. I think they provide a letter of comfort to employers saying if the spouse or the child applies for a job where Jersey registration requirements are necessary, they will be as flexible as they can and as constructive as they can in trying to make it work.

The Minister for Health and Social Services:

We will talk about those, the 5-year rule. These people will not have the 5-year rule and the employer may not have a licence, but may wish to employ that spouse, in which case ...

Human Resources Director:

If Voisins are recruiting for that secretary and had not got one, then the Population Office would give them a letter of comfort saying: "We would look very favourably on giving you a licence or some kind of qualified licence for Ms. Smith, the lovely daughter of Staff Nurse Smith" which works when it can. It works when it can, but it is an imperfect solution.

Deputy G.P. Southern :

So where it is possible to give permission, that is likely to happen, but as we say, we do not employ mountaineers?

Human Resources Director: No, indeed.

The Deputy of St. Ouen :

You said the adult children, but perhaps the teenage children who have been brought up in the U.K., I understand the difficulty is if they come to Jersey and then subsequently apply to the U.K. for university places they will be treated as foreign students, even though they have spent most of their life in the U.K. Is there a way of dealing with that?

Human Resources Director:

Apply to Scotland. It tends to be very, very popular: apply to a Scott ish university.

[10:15]

The Minister for Health and Social Services:

The only answer I can give to that is that people are warned in advance that this is the risk. We have no say over the U.K. policy.

The Deputy of St. Ouen :

No, no, of course. I understand that. The accommodation issues, so if staff are looking to purchase property then that is a lot more expensive than what they might pay in the U.K. or most parts of the U.K. Is that a reason they might leave us?

Human Resources Director:

Yes. People tend to do their research, they tend to use the internet, as we all would, in buying a property, so very few people engage in the recruitment process and are completely blindsided on the Jersey arrangements. So most have done due diligence beforehand and most manage to carry it off. What we do see is some attrition where people have come, have tried and just the rent or the mortgage and the inability of the spouse to get a job has collided and they just say: "Oh, I cannot afford this" but not too many these days. It was a bigger problem a few years ago.

Head of Workforce and Planning:

It is usually a combination of things, as Tony said. It is usually the male partner of the marriage or the household, it compounds the accommodation issue, because if they cannot get employment, then their ability to pay the rent like any other household that is in full employment is impaired.

Human Resources Director:

Because they are mature family units more often than not, they are not as receptive as the bright young things we used to get many years ago, who came as singletons and were quite happy to have single accommodation in what was a fabulous place for a young person to live and start their career, but these people now have developed an expectation of a quality of property and quality of life but it is usually a 2-income family unit, which is not a major obstacle but it is an obstacle that occasionally arises based on individual circumstances.

Deputy G.P. Southern :

We have schemes to help people with accommodation but without a specific ... we have not got a nurses only one I do not think. We used to but ...

Hospital Managing Director:

We do have some limited accommodation.

Head of Workforce and Planning:

We do have some limited accommodation. It is mostly single accommodation which addresses immediate need and certainly the need to accommodate any temporary staff as in locums or agencies. What we do not have very much of is accommodation for families or couples of a decent size. Hopefully, in the new year, once the Minister has approved, we will try and do some work with the Strategic Housing Unit to look at Health and Social Services housing needs, which would help to inform the housing survey going forwards in terms of recruitments and retention.

Deputy G.P. Southern :

So you will be putting somebody in there?

The Minister for Health and Social Services:

You will know that part of the Strategic Housing Plan at the moment is to review and come up with a key worker accommodation plan so that, as far as I am concerned, is primarily aimed at nurses but there may be other key workers in other departments.

Deputy G.P. Southern :

But I have also seen a list. I think it is 11 or 12 sectors of our community that we do not house so, yes, key workers is on the list. It is on the list, almost about 11. I do not know if you stopped the list.

The Minister for Health and Social Services: It is pretty high up there.

Deputy G.P. Southern :

Said the ex-Minister for Housing confidently, as he might well.

The Minister for Health and Social Services: You would expect me to say that.

Deputy G.P. Southern :

I expect you to be confident that is why I thought to ask, yes.

Head of Workforce and Planning:

But we do need to know exactly where our workforce is in terms of their needs for the next 5 years going forward and once we have got that information that will play into housing ...

Deputy G.P. Southern :

Do you carry out research? Do you do a leaver's interview to identify what is going wrong in retention certainly? Is that active?

Hospital Managing Director:

It is common practice and best practice to exit interviews. So when somebody goes we do talk to them about why is it they are going, because I mean that informs all sorts of things; is it something to do with the job, is it the accommodation, is it personal? So we do do exit interviews.

Deputy G.P. Southern : The top of the list is?

Head of Workforce and Planning: It would be ...

Hospital Managing Director: Retirement at the minute.

Head of Workforce and Planning:

Obviously the issue that Tony mentioned, certainly for the more senior posts, it is the combination of the inability for usually the male partner in the relationship to not be able to get work and accommodation because the 2 go hand-in-hand because you need income to pay for that.

The Minister for Health and Social Services:

Also occasionally ageing parents, wanting to go home to support them as well. I certainly know of a couple of cases where that has happened.

Hospital Managing Director:

We do try hard when we recruit people to give them as much information as we possibly can and say: "These are all the things you need to know about Jersey", how it works, how the Population Office works and we go out of our way, I think the H.R. Department, to make sure they get that information. We help them do their sums and tell them to make sure they have done their sums because it is a big move.

Deputy T.A. McDonald:

So there should not be many surprises obviously if they make the decision.

Hospital Managing Director:

But they do assume that they will get employment and things like that. If that does not happen then after a period of time they ...

The Minister for Health and Social Services:

To put the turnover into context though, I mean we are talking about the ones that do leave but the ones that leave are very low. However, if we can keep them that is even better.

Deputy T.A. McDonald: Yes, I understand that.

The Deputy of St. Ouen :

To what extent are we in competition in recruitment with nursing homes in the Island and especially Family Nursing; they have been asked to deliver, I am not sure of the health strategy in the community, they are also recruiting and trying to retain. Is there an element that the health service is in competition with Family Nursing and other institutions?

Human Resources Director:

The hospital service is fishing in a different labour market to F.N.H.C. (Family Nursing and Home care).

Hospital Managing Director:

We are looking at acute nurses which is a very different type of skillset than you would have for a nurse in a nursing home or Family Nursing. Arguably any trained nurse on the Island is in competition wherever the jobs are but I think the nursing homes and Family Nursing probably have more of a competitive workforce and I know it can be difficult for some of the care homes to recruit. Some of that might be their own terms and conditions, which are obviously not part of ours, but we are very much looking at acute nurses which is a slightly different workforce.

The Deputy of St. Ouen : Is that a different training?

Hospital Managing Director:

It is not different training but nurses like doctors make a decision at some point: "Do I want to be a surgical nurse, an I.T.U. (intensive therapy unit) nurse, a theatre nurse? Do I want to be a district nurse, a health visitor?" and they take that decision and it is your out-of-hospital nurses that Family Nursing are looking for; so the district nurses, the health visitors, those sorts of nurses, which do not normally work in hospitals.

The Deputy of St. Ouen : Yes, of course.

Human Resources Director:

From my experience elsewhere there is very little cross-pollination once people have made their career choices: "I am going to be a health visitor or a community nurse." They very rarely go back into acute nursing and once someone has gone into theatre nursing or I.C.U. (intensive care unit) you very rarely find them crossing back to do F.N.H.C. type work.

The Deputy of St. Ouen :

But we are dependent on Family Nursing and Home Care, are we not, so is there any assistance or do we monitor their recruitment efforts to make sure that ...

Head of Workforce and Planning:

We have been involved with them. I help them. In the summer they had a slight problem recruiting. They had about 5 vacancies and very quickly we managed to turn that round, as I worked in partnership with them to look at where their vacancies were and see if they needed a mix of maybe nurses from Madeira as well as newly qualified from the U.K. and our own locally- qualified nurses. Community nursing is something that appears to be attractive to a registered nurse who has been in practice for quite a few years so they have had quite a lot of experience. So that is why they tend to focus at the beginning of their career on their acute skills. They want to work in an acute environment. So what we are seeing is if there is movement across the Island towards family nursing or to hospice we have been able to backfill the vacancies in the hospital with our newly qualified nurses that we are training ourselves and this encourages the movement and everybody's careers to grow as they are getting on.

Deputy G.P. Southern :

Given the expansion of what is going to be traffic nursing in the community is there a role for the Health Department to get more involved in making sure that we have those particular critical skills coming through?

Human Resources Director:

Helen mentioned the workforce plan we commissioned and are currently working on, which is the first time we have done a whole system workforce plan across the entire workforce and all of our services, and we invited F.N.H.C. and we are in touch with F.N.H.C. about them joining in with our piece of work. So again as we develop our workforce over the medium and long term there is an opportunity for them to be working with us on that project to align their workforce and adjust that going forward as well. We see that as a very constructive way to take a whole system approach rather than a States department approach so I am hopeful those conversations will flourish.

Head of Education, Learning and Development:

Can I just say with regards to the nurses that we are growing on the Island the nursing programme is 4,600 hours of study; 50 per cent in an acute setting and 50 per cent in a community setting, so the student nurses we are growing will be fit to work in both services. Our students have already accessed experience from the community so the idea being is that each year, if our students do want to go and work within Family Nursing and Home Care, they can do that as well. So they can access job opportunities within the community too. So that will be ongoing as well.

The Deputy of St. Ouen : That is interesting.

Deputy G.P. Southern :

However, Jersey district nurses, so is the second point: "Employing local nurses is difficult, again nurses do not hold the appropriate qualifications and rarely have experience of working in the community setting" so it is noted as a problem. It is an issue.

Head of Education, Learning and Development:

Yes, and what happens when nurses qualify is that they have a period of preceptorship so they do work with another member of staff so you can learn skills to undertake certain components of care in the community and then if Family Nursing and Home Care identified there was a cohort of nurses to access the S.C.P.H.N. programme, the specialist community public health nursing programme, and that is where you can buy in a particular programme as well, that we will deliver on the Island. So there are different ways of making sure you have got the skills or workforce, and of course to make the point about our student nurses are fit for working both within the hospital setting and within the community care setting too.

Head of Workforce and Planning:

We have been doing some work, as I mentioned before, about the Family Nursing and their vacancies that they had earlier on in the year which very quickly they managed to fill them. If anybody approaches Health who has got a community background and they are interested in district nursing then those C.V.s (curriculum vitaes) and those people are always put in direct touch with the H.R. manager at Family Nursing and the clinical team to start up those dialogues. That happens. That happens all the time because of the relationship that we have got, and also their retirement rates or the data that they have, hospice family nursing, they are going to be sending it to me so I can look at the numbers in terms of making sure it ties in  with our preregistration nurse training. So it is a whole island approach rather than just for Health and Social Services.

Deputy G.P. Southern :

I think you said earlier there may be problems recruiting among some of the care agencies, ,the private ones, that we are increasingly using. I have absolute confidence that Family Nursing is a good employer with good terms and conditions. Is there not a case for ensuring that good quality jobs are there across the service, including the private sector, which I understand that the practices may be markedly different?

Head of Workforce and Planning:

Could you define if you mean nursing and residential homes or private nursing agencies that visit people in their own homes?

Deputy G.P. Southern :

Private nursing agencies going into people's homes.

Head of Workforce and Planning:

Right. Because the agencies going into people's homes, that is predominantly the non-registered workforce who we would expect to have got the vocational qualifications, certainly 2 and 3, really if they are working independently in the community. So there are 2 distinct types.

Deputy G.P. Southern :

Yes, sure and I accept that training levels are probably in place there but I am talking about something different, which is the terms and conditions under which they are working, where we know there have been problems in the U.K. previously. What is the thinking? So help us there.

The Minister for Health and Social Services:

Well, clearly it is not for us to insist on certain rates of pay or annual leave or anything else in terms of ...

Deputy G.P. Southern : Or hours worked?

The Minister for Health and Social Services:

Or hours of work, that is all covered by current employment legislation. What is for us ...

Deputy G.P. Southern : Is it?

The Minister for Health and Social Services:

Yes. Well, I believe it is. But what is for us, is to ensure that the standards of care are appropriate and that is why we have the Care Commission of course coming online with the standards of care and the levels of appropriately qualified staff including that those staff retain their qualifications through C.P.D. (continuing professional development) and all the rest of it .

[10:30]

That is for us. It is not for us to start interfering in individual businesses.

Deputy G.P. Southern :

So it is laying down some basic employment protection. Where in the Employment Law do you believe we are protecting people in their daily jobs in this particular area?

The Minister for Health and Social Services:

Well, the current Employment Law that covers all employees in the Island would apply to these establishments in terms of ...

Deputy G.P. Southern :

What has the Employment Law got to say on hours of work?

The Minister for Health and Social Services:

I am not sure that there is one on hours of work but that is a matter for the employer and the employee. It is not for us to start to micromanage small, albeit important, organisations any more than T.T.S. (Transport and Technical Services) would start managing the staffing of garages. It is not ... sorry, it is for us to set the standards, the Care Commission to set the standards, and to ensure that those standards in terms of the levels of staffing, the appropriateness of the qualifications, the environment in which the patients are cared for; that is our role.

Deputy G.P. Southern :

The possibility of quarter of an hour slots in somebody's home where you can do next to nothing does not exist in Jersey and no employees ...

The Minister for Health and Social Services: That is a different question.

Deputy G.P. Southern :

Can I just finish the question?

The Minister for Health and Social Services:

No, because you are ... you can in a minute but you asked me about hours of work and staff. You did not ask me about face-to-face patient contact time.

Deputy G.P. Southern :

Okay. On that, where someone can be on duty from 7.00 a.m. in the morning until 10.00 p.m. at night and only get paid 8 hours because they are not paid travelling time, for example. Do you think that is a good quality of care? Somebody is turning up on the doorstep ...

The Minister for Health and Social Services:

I would say that that is a matter of employment to be taken up with the individual employees and ...

Deputy G.P. Southern :

Nothing absolutely to do with your department? Is that your position?

The Minister for Health and Social Services:

I am saying that we monitor, and we have the Care Commission, to ensure that appropriately qualified staff provide the right contact and the right care in the right environment. Terms and conditions of employment are a matter for the individual employers.

Head of Education, Learning and Development:

Can I say something here in relation to the code of conduct that we produced for healthcare support workers? I do not know whether you are aware of it. We did lots of work working with agencies and care people across the Island and all our healthcare support workers do have the code and work all together to make sure that a healthcare support worker can see very clearly in relation to the care provisions. So it is just to make that point about we ...

Deputy G.P. Southern :

I do not know if we have seen that guidance but could you forward it to us?

Head of Education, Learning and Development: Of course we can do it.

The Minister for Health and Social Services:

Every States Member was sent a copy the day it was launched, but anyway.

The Deputy of St. Ouen :

Okay. We will remind ourselves of that, but the hospital directive ...

Hospital Managing Director:

There is also a relatively recent piece of regulation that has been in force for all providers of nursing care outside the hospital, outside H.S.S.D. (Health and Social Services Department), but I cannot remember its terminology, but all nursing homes and providers of agency staff have to meet certain criteria and standards and be on an approved list before they can provide ...

Deputy T.A. McDonald:

And subject to inspection obviously.

Hospital Managing Director:

Yes, and subject to inspection. So they have to say that their nurses are all registered with the right people, that they are part of the right bodies. So there are some standards laid down that all of these people have to comply with. I mean I am not responsible for that. I just know it is in place.

Deputy G.P. Southern :

Certainly at the nursing level but we are talking about below that, it was for carers.

Hospital Managing Director:

I think it was providers of care in homes, extended to that.

Head of Workforce and Planning:

It is that they are all working towards compliance with the Regulation of Care Law.

Hospital Managing Director: That is the next piece, yes.

Head of Workforce and Planning:

Yes. So that all those providers are included in that and they are working towards that compliance.

The Deputy of St. Ouen :

It is an issue which has been raised with us and I think when we get to review the law you have just mentioned, when it comes closer, and it is a matter that is of concern that some of these workers are travelling between jobs and effectively do a 10-hour day and be paid for 6 or 7 hours but that is for maybe another time. Can I ask about a return-to-practice course and what market might there be in the Island to bring ...

Head of Education, Learning and Development:

I am not getting phone calls or people asking about a return-to-practice programme. We know you have been privy to a lot of emails with one person. However, we run the programmes because there is interest. You have to have a cohort of at least 6 to 8 nurses to make it viable to run the programme and normally I would have a list. Now, we have run, and from memory, I think from about 2002, 3 or 4 cohorts and we have worked with different universities, University of Southampton, on programme provision and sometimes Islanders do go off Island and they come back here for their practice placements, but from a team point of view and having a small team we are concentrating on our preregistration nursing provision. With that provision also comes the need to monitor our mentors in practice, deliver mentor courses as well. So I want to make sure that I use my staff effectively and in turn I have that level of interest; not one person in the last 2 days has had that interest, and my plan is to go out and advertise about February/March next year to look to start a cohort in January 2017. So we have run cohorts. We ran a cohort 18 months ago and the numbers were 4 students with 3 accessing the programme and one person leaving the Island. It is an awful lot of investment for a small number of people who then decide maybe to work on the bank as well. So I am still committed to the programme, Health is committed to the programme. Before I would know because people were ringing me or contacting me and those numbers are not there. We are on one short corridor and my office is by the admin officer's office so we know if the phone calls are coming in, if Honor gets calls, but they are just not there. There is not a lot of interest.

The Deputy of St. Ouen :

Does that surprise you that there are not the numbers there wishing to return to it?

Head of Education, Learning and Development:

People know we are there and maybe we have exhausted the people who did want to come forward in the first place, but there has not been that interest.

Head of Workforce and Planning:

From the last cohort we have got one person actively working within Health and Social Services on a zero hours; it suits her lifestyle. She does not want a contracted post. So from that original number of 6 or 7 that we saw there is one person working maybe every couple of weeks ...

The Deputy of St. Ouen : Only one out of 6 or 7?

Head of Workforce and Planning: Yes, out of the people interviewed ...

The Deputy of St. Ouen :

So having trained up or renewed the training for 6 or 7.

Head of Education, Learning and Development:

Well, they may go to the private sector and there is that kind of altruistic, as in they are there for the Island really I think in that sense.

The Deputy of St. Ouen : Okay, understood.

Human Resources Director:

That is a fairly typical pattern as well. Before coming to Jersey we in a very large hospital launched a return-to-practice programme with masses of publicity. In year one - this is in a population of half a million - in year one we got a cohort of 8 and it was fantastic but the second time we tried it we had 2 or 3 I think. It just was not worth doing for 2 or 3.

Deputy G.P. Southern :

As a general question, can we meet the need for health provision in terms of the number of people that we have got available from our own resources or are we always going to be importing people from abroad, as it were?

Hospital Managing Director:

I see. You mean the ones we train on Island, will it be sufficient?

Head of Education, Learning and Development: It has to be a healthy mixture of both.

Hospital Managing Director:

It will be both and it is right to be both because we need to have people who are skilled.

Head of Education, Learning and Development:

We are creative in that when our registered nurses qualify if somebody wants to work in oncology then we would send them off the Island for that specialist training. So like a colorectal nurse specialist they would go to St. Mark's. If they want to work in sexual health it might be the University of the West of England. So while they may be accessing their degree or their Masters with us, part of that would be about the specialism, so we do look to where our staff can go so that when they come back they give that right provision of care and then they make those great links. Just sometimes they can have those supervision and dialogues as well, so I think we are always ...

Deputy G.P. Southern :

So career provisions, not least if you think you have a problem?

Hospital Managing Director: No.

Deputy G.P. Southern :

"If you want to specialise we will find a way for you to train."

Hospital Managing Director:

I think it is probably better here for this.

Head of Workforce and Planning:

Yes. It is a really good marketing tool. Our education provision that we have in Jersey within the organisation is really something attractive to nurses coming to the Island because they see that they can progress in their careers, they can get promotion but they can get academic qualifications out of this as well to support them in their role. So it is very ...

Head of Education, Learning and Development:

We have got our cadet nurses, who are cadet nurses, where our healthcare assistants who went to the senior healthcare assistants post and now they are registered practitioners, and that is what we want to see is that we can offer a career on-Island. Also I want to offer people an alternative career. So some people who may have got to their 30s and had a first degree of change in to something else but they said: "No, I want to make a difference", then, yes, they can come on to our programmes and access them as well, and they do go off the Island as well. So some of our third year students now are away on an alternative experience. That is good for them to see experiences in the U.K. and they come back and share those as well so good.

The Deputy of St. Ouen :

As they are undergoing initial training, perhaps preregistration, do we ask them to commit to returning to the Island?

Head of Education, Learning and Development:

Ours are on the Island but there are students that go away and Honor works with those. So the students that go through Education, Sport and Culture; that is their choice and the same with any student who accesses a degree. I do not think anybody on the Island is made to come back but hopefully in the fullness of time they will remember how beautiful the Island is and they will come back and they will bring their skills with them as well.

The Deputy of St. Ouen :

Of course that is right. Those that you train they are bound for the workforce.

Head of Education, Learning and Development:

Yes, and on the whole they have committed to the programme, so they want to be there, and what we have to celebrate sometimes is that a staff nurse may go off for a year or 2 for experience but then they come back because their home is here. So we must make sure we get the balance right in doing that.

The Deputy of St. Ouen :

You were talking about that further specialist training in perhaps oncology or something like that. Now is that funded by yourselves as employer or does the nurse or junior doctor have to pay for those courses?

Head of Education, Learning and Development:

I can only talk about nursing, is that we would work with the managers about the appropriateness of a programme. So if there is somebody who we know is going to work in a particular field then that is when Health would look at them in relation to what support we could give them to access the specialism. I cannot say about doctors.

Hospital Managing Director:

Junior doctors have a funded programme with the Deanery. So all of their training is included in that programme. Our permanent doctors, our middle grade and consultants, all have quite a healthy annual study leave budget because they have to comply with G.M.C. (General Medical Council) regulation that says they have to do at least 10 days study a year or 30 days in 3 years, and being on an island that is going to be more expensive to get off to conferences so they have got a generous study leave budget.

Deputy G.P. Southern :

Just moving away from nursing again just briefly. Are there any professions that are spectacularly difficult to recruit in the health field?

Hospital Managing Director:

The one that springs to mind for me is ultrasonographers. We do not have many of them but we do have a couple of vacancies that have been notoriously difficult to recruit and we are using agency sonographers.

Deputy G.P. Southern :

My stepson's doing I suspect someone is doing that, the very same skill but he is not coming back, I am afraid.

Head of Workforce and Planning:

I think social workers as a profession ...

Human Resources Director: Some specialist social workers on ...

Head of Workforce and Planning:

... are probably the ones that are quite challenging to recruit and retain.

Deputy G.P. Southern : Absolutely, yes, and long has been.

The Minister for Health and Social Services:

Yes. We have just recruited - they are not here yet - but just recruited the social worker with responsibility for the Children's Service I am pleased to say because it is part of our going forward, but it is difficult to get the right person.

The Deputy of St. Ouen :

Can I ask about issues of morale because a few of the people who have appeared before us have spoken about low morale within the service? What is your view? Can you measure morale?

Hospital Managing Director:

That is a very good question. I do not know whether you can measure morale. I have been in health in acute hospitals for 32 years now and every year everybody says, is not morale low? I do not see low morale among the nursing staff on the whole. I think, compared to when I came across from the U.K., I thought that the feeling here and the attitude towards work and the pride in their job was significantly better here. I think there are people that are finding sometimes it is a bit of a struggle when we want to make developments in services and we say: "Not this year." We have got to wait. I do not think I have heard people saying: "This is terrible" because of staffing or anything particularly workforce related. There will be different issues affecting different people at different times. I think the medical staff are not as happy at the moment because we are still talking pay deals with them.

The Minister for Health and Social Services:

I was going to say that is around one specific thing and the survey that was done there was specifically about their pay, if that is what you are referring to. So I think it is a bit like the curat(?) saying, to be honest with you. I go round the department regularly, as I know the managers do, rather than waiting until there is a problem and I would say that generally morale is reasonable.

Hospital Managing Director:

We have done a staff survey and one of the questions from recollection was: "Would you recommend this as a place to work?" and it was a good answer; people would recommend this as a good place to work.

Human Resources Director:

Higher than the answer to the same question in many U.K. hospitals.

Hospital Managing Director:

Yes, a lot higher than a benchmark comparison.

Human Resources Director:

It is never going to be perfect. There will always be times in departments and issues where the people, if you stop them in the street or in the corridor, and ask them the question: "How is your morale today?" they might say: "Not too good" but overall compared to hospitals I have worked in elsewhere.

[10:45]

A walk-around is the best way to get a feel for it. I would say it is as good as any place I have worked.

The Deputy of St. Ouen :

But hospitals are a place of constant change I am sure with the health services but then change can be difficult for people to deal with. So how do you assist people? How do you keep up the morale to ensure that we have the best possible motivated workforce?

Hospital Managing Director:

Well, with change the best way you can do that is to engage them and get them to be involved in what that change is going to look like and why do we need to do it and what sort of options do we have. Part of that is about the good leadership structures. So have you got good nurse leaders at ward level, have you got good nurse managers managing those sisters at ward level and part of change management is something that people with good leadership skills will know, that engagement of staff has to be the first and biggest aspect of that ...

The Deputy of St. Ouen :

How do you feel they are performing on that?

Hospital Managing Director:

I think it is varying by what changes we are talking about. We are doing some changes at very local levels, so all the changes on Robin Ward , for example, that we are just refurbishing at the moment, it was led by the staff. So the staff are very much involved in that. Bigger changes, like discussions around the future hospital, that has been a small group of people at the moment but as that becomes more detailed and more certain it will cascade right down to everybody. I think it depends on the change but you need to get people involved as early as possible.

Head of Workforce and Planning:

Certainly I think if the staff can see the benefits for patient care and service users, any change project whatsoever, then they are on board with it. I think it tends to be the things that affect them as an individual that the morale might be changeable. It is certainly not a fixed point on any particular day but if it is going to improve patient care then I have yet to hear any professional criticism about that.

Deputy G.P. Southern :

Well, one of your employees to me, said: "And look how long it has taken for this decision to have a site for a new hospital. We have been waiting a year now. In the meantime I am still going into the same place that is not fit for purpose and I will be for the next 3 years. Noting has happened."

The Minister for Health and Social Services:

So we could rush it and build a place that is also not fit for purpose.

Deputy G.P. Southern :

I do not think he said: "Rush it." I do not think he used the word "rush". He said: "Is it not about time we had a decision?" Minister.

The Minister for Health and Social Services:

Well, we will have a decision soon. I am not going to be drawn on that today.

Deputy G.P. Southern :

You never are. You have to be bashed at least half a dozen times.

The Minister for Health and Social Services: As long as we understand each other.

Deputy G.P. Southern :

The longest 100 days in history.

The Minister for Health and Social Services:

No, you are misquoting me. I said I would review the 2-centre hospital and report back within 100 days. I was just over the 100 days when I said: "It will not work." The trouble is I am struggling to come back with the what will work but we will soon.

Human Resources Director:

Just going back to the headline topic of recruitment and retention plan. I have seen some research and I have personally experienced it of the positive impact on recruitment in terms of developing a new hospital. Healthcare professionals are attracted to work in excellent establishments.

The Deputy of St. Ouen : Yes.

Human Resources Director:

If we have a new hospital with clinical involvement in developing what it looks like and how it feels like and how it behaves as an organism then clinicians will want to come and work there because most clinicians in the U.K. will be working in older or run down or less than ideal environments. So I have certainly worked on new schemes in the U.K. where our recruitment and retention has gone like that [indicating a steep rise] and as quickly following opening a new hospital. If we can ever get a site and go forward it will be wonderful.

Deputy G.P. Southern :

Even digs from your own side ...

The Deputy of St. Ouen :

Okay. You spoke about you have leavers' interviews and presumably you keep those statistics of why people are leaving. So are people asked about morale issues when they are leaving, if that has been a factor? Perhaps also burn out due to ... do you try and monitor staff if they are under stress, job stress?

Hospital Managing Director:

We have got a good occupational health system. We have got counselling systems in place. Yes, we do try and monitor that and we hope that we are quite good at spotting the signs and we have been able to talk to staff about how we might help them and manage things and let them have some time out if that is what is required. I have seen some very good flexible working since I have been here to allow staff to get through difficult periods in their life and then return as good and valuable workforce members, and I have seen better practice here than I have perhaps seen in other places. I think it is more difficult on an island. I think it is very difficult to manage those sorts of situations in a small community and I think we have done it very well in the few occasions that I have witnessed.

Deputy T.A. McDonald:

It is a challenge to your confidentiality more than anything.

Hospital Managing Director: It is, yes.

The Deputy of St. Ouen :

Are you getting any reports that pressures within the hospital are leading to burn outs?

Hospital Managing Director:

The ones that I have worked with myself have all included a significant amount of personal pressures, not purely work pressures. If people are feeling stressed at work we encourage them to talk to us. I mean one of the things we do want to do is know about it. Unless you know about it you cannot act on it. We have looked at changing rotas for some doctors that are saying that we felt that this is not helping our work/life balance and so we said: "Okay, let us change the rotas." So we do try and help the doctors. I am talking specifically doctors but we do try and make their work/life balance better and as doctors get older, some of the onerous on-call systems are harder to do, so we take that into consideration and try and make it easier.

The Deputy of St. Ouen :

Okay. Thinking of nurses, so they are contracted to work a certain number of hours a week but then there is also the bank nurses, many of them work on the bank. Might they feel under any pressure to take up bank work?

Head of Workforce and Planning: No. It is purely their own choice.

Human Resources Director: It is a voluntary step.

Head of Workforce and Planning: It is their choice.

Hospital Managing Director: Yes, absolutely voluntary.

Head of Workforce and Planning: It is absolutely their choice.

But if there are staffing pressures might they feel that for the sake of good patient care that they need to be there for those extra hours to provide the patient care?

Head of Workforce and Planning:

If they chose to change the off-duty within the clinical area that they are working with, that would be the first port of call. So we look at the rota and try and manage it in a different way and swap some shifts where possible. I mean certainly most of the nurses tend to work 2 long days and 2 short but what we found, and even though the evidence suggests that it is linked to burn out, our own nurses like those shift patterns because of the downtime that it does give them. If there is any reason, whether it is child care or for personal reasons, why somebody cannot or struggles with working night duty or working with long day shift patterns, then there is an operational agreement that the ward manager can discuss it with that employee and as long as there are not too many of them asking for specific shifts then it can be tailored into that rota for that ward area.

Deputy T.A. McDonald: So there is freedom to ...

Head of Workforce and Planning:

There absolutely is, yes, based on the individual and service needs. Obviously service need comes first but if that can be built around the individual then you have got a much happier workforce, then ideally that is the best thing that we can do but nobody's under pressure to do bank.

Hospital Managing Director:

Any organisation that works 24 hours a day, 365 days a year will have the necessity for people to do those unsociable hours and we know they can be stressful. So this is about making sure that we work with people and if something in their life is causing them difficulty or it might just be because they are getting older, we need to recognise that, but we still have to run the service 24 hours a day, 365 days a year.

Deputy G.P. Southern :

But since you are tasked with reducing agency nurses, their hours, there must be some sort of pressure, knock on, in terms of bank nursing. You still have got to cover so many wards. It has got to do things.

Hospital Managing Director:

We would always rather use bank than agency anyway because they are our staff. They are familiar with the areas. They know all the policies and it is a safer better continuity of care but nobody is ever pressured. When they put themselves forward they are registered with the bank and they will say: "I am on leave next week I do not mind doing 2 days and I do not mind doing Wednesday and Thursday" and that is registered.

Deputy G.P. Southern :

But your manager, who is tasked to cut down on agency, must be under some pressure surely.

Hospital Managing Director:

They are not the ones that ring up the bank nurses. They just say to the office, these are the shifts I am short and hand it over so that is not the manager at the ward putting pressure on anybody.

Deputy G.P. Southern :

There would not be any pressure coming from targets to reduce new spends and ...

Head of Workforce and Planning:

Again it just depends what that increased agency was for because it is not just about linking it to the number of beds. As I mentioned before, at one point we had nearly twice as many people waiting to come into post than we did have vacancies, which we have not seen before. A lot of those people have now started in post. Those that have not we will not see them in post until January going forward now, but it is the reason why you have got the vacancy, and the agency in the first place is to block pressure anyone might feel in terms of working a bank shift but that is about their individual pressure. That is about their professionalism and how they view their kind of principles of covering their ward area but I think that is about professional pride to them. It is not the organisation that puts pressure on them and a lot of those people have started in post.

Hospital Managing Director:

One of the examples is theatres; that is the hot spot. We really only cover the vacancies with agency because we do not have a group of people on the bank because they are already working with us during the normal operating hours. Yes, we want to reduce the number of those agency nurses coming in but we are doing that through their recruitment campaign, and we have got some good recruitment underway and hopefully we will start to see that reduce over the next few months but that is not putting pressure on a manager or anybody else to insist on people doing extra shifts.

The Deputy of St. Ouen :

Minister, I would like to ask about one issue that Dr. Lawrenson raised with us on behalf of the doctors as contributing to low morale, and that was the fixed percentage refund of their insurance premiums that you refund to the consultants. It seems to be on behalf of the doctors that because the private practice of the consultants varies tremendously it is unfair in just paying the fixed proportion of their insurance and he felt that there should be a more measured approach to doing this. What is your view?

The Minister for Health and Social Services: We have had this discussion before, have we not?

Hospital Managing Director:

I had a meeting last week with the doctors with the finance director, myself and with medical staffing to looking at what are the other options. The other options will need to have State agreement because it will be coming away from the model that the doctor insures themselves with an indemnity provider and we reimburse them 50 per cent of their premiums if they earn over a certain amount privately. If they do not earn that amount we reimburse 100 per cent. So if they are not doing an awful lot of private work they are not paying anything. So most of the doctors feeling ...

The Deputy of St. Ouen :

But if they can manage within the vacancy factor to cover with agency at 50% more, we would look to source agency as long as we do not go over the additional 50%.

Hospital Managing Director:

They still pay 50 per cent and their premium will be dictated by the indemnity insurer on their earnings so their premium should be proportionate, depending on their earning.

The Deputy of St. Ouen :

Yes, on their earning powers. So there are no plans to change that pattern?

Hospital Managing Director:

Yes, we had a meeting last week. We are looking at options. We have not gone any further than just looking at options at the moment.

The Minister for Health and Social Services:

It has to be fair to both, that is all I am going to say.

Deputy G.P. Southern :

It is all a matter of balance.

The Minister for Health and Social Services: Yes.

Hospital Managing Director: But they have to be insured.

Deputy T.A. McDonald:

No, I am happy. Can I just ask, we are coming up to winter and are we anticipating anything this year or ... I know you are fully prepared, norovirus and everything else, but ...

Hospital Managing Director:

It is norovirus and winter vomiting that are the things that put the pressures on us because it comes in a wave as a rule and you have to isolate patients, and that is when our hospital facilities do not lend themselves very well because of the 6 bedded bays.

Deputy T.A. McDonald:

No, they do not because of the 6 bay and barrier nursing and universal provisions, you are obviously trying to keep people ...

The Minister for Health and Social Services:

Do not be under any disillusion; if the 6 bay needs to be opened, if we had a real need for it, it will be opened.

Deputy T.A. McDonald:

Of course, exactly. Yes, it is as simple as that.

Head of Workforce and Planning:

The staff themselves, you would not be able to move them from that area; you would have to keep them in there for a certain length of time so you cannot ... that movement of staff that you get with the family, that is when the pressure starts because you cannot move somebody from an infected area to a non-infected area.

Deputy T.A. McDonald:

Let us hope it does not clash with your January time of the year.

Head of Workforce and Planning: Let us hope we do not get it at all.

The Deputy of St. Ouen :

So we have come to the end of our time but, Minister, perhaps I can ask you a final question: do you have any concerns for the future recruitment of medical staff?

The Minister for Health and Social Services:

If I was to say I had no concerns that would be a very - I will not say incorrect - but that would be an irresponsible comment to make. There are concerns all the time: can we get the right people with the right skills in the right place at the right price?

[11:00]

So we are always active in the way that we look at our workforce planning and our own education, our own training, what is happening worldwide, particularly what is happening in England. Am I overly concerned, no; but I think it is right that it is top of the agenda all the time. Can we recruit an appropriate workforce? I believe we can providing we keep on top of it.

The Deputy of St. Ouen :

Okay. Well, thank you for coming to speak to us about your efforts in that field. Thank you all for attending and that brings the meeting to an end.

The Minister for Health and Social Services: Okay, thank you.

[11:01]