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Health and Social Security Scrutiny Panel MONDAY, 21st SEPTEMBER 2015
Panel:
Deputy R.J. Renouf of St. Ouen (Chairman) Deputy G.P. Southern of St. Helier
Deputy T.A. McDonald of St. Saviour
Witness:
Dr. D. Lawrenson
[14:00]
Deputy R.J. Renouf of St. Ouen (Chairman): So, thank you once again.
Dr. D. Lawrenson: No problem.
The Deputy of St. Ouen :
This is a public meeting so I am going to be a bit formal at the outset because the meeting is being recorded. This is a meeting of the Health and Social Security Scrutiny Panel and is part of our review into the recruitment and retention of hospital staff. We have with us today, I believe, Dr. David Lawrenson. Is that right?
The Deputy of St. Ouen :
Thank you, and we are joined by our Scrutiny Officer, who is Kellie Boydens . I am sorry you feel ... it seems you are quite a way away from us but that is just the way this is set up. Thank you again for coming to assist us. Can you begin, perhaps, by helping us and explaining the organisational structure of the doctors within the hospital service?
Dr. D. Lawrenson:
Well, there are 3 groups of doctors, really. There is the consultant group and then working in conjunction with the consultant group is the group of middle-grade doctors. They are doctors who are not in training but are not in ... have not reached the consultant level for one reason or another.
The Deputy of St. Ouen : Yes.
Dr. D. Lawrenson:
Then there is a group of doctors who are usually employed on a temporary basis and often over from deaneries in the U.K. (United Kingdom) who are registrars or trainees, often quite junior doctors. I suppose, in broad, 3 layers of doctors.
The Deputy of St. Ouen :
Yes, I understand. In terms of numbers or number of posts within the hospital, can you tell us how many consultants there should be?
Dr. D. Lawrenson:
So when I first came to Jersey I think there were probably 50 consultants in the hospital. The exact number now I would not be able to tell you off the top of my head but it is probably something like 70 consultants.
The Deputy of St. Ouen : Seventy, yes, okay.
Dr. D. Lawrenson:
Middle grades probably slightly less than that, maybe 60 middle-grade doctors, and then F1 and F2s, which are the trainees, probably a similar number again.
The Deputy of St. Ouen :
You have referred to F1 and F2. Is that a distinction we should know about?
Dr. D. Lawrenson:
Yes, so the trainee doctors that are in that lower-tier of junior doctors.
The Deputy of St. Ouen :
Right. Does that refer to the level of training they have attained?
Dr. D. Lawrenson:
Yes, so they are in their foundation year 1 and year 2, so first year or 2 out of medical school.
The Deputy of St. Ouen :
I understand, yes, okay. So, of course, with that number of people in the service there is always going to be a rotation, but are there currently more vacancies than you would expect or otherwise?
Dr. D. Lawrenson:
The way the staffing is in the consultant tier is unusual in that there is a large tranche of consultants that are approaching retirement in the next 5 years, I would think. So we have not had a loss or many retirements in the last 5 years or so, but we are approaching a large tranche of doctors leaving from the consultant group. Personally, I find that a little bit worrying in that a large group going at once. In the middle grade, there are a few vacancies that are proving to be quite difficult to fill. In the middle-grade group we have had historically great difficulty recruiting 2 middle-grade doctors. That crisis seems to be improving but there are still some problems there. I do not think the third tier of trainees is really relevant to this discussion.
The Deputy of St. Ouen : No, I understand.
Dr. D. Lawrenson:
Because they are often provided by medical schools and a much more fluid group of doctors, you know, moving ...
The Deputy of St. Ouen :
Yes, perhaps we will come on to discuss their conditions later, but coming back to the consultants, what succession planning is in place, to your knowledge, to fill those posts as consultants retire?
Dr. D. Lawrenson:
Well, these are consultants in different departments, so each department will be making their own plans with succession planning. How attractive Jersey is looking to doctors moving in from outside - and we largely recruit from the U.K. - I think at the moment is quite questionable but I am not too sure if I am answering the question that you are leading to.
The Deputy of St. Ouen :
Yes, please, we want to go on to that. What are the difficulties?
Dr. D. Lawrenson:
Well, the difficulties, the way I see it, is that in the last 10 years terms and conditions for consultants in Jersey have deteriorated dramatically.
The Deputy of St. Ouen : Dramatically you say? Yes.
Dr. D. Lawrenson:
Yes, I think dramatically is an understatement.
The Deputy of St. Ouen :
Right. Can you elaborate? Tell us what has been the trouble.
Dr. D. Lawrenson:
Well, I think it is largely around the cost of living in Jersey and about the costs of working here as a consultant. One of the major costs for a consultant working in Jersey is about insurance. We are responsible for buying our own insurance because there is not a Crown indemnity in Jersey.
The Deputy of St. Ouen : I see, yes.
Dr. D. Lawrenson:
In the U.K. there are different regulations about that. There was a group of important findings in terms of payments for medical negligence, not in Jersey but in other jurisdictions, recently that have caused insurance premiums to change dramatically in the last 5 years. So we are seeing increased expenses there and that is affecting take-home pay dramatically. Then the third problem is how we have seen our remuneration deteriorate over the last 10 years. When compared to other civil servants we have seen an almost 20 per cent degradation in pay over the last 10 years. So I am speaking from my role in the local negotiating committee because I act in the local negotiating committee, and we have looked at doctors' morale in Jersey and found it to be extremely low in a survey that we ran about 6 weeks ago, with doctors coming back ... you know, on a linear scale of one being extremely happy and satisfied and 10 being extremely dissatisfied, we have come back with a very strong response rate of about 80 per cent of career- grade doctors responding to that question: "Where do you see yourself?" with the average rating being 8. So we have a problem with morale and although that at the moment is not showing in terms of problems with recruitment, I think we will see that when we start to look to recruit from the U.K.
The Deputy of St. Ouen :
Yes, that is alarming. But in comparison with the pay and conditions received in the N.H.S. (National Health Service), how do the Jersey pay and conditions fare?
Dr. D. Lawrenson:
Well, we have very similar pay conditions to the U.K. We have a natural increase annually with an increment on a 20-point scale. So as a newly recruited consultant you will start on point 1 and annually work forward to point 20. That is a little bit different to the way the scale works in the U.K., but the monetary value of the scale in the U.K. is slightly different. They have excellence awards placed at the end of their career, so as you move up the scale in the U.K. you will then reach the top tier and then there are ways that you can apply for excellence awards. That is similar to Jersey, so I would say there is not any particular advantage from a monetary perspective to the Jersey pay situation.
The Deputy of St. Ouen :
Are the pay and conditions under review in the same way that all public posts are being reviewed, we understand?
Dr. D. Lawrenson:
There is something as part of the local negotiating committee that we have offered as a way to try to break the deadlock that we have encountered. There is a body in the U.K. called the D.D.R.B., Doctors' and Dentists' Remuneration Body, and historically they have made recommendations for doctors' pay in the U.K. and that has been followed in Jersey. Now, the D.D.R.B. in the U.K. is falling apart and over the last 5 years the Department of Health has asked the D.D.R.B. not to make a recommendation and the D.D.R.B. has been asked not to make recommendations again for 2016.
The Deputy of St. Ouen : In Jersey is this the case?
Dr. D. Lawrenson: In the U.K.
The Deputy of St. Ouen : Oh, in the U.K.
For historic reasons, Jersey has followed the D.D.R.B. recommendations. So the D.D.R.B. recommendations I think will probably now stop being made and really the D.D.R.B. has become a puppet of the Department of Health. So I think we will see the D.D.R.B. being disbanded and we will ... so we are trying to find a way to form negotiations with the States Employment Board and we have looked at our pay structures and our constraints of work and offered ways that we can look at that and change our remuneration. But that would mean relooking at our contracts and I think that would be a long-term fix and it would take a long time to ... the current contract we have was formed in 2005 and I think took about 4 years to negotiate. So I do not think it is an easy task to negotiate these contracts, but it is something that we have offered to the S.E.B. (States Employment Board) as something that we would be willing to discuss and look at. In the U.K., the big drive at the moment for doctors is 7-day working and obviously that is something that we are concerned about. There are a lot of consultants in Jersey not quite doing 7-day working but very close to doing 7-day working because we ... I do ward rounds in the hospital every third weekend. It is not quite the same as being in work but we have ... there are moves towards 7-day working and we would like to see that go further so that we can improve our patient safety. That is something that we would like to align with a renegotiation.
The Deputy of St. Ouen : Yes, of course.
Dr. D. Lawrenson:
But we understand that times are difficult and that there is a fiscal problem, so we are not asking ... we do not think we are asking the world but we certainly are pushing for some uplift in pay so that we can improve morale so that we can attract good doctors.
[14:15]
Deputy T.A. McDonald:
While we are talking about obviously terms and conditions, we heard from nurses, for example, that for 10 years of service they had a leave entitlement of 33 days, but if they were coming to Jersey that would be 5 days less. How would things compare from an annual leave perspective at consultancy level?
Dr. D. Lawrenson:
I think our leave entitlements are very similar to the U.K. I would not think that there would be a material difference. I think my leave entitlements are very generous. When I started with my
contract I had 30 days' annual leave a year, and I do not know the exact numbers but slowly as I moved through the ranks that slowly increases. It is certainly not something that I see as being a major issue.
Deputy T.A. McDonald:
No, that is fine. It is, obviously, quite an important issue for consideration. No, that is fine, thank you.
The Deputy of St. Ouen :
Can I just come back to the issue you highlighted about insurance, professional indemnity insurance? Is that to cover your private practice work?
Dr. D. Lawrenson:
Well, that covers private practice as well as States practice.
The Deputy of St. Ouen : As well as States practice?
Dr. D. Lawrenson:
Yes. We do share the costs of the insurance with the hospital. There are a group of doctors working in Jersey who do not have any private practice at all, consultants.
The Deputy of St. Ouen :
Yet they have to pay some part of an insurance premium?
Dr. D. Lawrenson:
There are arrangements to reimburse that where there is no private practice, but there does not seem to be an arrangement ... so you are either doing private practice or you are not and there is a big variation in what private practice means to consultants financially. There does not seem to be some sort of scale in terms of refunding that to doctors. If I undertake no private practice at all, then I will get almost everything reimbursed to me apart from the small basic rate that I would pay in the U.K. But if I do a small amount of private practice, and the variation is enormous, then there is a standard reimbursement. So that can mean losses of income ... well, costs of tens of thousands of pounds to doctors at the hospital.
The Deputy of St. Ouen :
Yes. The standard reimbursement is a fixed percentage, is it?
Dr. D. Lawrenson: Yes.
The Deputy of St. Ouen :
Right, okay, regardless of how many hours are worked in private practice?
Dr. D. Lawrenson: Absolutely, yes.
Deputy G.P. Southern :
This differs markedly from the U.K. practice?
Dr. D. Lawrenson: Yes.
Deputy G.P. Southern : Which is ...?
Dr. D. Lawrenson:
Where doctors have the benefit of Crown indemnity and their practice is covered by that.
The Deputy of St. Ouen :
So there is no similar insurance premium in the U.K., is there?
Dr. D. Lawrenson:
No. So in Jersey my medical insurance company, which is either the Medical Protection Society or the Medical Defence Union, sees every patient that I see as a private patient because we are outside the barriers of the National Health Service.
The Deputy of St. Ouen : Right, yes.
Dr. D. Lawrenson:
So I pay them and go to the hospital with my premiums and tell them what my private practice is and we work out based on a very simple formula what my reimbursement is. So in the last 5 years, I have seen my insurance premium go from £1,500 a year to £14,000 a year.
The Deputy of St. Ouen :
Is that fairly typical among consultants' practices?
Dr. D. Lawrenson:
I am actually one of the consultants that has done fairly well. There was a huge change that was required in terms of the insurance that could be offered to the consultants working in obstetrics and gynaecology because it was just unaffordable, so we had to look for alternative insurers. So this is a major issue. As doctors, we have been pushing the States Employment Board, the Minister for Health and the directors at the hospital to look at ways that this can change so that there is a similar Crown indemnity.
The Deputy of St. Ouen :
Yes. Is there another way of dealing with it?
Dr. D. Lawrenson:
Well, I am sure that there is. One of the major issues is that you have to have liquidity in that because you could in your first year of insurance stumble into a major problem and be £10 million, £15 million down the pipe on that.
The Deputy of St. Ouen :
I understand what you mean, yes.
Dr. D. Lawrenson:
So it is about having that fund available and the perception is that the monies for that fund are not there, exactly the reasons why it has not happened ... because I must say I find that a little bit difficult to swallow and there must be ways of outsourcing some of that risk in the same way that you outsource the risk when you buy expensive pieces of equipment when you run a business.
The Deputy of St. Ouen :
Have the hospital authorities investigated themselves taking out an insurance policy to cover all doctors rather than ...?
Dr. D. Lawrenson:
There is an insurance policy that covers all the middle grades.
The Deputy of St. Ouen : I see.
Dr. D. Lawrenson:
So I think the issue is about the relationship that the hospital has with private practice.
The Deputy of St. Ouen :
Yes, this is interesting because it is something that we have not come across, I have not been aware of. So you are saying that all the work you carry out on the public wards as a consultant is insured under your private arrangements?
Dr. D. Lawrenson:
It is insured personally by myself through the Medical Protection Society with a premium that I pay to them personally, and then I have arrangements with the hospital that allows some of that to be reimbursed to me.
The Deputy of St. Ouen :
Yes, and yet if the same work was carried out by a registrar or a middle-grade doctor that would be covered by a separate policy taken out by the States?
Dr. D. Lawrenson:
By a separate insurance policy, yes.
The Deputy of St. Ouen : I think it is most odd.
Dr. D. Lawrenson:
It is something that we find to be a major problem and a consultant coming to ... thinking about coming to work in Jersey, when they look, they come to scout around and think about their salary and work out how much they might be able to make in private practice and look at house prices and look at schools and then hear that their insurance policy might be £14,000 a year, that might be a difficult circle to square.
The Deputy of St. Ouen :
Are you aware if that has happened to any prospective recruits?
Dr. D. Lawrenson:
I do not know of any doctors that have been put off by that but then there has not been a huge turnover in hospital consultants recently. We have had a new ophthalmologist recently. The new ophthalmologist just happens to be a doctor who has quite good insight into the way the hospital works and society in Jersey and ophthalmology just happens to be one of those professions where perhaps private practice is a little more lucrative. But I am sure it will be ... a paediatrician such as myself coming to Jersey having to consider that I think would be distinctly put off.
The Deputy of St. Ouen :
Yes, I can imagine. Anything more on that topic?
Deputy G.P. Southern :
It does seem like a whole tranche of people are going - therefore, recruitment will go on - and yet you are stuck with this barrier, a clear barrier there, which it seems to me is going to put off a number of applicants.
Dr. D. Lawrenson:
Well, and the barrier of where morale is at the moment. So when consultants look to move from one place to another, they go to speak to their counterparts.
The Deputy of St. Ouen :
I am just wondering is the concept that ... you are not employees of the States of Jersey, are you? Is that why you take out your own insurance? Would consultants prefer to remain independent in that way or ...?
Dr. D. Lawrenson:
This is a status quo that we desperately want to change.
The Deputy of St. Ouen :
You would like to change it, yes.
Dr. D. Lawrenson:
We do not see ourselves as independent practitioners. I see myself as an employee of the hospital and I would say that the other consultants would see it the same way, too.
The Deputy of St. Ouen :
Okay. So with that in mind, then you should have the proper insurance cover funded by your employer, yes?
Dr. D. Lawrenson:
I completely agree. [Laughter]
The Deputy of St. Ouen :
Well, no doubt we will hear from the Minister on that when we speak to him again.
Deputy G.P. Southern :
To what extent would you say that the level of dissatisfaction is directly correlated to any of those factors or is it correlated to the fact that discussions do not appear to be occurring in the sense that ...?
Dr. D. Lawrenson:
We have ... Helen O'Shea is the director of the hospital and she has assured us that she and Julie Garbutt and the previous Minister for Health and the current Minister for Health have looked at this issue and find it to be a thorny one but discussions are taking place. But this discussion has been on the table for 5 years, really since the sudden exponential rise in premiums has been found, and I have seen no movement at all in this issue at all. Exactly where the stumbling block is I do not know. The hospital has a strange relationship with private practice because they see loss of consultant time to private practice but they see the benefits of income from private practice. So some ... a lot of hospital consultants pay their entire salary with the money that they earn for the hospital, so they are effectively financially neutral. The radiologists, 5 radiologists, the private work that the hospital charges for and brings in from radiology is enormous. It pays their salaries over and over again. The private practice they would get from me as a paediatrician is zero, so it is different for different specialists. That is where the ambiguous relationship with private practice comes from in the hospital, I think. I do not know if they really know whether private practice is their friend or their enemy.
The Deputy of St. Ouen :
Oh, dear, that is a concern that they have not even resolved that.
Dr. D. Lawrenson: Yes, it is a major issue.
Deputy T.A. McDonald: Ongoing for 5 years?
Dr. D. Lawrenson:
The insurance one. I think the private practice relationship has been going on since long before I got here 10 years ago and I am sure it is as old as the age of the company Bupa.
The Deputy of St. Ouen :
I believe the consultants are contracted to work a certain number of hours for the public service?
Dr. D. Lawrenson:
Yes, we are contracted to work 10 sessions a week and we have job plans in place that ensure that people do work 10 sessions a week. I would think that if you looked at people's job plans you would find hospital consultants to be doing private work in their time in lieu but you would find the public work ... I cannot speak for every single consultant because I have not examined the job plans of every single consultant, but I know the work that I do and the work that my paediatric colleagues do. I see the obstetricians and gynaecologists regularly because I work very closely with them and I see them on the shop floor. I know where the surgeons are because every now and then one of my patients needs an operation. I am convinced that according to contracts hospital consultants are providing their 10 sessions of work a week.
[14:30]
The Deputy of St. Ouen :
Has that ever been a source of tension? Do the hospital authorities feel that to manage demand on their waiting lists they would like to ask consultants for more time?
Dr. D. Lawrenson:
I think it is a daily source of tension, this relationship because, you know, as pay in lieu for the on call that I do - I am on call one night in 3 and one weekend in 3 - I do not get paid for that, what I do get is time back in lieu. So I get 2.5 sessions a week where I am not in work.
The Deputy of St. Ouen : Right.
Dr. D. Lawrenson:
I take one of those sessions and offer a private service to families who are worried about their children.
The Deputy of St. Ouen :
Which you are free to do so contractually, are you not?
Dr. D. Lawrenson: Yes.
The Deputy of St. Ouen : Yes.
Dr. D. Lawrenson:
This is the way that consultants find time in their working week to see private patients.
The Deputy of St. Ouen : I see.
Dr. D. Lawrenson:
You know, exactly the minutes and hours of how it works ... for me, I do that and have hours and hours to spare because we have a fantastic paediatric service and so there is not a huge pressure to go and see a private paediatrician. The people who are going to see a private paediatrician are the ones who want to choose the person that they want to see and they want to dictate when and where they see them, and perhaps want a little bit of privacy in that they do not want to sit in a slightly grubby hospital waiting room. Whereas if I need to have my hip replaced and I do not want to spend my 18 months, I do not know how long the waiting list is, for my hip replacement with my aching joint and I have a few grand to spare I might decide to ... or I am insured I might decide to have my hip done privately.
The Deputy of St. Ouen : Yes.
Dr. D. Lawrenson:
I think the number of people having their hips replaced is perhaps slightly greater than the number of people worried about their 3 week-old. So the time pressure on different specialities is different. We have tried to have a contract in Jersey that is ... you know, that sees all possible consultants as contributing equally to the hospital as a whole. So we do not have a contract for orthopaedic surgeons or cardiologists or dermatologists or obstetricians, we have a single contract and largely I think it is probably reasonable but I think there probably are ways that it could be improved. There are ways that I think it could be improved.
The Deputy of St. Ouen : Yes, clearly, thank you.
Dr. D. Lawrenson:
That is not necessarily what everyone ...
Deputy T.A. McDonald:
I was looking back at figures, obviously we knew you were coming in today, and it tells me that hospital consultants receive approximately 2,000 referrals each month. Obviously there is 13,500 clinic appointments on top but there are some clinical teams who are almost single-handed and obviously I presume that becomes much more difficult for them with things like annual leave or leave of absence, or anything at all?
Dr. D. Lawrenson:
Yes, so we have a huge variation. The physicians are an unusual group in that they are all generalists but have special interests. So Dr. Kumar is a nephrologist and if you need your dialysis you need to see Dr. Kumar. Although he is working with a group of 9 physicians, effectively as the nephrologist he is single-handed. David Ng is a gastroenterologist, there are now 2 gastroenterologists but their referral numbers are enormous and their waiting lists are big. Generalists, you know paediatricians, orthopaedic surgeons, physicians are slowly becoming things of the past and are difficult to find. So often you have a surgeon who is doing a job locally who, when he goes, you will not find a replacement who will be able to do all the ... or will be willing to do all the work that he has done or she has done. Suddenly you find that to cover the service that a chap who has been in the role for 30 years has been providing, you need 2 or 3 people to do that.
Deputy T.A. McDonald: That is the danger.
Dr. D. Lawrenson:
Then because they are specialised, even though you have 3 people they are working single- handedly.
Deputy T.A. McDonald:
That is right. The classic example is ear, nose and throat, which originally was E.N.T. (Ear Nose and Throat) and there were E.N.T. specialists but that has now been broken down into ...
Dr. D. Lawrenson:
Yes, absolutely. The ophthalmologists, you look at the eye and you think: "Oh well, that is all pretty small area that must be quite simple" but even that is now being divided into people who focus on the lens ...
Deputy T.A. McDonald: No pun intended.
Dr. D. Lawrenson:
... or the retina. Our team are starting to subdivide that work into smaller specialities so that they can do ... provide a better service.
Deputy T.A. McDonald:
Well, survive and provide, as you say, a better service.
Dr. D. Lawrenson:
But it does mean that when people go away things back up.
Deputy T.A. McDonald:
That is the problem and this hospital is no different to any hospital anywhere in the U.K., it is all to do with patient waiting lists and all that sort of thing. There is ... the reasons for it obviously are huge. Certainly at consultancy level I can see the limitations, it is much more important. Going back to those figures, I think they quoted in August there were 6,800-odd people waiting for their first appointment and at the same time 1,763 waiting for a procedure. So, as I say, to the people outside - in other words, Joe Public - they are really interested in: "When can I see my doctor? How long will it take once I have been diagnosed?", et cetera, et cetera. But not an easy thing to tackle.
Dr. D. Lawrenson:
There are efficiencies that we can find. With the size of the hospital as it is, we are fighting each other for clinic space. So there are consulting rooms and I have a waiting list that I ... you know, I get a referral from the G.P. (general practitioner) today saying something is worrying about a child, I want to see them as soon as possible. Difficult for me to find a consulting room. You know, this is something that the potential new hospital will address and there are things being looked at in the hospital to try to improve that. But it is something that is a major issue. The theatres, you have surgeons waiting to work but perhaps a better use of the theatres could be looked at. That it is 5 days a week means that 2 days out of every week those theatres largely stand empty. But, you know, if you want to run theatres on the weekend, not only do you need your consultant and your anaesthetist and nurses, you need the porters in the background and you need the cleaners, you need the entire service.
Deputy T.A. McDonald: Infrastructure.
The Deputy of St. Ouen :
Yes, there are always implications.
Dr. D. Lawrenson:
The laundry needs to get done.
Deputy G.P. Southern :
To what extent is that dissatisfaction rating linked to the crumbling nature of the hospital?
Dr. D. Lawrenson:
I do not think that the crumbling nature of the hospital is contributing to that much because I think there is a feeling that that has been registered and is being addressed. Now, I know that we are not going to have the new hospital pop up in place of this old one next year but we are pragmatic people who are willing to work with the various bodies that are looking at the new hospital and try to solve it. The major issue regarding morale is about the fact that we have repeatedly tried to negotiate our terms and conditions and repeatedly found that we have hit a granite block.
The Deputy of St. Ouen :
To address some of the pressures you have been speaking of in the past few minutes, is there any working with the Guernsey Hospital whereby we could share a consultancy or ...
Dr. D. Lawrenson:
There are some groups that ... where there is working with Guernsey. I have been surprised by ... I thought when I came to Jersey that Jersey and Guernsey would effectively start becoming similar work but I cannot ... we never really talk to the folk in Guernsey and they do not seem to contact us. You know, I suppose we are 2 satellite hospitals. When we look for help we go to the hub. So we work in parallel but there is not much cross-resourcing. I have heard of a few plans to try to look at where a service is required and we do not quite have enough here or there to justify that service, about seeing if we could have one service for the 2 Islands. But that tiny little stretch of water in the fog sometimes makes that working difficult.
The Deputy of St. Ouen :
I know, but it seems to me ... well, but then ... okay, so using the U.K. is there more that could be done by either sending Jersey people out to the U.K. - I know it is not always an ideal solution - or is it possible to arrange consultant's appointments using the latest technology with the consultant based in the U.K. and the patient here in Jersey. Is there some mileage there?
Dr. D. Lawrenson:
We do some of that. So we have paediatric cardiologists in the U.K. on standby who will ... our technicians will be looking at doing an echocardiogram and will be worried about their findings and so we will give them a ring and they will go and have a look at the machine, the 2 machines will talk to each other and they will be able to see the images and, you know, Dr. Graham will saying: "Just hold that probe a little to the left I cannot quite see the aorta" and he will say: "Well that is fine, you were imagining that, there is nothing wrong with this child" or: "Pop him on a plane, we need him today." There are some ... and that is one example where it works very well. But there are some specialities where that is not possible. In fact, the cost of bringing consultants here is not much greater than having those facilities. So in a lot of specialities we will get a specialist from a U.K. hospital to fly over to Jersey and run an outpatient's clinic. They will see ... when our urologist comes over from Cambridge he will see 40 children with various urological problems in a day. That is fantastic value for money. Then he will say to us: "Bob, Mary and Bert need to come over to Cambridge and need X, Y and Z" but the other 37 are fine, do not worry about them." Largely that is what happens or: "Bring them back in a year's time and we will have a look at them and see which way that has gone." So that is a very cost effective way of working. We do send patients over to the U.K. where we do not have those arrangements or where things are a little bit more urgent and a child or an adult cannot wait 3 months for that specialist to come over, or where our numbers just are not big enough to justify bringing a consultant over because there is only going to be one patient or 2 patients with this condition a year.
The Deputy of St. Ouen : Yes, that is right.
Dr. D. Lawrenson:
There is a big drive to bring as much work back to Jersey as possible but that comes with costs as well, because often the stuff that has gone away is the slightly more specialised stuff and then you need a consultant, and suddenly you need 2 nurses and the equipment and all of that, and all the knock on ...
[14:45]
The Deputy of St. Ouen :
So, you say there is a big drive to bring it back to Jersey, for the work to be done here?
Dr. D. Lawrenson:
Yes, and we have brought ... just in paediatrics I have an interest and speciality in allergic disease and a lot of things that were being referred off Island or having expensive tests done, we are now doing the skin prick testing locally with the nurses being trained up to do that and I think the savings from that are enormous, and it is better for the patient because they would have had to sit on a plane, go and sit in Southampton General Hospital, spend 10 minutes talking to the consultant, 10 minutes with the nurse and then get told: "This is your diagnosis" and the mum has missed a whole day of work, the child's missed a day of school, there has been a flat on the other side, there is all the hassle of arranging things, dog has to be walked and all the day-to-day issues of that ...
Deputy T.A. McDonald:
Plus the stress on the patient, which is really most important.
The Deputy of St. Ouen :
But Southampton is a conurbation serving perhaps a million people, the Jersey Hospital serves 100,000, are there risks there that we will not have sufficient expertise in Jersey to be able to properly handle cases?
Dr. D. Lawrenson:
Absolutely. So where people will not be doing sufficient numbers of cases to retain their expertise, we cannot justify bringing that back.
The Deputy of St. Ouen : So that does not happen?
Dr. D. Lawrenson:
That is one of the reasons why this hospital is so much more expensive per capita than your average district general hospital in the U.K. If you live in Basingstoke your general hospital provides general hospital expertise, but if you have your stroke off you go to the stroke unit in London or in Winchester or wherever it may be and Basingstoke does not need to provide that. But we are in a situation here where that measurement has to be made constantly about what is the right thing to bring back, what is safe to bring back, and what is cost effective. It is not always an easy ... there might be plenty of stuff to bring back that is perfectly safe, absolutely cost effective to bring back but there will one or 2 a year that the cost of running the service outweighed the benefits of having it. It is tough decision-making.
Deputy G.P. Southern :
To what extent is coming to Jersey seen as a bit of a backwater that will impair, or could impair, your career progression or your training needs?
Dr. D. Lawrenson:
I think the juniors love coming here because it is a backwater. We constantly get praised by the deaneries for the brilliant training that we provide for junior doctors here, and the feedback that they give is excellent. In terms of how rewarding work is here, that is one of the reasons I came to Jersey, because the work that I will do as a paediatrician in Jersey will be so much more challenging than the work I would do as a paediatrician in Winchester, because the support services are so different. So the job in Jersey, for me, challenges me in ways that a job in a district general hospital in the U.K. would not. So some people will see that as a benefit, some people will see that as a risk. I do not think any consultant coming here would come here and see this as a backwater because just working on the frontline with the same patients and the same diseases and having to meet the same results ... provide the same results. I think probably that could be seen as a career motivator, whereas some ... from a social perspective it might seem you are trying to recruit people to come Jersey who are moving away from their families in the U.K., that might be an issue. So from that perspective the backwater issue might be one. But then there are benefits of living in Jersey where Jersey can be quite well sold. Young families moving to Jersey, fantastic schools, safety, all the outdoor facilities that Jersey offers. I think from a lifestyle perspective you can sell Jersey quite easily.
The Deputy of St. Ouen :
A while ago you briefly alluded to housing difficulties, can we look at each category of doctor, perhaps and examine how they are housed in the Island and what difficulties might arise?
Dr. D. Lawrenson:
The trainees have housing provided and partially funded by the hospital, and exactly how the funding of that works I do not know.
The Deputy of St. Ouen :
Are they generally content with that? I think for a short stay they usually are.
Dr. D. Lawrenson:
Yes, I think the feeling there is that that works out very well.
The Deputy of St. Ouen : The middle grades?
Dr. D. Lawrenson:
The middle grades will largely have come to Jersey and within a few years of moving to Jersey, if they found their feet, they would be looking to buy. I am sure you know what that means.
The Deputy of St. Ouen :
Yes, there is no greater expense ...
Dr. D. Lawrenson:
That is the same for consultants.
The Deputy of St. Ouen :
But at the time they come to Jersey are they made aware of the cost of property here and ...
Dr. D. Lawrenson:
Yes, and I think you would have to be pretty naive to move to a place like Jersey without doing a little bit of investigating.
The Deputy of St. Ouen : Yes.
Dr. D. Lawrenson:
I remember when we first moved to Jersey, you know, we sat with the back of an envelope and a pencil and did some pretty careful sums and came down narrowly on the side of moving to Jersey. But that was in 2006 when take home pay was better than it is now because there was a significant amount of medical insurance that I was not paying and we had not found ... experienced the 10 years of pay depreciation that we have seen. I do not know whether I would make the same decision now. Fortunately we have seen years of good mortgage rates and so people keep their heads above water, but a consultant or middle grade moving to Jersey now would have to do some very careful consideration to move to Jersey. I am sure that is not only for hospital doctors, that could apply to anyone.
The Deputy of St. Ouen :
Yes, you are right. Are there any issues about moving? What about education provision? We have heard from other professionals that depending on the age your children are when they come to Jersey, they might not be eligible for grant assistance from the Island. Is that something that has affected the doctors to your knowledge? Grant assistance to university.
Dr. D. Lawrenson:
Yes, I do not ... I know some people that have decided not to move because of the age of their children, they are coming to the end of their school careers and looking to university, you know, is now the right time to come? I think people with younger children take that as a risk for the future. It is certainly something that is starting to crystallise in my mind as my children get older, and the potential costs that a university education might be.
The Deputy of St. Ouen : Indeed.
Deputy T.A. McDonald:
Is there anything else at all which you feel we should really be aware of, because I must admit it has been quite an eye-opener for me at the number of problems that exist? Was there anything that you really wanted to bring to our attention under the heading of staff recruitment and retention, for good or for bad?
Dr. D. Lawrenson:
No, I think the issues that I mentioned straight up with the insurance and the morale are the major issues that I wanted to bring up.
Deputy T.A. McDonald:
We are told basically by the professionals that if your vacancies are 2 per cent in whatever it happens, that is okay-ish. If it is 2 to 5 per cent you need to take notice, and anything above 5 per cent you need to do something. Would that, do you feel, apply to doctors as well as everybody else?
Dr. D. Lawrenson:
Yes, we have got situations where middle grades have to provide cover where services cannot go unmanned and where there are vacancies people will get tired, potentially make mistakes or be overworked and start becoming unwell themselves.
Deputy T.A. McDonald: Head towards burnout.
Dr. D. Lawrenson:
Then you get the ballooning effect of poor retention and recruitment, one vacancy sort of makes another one.
Deputy T.A. McDonald: Yes, it does.
Dr. D. Lawrenson:
So our recruitment and retention is absolutely vital. I think our hospital doctors are a good bunch of people who work really hard and achieve excellent results for the people of Jersey. I just hope that it can continue. I do not want to come here and scaremonger, but ...
Deputy T.A. McDonald:
But obviously for us it is vital ...
Dr. D. Lawrenson:
... I think it is important to be frank ...
The Deputy of St. Ouen :
Yes, you must, and we appreciate that.
Dr. D. Lawrenson:
... that there is a potential problem.
The Deputy of St. Ouen : Yes, thank you.
Deputy G.P. Southern :
Just out of interest for myself, when you were talking about 7 day working, is it not the case that with 7 day working that people have been dying more at the weekend, or when they are let in at the weekend? Is it not the case simply that to ask somebody to be let into the hospital they are actually quite serious so ...
Dr. D. Lawrenson:
Yes, absolutely. So the data that suggests that you do worse when you get admitted to hospital at the weekend may be skewed by that. So it may just be that, you know, if I go looking for a doctor on a Saturday or Sunday at 1.00 a.m. there is likely to be something more ... I am not going for my verruca.
The Deputy of St. Ouen : No.
Deputy G.P. Southern : Okay.
The Deputy of St. Ouen :
I just had a thought about the need to recruit further consultants to cover retirement posts and so on, so could those consultants be drawn from the middle ranks of our doctors at present or are they not qualified to step up to consultant?
Dr. D. Lawrenson:
Largely they are probably not qualified.
The Deputy of St. Ouen : I understand.
Dr. D. Lawrenson:
If I think of the group in my speciality, very few have been ...
The Deputy of St. Ouen :
So we would be looking off Island and in the main that comes from the U.K., does it?
Dr. D. Lawrenson: Yes, almost exclusively.
The Deputy of St. Ouen :
Yes. Is that because the Island advertises only in the U.K. or are there other jurisdictions we could draw from?
Dr. D. Lawrenson:
We have such strong links to the U.K. as compared to other jurisdictions, with everything. Our culture is U.K.-centric, is it not?
The Deputy of St. Ouen : It is.
Dr. D. Lawrenson:
Although France is closer to us than the U.K. our influence from France is small.
The Deputy of St. Ouen : That might be difficult.
You get ... we get lots of doctors that ... well I originate from South Africa, although I might sound like I come from St. Ouen [Laughter], we get doctors that come from Spain and France, all over Europe, but they largely come through the U.K.
The Deputy of St. Ouen :
Through the U.K., yes, I understand.
Dr. D. Lawrenson:
Largely where we would advertise would be in the British Medical Journal, but the British Medical Journal is read all over the world.
The Deputy of St. Ouen :
Worldwide, I am sure, yes. Okay, we are very grateful, you have helped us with some very interesting things that we must consider and we will meet at a later stage with the hospital authorities and we will be raising some of these issues that you have raised with us. So thank you very much indeed for coming to speak to us, Dr. Lawrenson.
[15:00]