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STATES OF JERSEY
Health and Social Security Scrutiny Panel Service Users of Home Care
WEDNESDAY, 23rd NOVEMBER 2016
Panel:
Deputy R.J. Renouf of St. Ouen (Chairman)
Deputy G.P. Southern of St. Helier ( Deputy Chairman) Deputy T.A. McDonald of St. Saviour
Senator S.C. Ferguson
Witnesses:
Finance Director, Family Nursing & Home Care
Chair, Family Nursing & Home Care
Quality and Governance Lead, Family Nursing & Home Care
[10:59]
Deputy G.P. Southern of St. Helier ( Deputy Chairman):
Welcome to this hearing of the Health and Social Security Scrutiny Panel. We are talking about the future of Family Nursing & Home Care. Apologies from Jackie Hilton. She has had a bereavement, I think, and is not here. My Chairman has turned up and we are doing things in the normal way. The rules are in front of you. I think you have done this before. You have not? First time? Well, we will try and make it as warm and welcoming as we can. We are after finding out information about the situation with home care in particular and the funding thereof. As normal, we introduce ourselves around the table just so we can pick up on the tape who is who. So I am the Deputy Chairman of this panel, Geoff Southern .
[11:00]
Deputy R.J. Renouf of St. Ouen :
I am Deputy Richard Renouf , Chairman of the panel, but on this occasion I have asked Deputy Southern to chair this meeting.
Deputy T.A. McDonald of St. Saviour : Deputy Terry McDonald, member of the panel.
Senator S.C. Ferguson:
Senator Sarah Ferguson, member of the panel.
Finance Director, Family Nursing & Home Care:
Adrian Blampied, Finance Director of Family Nursing & Home Care.
Chair, Family Nursing & Home Care:
Ann Esterson, Chair of Family Nursing & Home Care.
Quality and Governance Lead, Family Nursing & Home Care:
I am Judy Foglia. I am Quality and Governance Lead for the organisation but I am just stepping in for Julie Gafoor.
Scrutiny Officer:
Andy Harris , Scrutiny Officer.
Deputy G.P. Southern :
Thank you. We have had one private hearing with you and we got some information from that. Would you like to start by updating us on what has happened since a month ago? You have had further meetings with Health and Social Services. Where are we now?
Finance Director, Family Nursing & Home Care:
We have had numerous meetings with them, particularly around the finances, and we have met I think since then with the Minister for Health, Julie Garbutt and Rachel Williams to talk about the process and make sure ... I think there was a lot of tit-for-tat in the media that we felt was being unhelpful and we wanted to try and make sure we were all on the same page. We are working together as 2 organisations; we are not combatting each other per se. We have got a process we have to get through. The finance meetings, there has been a lot of talk around how the organisation is funded, obviously, a lot of talk around fully funding this, fully funding that. We have been seeking clarity on that and we are still at a point where we are almost there. We have not had any written confirmation yet of what the fully funding looks like but we are working towards that and there has been progress made. There is still more to come. We do not have sight yet for 2017 of what the funding is other than in one part there is no funding for home care, no funding for it being a commissioned service, they are no longer commissioning it. However, there is this transitional funding that they can move to, which is purely to help our clients transition into a new charging structure that we have got to put in place. It does not help us with the transition we have got to go through with our staff terms and conditions. That is really where we are and the progress that has been made.
Deputy G.P. Southern :
I suppose the fundamental starting point for me is have you come to an agreement to a breakdown of the, let us call it, £6 million that is sitting there that looks like a block grant?
Finance Director, Family Nursing & Home Care:
The funding is very complex. When I first joined the organisation in 2012 that was pre any investment in the P.82 White Paper, so our block funding then was for the core commissioned services of district nursing, home care and the child and family, so that is health visitors, paediatric nursing, school nurses. That was £6.3 million that was not a grant. I think it originally had been a grant and it was turned into a contract for services to provide those, with service specifications behind the commissioning of that. Then there is the White Paper funding that came on board for rapid response reablement and the M.E.C.S.H. (Maternal Early Childhood Sustained Home-Visiting) which is an extension to the health visitor programme, a core commissioned service. In 2015 the total of that funding was about £7.4 million and everything was still commissioned at that point. In 2016 we have had a reduction of £430,000-odd, so we are down to about £7 million of our net revenue from Health and Social Services for all of our commissioned services. From that we know there is about £5.9 million that is around those original core commissioned services of district nursing, child and family and home care, and then there is other specific elements for rapid response reablement and the M.E.C.S.H. programme.
Chair, Family Nursing & Home Care:
I think from a committee perspective we have a situation where roughly 80 per cent is funded and every year we have this big problem of raising 20 per cent. It was getting quite worrying because in the past we have had some really healthy bequests; we do a lot of fundraising. Membership fees were a big component part but we were asked to disentangle membership as being a requirement to receive services because we were moving to this commissioning service. So we could see our income stream from the funding side diminishing and we were getting into some difficulty year by year, scrabbling around trying to make ends meet really across the pisté. So there has been talk for some years about fully funding. It has never actually happened and even the new services were not fully funded. They just paid the basic service not the on costs. So for us to move to a situation where the commissioned services are properly fully funded is a major step because then you target fundraising to the extras, the things that make the big difference to the client, and takes the pressure off us and the time it takes to raise money every year. From that perspective we are very pleased, if we can achieve it.
Deputy T.A. McDonald:
I notice this year, and correct me if I am wrong, there seems to have been quite a boost of fundraising since the news of the problems has broken, some fairly major events have been supporting...
Finance Director, Family Nursing & Home Care:
The biggest event we had this year, the new event was the colour run, which that again is to ... as well as the services we have been through already that are commissioned, we also do what are called high-cost packages, individual placement packages for children who have got very high care needs. We then engage to recruit staff to deliver the care for those children. It could be 24-hour care, overnight care, with very complex needs. As part of that service, it is very strict on what is commissioned on that, so we are paid for X number of hours to deliver those services against an agreed sort of care plan which is agreed with Health and Social Services and our paediatric teams. So we recognise the need but additional support needs to be put into that. It is not as robust. If a member of staff goes off sick, we do not necessarily have the right trained person to cover it. So the funding for that from the colour run is to put in a children's respite worker to help bolster those services and support them.
Deputy G.P. Southern :
You have talked about a cut of something like £400,000 in your core budget. How have you responded in terms of delivery of service? How have you responded in terms of clients?
Finance Director, Family Nursing & Home Care:
Service delivery has stayed. As an organisation we are taking the financial hit for that this year.
Chair, Family Nursing & Home Care:
We are forecasting a £500,000 loss this year.
Finance Director, Family Nursing & Home Care:
Yes, and part of that is from the funding reduction in terms of transition of decommissioning home care this year and the other part is investment we are making into the organisation in terms of the [Phone Interruption]
As Chair, I forgot to remind you.
Chair, Family Nursing & Home Care:
Can I just say we were expecting some money to be taken away this year because we were given notice we had to disengage the domestic part of the home care service. That was a very small part, so we were expecting money to be taken away from that but we had hoped that it would be less than we were actually asked for.
Deputy G.P. Southern :
Is your service delivery increasingly to the complicated end, the more complex needs?
Chair, Family Nursing & Home Care: Yes.
Finance Director, Family Nursing & Home Care:
Throughout all the conversations we have held, obviously we have been seeking to continue the funding, to keep us even with funding, to keep delivering what we think is a really valuable service and it is not just relying on the private sector, not that there is anything wrong with the private sector. We feel there maybe should be a safety net of a not-for-profit operator in that arena. I was touching on, before the melodic phone call, about the other investment that we are making this year, which is contributing towards the costs we are incurring this year, and that is the EMIS system. It is an electronic patient record system which is the same system the G.P.s (general practitioners) have, the same system that the hospice are putting in, and I believe Health have been looking at it for certain areas. We have had no investment for that either. It was part of our 2015 commissioning. It was in our commissioning agreement that we would look to implement an electronic record system but no funding followed that, so that has been funded through the substantial bequests we have received in the last couple of years. We are still investing in the organisation.
Deputy G.P. Southern :
Back to the starting point of you have not reached agreement with D.H.S.S. (Department for Health and Social Services) for fully funding...
Chair, Family Nursing & Home Care:
Well, we have not been advised. We have done our part.
Finance Director, Family Nursing & Home Care: Yes. We are at the point where agreement is close.
Chair, Family Nursing & Home Care:
It is just a question now of waiting for their decision.
Deputy G.P. Southern : It is close?
Finance Director, Family Nursing & Home Care:
Yes, we believe it is close but there is a couple of things we have to give Health and a couple of things we are waiting on back from them. When we met, I think it was in July, we had agreed, not that it is ideal, that next year's commissioning agreement is signed by November. We wanted it signed earlier but in July we realised of the time left November was a sort of drop-dead point for getting the commissioning agreement signed, so we are hoping that will still happen.
Deputy G.P. Southern :
Are you prepared to do that? That is a week away, is it not?
Finance Director, Family Nursing & Home Care:
It really depends whether ... we put a proposition of what fully funding would look like for the continuing provision of services. That includes the appropriate allocation of overheads and there is a cost associated with that that we have put to Health. We do not believe it is a million miles away from the funding that the Minister has mooted around what is available for the organisation.
The Deputy of St. Ouen :
Have you been able to agree the criteria, in other words what should be included in terms of overheads and the proportions of overheads you are bearing for the commissioned services?
Finance Director, Family Nursing & Home Care:
We have had no written confirmation that they agree with our stance on it. My stance is, and I think anyone who would be looking to fully fund a service would look at, it has got to have levels of overheads. A service is nothing without the support people behind it and with all the infrastructure, the IT infrastructure, buildings, training. We have no written confirmation but that is what they are saying is fully funding. I noticed in the transcript from the last hearing it mentions that rapid response reablement and sustained home visiting are fully funded but they are not. They are funded to the direct staff costs and some of the direct ... we have got some recruitment costs in there, it has got some training, it has got a little bit of equipment, but it does not have any allocation of, say, any support time, any premises costs, the infrastructure costs. So, while it is fully funded in terms of the
direct additional staff we have to employ for that, if you are looking at fully funding a whole service model it does not include the overheads.
The Deputy of St. Ouen :
Has the department given agreement in principle that it should include those indirect costs?
Finance Director, Family Nursing & Home Care:
The discussions I have had with Finance, I believe their view would be fully funding should include overheads. We have had nothing formal in writing yet but, like I say, we are meeting. It is not like it is a stalemate. We are still meeting and discussing that.
Chair, Family Nursing & Home Care:
I think what it would not include is pieces of equipment, any substantial projects.
Finance Director, Family Nursing & Home Care:
Yes, any substantial projects they say they will not. If we were going to invest in, for example, a new building or if we needed to look at some premises - we are doing a new clinic in St. Peter s at the moment - those sort of things will be excluded from the fully funding model per se, but there is nothing precluding us going to Health and saying we want to develop this part of the service and applying for additional funding.
Deputy G.P. Southern :
Returning to basically the cause of why we are having this meeting is a change in the funding mechanism for delivery of home care and various services from what is a subsidised service to one that is funded differently through the long-term care fund.
Finance Director, Family Nursing & Home Care:
It was a commissioned service, not just subsidised. By virtue of it being commissioned, it ended up the equivalent to there being a subsidy in place.
Chair, Family Nursing & Home Care:
Family Nursing was constituted to provide home care for the Island. It goes way back in history, obviously. So we have a responsibility, I suppose, to ensure that that is there.
Deputy G.P. Southern :
But now we have got a long-term care plan which is supposed to be paying for that home service and a new component of income support for those who do not meet the criteria for long-term care. How is that affecting (a) you and delivery of the service and (b) your clients?
Can I just say that we said at a very early stage we have got to consider affordability and that care is a continuum. It does not just start at long-term care and very often, I said this at the A.G.M. (annual general meeting) this year, what Family Nursing did very quietly in the past was pick up people at a very early stage and they did not know what was happening. They just got that increasing care allied to the district nursing care, completely seamless, did not know, just did it. So if you change the system you need to think about affordability and that is a big issue.
[11:15]
The long-term care system is means tested. This new policy 1 will be means tested. Our concern is that even now our clients say they cannot afford any more at £11 an hour, so what will happen to that band above those that are protected? But even the ones that are protected, just trying to wade my way through the long-term care scheme, they have got to have accrued quite an amount of money in terms of what they would have had, a credit or a cap as it is called, before they can get any money, it seems. So I think from a general point of view I am not sure we have got this sewn up yet and I think it is about developing an holistic home care strategy, not just a bit here and a bit there. You have got to think through that continuum and how people that will not afford or cannot afford it. They may be asset rich, they may have houses but not have particularly a lot of money, and we know that a lot of people do not go to the doctor for that reason. So when we are talking about home care at, say, £20 an hour, you are talking about someone getting, say, 2 hours a day that is halfway to the long-term rate having to find £14,000 or £15,000 a year. That is a lot of money for people and I think our concern has always been to try and avoid the U.K. (United Kingdom) situation where a lot of people end up needlessly in A. and E. (accident and emergency) because they have not had that early intervention, that early care. So I think that is our advice, that has been our advice all the way along, based on our experience in terms of our own clients.
Finance Director, Family Nursing & Home Care:
You also mentioned the impact on service. Our service is continuing as it was at the moment, so there has been no adverse impact on the clients. With the transition we are looking at going through, we do not want this to impact the clients. It should not impact the clients, so we are really grateful that there is the transitional funding for the client side of the charges that the Minister has confirmed will be offered. Unfortunately it still does not take out of the situation we have with the terms and conditions changes that we have to look at for our employees.
Are you still worried about this transition from the old system to the new system? Is that likely still to impact on your ... come the start of 2018, for example, how do you see things?
Finance Director, Family Nursing & Home Care:
Well, the transition is coming in 2017 for us. The 2018 date that is now being put about is about this transitional fund they have put in for the client charges. There is 2 elements we have got to look at, that is our terms and conditions and our cost base of delivering the care and then the client charges we can receive from that. We have been commissioned in what could be seen as a sort of quasi public sector service and that is how it has been commissioned, it is how it has been delivered. Our staff are not overly paid; they are paid the equivalent grades. So a health care assistant in Family Nursing gets what a health care assistant in the States of Jersey would get, in the Government. They are on exactly the same terms and conditions but we are now, because of the change in commissioning that service from us, that element of our organisation is being almost dropped into a highly competitive private sector. So we now have to compete with that private sector, so in terms of generated client revenue but in terms of keeping our staff but making the business affordable and viable going forward. So those changes for the staff have to be impacted sooner rather than later and the transitional funding from Health does not go any way to helping us with the transition of those terms and conditions for staff.
Deputy G.P. Southern :
You have taken me on earlier than I expected into an issue that obviously is an important one for you. The terms and conditions under which you operate now will, you say, in your business model need to be reduced. How are you getting on with that? I understand you have been in discussion with the unions involved.
Finance Director, Family Nursing & Home Care:
We have started a consultation process with our staff and unfortunately it affects staff throughout the whole organisation who are on similar grades or similar qualifications. We have had 2 consultation meetings with the elected staff representatives and we are also meeting with the unions. I have got another meeting on Friday with some of the unions about the recognition agreement we have got and just trying to make this whole process as painless as it can be. Unfortunately it is not going to be pain free, I do not think, for anybody. So we want to make it as smooth as possible and as fair as possible. We are not trying to make it a race to the bottom. We are not trying to do that. We do not want to go down the route of purely employing zero hour contracts, zero hour staff, and we want to offer better terms and conditions than the private sector will offer if it is possible. There is a very small window of funding with what you get paid from long-term care and if you start charging above that you will not generate the clients that you need to have a business.
The Deputy of St. Ouen :
I am a little confused as to whether staff are negotiating through their elected representatives or through the unions. Is that clear yet?
Finance Director, Family Nursing & Home Care:
It will hopefully be clearer on Friday. There is a recognition agreement in place with the unions that has come to light and both us and the unions have agreed that there probably should have been more conversations around that. We have had a good relationship with the unions for years and we have always worked well with them. We have always been very open with them but I think we have agreed there is maybe a bit more work done to highlight the terms of this recognition agreement so we are now going through a mediation process with them. Again, one of the outputs from that process is to have very clear definition of the groups and who is representing them, whether it will be staff-only representation, union-only or a mix. Not all of our staff are members of the unions but we do not know who is. We are not privileged to that information of who is in a union but we do know that a fair number are not in unions.
Senator S.C. Ferguson:
One of the big problems, surely, is going to be the degree of training and so on of your people compared to the private sector, which is uneven to say the least.
Finance Director, Family Nursing & Home Care:
We are very fortunate, because we have had the benefit of being a commissioned service, the whole organisation has been commissioned in that respect, our current home care staff have all had training under the governance framework for nursing levels of training. I am not saying they are not qualified as nurses but they get the same support, the same training, the same governance so we have a very robust and very well trained workforce. Our concern is to keep that. Again, it is not a race to the bottom in terms and conditions; it is not a race to the bottom in terms of just getting the bare minimum that you need under the approved provider framework. We feel that is where through our charitable side we will be able to potentially give enhanced training over and above what the approved provider framework requires. That is our desire and there is big value for that.
Chair, Family Nursing & Home Care:
We certainly would not compromise. To be honest, it was a fairly marginal decision as to whether we just packed up and went or whether we continue because what we cannot do is jeopardise the financial situation of the whole organisation, so it was a very closely balanced argument one way or the other. It is a difficult market to get into. It is difficult because the peak of demand, it is morning, late afternoon, and you have a big gap to fill. If you do not have zero hour contracts you still have
to pay your staff, you have to find work to do. What we have done in recent years is really concentrate on the very difficult cases with the integration of district nursing. They require a lot of effort and time. We had 3 new business members this year and they have taken us through a rigorous process, business planning process, and we feel we can get a good start. We feel that because we do not want to lose those great staff. They are tremendous. They do a wonderful job and to dissipate them for the Island I think would be a huge mistake.
The Deputy of St. Ouen :
When you say 3 new business members, is that committee members?
Chair, Family Nursing & Home Care:
Committee members, yes. They came from a very strong business background. We have already got 2 accountants. We had already done some but they really...
Finance Director, Family Nursing & Home Care:
It has been a fresh set of eyes, completely fresh set of eyes. One of their first tasks has been to look at the home care provision, so we have been scrutinised by them quite substantially over the plan and the decision as to whether we continue the service or transition it into a not-for-profit and still keep that good quality of staff.
Senator S.C. Ferguson:
Presumably you are supported by the Minister for Health, because this is their ultimate aim, is it not, to keep people in their homes longer?
Finance Director, Family Nursing & Home Care:
It is their aim, yes. They are investing in the rapid response reablement side, which is all about keeping people at home.
Senator S.C. Ferguson:
The home care is keeping them at home.
Finance Director, Family Nursing & Home Care: Absolutely.
Chair, Family Nursing & Home Care:
I suppose it depends. The view is that the private sector has created more provision with the advent of the long-term care scheme and certainly when we saw the Minister in April we did say that: "We are constituted by the States. Do you want us to change the constitution or do you want us to try to continue?" We got a steer from that meeting that, yes, it is good to have a mix of provision in the marketplace. So, based on that, we then did our sums and tried to see if we could make a go of it but it is a difficult process to go through with staff. We are doing all we can to support but it is not something that we are finding very easy.
Deputy G.P. Southern :
What is your unique selling point? What do you have to deliver in this area?
Chair, Family Nursing & Home Care:
Well, experience is huge. We have been in the marketplace 60-odd years and what we do not know ... the whole infrastructure in the department is immense. It is the nursing provision for the Island and the expertise is absolutely amazing. So there is the whole infrastructure, training and more importantly, I think, the governance because you have to have very strong governance to ensure that the care is properly delivered in the right way, appropriate way. So we have got the lot.
The Deputy of St. Ouen :
Can you tell us something about the risks of not having that governance?
Quality and Governance Lead, Family Nursing & Home Care:
If you do not have governance arrangements then there is a risk of patient safety in the community in terms of medication, dressings and patients that fall in the community, pressure ulcers. There is a wide remit really of risks to patients if you do not have governance. We look at all of their incidents, home care. I look at each division on a quarterly basis about the number of incidents that occur and the learning from that. We make sure that we do learn from any of the issues. We look at all of the staff training, because obviously training is a huge part. I think that is one of ... our reputation in terms of the quality of our training of our staff, so obviously we ensure that staff not only have mandatory training but there is also additional training. If the staff want to be more aware of, say, catheter care we have those arrangements so that we do not just expect staff to go out there, see one, do one, teach one. We have a proper training programme and competencies surrounding that. So there would be huge risk to patient safety if we did not have the governance arrangements surrounding that.
Chair, Family Nursing & Home Care:
Just if it is snowing ... a few years ago they were out there. It is the size of the unit that matters as well. If you have only got a few people in your organisation things like that are difficult to cover. For any epidemics, for example, we have enough in our organisation to be flexible and to meet that demand and that is key, I think, in any organisation.
I would have thought you had to have the possibility of an integrated service delivery from the simplest at one end, which might only mean a couple of hours a day, or a couple of hours a week in fact in some cases, to extremely complicated medical cases where you need specialists. Is that unique to you or is that being delivered by private companies as well?
Finance Director, Family Nursing & Home Care:
We have the district nursing arm to Family Nursing as well but that is an open service. That is not exclusive to our clients. Any clients who are under any of the other providers or through their G.P. have got access to the district nursing service.
[11:30]
I think the real benefit is that our staff in home care have had the benefit of the additional governance and training that we have got in place because we have the district nursing, which treats the more medical conditions rather than domiciliary.
Chair, Family Nursing & Home Care:
I have been chairing it for 5 years and I think we have got a very unique organisation and it is very precious and we need to really keep it going. It is an amazing resource. What I have seen is just truly gobsmacking. I do not say those lightly. I am a hard taskmaster, but they do it so quietly. There is no credit sought and it is all just done very quietly. I think if you start to divide that or take it away then you would see the gaps. We are not saying we are better than the private sector but we are saying that our holistic approach to the client is very important, I think. I have not got the figures but certainly the previous head of home care said that the statistics in terms of entry into A. and E. for elderly was much lower in Jersey than it was in the U.K. and I think that is largely because we are able to respond and help people in the home.
Deputy G.P. Southern :
Presumably you do work alongside the private sector domiciliary?
Chair, Family Nursing & Home Care: We do, yes.
Deputy G.P. Southern :
To what extent would you say that domiciliary home care is the building block on which the more advanced services can still be done in the home?
Chair, Family Nursing & Home Care:
I am not sure you can because some people maybe have a stroke, it happens overnight. Other people it is a slow decline, maybe start off small and work up. I am not sure you can, Judy, are you?
Quality and Governance Lead, Family Nursing & Home Care: I do not know how you would...
Finance Director, Family Nursing & Home Care:
I think if there was not any domiciliary care in the Island, whether it is through us or through private sector, we would see the implications of that. There would be implications on A. and E. admissions, on escalation into high needs of care. So I think for the Island it is really important that we have a robust domiciliary care provision. They are working towards that with the long-term care scheme. Hopefully it will be policy 1 or whatever it is called now, the P.C.4 (personal care) they are looking at. It is adding in another level of resource to needy or vulnerable people. We just want to make sure that we are here to bolster that and support that as well as a not-for-profit.
The Deputy of St. Ouen :
Can I take you back to the transition that is going to happen? I think we are aware that you sent out a letter that came from the Health Department to all your clients inviting clients to submit to an assessment. Have you got any idea of whether clients have taken up that invitation?
Finance Director, Family Nursing & Home Care:
We do not. It was a Health and Social Services letter signed by ... I forget who. It might have been Chris Dunne, I think, who signed it. I may be wrong on that. We sent it out with our monthly billing that goes out to all of our home care clients. It went out to I think it was 147 clients, but anyone who we are not aware of being in receipt of long-term care it went to. We are not aware if our clients are necessarily in receipt of income support, I think the P.C.3, which is up to £145 a month. So 147 letters went out. All of the responses to those have been directed to the social workers not to us so we have no ... the only visibility we have got is what Health have told us at a meeting a month or so ago that I think they had had about 50 or 60 responses and of that maybe half of them had been deemed to be eligible for long-term care. Whether they have reached their care cap is another thing but they could be a need that would require long-term care, but the actual management of that process sits with Health and Social Services rather than us.
The Deputy of St. Ouen :
Okay, but at some stage you are going to need to increase the charge you make to those clients, so is it intended that you will be informed when the assessment process has been completed? They will go through an assessment. It is still up to the client whether they want to apply for long- term care. They cannot be forced into it. So, if we have got a client who is currently just a private client of ours and suddenly gets a long-term care assessment, that will be routed back to us through Social Security in terms of a package of care which will attract a sum of funding to it. We will then be billing Social Security for that client, so we will stop billing the client individually and we will bill Social Security. That will be at the rate that we need to go to as an organisation. For any clients who choose to not accept long-term care or who do not qualify for long-term care, part of the terms of the additional funding or the transition funding the Minister is offering they are looking at increase ... they want us to increase our rate. Our base rate at the moment is £11 an hour, so there will be a marginal increase to that rate, which the client will necessarily pick up, and Health will pay the difference between that and the £20-odd an hour, £22 an hour, so we are not going right up to the full rate for clients immediately. So that funding is just to mitigate the impact on the client.
The Deputy of St. Ouen :
There will come a stage where Health will withdraw that transitional funding?
Finance Director, Family Nursing & Home Care: Well, it is public record that it sits for a year.
Chair, Family Nursing & Home Care:
There is the income support, whoever might qualify for that and however much that might be, so that is the next stage we will have to deal with. Then presumably we will have a number left who do not qualify for either and I think we would want to do something ... I would like to know a little bit more about them as to why and whether they can afford then to pay the market rate. I think we need to do some work around that.
Deputy G.P. Southern :
But at this stage you are fairly blind on that?
Chair, Family Nursing & Home Care: Yes.
Deputy G.P. Southern :
It comes down to the numbers and we are talking relatively small numbers there. When I look at, for example, the care component level 3 in income support, we are talking about 300 clients. Now, they are receiving up to £145 a week which would cover 7 hours a week of domiciliary care at the projected rates. That is a very low end need but 300 ... if we are going to introduce the new care
level, I am going to call it care level 4, then presumably there is a significant number in there who would maybe wish to be reassessed under the new method to see if from 3 they are actually at level 4 and able to claim more. That is significant numbers. How would you cope if there are?
Chair, Family Nursing & Home Care:
We do not know whether they will want to continue with our services so it is a very fluid situation. We plan as best we can but beyond that we will not know until the end whether they will stick with us or go somewhere else or even not apply for the benefit.
Finance Director, Family Nursing & Home Care:
One would hope, though, that currently, by and large, the people of Jersey who are requiring care are getting care. I think this new P.C.4 or policy 1 is a new funding stream rather than generating a new care requirement, so those clients should be getting care at the moment. They are obviously getting it at a "subsidised" rate through us or they may be paying a private sector rate if they have gone to another provider. So the fact they could get more benefit from it to pay for the care is a good thing.
Deputy G.P. Southern :
The Minister for Health and Social Services and his officers made great play of there will be lots of people only receiving a couple of hours or an hour a day at the bottom end, and that was a low-level need. I am thinking: "No, hang on, if they are on personal care level 3 then that is what they can afford."
Finance Director, Family Nursing & Home Care:
Yes. Some of our clients do only receive a couple of hours a week but that is not the only care they necessarily receive. Because of how they have been commissioned, a lot of our staff contracts are around the morning work. Probably 90 per cent of our contract is morning work. If we do not have the client because we do not have all these zero hours and all the flexibility that the private sector have, people who need care in the afternoon will have to go to another provider to get it. That is how it is currently set up, so just because someone is only getting a couple of hours of care a week, half an hour a day or whatever, from us does not mean they are not getting other care from other providers or from family members. That is just looking at a snapshot of the care we deliver for a client rather than the care that client receives overall.
Deputy G.P. Southern :
But if it is a matter of additional care from family members, who if they can get the break they can continue to care for them in the home, although on paper it looks like a minimum need it is actually a vital need, an hour a day or 3 hours a week to make a difference to the carer.
Chair, Family Nursing & Home Care:
I am not sure we know at the moment until people go through some form of assessment, a standard assessment or whatever it is, and even that is just an indicator. It takes an experienced nurse, home care member to really assess what is needed and certainly that has come out in discussions with the home care staff. Their first concern was not about themselves. A lot of them their first concern was: "Will my client be able to afford it? They need more care now but they are not getting it." So I think from our perspective we are able, if we set up a not-for-profit organisation, to organise it the way we want it and the way that suits the customer rather than being commissioned, which constrains it really in a way. We would like to be able to offer a full service to the customer so they have the same person, continuity of care. We are really quite constrained at the moment.
The Deputy of St. Ouen :
If the client goes through with the assessment process and is found not to be eligible, would you be increasing your charges as soon as that finding comes through?
Finance Director, Family Nursing & Home Care:
No. The offer that Health have put on the table is that for 2017 any clients who are not in receipt of long-term care will continue to get this transitional assistance until the end of 2017. So in 2018 that is when the clients will have to either be in long-term care or the new policy 1 when that comes in from July onwards.
Deputy G.P. Southern :
Come 2018 you will be charging the full rate of £22, if that is what it is by then?
Finance Director, Family Nursing & Home Care: Charging at the market rate, yes.
Chair, Family Nursing & Home Care:
We are going to try and set up a hardship fund because there will obviously be another period where we will have to make sure that suddenly services are not withdrawn because the person says they cannot afford it. I think there has to be a lot of evidence gathering in this period to see who slips through the net, because there are bound to be...
The Deputy of St. Ouen :
But if they do not submit to an assessment, how are you confident they are going to talk to you about their financial circumstances?
I do not know if financial is the sole raison d'être. It is need. Our home carers will know a lot about that person. They might not know their total financial affairs but they will know from going there what the person needs.
The Deputy of St. Ouen :
Yes, but can I suggest you do not want to get into a situation where you have clients who are saying they cannot afford it and relying on a fund you might have created.
Chair, Family Nursing & Home Care: No, we had this conversation yesterday.
Finance Director, Family Nursing & Home Care:
There will be criteria for it. We have mooted the idea with Social Security and there may be some way of getting information exchange, with the client's agreement as well, if people qualify for income support or if they have got certain types of support in place. We do not want to go and burden ourselves with a whole bureaucratic red tape process of trying to assess someone's financial need; that is not for us to do. But I think using a certain amount of the financial information we can maybe get on a client relatively easily and using our staff's knowledge of a client's personal circumstances, personal situation, whether they are deteriorating in care, it will be an approach like that.
Deputy G.P. Southern :
Can I just try and sum up what I think I am hearing, which is that come 2018 you will be charging £22 an hour for your domestic care.
Finance Director, Family Nursing & Home Care: Domiciliary care.
The Deputy of St. Ouen :
Or whatever you decide it might be, a commercial decision.
Chair, Family Nursing & Home Care: What we decide, yes.
Deputy G.P. Southern : Yes, or thereabouts.
We have got different assumptions at the moment.
Deputy G.P. Southern :
You can only deliver at that rate by reducing the terms and conditions of your workforce.
Chair, Family Nursing & Home Care:
We are not in it to make a profit. We are only in it to balance it out, but what we would have to do to make it pay its way is increase our clientele. We need to fill in the hours, if you want.
[11:45]
We somehow have to increase productivity in that sense.
Finance Director, Family Nursing & Home Care:
But again, just touching on productivity - it is not a term I like really, productivity, but it is what it is - because we follow the States of Jersey terms and conditions, in terms of what our market now is, we have a high cost base, hourly rate. We are in the care scheme, the States pension scheme, we are an admitted body to that. We have got a 16 per cent contribution rate there as an employer. The sickness benefit they get is 6 months full pay, 6 months half pay. So they are very generous terms and conditions. I am not saying that they are not valid, that those terms and conditions should not necessarily be being paid for certain people, but when you compare it to the market we now have to operate in and compete against, they are non-viable. You would not be looking to set up ... I am not aware of any private sector home care agencies that have tried to be an admitted body for a pension scheme. They could not afford it. Our staff have been contracted, because it has been a commissioned service. They have been contracted around specific pressure points and mainly around the morning and some 10, 15 per cent in the evening, putting people to bed and doing medications in the evening. We have been constrained by terms and conditions and by the way the staff are contracted as a result of the commissioning. We need to make it all more flexible. If we know we have got a client that needs some extra care or a new client needs care in the afternoon, we have got a flexible enough workforce to deliver that care as well. Those are all the elements that are going to affect our productivity.
Deputy G.P. Southern :
Just widening and broadening the scope of terms and conditions, presumably your staff know what their hours are per week.
Yes, they are permanent contract staff.
Deputy G.P. Southern :
They have a 39-hour week or whatever it is and they know what their rota looks like and who their clients are going to be, because you want that consistency.
Finance Director, Family Nursing & Home Care: Yes.
Deputy G.P. Southern :
They would not be working over-demanding hours, for example. I did see a case where a domiciliary care worker was working 15 hours in a day and 12 of those hours were contact time with clients. That made me think at the end of that day what sort of quality of care was she delivering. I would suggest it was not very good.
Finance Director, Family Nursing & Home Care:
At the moment the majority of our staff have, by and large, permanent contracts. We do have some who are zero hours but they are bank staff and it is a model that medical organisations have. We do not rely on them. They are there as a bit of support when you have absence or sick leave or extra pressure points. So, most of our contracts are morning contracts and they will be 20 to 25 hours a week is their contracted rate but because you are only contracted from, say, 9.00 a.m. to 12.00 p.m., Monday to Friday, it does not give us a lot of flexibility but that is how we were commissioned. We will have to look at more flexible ways of working and we are setting up a working party with some of the home care staff, and with management as well, to talk about how best to get that flexibility. We do not want to just impose things on our staff. The workforce know how best to operate and what is best for the client and we really need to engage with them and get them on board with those decisions about how to build that flexibility but also not make it such that staff do not know from one day to the next what they are doing, because that is not fair. It is not where we are going.
Deputy G.P. Southern :
In terms of the commissioning of services, when I come across the Minister who says that terms and conditions are not down to him, they are down to employers, and he does not appear to see any safety considerations coming from examples that I just quoted like the 15-hour day, I would say that is a health and safety issue involved there. You are not going to do many of those days, I would have thought, before something very risky is happening. Do we need a different level of regulation,
do you think, in order to make sure that safety issues are met in terms and conditions of staff delivering care in homes?
Chair, Family Nursing & Home Care:
I do not know if we can comment on that, but what I would say is we drew a line in the sand when we were deciding to set up this organisation and where we would not go. You can be assured that if we make a success of this it will be done not on that basis. It will be done on a reasonable working day and reasonable support, training, as much money as we can afford to give in salaries, because we have not got the incentive of making a profit but obviously we want to generate as much money as we can to plough that back into the business, keep clients' fees low, keep our employees' salaries as high as we can. That is our raison d'être. Whether others use those tactics and whether regulation is needed, I am not thinking it is for us to comment really, but we will not do it.
Deputy G.P. Southern :
The other issue that comes to my mind is that here we are at the end of 2016 with a new benefit level, this level 4 for care, still not in place. The worst case scenario, if the Social Security Department cannot get this legislation drafted and in place by their official plan is July, what happens? How would that impact on your organisation?
Chair, Family Nursing & Home Care:
We have got until the end of the year. We have got an agreement that they will meet the difference to the end of the year.
Finance Director, Family Nursing & Home Care:
We have got a safety net for the client fees to the end of 2017.
Chair, Family Nursing & Home Care: We would need to renegotiate it.
Finance Director, Family Nursing & Home Care:
If it got to the point where the new level of benefit was not in place by the end of 2017 then obviously there would have to be discussions on that. I think we are working to a point in time at the moment and there is not much more we can comment on it really.
The Deputy of St. Ouen :
I wanted to ask about how you view the future of Family Nursing from 2018. If you are delivering services that are commissioned and fully funded by Health and you are also charging clients in full for home care services as an organisation in a commercial market, how can Family Nursing continue
as a charity? What would its charitable work be? Would you still be fundraising for any charitable work?
Finance Director, Family Nursing & Home Care:
We will still be fundraising, yes. It gives us a completely different focus. I can see it like a glass really. Our glass has been three-quarters full with the funding from Health and Social Services and our fundraising initially has then been to top that up. Then any of the really nice-to-do stuff ... like we have a project for the provision of end-of-life care, so it is doing additional hours, overnight sitting and that is to support clients who are at end of life and at home. We had private funding for that, about £250,000, and that funding has now gone, but it is something that was very well received, got a lot of information from it. It really supported clients and families in their time of need, but because our fundraising initially was around topping up to get our organisation to have fully funding from Health and from us, it is difficult to then fundraise for the next bit because all your efforts have gone in just to survive. The benefit it is going to give us is to have the financial security around fully funding and a commissioned service. It is not going to commission things like the end-of-life overnight respite but it puts us in a situation where we have got staff, we have got the governance, we have got the training and the experience to deliver those services, and that is where our focus will be. It is going to be doing the additional services to what we are commissioned for that support the commissioning.
Chair, Family Nursing & Home Care:
Family Nursing has been very forward thinking for years, very fleet of foot. It tries this and develops that and monitors it for success. It is built into the organisation. That is the great area really to fundraise; people relate to that. Equipment, we raise money for ... we wanted money for one portable scanner and we got 2. So these are the things that make a difference to people's lives and that you can fundraise for as opposed to expending a lot of energy just making ends meet. We are very grateful for getting to this stage on the commissioned service and it will make a huge difference.
The Deputy of St. Ouen :
Does it also depend on the degree of understanding from the public who might make donations? In the example you gave, Adrian, of end-of-life care, there would be an element of funding already, public funding via perhaps the long-term care scheme if the person was eligible and then you are asking for funding to deliver additional care. Is that the case?
Finance Director, Family Nursing & Home Care:
I think it is to support people who need it at the time. I touched on the fund, raising money through the colour run to put in ... there is a commissioned service for high-cost children packages but we feel there is additional resource that could go into that. There is not necessarily the funding for it in the system but we feel ... because when you are delivering the care at the coalface you see the real issues and have to live with them day in, day out with our carers seeing those clients. There is always additional resource, additional services that can be delivered and it is something that we feel that when we have got the sustainability of having what is commissioned being fully funded, which has never been the case before, it gives us that sure financial footing to go the extra mile and support those services.
Chair, Family Nursing & Home Care:
We would not fundraise for fundraising sake. We would need to have something in mind to fundraise for. The States do not fund to a gold standard, as you know. Well, they did not in my day but I do not know anymore.
The Deputy of St. Ouen : There are always pressures.
Chair, Family Nursing & Home Care:
It usually is for the bare minimum and it is fairly well prescribed in our service level agreement as to what is expected. So the great thing is we have got the ability to move quickly, raise some funds, try out a new approach or get some new equipment, and develop the service from there. We are constantly developing the service.
Deputy G.P. Southern :
One of those developments, I was just noticing in your latest newsletter, is the EMIS system. How is that bedding in with co-ordination of G.P. services?
Finance Director, Family Nursing & Home Care:
It is not at the point of actual data sharing yet with the G.P.s although all the protocols are in place. I think there was an issue with one of the G.P. databases. There was some issue beyond our control that had to be cleared up, but it is nearly there. All of our adult nursing, rapid response reablement team have been live on EMIS since July, August time. They are doing clinical assessments in a client's home on their iPads. It has got a mobile solution to EMIS as well. It has been very well received. It is going to give us a wealth of information that we have never had before and that Health have never had before. I think it is a really good investment we have made there and Islanders are going to benefit from that and Health and Social Services are going to benefit from it as well. Our child and family offerings are due to go live on 5th December and they are all going live at one time and by then everyone will be on the system. It is a large investment but I think the benefits ... it is really exciting that a clinician will be able to be at a client's bedside and have a complete view of their medical record, with the client's consent, pulling up a G.P. record. Potentially records of the Jersey Hospice Care are going on to it as well. So when they are at the point of data sharing we can all share, all see what medications they are on, whether there have been any incidents, any trips or falls and just have real-time information.
Deputy G.P. Southern :
That includes the hospital, does it?
Finance Director, Family Nursing & Home Care:
No. The hospital are on TrakCare. There is a piece of work going on looking at integrating TrakCare and EMIS as far as integrations can go. I do not think you are ever going to get to a full sharing but it would be people have got the key data that needs to be shared is what they are looking at.
Deputy T.A. McDonald:
With that mention of the hospice, did it make a difference to your organisation looking at palliative care, end-of-life care when they moved from just dealing with cancer patients, for example, and then suddenly they have opened to encapsulate the whole Island or there are facilities available for the whole Island and beds available and so on? Has that made quite a difference not only instantly but to your sort of business plans for the future?
Chair, Family Nursing & Home Care:
I am not aware of any. Our role is to give people choice and if they would prefer to stay in their own home; particularly with young children the parents generally want it and the child wants it. Also, as Adrian said, we have set up this pilot to provide intensive end-of-life care in the person's home. So there is a demand for it and it is a question of choice.
[12:00]
If people prefer to go to the hospice they will do so. If it is important to them to stay at home then we are there to help them.
Deputy T.A. McDonald:
That is right, and obviously respite for whoever their own carer is.
Chair, Family Nursing & Home Care:
Exactly, support. We do not want to overlap in what we do.
We work with the hospice and if clients move to the hospice we will go in and deliver some of the palliative care as well. It is not an either hospice or Family Nursing. There is pathways for us to work together and we do work very closely with them.
Chair, Family Nursing & Home Care: It was very well received.
Deputy G.P. Southern :
We have had our allocated hour. Sarah, do you have anything to add? Is there anything that we have missed, overlooked that you thought you were going to be talking about today?
Chair, Family Nursing & Home Care:
No, just thrash out the home care strategy for the Island, the care strategy. It is a big challenge but it is important.
Senator S.C. Ferguson:
But please do not talk about the problem of the ageing population.
Chair, Family Nursing & Home Care: No, do not. I am not a problem.
Senator S.C. Ferguson:
I am a trustee of Age Concern and they do not like being called a problem.
Chair, Family Nursing & Home Care:
No, it is not a problem. The problem is funding as always.
Deputy G.P. Southern :
No the problem is remembering why you [Laughter].
[12:01]