Long-Term Care Scheme - Minister for Health and Social Services - Transcript - 19 September 2017

STATES OF JERSEY

Health and Social Security Scrutiny Panel Long-Term Care Scheme Review

TUESDAY, 19th SEPTEMBER 2017

Panel:

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

Deputy T.A. McDonald of St. Saviour

Professor M. Johnson (Panel Adviser)

Witnesses:

The Minister for Health and Social Services

Assistant Director of Policy and Ministerial Support: Director of Operations for Community and Social Services: Acting Team Leader, Adult Social Care Team

[14:00]

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

Ladies and gentlemen, many thanks for attending today. This is a hearing of the Health and Social Security Scrutiny Panel as part of our review into the long-term care scheme. We have with us today the Minister for Health and his team. We are pleased to see you, Minister, because we know that you have had some trauma recently and gone under the knife, but we are pleased to see you back.

The Minister for Health and Social Services: They would not dare let me die on the table.

The Deputy of St. Ouen :

No, I am sure they would not. So as this meeting is being recorded we will proceed in the usual way, which is members of the panel will introduce themselves and then, Minister, if I could ask you to introduce yourself and your team. So I am Deputy Richard Renouf , Chairman of the panel.

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

Deputy J.A. Hilton of St. Helier : Deputy Jackie Hilton, panel member.

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

The Minister for Health and Social Services:

Senator Andrew Green, Minister for Health and Social Services.

Assistant Director of Policy and Ministerial Support:

Mark Richardson, Assistant Director of Policy and Ministerial Support.

Director of Operations for Community and Social Services:

Jo Poynter, Director of Operations for Community and Social Services.

Acting Team Leader, Adult Social Care Team:

Hello, I am Paul Rendell. I am Acting Team Leader of the Adult Social Care Team.

The Minister for Health and Social Services:

Before we start, could I just give apologies for Chris Dunne, who would have been here but unfortunately due to a serious family situation he cannot be here today. He sends his apologies.

The Deputy of St. Ouen :

I understand. Can we give apologies for Senator Ferguson who has a prior engagement? Can I also say we are also joined today by Professor Malcolm Johnson who has been our extremely knowledgeable adviser to the review and Kellie Boydens , who is our Scrutiny Officer. Minister, the long-term care scheme, could you give us your overview of the scheme, as you see it?

The Minister for Health and Social Services:

If you can bear with me, I would like to give 2 views: I would like to give one as the Minister and then one as an individual and they are both very positive. I think we are really lucky to have the scheme. I think it is appropriate and right that you review it because there are some areas which we will be talking about later on where perhaps improvements could be made. But we are extremely fortunate, as an Island, to have had in the past a Council of Ministers that saw the need for this and brought it through. I know from contacts in the U.K. (United Kingdom), in particular, that there is a lot of envy about what we have done. That said, it was difficult at times with all the assessments that needed to be done at the beginning but we got through that and I think the outcome for people in Jersey is one where they can make better choices because they are in control - providing it is an approved provider - where their money is spent. They can select whether to be treated at home or in a care home. There are some cases where that is not possible, but generally they can. I think there is a lot going for the scheme. Having said that, I do believe, talking as an individual, less so as a Minister, there perhaps needs to be a little bit more flexibility.

The Deputy of St. Ouen :

That is interesting. Minister, you are politically responsible for the Social Services team that carries out the assessments, and we have been advised today that you have an Adult Social Care team with 14 full-time equivalent social workers that would prepare assessments of need and also 5 full- time posts in an Older Adult Community Mental Health team, who would also be, we understand, assessing long-term care needs. We know from previous questioning that there is a very large turnover of social workers and many of your posts are covered by agency staff. Is this a concern to you that inconsistencies may arise in assessments due to the numerous turnover of social workers?

The Minister for Health and Social Services:

I do not know enough about the assessment system - I will let officers talk about that - but I am concerned about the number of interims that we have and the fact that when people build up a relationship with a social worker, be it one that assesses them or be it one that they work with for their care generally, that relationship is severed whenever there is a change. That is not good. But it is not a conscious decision of ours to not fill these posts. We are desperately trying to fill the posts. We are fishing in a very small pool I am advised. However, we continue to do our best. We continue to try and recruit and we intend to next year introduce ... or it might be the end of this year, but we intend to introduce our own training system for social workers here in Jersey in conjunction with ... I cannot remember the university but we do know that we cannot just wait and see if people come to us while we advertise, we need to do more. With regard to the consistency of assessments you will need to ask the officers.

Acting Team Leader, Adult Social Care Team:

I think I should start by saying we are in the fortunate position in Adult Services, and I think Jo will probably back me up, that there is marginally more ease in recruiting and retaining in Adult Services than there is in Children's Services. To go back to your numbers of staff, the numbers you are given in terms of social workers is correct, but we should also point out that there are various nurses, various individuals, a personal brain injury co-ordinator, a social worker in the reassessment clinic and so on, in place. So it is not just the 14 social workers who are out there doing assessments. I oversee an F.T.E. (full-time equivalent) of 32 people and within that we only have 2 locums and they are both covering for maternity leave for a substantive staff member.

The Deputy of St. Ouen :

How long has that been the case that you have been settled in that way?

Acting Team Leader, Adult Social Care Team:

That is where I was going next. I think when this was implemented in 2014 there were a lot of things going on and one of them was a higher turnover, particularly in older people services. We have managed to settle that down a lot, but the point is a valid one and feedback we have received is that in times where staffing was more difficult it impacts on our customers when they have to tell their story more than once or build a relationship with someone to then have to rebuild it with another. The Minister is absolutely right; it is entirely in both our interests in work for planning and in our customers' interests that we have the greatest consistency we can. I hope that the on-Island training progresses because my experience out there is that there are a lot of professionals who, through circumstance, would do this qualification but have not been able to for reasons of finance or logistics of getting off-Island, so I think that would be a great thing to do.

Deputy J.A. Hilton:

Can you just clarify for me? So you have 32 full-time employees in Adult ...

Acting Team Leader, Adult Social Care Team: So, on the Adult Social Care Team.

Deputy J.A. Hilton:

So, in the Adult Social Care Team you have 32 full-time, of which only 2 are locums?

Acting Team Leader, Adult Social Care Team: Yes, to cover substantive maternity.

The Deputy of St. Ouen :

Can you tell us about the training and supervision that is given in the assessments for the long-term care scheme?

Acting Team Leader, Adult Social Care Team:

That is what I was going to say and what I should have said already. So to ensure consistency we have worked with the company called F.A.C.E. (Functional Analysis of Care Environments) who originally had this I.T. (information technology), it is now Imosphere. We have worked with them to train or when it was implemented they trained all the staff. They then did a series of train the trainer so that we have got trained people who are trainers and kind of champions of the system here on- Island. Everyone who comes into the service has to do that consistent standardised training; has to pass it before they start assessing.

Deputy G.P. Southern :

Is that anybody in the 32 who might be ...

Acting Team Leader, Adult Social Care Team: Anybody who does assessments.

Deputy G.P. Southern : ... required to start?

Acting Team Leader, Adult Social Care Team:

Yes. Regardless of profession anyone who is doing assessments should do that training. There then is a monitoring system where there are a series of authorising officers so when a professional does an assessment they send it through to an authorising officer who does a series of quality assurances that people who are registered to do those quality assurances are registered with the Minister and they do additional training.

The Deputy of St. Ouen :

Does it happen for each and every assessment that there is a second look at it?

Acting Team Leader, Adult Social Care Team:

Yes, every assessment has to go through an authorising officer.

The Minister for Health and Social Services:

There is a right for the applicant to ask for it to be re-determined as well.

Acting Team Leader, Adult Social Care Team:

For every determination, yes.

Deputy J.A. Hilton:

So when a new social worker comes into the team they all undergo this F.A.C.E. training?

Acting Team Leader, Adult Social Care Team: Consistent training.

Deputy J.A. Hilton:

How long does it take to undergo that training? Presumably they are not doing assessments while they are undergoing the training, is that correct?

Acting Team Leader, Adult Social Care Team:

Yes, that is correct. The training itself in terms of sitting in a training room with a trainer is not long. I think it is 2 or 3 hours on assessment scoring, 2 or 3 hours on care planning; that would be built into their induction period. We do not have people who come in on a Monday morning and are dong assessments on Monday afternoon.

Deputy G.P. Southern :

To what extent is the F.A.C.E. system subject to or is it entirely objective? It deals with human beings after all.

Acting Team Leader, Adult Social Care Team:

It does. Before long-term care there was a problem as everything was entirely subjective. The Imosphere system, as it is now, or the F.A.C.E. system, provides a consistent framework for assessment. So the assessment potentially is quite lengthy although there is an element of judgment on which sections you need filling in. It is not arduous or inefficient in that we say you have to fill out every box, even if it is relevant or not. So I think we have cut down this objectivity to an appropriate amount. But obviously we now have a set framework and a consistent system that acknowledges that everybody is individual and individuals are fluid by nature. That is reflected in what the assessment officer puts into the system.

The Deputy of St. Ouen :

You say that every assessment is looked at again, but are there occasions where you undertake a more formal review of the whole procedure within the department to ensure that excellence of assessment and quality control?

Acting Team Leader, Adult Social Care Team:

Do you mean an individual assessment or do you mean audit system?

The Deputy of St. Ouen :

A kind of audit system, yes. Does that happen?

Acting Team Leader, Adult Social Care Team:

Yes. So we have our authorising officers and there are a set of key performance indicators behind that, so we are monitoring any problem areas in the ... it does not happen very often but any problem individuals, if there is someone getting a high rate of return. We are monitoring that. We also have quarterly audits carried out by Imosphere on which the results are consistently reviewed since the implementation in 2014.

The Deputy of St. Ouen :

Could Imosphere be regarded as independent because after all they would want to make sure their system is working well? Do you have any independent verification of these assessments?

Acting Team Leader, Adult Social Care Team:

There is no third party; we do have the appeals process as the Minister outlined.

Deputy G.P. Southern :

When you chose the F.A.C.E. system was there a market out there, were there other companies you might have chosen or is F.A.C.E. universal in the U.K.? Has it got a monopoly?

Acting Team Leader, Adult Social Care Team:

That question is slightly beyond me. I was not involved in that. It is widely used in the U.K. but not exclusively.

Director of Operations for Community and Social Services:

I was not around when it happened so we would have to ask Chris about the process but there are other providers that provide similar systems across the U.K. But when they do audit they do benchmark it against other U.K. ... where they are providing that service and become then capable in those ...

The Minister for Health and Social Services:

There would have been a procurement process. Again, I was not around then either. But there would have been a procurement process because I just know how these things work.

Deputy G.P. Southern :

Would that be evidenced somewhere?

The Minister for Health and Social Services: I will ask.

Acting Team Leader, Adult Social Care Team: It is regrettable Chris is not here.

Deputy G.P. Southern :

If you could supply that then. One of the areas that I have come across, in my experience, where previously assessments of need were difficult are where an illness is periodic so, as I always say to my clients: "Do not tell them about the good days, tell them about the bad days."

[14:15]

Because that is when you need their help. The other is mental health issues. We are notoriously bad at diagnosing, it seems to me, mental health issues compared to physical health. We can easily do a tick box and see how somebody physically is, harder to discern ... what is your experience with the F.A.C.E. system in terms of doing a good job in those areas?

Acting Team Leader, Adult Social Care Team: Okay, I might have to ask you to recap the question.

Deputy G.P. Southern :

It is periodic and it is mental health.

Acting Team Leader, Adult Social Care Team:

Imosphere, in their training, and how our trainers in the training they deliver, say something very similar to you about good days, bad days, and the mantra that is given is imagine someone with no support of other human beings as your starting point and imagine them on your worst day. So that is the way ... that sounds slightly conflictual because we  want to be strength based in our assessments obviously but for the purpose of long-term care the training given is assessed for worst day. So on that front they are in agreement with you. In regard to mental health, so if you recall when we went through an assessment up at Eagle House there are substantial sections for emotional wellbeing and varying aspects of that that can be completed as appropriate and, forgive me, because I cannot go too far down the technical road, but are weighted to give the courses to people who need it. Again, it is not my area of expertise, but we should just say that long-term care of this nature is one aspect of improving mental health but there are many other areas as well outside of the long-term care scheme, Talking Therapies, psychological input, things like that.

The Minister for Health and Social Services:

I think I would add to what you said, Paul, that advocacy is really important for people, both with mental health and with conditions that are on and off, because I know of occasions - I am not involved in any assessments but I am talking with my charitable hat on now - where somebody would be having a good day and may well say to the assessor everything is fine that day. That is why it is really important to understand the good day/bad days and also advocacy and support which is provided. It is very, very important.

Deputy G.P. Southern :

It is the classic, you go to see your doctor he says: "How are you?" and you say: "I am fine." "Why are you here?"

The Minister for Health and Social Services: Exactly.

Deputy G.P. Southern : We all do it.

The Minister for Health and Social Services: What I am saying is we are aware of that.

Deputy G.P. Southern :

One of the other issues that has been raised by us, especially people working with the elderly in homes, is that only limited notice is taken to carers who might be able to spot things or knows what the situation is, carers or family members who may also have been caring as well. To what extent is there involvement in the group around the clients?

Acting Team Leader, Adult Social Care Team:

We always strive that our assessments are holistic and that involves as many relevant people as we can involve with the consent of the individual. So sometimes there are very difficult assessments to conduct because a person says: "I do not want you to discuss my matters with anybody else. I will tell you how it is" and that person has the capacity to do so. We have to respect that. But our starting point is to get what we call "consent to share information" regarding their assessment, and that is to basically say: "That those involved in your care, those who know you well, as long as you consent, are involved in your assessment."

The Deputy of St. Ouen :

We have had submissions made to the panel that a social worker has gone into a care home, seen the person being assessed and then left and not spoken to any of the staff who are doing the caring. How can that be right?

Acting Team Leader, Adult Social Care Team:

I do not think that is right unless that person has said: "I do not want you to speak with the home." I am aware that that was said and I am not, unfortunately, aware of the individual cases. As it is presented that would not be a satisfactory level of service.

The Deputy of St. Ouen :

But is that a barrier because here we are, we have a system that is trying to provide the support that the carers are giving and yet the system is saying: "We cannot speak to those carers to find out what support is needed." Surely there must be a way through.

Acting Team Leader, Adult Social Care Team:

I think it is only saying that in very isolated cases. It is very rare. But I am flagging it because we do have to respect the wishes of the people who have the capacity to ...

Deputy G.P. Southern :

That is an area where I think it is accepted that your information is your information. You own it. You say if it is shared. But having said that, the complaint was also that when an assessment is done the assessment was not shared, the mechanics of the assessment were not shared with the caring staff. Is that likely? How do you feel about that?

Acting Team Leader, Adult Social Care Team:

I think the assessment is a bit more discretionary, particularly around the person concerned. You cannot ask someone to provide care for an individual, in my opinion, without giving them a care plan. That is the crucial document.

Director of Operations for Community and Social Services:

That care plan will identify the assessed need that care would be required for. There are all the assessed needs that have been identified within that care plan and the care plan should detail what it is that the person would get in support for is detailed. That should be shared with anyone that is ...

Deputy J.A. Hilton:

So the residential/nursing home will always be given a care plan for an elderly person that they are providing care for? Always?

Acting Team Leader, Adult Social Care Team: They should always.

Deputy J.A. Hilton:

But you would not necessarily share the assessment of needs report? It is just the care plan?

Acting Team Leader, Adult Social Care Team: Not necessarily.

Deputy J.A. Hilton:

So to be clear, it is the care plan that is always shared?

Acting Team Leader, Adult Social Care Team: It would be mandatory.

Deputy J.A. Hilton:

That is regardless of whether the person gives consent or not? Would they be asked? Would the client be asked?

Acting Team Leader, Adult Social Care Team:

They would be asked. I do not know if you know, Jo, of instances where someone said: "No", but obviously the conversation that follows is: "Well, we just had a conversation that says you need some support and this is the document that will set out how that support is to be given. It is quite difficult to justify how it is not in your interest.

Deputy J.A. Hilton:

Can I just ask a question about where care is being provided in the home and because people have mentioned to us that, again, the person who might be suffering from dementia or something had been written to rather than ... and the family member has been excluded from that?

Acting Team Leader, Adult Social Care Team:

It would be likely to depend on capacity. It is a very difficult balance at times with dementia. It would not be completely alien that there is conflict of that type but our standpoint is where there is no evidence that someone does not have capacity we would respect that wish.

Deputy J.A. Hilton: Thank you.

The Deputy of St. Ouen :

At the end of the day, you have spoken that applicants or their families can ask for a review of an assessment and if they are still not satisfied is there a more formal appeal route?

Acting Team Leader, Adult Social Care Team: Yes.

The Deputy of St. Ouen : What is that?

Acting Team Leader, Adult Social Care Team:

Review/reassessment is a daily occurrence for us. It is our bread and butter. It is constantly happening. So when someone has a service from us they are either open to a worker or they are on a review system. That review can be brought forward at any time and that is what I am talking about as our bread and butter, so changes in the care agencies or relatives or individuals themselves who are concerned that there has been a change, there is a deterioration, and so on. That is the less formal side and that is what we are doing all the time. That is not to be confused with a formal redetermination, which is when an assessment is completed and there is dispute over the content and outcome of that. That is a more formal determination system which involves being reassessed with someone different who is objective to the private conversation.

The Deputy of St. Ouen :

Who hears that appeal and can the appellant before somebody to say: "I think Social Services has got it wrong"?

Acting Team Leader, Adult Social Care Team:

Yes, but at my level it would be to the new person from Social Services. I give my apologies really for my lack of familiarity with of the whole appeals process. I would need to direct you to my colleagues in Social Security. Where we tend to hear about that it tends to be via Social Security. In terms of formal redeterminations, if we have had any at all, it is literally one or 2.

Deputy G.P. Southern :

I was going to ask about numbers but if it is only one or 2 formal redeterminations, second determination effectively, by a different officer.

Sorry?

Deputy G.P. Southern :

A second determination by a different officer.

Acting Team Leader, Adult Social Care Team: Yes.

Deputy G.P. Southern :

That is the normal route. Then it would become an appeal to presumably, or we were told yesterday, a Social Security medical tribunal.

Acting Team Leader, Adult Social Care Team: It would go to, yes, some sort of panel.

Deputy G.P. Southern :

But again that has not happened yet?

Acting Team Leader, Adult Social Care Team: I do not know that.

Deputy G.P. Southern :

You do not know? Okay. Can we find out if it has?

Assistant Director of Policy and Ministerial Support:

We are not aware of any. Yesterday, Social Security, which administers the panels, said they were not aware that any had occurred."

Deputy G.P. Southern :

Okay, thank you. But again we talked yesterday about whether that was the appropriate mechanism and whether it is a timely mechanism. If this is an issue at all then one thing, in my experience of Social Security tribunals, is they can take up to for ever to set up. It is a lengthy process. You are not going to get a hearing and any satisfaction in under 6, probably 8 weeks and longer. So it seems to me that somewhere in the system it may be possible to have a look at that. I do not think the tribunal system in Social Security worked spectacularly well with those sort of length gaps, it cannot, but, okay, address that later,

The Deputy of St. Ouen :

You began to speak about reassessments and it must be the nature of people with long-term care needs that their needs will often deteriorate. So are reassessments built in as part of the system and are they built in as a regulatory, say, annual reassessments?

Acting Team Leader, Adult Social Care Team:

There is something of a dichotomy in social carebetween what is a review and what is a reassessment . Like I said, everyone who is in receipt of the long-term care benefit service will be on the review database if they are not held over to a practitioner. So where something is ...

The Deputy of St. Ouen : Sorry, what does that mean?

Acting Team Leader, Adult Social Care Team:

If you are assessed and a package of care is implemented but things are very unstable, a swift deterioration is anticipated or a swift change is anticipated, then the likelihood is that your long-term care nurse or your social worker will say: "I am keeping you to me. You are going to stay on my caseload and I will check in with you every week, every 2 weeks, or I will come and see you every Friday" something like that. Where things are more stable, so where we go and do an initial review and, for example, someone is in a care home and they have settled great in a care home, saying they have settled in wonderfully, then they would go on to what we would call our review database, and they are flagged on that review database no less than annually. It is discretionary down to the practitioner who can say: "I want a review in 3 months or 6 months" but it is no less than annual.

The Deputy of St. Ouen :

Are you meeting those targets of the reassessing annually?

Acting Team Leader, Adult Social Care Team:

We have slightly fallen behind in that in the work that we have done catching up with the assessment because we did ... at the point of implementation we have a backlog of assessments. We have a plan in place and we have just made 2 appointments, so we are up to full quota of staff. That should allow us by Christmas to be back on plan, back in the right timescale with those reviews.

The Deputy of St. Ouen :

So there are little more than 1,100 people drawing long-term care, you are saying the system is going to allow every one of those annually to be reassessed; that will be about 3 reassessments each day, but with working days it might be 5 reassessments. Are you able to do that?

Yes, and this is the dichotomy I am talking about. It is not always a full reassessment, as we would call it. So if the person that I referenced, who settled in really well, if you are going out to them a year later and be back here and still doing really well: "My care needs are being really well met" and the care home is saying: "We think they continue to do really well here and we have no problem meeting their care needs" you would not necessarily need to do a full reassessment. I think full reassessments come into play where there has been a change in need and a need to respond if we have to.

The Deputy of St. Ouen :

I see. We had one example given to us in evidence where a person was receiving care at home and then cancer took a turn for the worst and they ended up receiving palliative care at home, a lot more input by the care providers, therefore more expense being incurred. But additional financial support could not be given without a reassessment, and yet the family and the care providers thought that was quite intrusive for a social worker to come in and start reassessing when hospice care could have said: "Yes, this gentleman is receiving palliative care." Does there have to be that formality of a reassessment?

[14:30]

Acting Team Leader, Adult Social Care Team:

There has to be a reassessment because obviously we there is not necessarily a bottomless pit of money and there has to be some sort of assessment process built in. What of course one would hope is that if, for example, the hospice team were very involved that that assessment could be as least intrusive as possible but, you know, essentially it is true that there is nothing to say, yes, you can double or treble the amount you spend on this person, however genuine, without some sort of check and balance by way of assessment.

The Deputy of St. Ouen :

In a case like that does it mean that a social worker has to visit, has to pay a visit to the home?

Acting Team Leader, Adult Social Care Team: Yes.

The Deputy of St. Ouen : It does, does it? Okay.

Director of Operations for Community and Social Services:

That is the process that we have but they would gather most of their information from the other professionals that are working with that individual. So we would expect a social worker to do the visit in the least intrusive way, liaising with the palliative care team and then filling out the assessment as much as possible.

Acting Team Leader, Adult Social Care Team:

So to use your example, yes, there should be a wealth of good quality clinical information from the hospice and the people who know this person best that they should be able to access and it may well be that the time the social worker is going out to visit, it is a final check in, introduction, this is who I am and this is what I am doing based on the information.

The Deputy of St. Ouen :

Then how quickly can a reassessment be dealt with? Once the social worker makes that reassessment, it has to be agreed by somebody else within the department, does it? How long does that take and then for the additional support to come through?

Acting Team Leader, Adult Social Care Team:

So there are a number of different things that fall into play here. The first one to say is that our current average from referral arriving in the team to contact being made by an allocated worker is 5.7 days. We have a triage system and to use your example of palliative care, that is treated as urgent, so same day response, same day or within 24 hours. At this moment in time we are able to do that. That is the timescale we are responding on. You know, if we are being honest, in 2014 and early 2015 when this was implemented we had a big backlog of work and reassessments were coming back into the backlog, if that makes sense, and things were much more difficult because effectively that scenario it is akin to another referral really. We might have some building blocks in place already but it still needs to be allocated to someone who needs to pick the case up. So at the moment we are responding accordingly.

Deputy G.P. Southern : That is for a reassessment?

Acting Team Leader, Adult Social Care Team:

Yes. Well, the timescales are the same for assessments and reassessments.

Deputy J.A. Hilton: So it is 5 days?

Acting Team Leader, Adult Social Care Team:

At the moment it is 5 days.

Deputy G.P. Southern : Five days to first contact?

Acting Team Leader, Adult Social Care Team:

Yes, from arriving in our team to first contact by an assessing officer.

Deputy G.P. Southern : Then the process starts?

Acting Team Leader, Adult Social Care Team: Then the process starts.

Deputy G.P. Southern :

I was not going to ask how long the process normally takes but I am going to ask that anyway. In a particular format, which is evidence from the parish of St. Helier who said: "Although long-term care will tell you that new claims are taking 2 weeks to process that is not my experience" he says, and he then goes on to talk about social worker assessments, including a B.I.C.A. (Background Information and Contact Assessment). A summary of review of budget at the end of a 4-week period, then the application for funding form, a 12-page form which takes some time to get through and then assistance with providing data such as 3 months' bank statements, award letter confirming pensions, official documents, value of assets, blah, blah, takes some time. What is your best guess?

Acting Team Leader, Adult Social Care Team:

At this moment in time, something that comes into S.P.O.R. (Single Point of Referral) is referred to the appropriate team within 4 hours, allocated to a care manager within 24 hours. That is working, so our average on that is 1.7 days at the moment. We then allow 21 days for completion of assessment and a further 3 working days.

Deputy G.P. Southern : Twenty-one working days?

Acting Team Leader, Adult Social Care Team:

No, 21 days, so 3 weeks. Three working days for authorisation and then one working day for completion of the project summary. Now, there is, of course, variance within that so some are done very quickly, the type of scenario you talked about is not going to take 3 weeks and we will very much be prioritising that. I would be disappointed if it was not done in a matter of days. Others stretch out while a complex package of care is put together or while the right bed in the right home is awaited. I can only really talk to you about the aspects that my service completes. There are other aspects, you are right, in terms of amalgamating the information needed for financial assessment, which is a social security function and is after the period of live assessment.

Deputy J.A. Hilton:

Presumably if you have a client who is going to because they do not have their own means to pay, it will probably be much more straightforward because they would not have the assets to value?

Acting Team Leader, Adult Social Care Team:

It can be. What does happen is when Social Security know that someone is on income support, because if you are on income support then if someone is on income support then effectively they require it quickly, we know that, however we do explain the process to people, regardless of circumstance, we make them aware of the liabilities and we try to get the care in quickly.

Deputy G.P. Southern :

So the first point of contact, the referral is made, how long before you would expect that case to be dealt with and this person receiving help? What would you be looking at? Then the follow up question, and if you found out that it was X weeks later and they still had not been done, when will you be holding your hands up and saying: "Hang on, what is going on here?"

Acting Team Leader, Adult Social Care Team:

There is an element of how long is a piece of string because it depends on individual circumstances. We would find ourselves responding within hours to someone who for example, the scenario you have given. We pride ourselves on working sensitively through the formation of a complex care package. So I can give you averages but there is no such thing as an average case really.

Deputy G.P. Southern :

But you will give us an average?

Acting Team Leader, Adult Social Care Team: I can give you some averages.

Deputy G.P. Southern :

Because some of the evidence we have got is, certainly historically, when you had the backlog it was months in some cases and more in some.

Acting Team Leader, Adult Social Care Team:

I think there are different facets to this process, some of which we can talk about quite well, some of which are more Social Security, but what we did know at one stage, because there was a backlog, was the first thing you hit was a delay before it was even started and then the assessment was done.

Director of Operations for Community and Social Services: That is not the case now.

The Deputy of St. Ouen :

No, so is it the case now that everyone who has applied for long-term care has been assessed?

Acting Team Leader, Adult Social Care Team:

We currently have 7 people on the waiting list and a top wait for assessment is 13 days.

The Deputy of St. Ouen :

Okay, so those are the recent applicants.

Acting Team Leader, Adult Social Care Team:

Yes, so apart from those 7 who were referred in the last 13 days, effectively last week, or since the end of last week, there is no one else waiting.

The Deputy of St. Ouen : Okay.

The Minister for Health and Social Services:

There is no doubt there were some delays right at the beginning. We all know so we should not try and hide that. But the bulk of assessments that overran the department at the beginning, they have now got that under control.

The Deputy of St. Ouen :

But then I have to say this conflicts with evidence given to us by Les Amis who say that 70 per cent of their residents living in their care homes are still awaiting assessment.

Acting Team Leader, Adult Social Care Team:

I disagree with that view. In 2015 we completed a project to assess everyone in Les Amis ahead of the kind of financial modelling to be in place for 1st January 2016. Those assessments were completed. There was, however, towards the end of 2015 a change to the base system, so an upgrade on the system and there was

The Deputy of St. Ouen :

What, in the long-term care assessment tool?

Acting Team Leader, Adult Social Care Team:

The care partner analysis system that was upgraded to a web-based system. There was an issue with that in that the information on what was - forgive me being technical - version 6.1 did not migrate to version 6.4 so we had get basically we did that in every case where there was a not a dispute but where there was a deficit in the current funding to the projected funding on the system, so we did that. We have a project in place to get everyone on to the new assessment and subsequently the new care plan, which is quite crucial as I will explain, by the end of this calendar year. However, you know, I am keen to stress that that makes no difference to the fact that everyone has an assessment and everyone has the right level of funding that will not change as a result of what we are doing.

The Deputy of St. Ouen : Do you know that?

Acting Team Leader, Adult Social Care Team:

If there were 70 per cent of people not assessed within Les Amis then Les Amis would not be receiving payment for those 70 per cent.

Deputy G.P. Southern :

But there are currently numbers not reassessed, for want of a better word, on the new system?

Acting Team Leader, Adult Social Care Team:

Who we want to put on our most up to date system. The reason for that is there is a slightly different care plan that arises out of system 6.4 and that is where we agreed with Les Amis that for consistency we want all of the people who you provide a service to to have the same type of care plan.

Deputy J.A. Hilton:

So that is where the 70 per cent come from, it is those people who are not on the new system at the moment, but you are saying that it does not affect their care plan?

Acting Team Leader, Adult Social Care Team:

It does affect the format of their care plan, it does not affect the money. Their assessment is the same, it is migrating that same assessment content and then putting it

Deputy J.A. Hilton:

We just wanted to understand where the 70 per cent came from.

Acting Team Leader, Adult Social Care Team:

Absolutely, but in terms of the new documentation that will be about right. My understanding is we have 50 something out of it, something to do with if we give the crude figures and that was I must stress that everyone has an assessment, everyone is receiving the right financial input.

Director of Operations for Community and Social Services: We have a lot of people working that.

The Deputy of St. Ouen :

Do you get a sense that there is still people in the community who have not yet applied for long-term care and might well be eligible for it?

Acting Team Leader, Adult Social Care Team:

I suspect there always will be. I think the initial wave - if that is the way to put it - through 2014 and 2015 is maybe easing off or has eased off a little bit in terms of people who were out there receiving care that we did not know about. We are a very busy department, our referral rates are not going down, at least in the future. You will be well aware of the demographics that we have projected and so on. I think that means when my team my team has received an average of 35 referrals a week this calendar year, so that would suggest that there will always be people who are in that position.

The Deputy of St. Ouen :

Thirty-five referrals a week? That is about 140 a month.

Deputy G.P. Southern :

When you say referrals, do you mean referrals to long-term care?

Acting Team Leader, Adult Social Care Team: Referrals to the Adult Social Care Team.

Deputy J.A. Hilton:

Before we finish with assessment, can you just tell me, because one of the issues that has arisen through the evidence that we have gathered is the lack of communication that goes on between the department and the client. So where you have a client who has been assessed - and I think you said it could take up to 3 weeks after you have done the initial how do you communicate all that information to the client? Are they regularly written to and said: "This is what is happening, this is the next part of the process"?

Acting Team Leader, Adult Social Care Team:

Well, at that stage they would always be - sorry to be technical - allocated to their assessing officer and that dialogue should be ongoing really.

Deputy J.A. Hilton: Okay.

Acting Team Leader, Adult Social Care Team:

There will always be difficulties if someone comes in and what have you.

[14:45]

Deputy J.A. Hilton:

I think quite a bit of the evidence we did take was that this communication problem in the early days - I will stress that - that there were problems with because I think of the length of time, but I think communication when you are dealing with vulnerable older adults or vulnerable adults is really vitally important, that they know exactly where they are in the process. So, as far as you are concerned, that problem should not arise now?

Acting Team Leader, Adult Social Care Team:

I think we have to be honest and acknowledge that in the difficult phase after the implementation, people were on a waiting list and when they are on a waiting list, apart from sporadic check ins to say: "You are still on the waiting list and this is what we are doing about it" there were periods when people were not contacted. I think we have to acknowledge that that was the case. I am confident it is not now.

Deputy J.A. Hilton:

You are confident it is not the case now.

The Deputy of St. Ouen :

Minister, in the couple of years the scheme has been operating now, do you feel that there is any area in the assessment process that can be improved?

The Minister for Health and Social Services:

To be honest with you, I do not know enough about the assessment system. We have one that is recognised and I have no doubt that we will need to update that and change that from time to time. So I am comfortable that what the staff do with the package that we give them is appropriate. I am not saying I do not know if there is any other I know there are other systems, I do not know if there is a better system.

The Deputy of St. Ouen :

Panel, Professor Johnson , is there any more questions regarding assessment that we would want to ask?

Professor M. Johnson :

Can I raise one or 2 questions? You have given very detailed answers, I just make an observation that the F.A.C.E. system looks pretty good but we have not been able to find any independent evaluations of it and there are other systems out there which have long records and lots of independent evaluations. So I hope you will keep it under scrutiny because it is a commercial product and you ought to be able to find other assessments of it than the embellishing words of the Chief Executive, good as he is. However, the tool is capable of not just being one which is an entry gate into the long-term care scheme, that is the first thing, that is what we have been talking about, but as the Chairman said people's situations change and we know in any kind of care system keeping people's changed circumstances under review is critical. Now the F.A.C.E. tools are capable of review and they have within them what are called triggers and other ways of alerting practitioners to changes in circumstances. But you appear not to be using those other capabilities so at the moment it is a kind of entry gate. You get gathered into a pool of people waiting to be assessed and then you are let out, so to speak, with a badge on you that says: "I am in the long- term care scheme." Of course that is necessary because quite at lot of resource is involved and your partners in Social Security require that, but the tool relegates people to one of the 4 levels, each of which has a budgetary consequence. There are now going to be 5 levels, of course, and then there is another one at the top, 6 top up, which I am sure Members of the Panel will want to talk about why is there a top up scheme, is it getting any bigger, and so on. However, I am sure others will ask that question. I am a bit concerned that you have what looks like a much more professional, much more consistent entry assessment but annual reviews for people with long-term and complex conditions on the one hand, the younger people, and the older people who are almost by definition in the later stages of their lives with complex needs and they are declining. If they are in care homes they are at the far end of life. So reviewing them once a year in care planning terms, is not enough, to put it loosely. So are you planning to use the tool's capability for these purposes and not just do it when you can?

Acting Team Leader, Adult Social Care Team:

Yes, absolutely. I did say no less than once a year so there is a discretion as to whether reviews are done. There are cases within my team who are reviewed weekly right through to people who are reviewed annually. But you are right what you are saying, and this is part of the fact or part of what contributed to a huge backlog that has now diminished. The system is a building block system in that once the information is on, once an assessment is done, to reassess and review is much, much less of a piece of work and much less intrusive as a piece of work. So I complete an assessment on Mr. Smith, it is quite a thorough process of getting to know him and getting to know the circumstances, filling out the assessment form. If, as you say, for example, a week later there is a change in Mr. Smith's needs, I can go back to that assessment and build upon it. I do not have to start again. Does that make sense?

Professor M. Johnson :

Quite a lot of the older people that you would assess well, some will remain at home with support packages, their circumstances might change quite a lot, will involve review. Review is really important in the late life care of older people, so when people go into care homes, which for the moment looks like the predominant group, they go into care homes where the assessment schemes and the care planning tools they use are as diverse as you can get, probably a different one for every home. You will know that many of them are grossly inferior, untested, cut and pasted, subject to knitting and sewing, frankly it is a way of saying they are not very good. Now, have you considered taking the F.A.C.E. tool and mandating it for the care homes, saying: "If you are going to receive people on long-term care you need to use the same tool as us"?

Acting Team Leader, Adult Social Care Team:

I could not tell you if consideration at a high level has been given to that. I think at the moment we are a separate system. The relationship is there as commissioner and provider. If a particular care home wished to use verbatim our care

Professor M. Johnson :

No, that is not what I am saying. I am saying in some other jurisdictions I am not talking about the U.K. which is a basket case because I know it well, but in the United States where similar systems were fashioned for the Social Security administration, they paid for the research. They put a lot of money in it and they said: "Now, we have this system, all the care homes who want to take people on public benefit must use it and they must submit their assessments online for inspection." Now, you may think that is rather oppressive and not acceptable but it has the advantage of not duplicating and it also has the advantage of taking all those triggers and reviews and making sure they happen, conducted by the people who are doing the caring, using the same tools rather than sending the care workers, social workers, nurses and others who referred them there but may not see them for a long time, so they do not have a continuing active relationship with them. So I am not saying it is the only possible thing to do but I want to suggest to you that it is something that should be considered because people not in continuous contact would not be doing the reviewing but overseeing the reviewing by people who are dealing with them every day. I think that has quite a lot to commend it. It may also give strength to Social Security who would see that review is going on so when a case for upping the care so people who are in care homes, if the do not go in with dementia, which is now the predominant condition, may well develop from memory loss into something much more serious where the level of care has to go up, would be able to see the flow of evidence not just these snapshots which take quite a lot of time and resource and are done by people who are outside of their care system. Does that make sense to you?

Acting Team Leader, Adult Social Care Team:

It does make sense. It is quite high level. I think there are some interesting comments there that certainly, you know, I think we should explore.

Deputy G.P. Southern :

Can I just ask, Chair, that seems to be pushed upwards, is the Minister going to pick that up as a thought or is it somebody else's job?

The Minister for Health and Social Services:

The Minister will not pick it up, what the Minister will do is ask Chris Dunne, who is not here today, whether it does seem appropriate to have a look at it and say whether he does anything like that or whether he has plans to do that.

Deputy G.P. Southern :

Is that a role which lies with the Care Commissioner?

The Minister for Health and Social Services: Does it? I am not sure.

Deputy G.P. Southern :

Could I ask of the officer, many of the contacts at home will be with a care assistant, not anything higher level than that, how easy would it be for a care assistant to be able to monitor in the terms that we are talking about?

Acting Team Leader, Adult Social Care Team:

Well, I take the point that that is the person that who sees that individual most often. I think that is one of the elements that will need exploration.

Deputy G.P. Southern :

Yes, I have certainly talked to a care assistant or health assistant who has said to me they see the deterioration and they must do something about it. She was very aware of flashing it up the chain and say: "We need some more help here."

The Deputy of St. Ouen :

Okay, so we are halfway through our meeting time. I think I would like to move on to questions of sustainability of the fund going forward, Minister. Are you as Minister for Health involved in modelling the long-term care fund into the future?

The Minister for Health and Social Services:

No. No, I am not, that is a matter for the Minister for Social Security to ensure that she has - or he, depends who it is - has sufficient funds coming in to meet the projected needs going forward.

The Deputy of St. Ouen :

Yes, but then in terms of the allocation of resources from within Social Services, do you not need to know and are you informed to plan what services need to be provided by the Social Services Department?

The Minister for Health and Social Services:

In terms of the long-term care scheme, our contribution is predominantly one of assessment of care needs. Funding then buys, if they require it, services - from ourselves in some cases, and we do have that with the mental health in Orchard House. But they are buying a service. They could equally choose to buy that service from any other approved provider.

The Deputy of St. Ouen :

So not involved in modelling of sustainability.

Deputy G.P. Southern :

We have seen from Social Security a short-term, relatively short-term, progression between now and 2024 in terms of the growth of the fund. What we have not seen, and I have not looked at, is an equivalent long-term projection which goes on to 2036 or 2044. Given the limitations of the work that was done by Oxera, what is in the pipeline for looking further at how this scheme is going to grow? Because it will grow.

The Minister for Health and Social Services:

Clearly we look at, from the stats unit and other sources of information, what is likely to happen in terms of demographics and our work is around things like the need for the new hospital, why we need the extra beds that we need and we have to ensure that we have sufficient care home places. It is not our job necessarily to provide them but, as Minister, I encourage, where appropriate, development of care homes and so on but the funding of care is a matter for the Social Security department and the Minister.

Deputy G.P. Southern :

Will you be involved in looking at provision planning?

[15:00]

The Minister for Health and Social Services: I would be advised what it says ...

Deputy G.P. Southern :

It is entirely the responsibility of Social Security to make sure that ...

The Minister for Health and Social Services:

 Social Security looks after it, or the Minister, and, yes, I would be advised on where it is progressing, what the outcomes are likely to be, but I would not be involved in determining what the contribution level should be, for example.

Deputy G.P. Southern :

No. I have mentioned the limitations involved in the October report which looked at the long-term growth of the scheme and it contained 4 caveats relative to the modelling they did. When an individual enters the L.T.C. (long-term care) system they were assumed to need the same level of care until they exit the system. We know that is not going to be the case, almost guaranteed that their demand will get greater. The model focuses on the costs of care and does not include the administration costs of the scheme, so administering it is not built into any projections. The model focuses on policy options for the scheme providing long-term care for individuals aged over 65. There is no catering in there for family units but both would require some support, and again that seems to be something that should be involved. Within the model ... the other reservation was it does not cater ... it only appears to take into consideration the over 65s. It does not consider the load of the under-65s, the young people who are going to need some support throughout the scheme. To what extent is the Council of Ministers, are you as Ministers, aware of the need for some long-term protection with those sort of reservations in mind?

The Minister for Health and Social Services:

I am not an expert on it but I believe, for example, that that information is not strictly all correct because long-term care applies to adults under 65 if they need the support. Some will be over 65 but many of them will be adults of 20, 25, 26.

Deputy G.P. Southern :

Indeed, but my point was Oxera did not model that in its initial projections. The fact that you have got young people who are going to be lifetime needing support was not modelled, so the growth predictions about what it is going to cost you down the line.

The Minister for Health and Social Services:

That is something the Minister for Social Security has to make sure she takes into account when looking at the funds available going forward.

Assistant Director of Policy and Ministerial Support:

Can I just add something. I worked with Sue Duhamel (Director of Policy at Social Security) when we researched and brought in the long-term care scheme, including thinking about how it was all going to work. I do not want to repeat again what was said yesterday but it was a case of us wanting to get moving on the scheme. We had to do what we could do at the time. As I think they said yesterday, there were some known unknowns, if you like, and we could not actually factor everything into the equation. So that is why on those points you made, I think we were very upfront about saying those things have not been taken into account. But I think as the Director of Policy at Social Security mentioned to you yesterday, , some of these things would not have made too much of a difference to the actual way forward. I think I remember Sue saying yesterday that obviously when they come to look at it afresh, I think they were going to do some work on those factors. Now we know where we are, if you like, and we have got it running and it is happening and it is going pretty well, those factors would be taken into account, at least some of them, going forward. So I think you can look back and say: "Yes, you did not look at those things", and I think we did not, but I think it was a case of looking at the most important aspects and that is what we did when we did the planning with Oxera to give us a bit of a flavour. Things changed quite a lot, as Sue reflected on yesterday, in terms of the scheme as how it was originally thought about and then as to when it actually came in.

The Deputy of St. Ouen :

Minister, I want to talk about policy 1 and policy 2. The Island is trying to introduce a scheme to meet the long-term care needs of the population and yet it seems to me that we have right at the top people with the highest needs that fall outside the scheme and they become the responsibility of your department and people with long-term care needs at the bottom end are not taken into the scheme. Does that strike you as odd?

The Minister for Health and Social Services:

Let us deal with the bottom end first and then we will talk about the top end. It became evidently clear in the last couple of years, it may have been clearer before but it became evidently clear, that there was this gap at the bottom end of people who needed support but did not need as much support as the long-term care scheme was designed to provide, that we needed to do something to bridge that gap, and that is what we plan to do. I do not know if Mark wants to say more about that.

Assistant Director of Policy and Ministerial Support:

It was that gap between £350 and £150, was it not, if I recall?

The Minister for Health and Social Services: Yes.

Assistant Director of Policy and Ministerial Support:

I know Deputy Southern will probably talk about the different process.

Deputy G.P. Southern : I may well ask.

Assistant Director of Policy and Ministerial Support:

People who are covered by policy 1 are likely to require a package of care. This would be my explanation as to why the assessments are different. It might only be a small package of care but as regards people who are getting the impairment components of income support it might not be such a formal package. It is more likely they might be getting assistance with certain elements. I think that would be why I would defend the point about making sure it (policy 1) follows a long-term care assessment as opposed to the income support (impairment) assessment, which I know you are asking about.

The Minister for Health and Social Services:

For me, I just saw it as bridging that gap between the top of the income support scheme and the beginning of the long-term care scheme. There was definitely a gap, there was definitely a need, and that is why we came out with that one. The other one at the top end, why do we top it up, I was not party to when this came in but I presume this was because if the fund paid everything it would be totally unsustainable, so it was accepted that Health would pick up very complex cases and top it up so the person was not left vulnerable.

Deputy G.P. Southern :

Is that the transitional arrangement or is it permanent? Are you expecting some element of that to be on your information?

The Minister for Health and Social Services:

It is a permanent arrangement at the moment but it could change.

Director of Operations for Community and Social Services:

For individuals it could be they might need a top-up for a period of time and then with the right support that comes down. You are talking about the scheme ...

The Minister for Health and Social Services:

Some would say we just get the scheme going and we are going to change it. At the moment it is a permanent arrangement. That does not mean when the scheme is reviewed they might not look at it.

Deputy G.P. Southern : But you expect them ...

The Minister for Health and Social Services:

I do not expect it to change. I am not saying it must not change but I do not expect it to.

The Deputy of St. Ouen :

Do you expect the number of people with these high level needs to grow?

The Minister for Health and Social Services:

Well, the only answer is, yes, over time. As medical science keeps people alive longer then complex cases will grow, and that is why constant review is really important.

The Deputy of St. Ouen :

Can this be seen as weakening the long-term care scheme for the whole cohort of people who are beyond it?

Assistant Director of Policy and Ministerial Support:

Can I just say, I think number-wise it is less than 25, I understand. So I think calling it a whole cohort of people is probably being a bit grand.

The Minister for Health and Social Services:

I suppose is your glass half full, is your glass half empty. We saw it as supporting those few people who just needed more than the long-term scheme is designed to provide, supporting them and not leaving them vulnerable. So that is how I see it.

Deputy G.P. Southern :

Congratulations on introducing the half full, half empty cliché. Brilliant. I love it. You know I like that one. No cliché left unturned. Can I move on and ask the assessment of the social workers involved that what we have got is actually a 2-tier system at the bottom end where we look at people on income support in receipt of personal care components up to level 3, which is up to £150, which is assessed completely differently to the way you assess the rest of the long-term care scheme by different officers and which is for the client to spend how they see fit. So it is for care but if they choose they need to spend it on care whereas the other system has a completely different assessment system by different officers and with a different outcome which is directed to the receipt of care. If you were designing a system for this Island, I do not think you would want to start from here. You are going to end up with that system, a 2-tier system. I call it a 2-tier system. Have you thought about how you deal and had any involvement in how you deal with that bottom end so that you have got a clean sweep through? Also, and this is the important question, are you confident that an assessment which gives personal care level 3 is not actually equivalent to your assessment of that same person where you are saying, no, they qualify at level 1 or 2 even on our scale? Have you done any check that one set of assessments at the bottom end matches the assessment that you do going upwards, because that is important? I have certainly seen people on personal care 3 that needed significant amounts of help just to function. They were getting it from their family, but I would have thought that is looking to me like long-term care. Where are you there?

Acting Team Leader, Adult Social Care Team:

There is quite a lot there in what you said. We have certainly looked with our colleagues in Social Security about ways to make this more efficient in terms of particularly when we are assessing people and they are not meeting the criteria for long-term care, it does not feel completely right that that person has to start again in applying for a benefit. I think we have certainly looked at how we might, and we continue to look at how we might, with people's consent, give that information directly to Social Security to make the process more efficient.

Deputy G.P. Southern :

So you are saying with consent take your assessment of the level of need and pass it on to Social Security?

Acting Team Leader, Adult Social Care Team:

Or elements of it. The difficulty is - and what you said is true and absolutely right - they are different types of benefit and assessed in very different ways, so there are only certain aspects that are transferable and of course they are inherently different, as you rightly said, in that one is a cash benefit, the expenditure of which is not cross-checked, if that is the word. The other is a benefit that is safeguarding directly for the provision of care from the approved provider framework. There is an element of choice in that so I am not entirely surprised that you have come across people: "You are getting P.C.C.3 (personal care component 3) but I think you are eligible for long-term care" and they may well be.

Deputy G.P. Southern :

But they might turn it down because the support network that they have, the family around them, treat that piece of income as that income which helps us cope and were they to apply for long-term care that would then be directed to suppliers of assistance rather than the family.

Acting Team Leader, Adult Social Care Team: Currently only approved suppliers can be ...

Deputy G.P. Southern :

Yes, absolutely, so they would see that as a reduction in their income and a worsening of their situation even though one of the problems was dealt with more effectively by the long-term care scheme.

The Minister for Health and Social Services:

I have spoken to families in that situation and it then needs to be made very clear that if they are not going to take that level of support, the long-term care, that they would be better off staying where they were.

The Deputy of St. Ouen : Can they do so?

The Minister for Health and Social Services:

Yes, they can. However, they cannot go into long-term care and maintain the income support.

The Deputy of St. Ouen :

No, not have both. That is right.

The Minister for Health and Social Services:

However, they could, and I know of families that have, asked for an assessment and then when they weigh it all up they are better to stay where they are for the time being.

The Deputy of St. Ouen :

Does that apply equally to families who are caring for a child who has learning disabilities and that child has now grown up into adulthood? Is it the case your department is supporting many of those families?

The Minister for Health and Social Services:

I am not an expert on this although I have some personal experiences. As I understand it, once a child becomes an adult then any payments of income support or personal components or long-term care is made for that person and no longer to the carer in the family. That is my understanding.

The Deputy of St. Ouen :

Yes, that is correct but is it the policy and the aim of the Government to move those people on to the long-term scheme or are they going to be permitted to remain on income support if they choose?

[15:15]

The Minister for Health and Social Services:

Well, 2 families I know of made the choice to stay where they are.

The Deputy of St. Ouen :

So there is a true element of choice, is there?

The Minister for Health and Social Services:

There is a choice, yes. Now, whether there should be a little bit more flexibility, and I did say right at the start that I think we have got a really good scheme here but maybe it would benefit from a bit of flexibility. Whether there should be a little bit more flexibility ... if they have not told you of this case you probably will have heard of it, and I am not going to give any names, where someone has, if you like, a retainer that has done a very good job of looking after a relative but is not formally qualified, therefore if they went on to the long-term scheme that retainer could not be paid. Whether there should be some flexibility around that, I think is worth looking at but there are not any plans immediately to change it.

The Deputy of St. Ouen :

Are there any other areas where you think the system could possibly be changed?

The Minister for Health and Social Services:

No, just what I have given you as my personal experience.

The Deputy of St. Ouen :

Yes, okay. In the case of those families who are looking after an adult with learning difficulties, I think the problem is that adult needs support rather than care. That adult is not frail or sick and is in the community. But if that adult moved into the long-term care scheme, he would only receive something like £35 a week to meet his living costs. That is the pocket money element of long-term care, I understand. If he is in the community and he wants to go out to the cinema, go to the pub, very often they have a support worker with them, that just is not sufficient to provide enough support financially, it seems to me.

The Minister for Health and Social Services:

The support is paid for. I understand what you are saying about the pocket money.

The Deputy of St. Ouen :

Yes. Do you think there should be any flexibility to allow that ...

The Minister for Health and Social Services: I do think it is worth looking at.

The Deputy of St. Ouen :

Do we recognise that the long-term scheme has 2 separate groupings of clientele? There are the elderly who need care by reason of their age and frailty, but there are also those with long-term health conditions, perhaps from birth or a very young age. Is there a conflict sometimes?

Acting Team Leader, Adult Social Care Team: And all that life throws at you in between.

The Deputy of St. Ouen :

Yes, serious accidents and things like that. Is there something that can be done to make the scheme fit those ...

Acting Team Leader, Adult Social Care Team:

I would not go as far as saying there is conflict. There is a great deal of individualisation and flexibility built into the system. However, I agree with the Minister we should never stop looking at ways to be as personalised for an individual, and you have touched on some of the areas of difficulty.

The Deputy of St. Ouen :

Has any thinking gone into that or consideration as to what might be done?

Acting Team Leader, Adult Social Care Team:

Direct payments or personal budgets may deal with it but we need to do appropriate exploration. The other stuff around of personal allowance elements paid with a placement and the loss of the personal care component if one goes on to long-term care benefit, they are probably more questions for the social security side of things.

Professor M. Johnson :

Is it the case that the long-term care scheme, intentionally or not, is a retreat from personal payments because once the assessment is produced it generates a budget level and then the social worker creates a package, either a care home, which is a package, or somebody living at home is a package? As we understand it, the payments for those services now go directly to the provider. So the personal budgets which were - I will use the word - fashionable in governmental agencies for quite a long time and are still much preferred by many, that has been left behind and I think it is behind some of the questions that we have just heard that individuals may well be given care and support. The question mark is how much are they part of fashioning those packages and choosing the providers. I think that is the question that will come up. But also taking away their personal agency in having money, income that they can dispose of as they see fit, so that is coming back ... I will summarise that. Are we knowingly or otherwise retreating from personal payments?

Acting Team Leader, Adult Social Care Team:

I do not think we are retreating from it but we do not have them and we are not there as yet, I think.

Professor M. Johnson :

Is that an issue, Minister? We know this is a scheme that is not fully matured yet, so you and the Minister for Social Security have both said that the first phase has been very busy and lots of things have had to be addressed. I think the panel understands that but now that the scheme is in more even waters, there are a whole lot of things that need to be addressed. This may be one where returning some level of personal payments to take the sort of issue that the Chairman illustrated might be something to return to.

The Minister for Health and Social Services:

That is what I was referring to when I said that I think it could benefit from some flexibility. It certainly needs to be looked at because you almost fall off the cliff edge, if you know what I mean, if you go from one scheme to the other. I think it is worth a review.

Deputy G.P. Southern :

And cliff edges are bad for you.

Professor M. Johnson : Only if you fall off them.

Deputy G.P. Southern :

Can I take us on to an aspect of the care scheme, which is you get your assessment. That comes with a care plan and a cost, for which the individual client is supposed to choose an agency or a home, but let us stick with agency, in order to deliver that and basically they may have no idea whatsoever what the difference is between total living care and living total care over there. Like it or not, social workers are being drawn into that decision by giving advice.

The Minister for Health and Social Services: Yes, especially if there is no close family.

Deputy G.P. Southern :

Two questions: are they comfortable doing that and, secondly, have they noticed a difference in standards among those offers, the 23 or whatever it is offers now?

Acting Team Leader, Adult Social Care Team:

I think the difference in standards that we have noticed has been an improvement as a result of the approved provider framework and I would hope that continues with the Regulation of Care (Jersey) Law. I think you are right, to a degree, there is a need for my team to be highly aware of what they are doing in terms of being impartial, making sure every individual has a range of options available to them, and where they can and where they want to that they are encouraged to make that decision as much as possible. We have evidence of some very good work where we have set up interviews or meet the agencies sessions, but I think it is fair to flag it and I think you are right to flag it. It is something that my team has to be highly aware of themselves when they are doing that, when they are procuring care.

Deputy G.P. Southern :

Because it opens you to compromise or the suspicion of some form of compromise?

Acting Team Leader, Adult Social Care Team:

I am highly compromised if I keep recommending the same agency for any reason.

The Deputy of St. Ouen :

What guidance do you give to your social workers?

Acting Team Leader, Adult Social Care Team:

I think it is about co-production, working in partnership with the person as much as possible, being as open with them with all the options that you can be, being creative and thinking can we facilitate interviews, can we facilitate multiple meetings with agencies so that individuals can get a flavour for them, let the people decide who they want to, because quite often we are going into a situation where the person is saying: "I do not know anything about this world." The difficulty is, what tends to follow that is: "I do not know anything about this world. You choose me somewhere."

Deputy G.P. Southern :

Let me pick an example then and see if we can pin you down. Let us say one company, one agency has got excellent dementia training, another has not. Would that go into your recommendation? Would you look at the client and definitely steer them that way?

Acting Team Leader, Adult Social Care Team:

Yes. It is not really my complete area of expertise but there is provision within the approved provider framework for agencies to extol their abilities in that way and say: "We specialise in this and this is the training our staff have" and so on. So, yes, that would be a factor. I do not think I am speaking out of turn to say there are agencies for people with autism, for example, that have a wide range of experience, have relevant training, so a person can follow that. I will use in the majority of cases of what they need.

The Deputy of St. Ouen :

At that stage also where somebody is considering how to take their care, is there a real choice for somebody who might not want to stay at home? We might think it is strange but they might want to move into a care home. That would be more expensive to the long-term care scheme, but do they have a completely free will to say?

Acting Team Leader, Adult Social Care Team: Often it is more expensive to keep someone at home.

Professor M. Johnson : Yes, I agree.

Acting Team Leader, Adult Social Care Team:

But there is choice because your choice is ... I do not like to use the word "governed". Your choice is determined by your care level. If you are care level 1, 2, 3, 4, within that care level you have a choice of domiciliary or residential care at that level. There is a residential option or equivalent at every care level for you, so I am fairly confident there is choice at all levels of long-term care.

Deputy G.P. Southern :

Can I just explore the statement you made that domiciliary care is often more expensive than going into a home? We received the opposite information yesterday when it was stated that it is more than 90 per cent savings, between 80 and 90 per cent cheaper to keep somebody at home. Would you like to ...

Acting Team Leader, Adult Social Care Team:

Forgive me, I am talking very liberally. Ultimately it depends on the individual needs and there are certainly ... and they are not isolated. There are examples where we are costing out both and it is more expensive for someone to stay at home.

The Minister for Health and Social Services:

Somebody who needs a visit in the morning and a visit in the evening compared to somebody who needs 24-hour one-to-one care, and possibly even 2-to-one care, which does exist, is going to cost a lot more.

Professor M. Johnson :

But even 5 hours a day is more than the cost of a residential home. I do not know what the going rate is here. In the U.K. it is about £20 an hour and you can do your own sums. So somebody who is immobilised, who is doubly incontinent, who may not see very well, whose hearing is almost gone, those people can be left in miserable isolation in a place where they think is best for them but it is not, and they are neglected by not getting enough care, which I make no judgments about Jersey but I know in other places, and in order to provide their care you are talking about costs much higher than in a nursing home or a care home. That is hardly ever acknowledged because there is a mantra that says staying at home is better and cheaper, and it is often not. I think what we heard yesterday was that home care is almost always cheaper and I was glad to hear you acknowledge that that is not the case.

Assistant Director of Policy and Ministerial Support:

That might also be the case because there are people, other family members, who are assisting with the care at home. The other thing I would like to say is please remember where we have come from, because when we were bringing in this scheme let me just say "everybody" was going into a care home. There was little scope for people to have care at home, so one of the big things about the scheme, and the difference with Guernsey, is that domiciliary care was brought into the scheme so you could get funding for domiciliary care, which was rare before. I am not saying it never happened but it was not easy to get. So where we have come from is a factor in this as well.

[15:30]

Professor M. Johnson : I acknowledge that.

The Minister for Health and Social Services:

You are right Mark. What was missing, I think, was we had people in care homes, we had people in nursing homes and we had very little support for people in their own homes - people who just needed a little bit of help, so they went into care homes too early in some cases.

Professor M. Johnson :

May I just ask you there about housing? I did some work on the Island some years ago and I worked with a group from a number of departments, one of which was Housing who then had no specialist provision for older people. I think there is some now but housing has a contribution that does not seem to fit into the long-term care scheme. Have you any observations about that?

The Minister for Health and Social Services:

Your initial observation that there was little there before was correct and there is some more now. There needs to be more, particularly around sheltered, supported, proper ... not just a flat with an alarm, proper supported with ...

Assistant Director of Policy and Ministerial Support: Ward ens.

The Minister for Health and Social Services: Yes.

Professor M. Johnson :

The sheltered housing model does not operate anymore and it is not ... supported living can have all kinds of elements in it but it requires also dwellings where people can reasonably live.

The Minister for Health and Social Services:

We have got a very good model of that over here. It is not a States model but at Jeanne Jugan (Little Sisters of the Poor) people live independently in their flats but are supported and when they require greater support they go into the residential building in the same grounds.

Professor M. Johnson :

Okay. I am going off-piste, because it is not my role to go any further, but I just wanted to put up that marker that there is a department that does not get mentioned in any of this.

The Minister for Health and Social Services:

It is something I was interested in because I was Minister for Housing before this role.

Professor M. Johnson : You see, I did not know that.

The Minister for Health and Social Services: It is something I was really keen on.

Deputy G.P. Southern :

Can I ask the Minister to put into context the statement we have just heard that domiciliary care is often more expensive than residential care?

The Minister for Health and Social Services: It can be.

Deputy G.P. Southern :

Into the context of treatment in the community and care in the community is supposed to save us money.

The Minister for Health and Social Services:

No, I have to disagree there. I do not think the intention of people being cared for in their homes was to save money. I think it was to allow people to have the choice to ...

Deputy G.P. Southern :

Care in the community, moving facilities out into the community and not centralising them in hospital is supposed to be saving us money. It is a major plank of your platform, is it not?

The Minister for Health and Social Services:

No. I go back to what I said. It was about providing choice for people who wished to stay at home or wished to go into residential care. The long-term care scheme and caring for people in the community was not about saving money per se. If you want to look at it from a different angle - and maybe this is the angle you are looking at it from - it was to prevent people being in the acute setting when they should not be, that is the general hospital when they should not be.

Assistant Director of Policy and Ministerial Support:

You could argue it is not saving money in the sense that most of these people who were being cared for at home were getting nothing because there was no provision to help people have care at home whereas now a number of them have come into the system and some , not all of them, will be getting some funding from the long-term care scheme, so that is an expense.

The Minister for Health and Social Services:

Health's push about supporting people in their homes, and I think this is what you are trying to ask me, was about making much more efficient use of the acute beds and not allowing people to be in there weeks on end because they needed to go home but there was not a package of care for them to pick up when they went home.

The Deputy of St. Ouen :

Nevertheless, I believe it is the case that when long-term care was modelled by Oxera they were of the view that the costs of providing care to somebody in a domiciliary setting was 90 per cent of the costs of providing care in an institutional setting, but of course things might change.

The Minister for Health and Social Services:

In some cases it could be but for people who want a high level of or significant amounts of care it is not, but what we do know is it is not good to have people in the acute setting when they do not need to be. It is not only about the high costs of an acute bed. Off the top of my head I cannot remember what that is, but you also have got the opportunity loss of people waiting to come in for surgery.

The Deputy of St. Ouen :

Yes. We have got less than half an hour. Minister, I want to ask you about respite and how respite provision fits into the long-term care scheme. How do you see it?

The Minister for Health and Social Services:

I do not know a huge amount about it, to be perfectly honest. It does come into the scheme but ...

Acting Team Leader, Adult Social Care Team:

I may be able to help. The assessment document that you have seen has a section around carers' needs and ongoing carer support. Based on that ... so there is 2 facets here. There is the need that the individual has and then the care and support that they receive on an informal basis and what break the informal carer needs. That allows for what is called a sustainability allowance to be built into the allocation given, the resource allocation.

The Deputy of St. Ouen :

A sustainability allowance. That is effectively a period of respite, is it?

Acting Team Leader, Adult Social Care Team: Yes, that is right.

Director of Operations for Community and Social Services:

Or whatever support for carers, an amount for what you have to do to support the carers.

Deputy G.P. Southern :

It might not be right to respite. It might be something ...

Director of Operations for Community and Social Services:

It could be care for themselves or it could be outreach coming in to support while the person is there.

Acting Team Leader, Adult Social Care Team:

We have used it for taxis, things like that. There is a degree of flexibility around that.

The Deputy of St. Ouen :

All right. Yesterday Social Security told us that there was 6 weeks respite available to carers. Is that the case?

Acting Team Leader, Adult Social Care Team:

Up to. Again, it is based on the individual assessment.

The Deputy of St. Ouen :

So for someone at level 1 the carer would not receive 6 weeks; they would receive a lesser period. Is that how it works?

Acting Team Leader, Adult Social Care Team:

I cannot tell you offhand whether that person would still qualify for 6 weeks at their assessed level or whether the amount would increase or decrease. I would just be speculating.

The Minister for Health and Social Services:

I think the person who would know all that information unfortunately could not be here today, so we will ask him to answer that for you.

The Deputy of St. Ouen :

Minister, what was the arrangement for respite before the introduction of the long-term care scheme?

The Minister for Health and Social Services:

Honestly, if you were lucky enough to be recognised and get some you got it and if you were unlucky you did not. It was as simple as that.

Deputy G.P. Southern :

Your name appeared on the list.

The Minister for Health and Social Services:

So it became more challenging, and I am talking now from personal experience. It was much easier ... I am talking about children now and not adults. It was easier if the child was born with a disability and therefore was recognised all the way through but if they became disabled many years later, still as a child, it was very hard to get in because what was there had been allocated. It is much better now with short breaks, working with other charities and funding those charities through sometimes the long-term care scheme, sometimes through other grants. There is much more available now but there was very little a few years ago.

The Deputy of St. Ouen :

Is your department still funding some respite?

The Minister for Health and Social Services:

I think so, but I honestly do not know that answer to that one.

The Deputy of St. Ouen :

I am thinking of those older adults supporting an adult child with learning difficulties and they are not in the long-term care scheme.

The Minister for Health and Social Services:

Historically people that were getting it I think are still getting it, but again I would have to ask Chris Dunne that question.

Deputy J.A. Hilton:

Would it be possible to get those answers?

Acting Team Leader, Adult Social Care Team: I can answer it.

Deputy J.A. Hilton: You can answer it?

The Minister for Health and Social Services: Sorry.

Acting Team Leader, Adult Social Care Team:

There is a historical cohort of people who are still getting services funded by Health and Social Services.

Deputy J.A. Hilton:

How much is that budget? So, there is a budget within the Health Department that does provide for respite?

Acting Team Leader, Adult Social Care Team: For the existing cohort.

Deputy J.A. Hilton:

Only for the existing cohort?

Acting Team Leader, Adult Social Care Team: Yes.

Deputy J.A. Hilton:

Okay. So where you have a family as was just described, an adult caring for an adult child who are not part of the long-term care plan, there would not be any budget for them then outside of the long- term care?

Acting Team Leader, Adult Social Care Team: No, because long-term care would be ...

Deputy J.A. Hilton:

Would do it, yes. So they get nothing, basically, then?

Acting Team Leader, Adult Social Care Team: They get something through the long-term care plan.

Deputy J.A. Hilton:

No, but they were not part of the long-term care plan.

Acting Team Leader, Adult Social Care Team: If they did not go into it, unless they used their ...

Deputy J.A. Hilton:

Right, okay. So if you could let us know the budget and whether the budget is actually spent each year and how many people have benefited from it and the average length of time.

The Minister for Health and Social Services:

Overall the respite is in a better position than it was. Whether we are in the right place yet is questionable, to be honest.

The Deputy of St. Ouen :

Is there provision for an emergency arising within a family, perhaps the carer has to be hospitalised?

The Minister for Health and Social Services: Yes.

The Deputy of St. Ouen : What is that provision?

The Minister for Health and Social Services:

I do not know but I can categorically say it exists, that social workers have had to step in at very short notice.

Acting Team Leader, Adult Social Care Team: Yes, we do reasonably frequently.

The Deputy of St. Ouen :

The arrangements for respite are all made through social workers; is that the case?

Acting Team Leader, Adult Social Care Team:

Social care assessors, not necessarily social workers but social care assessors.

Deputy G.P. Southern :

I have got 4 questions left to ask. The first one is adaptations. There used to be an adaptation budget in Housing, in Health with the O.T.s (occupational therapists) both of which seemed woefully inadequate in that they used to regularly run out by July and if you applied in the second half of the year you got nothing because it had been spent. If we are encouraging people to stay in the community in their own homes, adaptations is one of the things that we should be perhaps doing more about. What is the situation?

Acting Team Leader, Adult Social Care Team:

There are some I cannot comment on. I could not comment on the Housing Department.

Deputy G.P. Southern : No, that was preamble.

Acting Team Leader, Adult Social Care Team:

The long-term care benefit budget does make some provision for more localised specific pieces of equipment, so I am confident in saying there is not that scenario where you could get something in March and you could not in November any longer. It is more individual.

Deputy G.P. Southern :

But it is part of the assessment, is it?

Acting Team Leader, Adult Social Care Team: Yes.

Deputy G.P. Southern :

That would be delivered without the weekly budget?

Acting Team Leader, Adult Social Care Team:

It can be delivered within that. I am stepping slightly out of my area a little there are a lot of different provisions of equipment in the community. One avenue is via the long-term care allowance but there are others as well which I am not expert in. Again, with apologies, Chris could probably tell you more.

Deputy G.P. Southern :

Okay. I think that is one we will follow up and see what the arrangement is there. The F.A.C.E. system does not come free, I presume not. It is a commercial body. How much do you pay for it?

The Minister for Health and Social Services:

I do not know but I would expect to pay an annual licence, I would have thought, for the software support and upgrades and suchlike. We will let you know.

Deputy G.P. Southern :

I just wondered in the great scheme of things where it fits and whether it cost tuppence or £200, I do not know. Secondly, it is always the money, is it not? Why do I get that? You are working on 36.3 F.T.E. covered by agency staff at the moment, according to your figures. How much extra does agency staff cost and what is the total bill on that almost one-third?

The Minister for Health and Social Services:

We will send that to you. We acknowledge it costs extra. Unless Paul has those figures to hand.

Acting Team Leader, Adult Social Care Team: I do not think I can because it incorporates ...

Assistant Director of Policy and Ministerial Support:

Are you talking about the agency staff that Paul has referred to, the 2 that ...

Deputy G.P. Southern :

I am talking about the figure on the paper that we have got today, 18th September, saying we are running at 36.3 F.T.E. covered by agency staff, so it is the whole package, wide ranging.

Assistant Director of Policy and Ministerial Support: Just so I know what figures you are asking about.

Deputy G.P. Southern :

Then finally how are we with the ethical care consultation? You were due to report back and produce a nice document to say this is the way forward.

The Minister for Health and Social Services:

Yes, by Christmas we will have, as I remember, a report and proposition lodged. We are almost ready to go out to consultation.

Deputy G.P. Southern :

Okay. Consultation will start soon?

The Minister for Health and Social Services: Yes.

The Deputy of St. Ouen : Who are the consultees?

The Minister for Health and Social Services:

The consultees will be, off the top of my head and Mark will correct me, providers, so employers or providers of service, users of service and ...

[15:45]

Assistant Director of Policy and Ministerial Support:

The commission itself, the Jersey Care Commission. We committed to lodge a proposition with the States by 31st December 2017 to establish a Jersey care charter.

Deputy G.P. Southern :

On the back of the consultation?

Assistant Director of Policy and Ministerial Support: Yes, that is right.

The Minister for Health and Social Services:

So we are close to starting. We have done a lot of the work in line with the proposition and ...

Deputy G.P. Southern :

That is what I love to hear, a Minister responding saying: "We have done a lot of work because of your proposition."

The Minister for Health and Social Services: I said "in line". I did not say "because".

Deputy G.P. Southern :

If you did not say that, I will make it up anyway. What you said in that meeting, what you said in the J.E.P. (Jersey Evening Post), is what I said you said.

No, but seriously it is a good wait for me to come back but ...

Assistant Director of Policy and Ministerial Support: It is not quite true, Minister. We were doing things.

The Deputy of St. Ouen :

I would like to ask some questions about the voluntary sector, Minister. In the past before the long- term care scheme, charities, and I will use Les Amis as the example, I think they were supported through a block grant from your department. But now that no longer exists and Les Amis receive income as a result of the long-term care payments made to their residents. So those long-term care payments are particularly assessed with regard to the care they need and the living costs for the co- payment. Is that not right? Les Amis report that they suffered a drop in income of about £500,000 as a result of that change. That suggests to me that while the care needs of their residents are being met, the structure they have, such as the building and the maintenance and the provision for rebuilding, is not met from long-term care. Is it the intention of Government that the charities will maintain properties such as Les Amis out of their charitable donations?

The Minister for Health and Social Services:

That is a very general question but the charities in many cases have gone from, as you said, just receiving a grant to being a recognised service provider and paid for that. I have to congratulate Les Amis on the way that they have changed their model to meet today's needs. They recognise themselves that trying to provide the landlord function and trying to provide the support, care and everything else that goes around people with learning difficulties was perhaps not right and so they have moved the model towards renting their accommodation where the function of the maintenance and everything falls to the landlord and they concentrate on providing the support and the care, and that model is working. That is why they have been able to reduce their costs. There will be some historical buildings that they still own that they need to maintain but nursing homes have to maintain their properties as well out of the payments they receive from the long-term care scheme. But I have to congratulate them. They have changed their model, they have met the challenge and I think that they have moved a very long way to becoming a more modern and sustainable service.

The Deputy of St. Ouen :

Yes, Les Amis do appear to have adapted very well but, Minister, with a growing population and therefore growing calls on them, the charitable sector is not in the position of government where it can just draw capital or raise taxation, at the very extreme, to build buildings. How is the charitable sector going to do that?

They do not need to build buildings. They need to be talking, as indeed they are, to housing providers like Les Vaux and Andium Homes which will provide the building and the rent is paid for from the funds that they get. Sometimes in some people's cases that will be the rent component. The maintenance of that is paid for within the rent and therefore provided by places like ... I cannot remember if Jersey Homes Trust do it as well. I think they do. They are maintaining the home and the charity is providing the service to support people in that home. That is the model that works.

The Deputy of St. Ouen :

In the case of residential and nursing homes, is there an element in the long-term care support that is applied or is allowed towards the maintenance of a building?

The Minister for Health and Social Services:

There is an element in the charge that the company makes in providing that service that allows for administration, buildings, maintenance, grounds maintenance and all the rest of it.

The Deputy of St. Ouen :

Right. So the long-term care will meet that in one part?

The Minister for Health and Social Services:

There is not a specific element within the long-term care but in making that payment for the service, that is what you are paying for.

The Deputy of St. Ouen :

Yes. Is there a risk that at any stage the residential and nursing homes would seek to charge more than the long-term care plan was willing to pay?

The Minister for Health and Social Services:

Some do and then that is up to the individual. If they want to top that up and have extra services and so on or if they choose not to go there then they negotiate ... sorry, if they want to live within the budget allocated they negotiate that with the provider who has to make that choice or they go to another provider that is doing it within that price.

The Deputy of St. Ouen :

Yes, but is there a risk that too many homes would charge the higher price and there would be insufficient beds for the persons drawing solely on the long-term plan?

The Minister for Health and Social Services:

Personally I do not think so because if they do that they will not have sufficient income to continue that model.

The Deputy of St. Ouen :

So you think we are secure and we do not need to worry about that scenario?

The Minister for Health and Social Services:

Well, let me put it this way, there are lots of companies interested in building care homes in Jersey, far more interested than they are in building them in the U.K., and that is because there is a legal entitlement, once assessed, to have that payment. Our expert will tell us, or maybe contradict me, that in the U.K. councils are just saying: "We are not paying that or we are not paying that amount" and people are left almost high and dry. That does not apply here. People have a legal right, once assessed, to the funding they are eligible for.

The Deputy of St. Ouen : Very well.

Professor M. Johnson :

As I understand it, they are only entitled to the funding that their assessment allows and then they must make their co-contribution.

The Minister for Health and Social Services: Yes, that is correct.

Professor M. Johnson :

So they cannot get the States to agree to pay whatever the care home ...

The Minister for Health and Social Services: No. They can choose to top it up.

Professor M. Johnson :

Whereas in the U.K. local authorities are now routinely pressing for the lowest price even when it is below the economic cost, and I will say that is disgraceful but you do not do it here.

The Minister for Health and Social Services: No, we are not going to do it here.

Professor M. Johnson :

I am glad to hear that.

The Minister for Health and Social Services:

We are not going to do it here and I believe that is why we have got companies interested in building here.

Deputy G.P. Southern :

Can I just bring you to a point that is dear to my heart, which is the removal of the block grant to Les Amis was also the removal of the block grant to Family Nursing Services which has resulted ... one of the measures that took place was a reduction in the terms and conditions of their employees, of the carers. I am just wondering what impact that might have longer term, reducing carers' terms and conditions, on other objectives that we have in government, which is reducing the number of inward migrants and getting paid employment by our own people in terms of carers, care assistants.

The Minister for Health and Social Services:

I have to say that we will probably never agree. We may have to agree to disagree, but there is no problem with recruiting at the market rate at the present time.

Deputy G.P. Southern : Locals, on your evidence?

The Minister for Health and Social Services:

Well, people who are locally qualified living in Jersey, not the ... well, there may be some agencies coming in. I do not know the answer to that.

Deputy G.P. Southern : Of more than 5 years?

The Minister for Health and Social Services:

I do not know the answer to that, I am not the employer, but what I do know is that we are not having any trouble filling the vacancies.

Deputy G.P. Southern :

In that particular sector there has been a marked increase in net inward migration into the care sector.

Assistant Director of Policy and Ministerial Support:

Just to be clear, there is only one small element of the grant that goes to FNHC that was cut.

Deputy G.P. Southern :

Yes, I agree it was not the whole ... but the net effect was on terms and conditions of those workers and that is probably to be regretted, I think, and we will see the effect.

The Minister for Health and Social Services: We will see.

The Deputy of St. Ouen :

We have only got a few minutes left. I just want to make sure that, Professor Johnson , are there any questions that you would like to ask?

Professor M. Johnson :

I just wanted to ask about the new inspection and recognition agency that is going to be rooted in the Chief Minister's Office and how you think that that will relate to the quality of services delivered under the long-term care scheme?

The Minister for Health and Social Services:

Again, I am not an expert on this but I was quite keen. I had officers in my department when I first became Minister who were responsible for regulation and that was fine but I had some difficulty, though, with the officers reporting ... because I want the hospital and health facilities to be under the same quality control and I had some difficulty with officers reporting to the Chief Executive of Health who was both provider and regulator, in essence. It is fair to say that they have only just appointed a commissioner of standards, not the States commissioner of standards, the care commissioner, so that is yet to be worked through but I hope that I will have some influence on both the standards applied and that all those standards will apply to all providers be they public, States if you like, or private providers.

Assistant Director of Policy and Ministerial Support: And the home care sector as well.

The Minister for Health and Social Services:

Yes. So we have yet to work out the detail, but it is something that I think is right and proper and any advice would be gratefully received.

Deputy G.P. Southern :

We will be full of advice, we always are, recommendations, key findings. Rename it advice, new sector advice, yes.

The Deputy of St. Ouen :

There is no immediate impact foreseen on the long-term care operations there?

The Minister for Health and Social Services:

No. At the moment the officers who were providing the regulation, if you like, but only providing it for non-States departments, care homes in effect, are going over to the commissioner for care. Whether that will change I do not know, but there will be an improvement in standards. There will not be a reduction in standards.

Director of Operations for Community and Social Services:

It should help with those issues around choice, if you can direct people to where there has been inspections and regulations and it helps that. It takes away social workers saying: "Do this" because they can say: "Look at this; this is what is here." So if it raises the standards, as one would expect, and that is published then it helps with some of the things we were discussing.

The Minister for Health and Social Services:

I do not want to do the job of the commissioner but in a very simple way, if you look at how effective the star rating of food hygiene in restaurants has been in Jersey, it has made a huge difference. The new Minister for Housing is about to bring that in for landlords as well, and that is the sort of thing that I would like to see: level 3 meets all the standards, level 4 goes that bit further and level 5 is wonderful.

Deputy T.A. McDonald:

Positive, easy to understand, easy to interpret, so we can go back to the suns, possibly, in the 1960s at the hotels.

The Deputy of St. Ouen :

Professor Johnson , any more questions?

Professor M. Johnson :

No, thank you. I think we have given our guests a good run for their money.

The Deputy of St. Ouen : It has been interesting.

Deputy G.P. Southern :

We should never have a Minister in front of us without asking this question, because it is essential to everything, which is: are you looking forward to the new population policy which might reduce in many ways the debate on what we are going to do with our elderly and are you looking forward to a debate around 350, which I believe the hospital was designed on, net inward migration or the Oxera report which is 700-plus based on or, worse still, what has come out recently from the stats department is 1,000-plus based on the last decade? It could be interesting times, Minister, could it not, in terms of what we actually provision for?

The Minister for Health and Social Services:

What I want is a policy that is sustainable both in terms of our infrastructure but also sustainable in terms of our ageing population, so I also look forward to seeing the work of the Population Office.

Deputy G.P. Southern :

Which between 350 and 1,000 would you call sustainable?

The Minister for Health and Social Services:

I am not an expert on that. I wait to see the basis of their calculations.

Deputy G.P. Southern : Lovely.

The Deputy of St. Ouen :

Minister, thank you very much for meeting us, and your team, and that brings ...

The Minister for Health and Social Services:

Can I say a special thank you to Paul and Jo, not to mention Mark of course.

The Deputy of St. Ouen : Thank you.

[16:00]