Redesign of HSS Governance Model - Minister for Health and Social Services - Transcript - 19 October 2017

STATES OF JERSEY

Health and Social Security Scrutiny Panel Redesign of Health and Social Services Governance

THURSDAY, 19th OCTOBER 2017

Panel:

Deputy R.J. Renouf of St. Ouen (Chairman) Deputy J.A. Hilton of St. Helier

Deputy T.A. McDonald of St. Saviour

Witnesses:

The Minister for Health and Social Services

Director, System Redesign and Delivery

Chief Executive Officer

Managing Director, Community and Social Services

Assistant Director, Policy, Communication and Ministerial Support

[12:01]

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

Good afternoon, everybody. This is a public hearing of the Health and Social Security Scrutiny Panel with the Minister for Health and Social Services in connection with the panel's review of the Minister's proposition, P.60, which is all about governance of Health and Social Services. This meeting is being recorded, so in the usual way I will introduce ourselves as a panel and then I will ask the Minister to do the same and we will proceed to questions. I am Deputy Richard Renouf , chairman of the panel.

Deputy J.A. Hilton of St. Helier :

I am Deputy Jackie Hilton, panel member.

Deputy T.A. McDonald of St. Saviour :

I am Deputy Terry McDonald, panel member.

The Minister for Health and Social Services:

Senator Andrew Green, Minister for Health and Social Services.

Chief Executive Officer: Julie Garbutt, Chief Executive.

Director, System Redesign and Delivery:

Rachel Williams, Director of System Redesign and Delivery.

Managing Director, Community and Social Services:

Susan Devlin, Managing Director of Community and Social Services

Assistant Director, Policy, Communications and Ministerial Support: Mark Richardson, Ministerial Support.

The Deputy of St. Ouen :

We are assisted by our officer, Andy, and apologies from Senator Sarah Ferguson who has a prior engagement and she may come in as this hearing progresses. We plan to be here for an hour and a half. I think we have enough questions ... plenty of questions that we want to ask.

The Minister for Health and Social Services: We have got plenty of answers, Chairman.

The Deputy of St. Ouen :

We hope to get lots of good answers. I should say we were able to formulate questions with the help of the panel's adviser and we have put those in advance to the department and the department has very kindly assisted and given us some written answers, which will be published and put within our report in due course. But it has enabled us today to perhaps go beyond those questions and dig down into the deeper elements of this proposition. Minister, can I ask first of all: why have you decided to bring this proposition?

The Minister for Health and Social Services:

It is quite simple really. We are going through a huge change in the way that we deliver services for health across the Island, as we have seen with P.82, and involving the community more than we have ever done. It just seems to us to be the right time to let the community have a say in how services are provided in a more formal way i.e. rather than doing things to the community, we are doing things with the community. By the community I do not only mean members of the public but our partners that provide services with us.

The Deputy of St. Ouen :

As I understand it, nothing changes in the powers or the duties that are vested in the Minister so ...

The Minister for Health and Social Services: You would not want that to change, would you?

The Deputy of St. Ouen :

No, so why is it necessary, if these are internal arrangements within the system, to bring the matter to the States?

The Minister for Health and Social Services:

I could turn that on its head and say if we did not you would be asking us to bring it to the States. But for me it is really quite simple. As a Minister I get advice from health experts, my chief executive and the team, but also I get other informal advice from other service providers, be that charities or be that service providers as well as members of the public. It just seemed to me to be the right time to formalise that. If we are going to go forward you have only got to look at the other models that have been successful. Okay, ours is a hybrid to fit Jersey but if you look at the models that have been successful ... we could look at the U.K. (United Kingdom) and there is a bit of the Community Health Council principle in this as well, but you really need to look at places like New Zealand and other places like that where community involvement is formalised, not just something that is ad hoc and done by the odd consultation. Community involvement is so important when you are looking at changing the way that we deliver services. We are going to become a community-based service provider, a lot of it in the community, just keeping the acute care in the hospital when it needs to be. So why would you not involve both service providers and users?

The Deputy of St. Ouen :

Has any one group within the community agitated for this change?

The Minister for Health and Social Services:

I think we have whet their appetite to such a level that they want it, you would have to ask them, but I do believe that the people who have been working with us in developing this will be very disappointed if we fail to deliver it.

Chief Executive Officer:

We were talking earlier about the progress we were making with the delivery of P.82. Obviously the impact that we have been making in terms of developing a whole range of new services in the community, one of the principles sat behind that was to seek to have those who were best placed to deliver services delivering them. That inevitably means more services being provided by voluntary sector organisations, more services being provided sometimes by our independent sector, and so the way we provide services is shifting; it has been shifting for the last 5 years. Obviously, as we provide more services together - sometimes in partnership, sometimes they are providing the service and we are, in effect, commissioning it on behalf of the people of the Island - the nature of the relationship between those organisations and the Health Department has changed. Not surprisingly, the more engaged and involved and brought into this new system those types of organisation have become, the more they have raised their voice to say: "This is great, we like this, this is the right thing for local people but we do not feel like we are equal partners." We recognise at the end of the day we can meet, and we can form views, and we can put things forward, but then it comes into a very straightforward departmental system. They were asking for, and I think very reasonably, a greater voice and a greater ability to feel that their influence and their thoughts were reaching the ear of the Minister. As much as I would say that is exactly what I do and Rachel does and all of my team will do will be to reflect those views, I think it is right that they are able to put their views directly. Because the proposition that we have made starts with P.82 we are able to build on what we already have. So we have good working relationships. We have a transition steering group that brings those partners together but it gives it a more obvious and formal way of interacting with the Minister in its own right rather than depending on a flow of information coming through a team of officers. The impetus for this started out and came from those organisations themselves, including our primary care practitioners because of course G.P.s (general practitioners) and pharmacists and others are really at the heart of P.82. The more we look at how do we deliver the primary care strategy, how do we deliver the acute services strategy, how do we go into delivering the mental health strategy, we are talking to and working with all of those providers all the time. This formalises that and regularises it.

The Deputy of St. Ouen :

Is there a danger that some people might see this as another level of bureaucracy because if that engagement is already happening why does it need to be put on this formal level?

Chief Executive Officer:

Because I think it is important to the stakeholders. I think that is what they are telling us, that they feel that that enhances their ability to play the part that they are playing in developing this new system. It gives us the basis to develop more integrated service because the relationships and status of those relationships is changing and I think the governance process does have to relate to that in some way. Of course the other benefit it gives us is a way to bring the community, the public, into that in a very clear way. I would like to think as a department we have embraced the need to consult with and involve the people who use our services. I think the mental health strategy work is a good example of that but it needs to be something that happens day in and day out, as a way that we do business rather than be a special initiative that we do with certain groups of the population. It is one of the areas though that ... there is much that we do in Jersey that is streaks ahead of other systems. We should rightly be proud of it and we should build on it. The integration of our services is what people are aspiring to in other systems, but we do not do public and patient involvement and engagement anywhere near as well as other systems that have been doing it for decades. It really is important, I think. But at the end of the day it is the people of this Island who are paying for this service. This is their service, they fund it and they need to have a stake in describing what they would like to see for it and helping us to change it.

The Minister for Health and Social Services:

Can I just come in and challenge one thing that you said there? You said "another level of bureaucracy". It is not another level of bureaucracy. This is a system of governance, a device for the Minister. This is not another level that things have to work their way through in the administration of the health service.

Deputy J.A. Hilton:

Can you tell us who sits on the transition steering group at the moment?

Chief Executive Officer:

The transition steering group is a group of representatives from most of our key stakeholders. For example, there is a representative from Family Nursing and Home Care, there are representatives from G.P.s and pharmacists. There is a representative from ... who does Jim represent?

Director, System Redesign and Delivery: Disability Forum and public and patients ...

Chief Executive Officer:

So a broader patient voice coming through Jim Hopley. Then obviously there are various clinical people who attend; so the chief nurse and the medical directors, people like that, and obviously people like the Director of System Redesign and Delivery because it is very much her key priority to

deliver this system change. What it does not have is it does not have that direct link into some sort of patient voice. By proxy we get it from the third sector organisations and it does not have the non- executive input. That is something that has been at the heart of the workshops that we have held. You will know from the background, the piece of work that we did, that it was a whole series of workshops over a period of time getting quite a significant number of stakeholders together to work through why a change was necessary, what a change might look like. We benchmarked against a number of other jurisdictions to look at what we could learn from them. That is how we brought it together. But one of the strong things that came through was the benefit of feeling that they had an independent chair and that they had an independent person or people who would make sure that that board worked well together, that all the voices were being heard, that all the contributions were being recognised and taken on board, because there is always that fear that ... people like myself and my team we are very used to sitting in venues like this and answering questions and making our views known. Not everybody is. So it is really important to hold that in and guide and encourage and make sure that we do not get carried away. It is not the service of, clinicians do not just think it is all about clinicians but it is about hearing that public voice. So they were very, very keen that that was an element of this approach. Equally, it brings a different level of challenge to our work as well, to bring people in who have got a different range of experiences and say: "Well, why are you looking at it that way? Is there a different way to look at it?" That is probably the biggest difference between the 2 models is the input, the directive of a patient voice and the direct co-ordination and guidance of that independent external non-executive role.

The Deputy of St. Ouen :

Can we delve down and look in that patient voice, as you say? I understand from the answer you have given that there are going to be some public awareness sessions to try and draw members of the public into the public and patient advisory group that you want to set up. I am wondering how you would engage with people who are not already engaged in the voluntary sector, or who might not have a professional interest already, what sort of people are you hoping to bring in by that means?

Chief Executive Officer:

My experience of working with these sorts of groups in other places is that you will bring in people who are of working age who perhaps would not normally interact with any of those type of third sector organisations. They may not have a relative with a particular condition, they may not have a particular condition themselves so they are not engaged with, for example, a voluntary sector organisation. Young mums with children, quite often you have got to think of creative ways because they have not got the time or the inclination.

The Deputy of St. Ouen :

So you think they will put themselves forward to sit on the group of public...

Chief Executive Officer:

My experience of similar things is that people are engaged in lots of different ways and one of the important things here is it is not me or the Director of System Redesign or any officer that is designing and thinking through how might a patient in a public forum work. It is people who are representative of, so for example, Citizens Advice Bureau, Consumer Council, who are used to having relationships with the public, and we are working with them and asking them to help us to formulate what will work better for people in Jersey.

[12:15]

There may be a grouping that forms which calls itself a forum. It may very well have lots of ways of interacting with groups that already exist who are not already in contact with us and they may develop new ways of doing it. Some people like to be involved by receiving documents to comment on and they will send us some views. Other people want to be talked to face to face. So I think we need to be guided by the people who have that experience and expertise in working with the public.

The Deputy of St. Ouen :

Yes, but how can you ensure that the people that come forward from this public awareness initiative will be a balanced group of people that represents the community and will be able to represent the community? How can you avoid perhaps a particular group of people who may have strong views on, say, the medicinal use of cannabis, putting themselves forward and championing their cause by virtue of their numbers in a group like that?

Director, System Redesign and Delivery:

That is always a challenge. We can be really clear on what the group is for and what it is not for. We can be really clear on what the system partnership board will do and therefore the sorts of people that we are looking to put themselves forward. What we do not want is people coming to air individual patient identifiable operational matters. This is a strategic forward looking board. A lot of the ...

The Deputy of St. Ouen :

Yes, but at the lower level where you are trying to establish the patient and public group.

Director, System Redesign and Delivery:

A lot of the how will we exactly do this we are working through, so it is fantastic that the chief executive of the Citizens Advice Jersey is leading on the public and patient element for us because he has great experience of doing exactly that. We can also learn from experience like with the mental health strategy when we have a citizens' panel, there were various mechanisms that we used then to elicit the views of those groups that are less heard. But it goes back to having strong leadership and a strong chair to make sure that those people who might be more used to speaking out or might be more vocal or might be more passionate about a subject, get their opportunity to be heard but that that does not drown out the others that perhaps are less used to speaking or a little bit more shy.

The Deputy of St. Ouen :

Yes, but that is within the system partnership board when it is established. But I am ...

Director, System Redesign and Delivery: And within the patient group.

The Deputy of St. Ouen :

Yes, I am seeking to work out how that group is going to be formed. Is it going to be a random collection of individuals who have come forward but this group will need to conduct elections for seats on the board, it is going to need some administration help, it will perhaps have a small budget. There is a suggestion in the proposition that it could commission research to pass up to the board. So is it just going to be a group of individuals or is it going to be registered as a charitable body?

Director, System Redesign and Delivery:

Not imagining that it would be registered as a charitable body but I think this is where ... the philosophy behind the groups that feed into the system partnership board is that they are developed and evolve and are led by the people that are not Health and Social Services executives because we could tell people what to do and how to do it but then that would be our plan. As the Minister said earlier on, this is about the community. So we can support and guide, we can give examples, we can give some resource to help people with administration, those sorts of things, but I really strongly believe that if I wrote a terms of reference for that partnership board and if I said: "This is how you are going to select your representatives", it would be my way. I do not want it to be my way. It is about it being their way. That they co-produce and develop together.

The Deputy of St. Ouen :

But then I come back to the question: how do you ensure that there is diversity and the people who joined that group are truly representative?

Chief Executive Officer:

Because the partnership board would work out together its modus operandi: its rules of engagement, its expectations in relation of its behaviours, what they would value, how they would hold each other to account. So they would be making it very, very clear the types of representatives that they would see being brought forward from these individual groups. The individual groups themselves will negotiate and agree their terms of reference and how they want to work together and it will be very clear that allowing single interest organisations to dominate proceedings and get places on a board would not be tolerated by the independent chair because it would be not in accordance with the terms of reference and the rules of engagement that they themselves have agreed.

The Deputy of St. Ouen :

But by then those groups have got themselves elected ...

Chief Executive Officer:

But they have not because they could not be elected because their terms of reference would not allow them to be elected. I am struggling a little bit to give the level of detail because obviously what I would really like to do is have the person who is working that up and thinking about it able to tell you about their experience and the way they would tackle some of those things. Obviously that is not me for the reasons that Rachel has said. We can give a lot of ... this is not a novel thing that we are suggesting. There are lots of examples of these types of boards with that type of complex membership that exist in lots of other systems. Therefore there is lots of material we can draw upon to share with the people who are doing this thinking at the moment to say: "These sorts of things seem to work quite well. These are some of the dangers and you have identified one of those dangers of being hijacked. And this how different groups have dealt with it." The reason we have called it a pilot is exactly that. We are going to be testing and trying things out. If something does not work very well then we can change it. But the core of it is that this is not about the department dictating to everyone else. This is about us being a good partner and supportive and in return we get that powerful voice to the table that allows us to make better decisions.

The Minister for Health and Social Services:

The services provided with the community have definitely got to be better than those imposed on the community or form the right reasons. The other moderating factor that - I do not know if you have forgotten about it or whether we did not explain it properly - but we intend to hold these meetings in public as well. So that is a moderating factor in itself.

The Deputy of St. Ouen :

The voluntary and community sector forum as well, it must face the same difficulties. So we have got any number of charities or voluntary sector groups in Jersey. They have somehow got to come

together and elect 3 members to the partnership board, but there is no constitution for this group to provide for that election. Is it expected that ...

Chief Executive Officer:

Again the partners in the third sector are busy meeting and talking about these issues currently. Again, we are guiding and supporting them in terms of providing them with evidence from elsewhere about how that would work. They are very conscious of the sort of challenges that you are raising because obviously we know them as well, and they will need to find a way of getting their representatives that they, as a broad group, are comfortable with. They will have to work hard. There are large charities, there are small charities, there are charities that deal with children, people who deal with older people.

The Deputy of St. Ouen :

Is it enough to say that these groups will need to find a way because they are each going to put 3 persons on to a board, which is going to have a very great influence on the direction of health and social care in the Island? Do we just say it is up to them to find the way through?

Chief Executive Officer:

But that is not what we are saying.

The Deputy of St. Ouen :

I thought you were; they must find a way.

Chief Executive Officer:

They must find a way that they are comfortable with and we will support and give them information that will help them do that. But at the point they put their representatives forward they will be meeting a specification which the board has agreed. In the early days that is the chairman and the non- executives and we work with the people who are already a part of our partnership relationship who can give us guidance until they have got to the point where they have gone through a process, which is open to scrutiny, and which gives them confidence that they are putting forward the right sorts of representative. Ultimately, the chairman and the non-executives will take a look at that and say that feels right or they may go back to those representatives or the chairman of whatever the voluntary sector have come up with and say: "Not entirely sure about this, can we just revisit it and think it through?" This is a trial and error.

The Minister for Health and Social Services:

I am struggling to see your difficulty with public involvement. We have still got to work out how the forum would function entirely but my experience of public involvement is a much more co-operative one that works. I am really struggling why, Chairman, if you are ... are you saying that we should not involve the public?

The Deputy of St. Ouen :

It is not my proposition and I am not amending it.

The Minister for Health and Social Services:

No, I was just trying to understand where you are coming from?

The Deputy of St. Ouen :

I suppose I was saying how are you going to ensure that the public voice is adequately represented because you are basically saying it will come together. You are not going near or putting any organisation together because you want members of the public who express an interest ...

The Minister for Health and Social Services:

We have not said that. We will support the development of a patient forum and the people being elected would have to be elected according to certain criteria. But we are not doing anything new here. This is done in loads of other places and it works so why would it not work here?

Director, System Redesign and Delivery:

The proposition was based on a report that KPMG helped us with that was co-produced through a number of workshops and interviews and international best practice over the course of last year. The individuals that were involved in that were heavily involved, and were really vocal in their views, all agreed that this is the way forward. This is the right way forward for Jersey; to increase that transparency, to increase involvement, to increase accountability, to keep the Minister's role as it is, to increase that community involvement and the public involvement. So we have got that broad framework. Subject to the outcome of the States debate on 14th November then we will start to put in place, with the partners that will be leading the elements of this, the exact details of how it is going to work, but we will do that together. It is not a case of saying: "We want you to run the public forum, off you go. Do whatever you want" because the individual that is currently working on what does the public forum look like was part of all of those workshops, was part of all of those interviews. It set this desired direction together with us. Once the States debate has happened then is the time for us to then go out and start talking with the public about: "This is what it looks like, this is how it might operate, this is what it is aiming to do, and this is how you could be involved." As Julie said earlier on, there may be different ways to be involved because one way will not work for everyone. Then there will be a process of pulling together whatever means are agreed, whether they are meetings or focus groups or workshops or communications or newsletters, to keep the awareness up and to ask people: "Would you like to be involved? How would you like to be involved? What is

going to work best for you?" So to some extent it will evolve. We will continue to help with providing evidence from elsewhere. What do they do in New Zealand? What do they do in Alaska? What do they do in Sweden? What do they do in the U.K.? Which bits do we want to use in Jersey? How do we want to make it feel real and bring it alive? We will keep adjusting it as we go through. That is why it is a pilot. But the aims and the framework, if you like, have been produced together. The job will then be to bring that to life and to make it feel real and to keep on evolving it as it goes through. We will be continuing to support because it is in all of our interests as an Island to do that, but we will not be controlling it and we will not be leading it overtly. If you like, we will be sort of supporting it from behind rather than leading it from the front so that it evolves in a way that those people whose voices we want to hear want it to evolve. Does that make a bit more sense?

Deputy J.A. Hilton:

So what are you hoping the partnership board is going to achieve? How is it going to be different?

The Minister for Health and Social Services:

It is going to involve a wider group of people, G.P.s, pharmacists and primary care providers, the voice of the public, and the more formal administration side is going to give me a much more rounded advice on the strategic direction. It will be the Minister's decision.

Deputy J.A. Hilton:

So it will be responsible for policy then?

The Minister for Health and Social Services: Advising.

Chief Executive Officer:

The agenda is very much around the implementation of P.82. So it will be about ... the process we use at the moment is that obviously we are on the cycle of medium term financial planning. So as we start looking towards M.T.F.P. (Medium Term Financial Plan) 3 clearly we will be thinking across the partnership what are the next phase of things we need to do to deliver the acute services strategy ...

Deputy J.A. Hilton: Is that 2019 to 2022?

The Minister for Health and Social Services: Yes.

Chief Executive Officer:

So we start to think about that and at the moment the way we do it is that we would, within the department be thinking through, particularly in Rachel's team: "What are the next stages of services we need to develop? What is the next step? What does that look like that? Build a business case." We will be testing those out as we go along through the transition group and with the various implementation groups we have. Then that would go through our internal governance process and eventually we would sit with the Minister and say: "This is what it is looking like, Minister" and that goes into the Treasury and it all gets put together with all the departments. Then the bun fight starts because inevitably all the bids for growth and development far outstrip the resource we have. So it will come back and iterate and we will be asked to perhaps shave a bit here and add a bit there and could we do something different? Could we phase it differently? We have very sophisticated prioritisation tools that we use and we try and involve the partners but at the moment they feel a little remote and they feel a little bit like: "That seems to make sense but I do not really know because we have not really been the architect of this bit of the plan."

Deputy J.A. Hilton:

Do you feel like it is a way of empowering and informing your partners?

Chief Executive Officer:

Absolutely, yes. The assurance that the Minister gets is that when this comes to him via the chairman of the partnership board he can have a sense of: "This is the voice of the partners."

[12:30]

They have had all those discussions, they have worked it through where the priorities are, they have held each other to account, because not everybody gets everything they want. Unless I can feel confident that when I go into a Council of Ministers, when I go into the States Assembly and present to you what the plan is within the Medium Term Financial Plan around Health and Social Services, for the P.82 agenda you can be confident that you are hearing the voice of the partners who ultimately are going to be the people who will be developing these services that we want to have in place. Then that is the big benefit. It gives an assurance and a confidence to the Minister. It also gives him an ability to hold to account because of course through his memorandum of understanding with the chairman he can set some very clear objectives to say: "I want you to bring forward to me robust plans that are owned by the partners, that are deliverable, that are good value for money" and when they appear he can say: "Yes, great, I understand these. Fantastic." Or: "I do not think it is good enough, please can you go back and have another look?" I think it strengthens and enhances but it grows the ownership and that is really important.

Deputy J.A. Hilton:

How often do you see this board meeting?

Chief Executive Officer:

At the moment, because obviously that is something we would see with the chairman coming in as well, but I think we are probably looking at every couple of months, and it would spawn working groups and all of our infrastructure that sits underneath the transition group have implementation groups for different aspects. That will all carry on. It is all populated by the partners but that group would meet to create the framework to test and challenge, to iterate business plans. So we would think probably on a 2-monthly basis because if it is shorter than that you are just in a cycle of meetings, we cannot get the work done.

The Deputy of St. Ouen :

Would the board be involved in looking at the delivery of services and any failings that may occur there?

Chief Executive Officer:

No. That specifically remains the responsibility of me and my officers directly to the Minister. Obviously if you have read, and I know you will have read the big piece of work that we did with KPMG, this can evolve into all sorts of directions at the will of the Minister and the States Assembly. But we have started in a place that is safe and secure and makes sense to test the model. If it works really well, in a few years' time it might make sense for you to have some delivery responsibilities and a budget that goes with it, you can choose to move in that direction, but at the moment, no. If the States Assembly had a problem and a concern about a service, and at the moment there is a lot of interest in Children's Services, quite rightly you hold the Minister to account for that and he holds me accountable for that. That does not change. My accountabilities remain absolutely in place, as does the Minister's and if there is some problem with the service then it is down to me and my team to make sure that ...

The Deputy of St. Ouen :

Okay, because the proposition reads ...

Director, System Redesign and Delivery:

The board would have the overview of the outcomes from the P.82 services though in order to complete that loop, because otherwise the board would be advising the Minister around the strategic decisions and then not seeing the effects of that. So that when ...

The Deputy of St. Ouen :

So specifically in the proposition it talks about compacts to be developed to govern behaviours, values, service delivery, and partnership working.

Chief Executive Officer:

The service delivery is, in a sense, the planning and delivering those plans, but we would not say, okay, that the board is now going to have £200 million of taxpayers' money to deliver the health services and social services for the Island. But the people in that board may well be producing plans and overseeing the delivery of those plans for new services that will help to deliver the objectives of the department.

Director, System Redesign and Delivery:

So the compact around service delivery, for example, might say specifically any organisation that gets P.82 money must seek the views of the people they are providing the services for in order to assess how well they are doing. So you are keeping that patient and public voice through the delivery of the P.82 investments as well.

The Deputy of St. Ouen :

Okay. There is another reference to performance under "service provider alignment". It talks about oversight of performance from a system perspective. Is that broadly what you were saying?

Chief Executive Officer: Yes.

The Minister for Health and Social Services:

Another example of that is the example that Rachel gave you in the earlier hearing around how you evaluate pilot schemes.

The Deputy of St. Ouen : Yes.

Director, System Redesign and Delivery:

It also recognises that for some of the investments in the P.82 services, so for example rapid response and reablement, the impact is felt elsewhere in the system. So investing in rapid response and reablement has an impact on lengths of stay in the hospital and numbers of people that go to E.D. (Emergency Department). So you have to have a system-wide outcome view.

The Deputy of St. Ouen :

I understand. So, Minister, you will still control the purse strings, will you not? The board will have no power over the budget?

The Minister for Health and Social Services:

I do not control the purse strings. I have an accounting officer that does that.

The Deputy of St. Ouen : Understood.

The Minister for Health and Social Services:

But my job is to get them the resources to do the job.

The Deputy of St. Ouen :

Yes, so if the partnership board was reviewing the outcomes of a service and felt that additional funding was needed, but you were constrained by the States budget and the M.T.F.P., how would that be resolved?

The Minister for Health and Social Services:

If the service that needs to be developed needs more resources, this is no different to now really, the case is made, the Chief Executive and I get into, as she described it, the bun fight to get the resources for Health and Social Services. The only thing is, if it is a new development, we will be coming from a more-informed position as to why we need to do it, where we need to go.

The Deputy of St. Ouen :

But if you were instead reallocating within your departmental budgets, it is the States Assembly that has agreed the M.T.F.P. spending, but would the board be suggesting to you that you should alter those parameters and priorities and spend in one area and not another, where the States might have decided differently through the M.T.F.P.?

The Minister for Health and Social Services: The States do not do that.

Chief Executive Officer:

I think that, as the Deputy Chief Executive said in our earlier meeting, the States decides where its money is going to go and that is where we spend it, and that can only be changed by coming back to the States and asking for permission to vary it. So the P.82 monies are very specific; they are on the back of a business case that says: "Shall we develop service X?" The States says: "Yes, we think service X is a really good idea; that is the money for it." That cannot be touched. Obviously

there is the global budget that comes to the department to run the business as usual and services that have been developed and absorbed into business as usual. The way it would happen, I think, because this is my experience of working in these sorts of systems in other places, is if the partnership board had commissioned a piece of work or one of the subgroups had done a piece of work that resulted in a case coming through that said: "We have been looking at this particular aspect of service and we have raised some issues that we think need addressing", there are 2 ways of doing that. One might be to say that is a good service development so we will build that into the business case when we are going through to the next round of funding, or we may look at it and say: "This is pretty serious; we need to do something about this." Clearly what I would be doing is bringing that back and informing the Minister and then we would look at our resources that are able to be moved about. So, for example, when we knew we had issues with Children's Services we immediately looked at our resources and reallocated and moved around to create a bigger budget so that we could get straight into looking at issues of recruitment and retention. Now we know where some of the problems are around that, but it was not a shortage of money, because we reprioritised. So I think it just gives us another rich dimension of people who have got a real interest and a knowledge being able to put something on the table and we would look to see what we could do about it. If it was urgent we would find a way of dealing with it and if we could not do it within the budget clearly what I would do, with my officers and with the Minister's support, would be to take it to the Treasury and say: "This may need a contingency allocation." So there are different ways, so we would never just sit and say: "We have found a real problem but there is nothing we can do about it", we would always seek to find a way of resolving it.

The Deputy of St. Ouen :

Okay. Minister, I would like to ask you about the size of the board. It will have 21 members. Is that workable?

The Minister for Health and Social Services:

It needs a skilled chairman, as you are probably implying, it needs a skilled chairman to do that, but I like boards of 9 or 10, if I was to be honest, and then I started looking at who would you not have at the table? There is nobody you would exclude. If you are going to be truly inclusive and involve all the partners, there is nobody there that you would not have at the table. That is why I think it is important that we have that independent very skilled chairman to ensure that everybody gets a voice. A board of 21 is not the easiest thing to manage, and it would be very easy for those with the loudest voice, if I can put it that way, to drown out those who are less used to working on boards, however, they may have very important contributions to make. That is why the selection of the chairman, not only in their past experience, but their skill in running a board of that size, is going to be crucial.

The Deputy of St. Ouen :

So why was it decided to elect 3 members from each forum and not 2, for example, which would reduce the numbers?

Chief Executive Officer:

We have had those conversations with the stakeholders and we have been around this loop many, many times, because naturally you do want to have a smaller group. I can say from my own experience I have worked in boards of this size and I have seen boards that have worked really, really well and I have seen boards that have struggled. Usually they have worked well where they have had strong chairmanship, where they have had very nuanced leadership, but where there is a real clarity among the members as to what their role is and the rules of engagement, so they are respectful to each other, so it is possible to do it. I have also worked on smaller boards that have worked really well and ones that have been terrible. So it really does come down to having your clarity of purpose, having your rules of engagement, then having clear leadership to ensure that is the way that the board members behave. But we have looked at different combinations and it is trying to be a broad enough church to get the interest. So, for example, when we looked at the third sector, could you get by with 2? Could you get by with one? Initially we said we would just have one of everything and that would have been a smaller grouping. But, as we have already alluded to, there are third sector organisations that are very large and very complex and very professional in the way they operate, there are much smaller ones, which are much more agile and nimble, but do not necessarily have all that resource. There are some that work with children, some that work with older people, some that work with mental health. Trying to sort of think about how you might get a broad church of representation from that led us to the number 3. There is an element of, if there are going to be 3 of them, there really does need to be 3 of this, so there is a little element of that goes on as well. There has been a lot of challenge, very legitimate challenge, to say: "Why do all your directors need to be there, Julie?"

The Deputy of St. Ouen : Yes, the next question.

Chief Executive Officer:

We did go through and say, should we not have the chief nurse there? Absolutely, she has to be there because she is representing the professional nursing voice on the Island. We clearly want to have the medical director for primary care and the medical director for the hospital. I rather think the person who runs all the money should be there to give guidance and support around the resourcing issues and M.T.F.P., et cetera. The person who is charged with developing our new system really does need to be at the table, because she is going to be helping to implement it all. It came down to, well, do you want me here? If you do not have the accountable officer then is this really going to be a powerful board, because I straddle the 2 governance systems. So it became quite difficult, who would you drop out of that?

The Deputy of St. Ouen :

Can I ask the Minister: is that your view as well, Minister? Is it essential to have all the 6 corporate directors there?

The Minister for Health and Social Services:

Yes, because I challenged on this and when you look at who would you not have there, other than you might say we will have less representatives from the community or from the voluntary sector or from the service providers, and then when you drill that down, so who are you going to have directed at primary care, you are going to have G.P.s or you are going to have dentists or you are going to have pharmacists. I think initially everybody has to be at the table. It may change.

The Deputy of St. Ouen :

It is not possible for a corporate director to represent another area of the department, is it?

Chief Executive Officer:

The first thing that would happen is we would have an item for debate and we would be saying we cannot answer half the questions because it needs a level of understanding. At the end of the day, we are recreating, redesigning, developing new services all the time. One of the critical things about that is, well, can you get the staff to run these new services. If you need a new type of staff, so that person does not exist, we will have to train them or go and recruit them, it is not much point us sitting and thinking about that without the director of H.R. (human resources) there to say: "That works well; those sorts of people already exist, we can go out and find them", or: "You are going to have to design that post from scratch". Because that might be the difference between us prioritising a business case at the top of the list, because we need to do it fast, and saying: "That is great but it is medium term because we are going to have to grow the workforce." It is the complexity of those discussions, you need to have that intelligence and competence at the table.

Director, System Redesign and Delivery:

When you look at the corporate director group of Health and Social Services, there is probably only the hospital managing director that has a solely Health and Social Services role, because the managing director, community and social services, also has a lead social work role across the Island. The chief nurse, Island-wide remit. H.R. director, workforce across the Island. Finance, finance for health and social care, not just the Health and Social Services Department.

The Deputy of St. Ouen :

Okay.

The Minister for Health and Social Services:

We spent ages looking at this and challenging each other on this and it may evolve over time, but I doubt that the evolving would result in the number of officers being reduced. It may be that other areas might be able to be reduced, but at the moment I do not think it can be, and yet I do not like boards of 20.

The Deputy of St. Ouen :

No. Are the forums going to be as large?

Chief Executive Officer: Some may be.

The Deputy of St. Ouen :

Gosh, right, that is a lot of people involved.

Chief Executive Officer:

There are a lot of people involved and I think it is a feature of the fact that we are talking about a whole system and when you bring a whole system together of Health and Social Services providers you end up with a lot of people in the room.

[12:45]

That is one of the challenges. We are very fortunate here in Jersey that, not only do we have a lot of integrated provision already, but we have over these years of developing P.82 and implementing it developed some really strong working relationships across our partners. If you were to look across the water to England, for example, they are now busily trying to develop system transformation plans, they are busy setting up system-wide bodies, and if you think 21 is large they have bodies of 40 and 50 because they are setting these things up across very large areas. They are trying to bring a very fragmented system together because no one bit of it can do it on its own and, because they have lots of independent organisations all going after their own agendas, they find it really, really difficult. We are so far ahead of the game in terms of having that relationship, this we just take as that next step to allow us to complete the transformation of health and social care and become a very integrated provider where all the partners feel that their voices are heard and, as best we can, listened to. It really is something that people elsewhere would look at with great envy because they cannot do it because of the way their systems work.

The Deputy of St. Ouen :

Is there any possibility of conflict of interests of board members, particularly within the department, if the directors are sitting on the advisory partnership board also and they have their role within the department, and particularly the chief executive, yourself, Julie, so if you have responsibilities for the operation of the department, but you are also sitting on a board, which is independently advising the Minister, is there an area of conflict there?

Chief Executive Officer:

I do not think there is an area of conflict in that particular aspect, but I think you are right in terms of as a general principle everybody who takes part in that board will have conflict of interest because they are all providers. We are a provider, the department is a provider as well, and this is not unusual. We find this in other systems where you have providers of services, professional experts who are making decisions about how resources might be deployed, and ultimately we are making decisions of what can we recommend to the Minister is the right way to bid for and receive transformation monies. We all have an interest in that because a bid might say: "Give another £1 million to the Department of Health and Social Services so they can radically transform in-patient mental health services." Now clearly I have an interest in that going through but the way that boards deal with that is that they have rules agreed in advance that set out: "When conflicts of interest arise, this is how you deal with them." The first thing is you declare it, so it is very clearly minuted and noted by all the members in the room that you have a conflict of interest. Then they can take into account that when you are perhaps making comments and giving your advice that yes, there is a conflict of interest. You have to be aware of it yourself and everybody else does. If you had a direct interest, so if the board ... and I do not think the board will do this but if the board was saying: "We want to recommend to the Minister that an investment is made in that general practice in that road" then that general practice, if it happened to be the representative at the table, would have to excuse themselves from that debate. They might excuse themselves but they could hear the debate. In certain circumstances the chairman might say: "I would like you to leave the room while we have this debate." Those rules are set out very clearly in advance. It is part of the learning and development that we will do, informing this board, that we learn about those things, we understand when they come into being and we make the right declarations and we behave in the right way. That is the way that you deal with it because you cannot ... there is nobody you could put into that board that does not have a conflict of interest.

The Deputy of St. Ouen :

No, that is not involved with the industry, let us say.

Chief Executive Officer: Exactly.

The Minister for Health and Social Services:

When you think about it, that is exactly why we want them there, because they have the knowledge and, in the case of the community, they have the experience of using the services and so on. That is the reason they are there. That conflict or that potential conflict that you have described would be the same in any board virtually anywhere. It is about proper professional behaviour and standards ...

Chief Executive Officer: Good governance.

The Minister for Health and Social Services: ... when that is running.

Director, System Redesign and Delivery:

It is one of the other reasons why we need a really strong, robust chair and the 2 non-executive directors whose key role is to make sure that the board governance is adhered to.

Chief Executive Officer:

They do not have a conflict of interest so they can genuinely hold the ring.

The Deputy of St. Ouen :

Have you an idea how many hours a week the chair and the non-executive directors will need to spend on board business?

Chief Executive Officer:

I think at the moment we are still scoping by looking at other roles in other jurisdictions to get a sense of what might it look like. Obviously the chairman will have a greater time commitment than the individual board members will, the non-executive directors. Equally we are also giving some thought to ... the chairman probably will be recruited from off-Island because to get that level of experience of working in a complex health and social care system in this type of environment, that is ... probably you are going to have to go and look elsewhere. The non-executives could perhaps be based on the Island. Clearly there is a commitment for the number of hours to populate the meetings and there will be some reading time that you might allow so that people can familiarise themselves with the reports that are coming to them. I think you can build it up but again it is something that we would want to firm up. We are walking a line all the time around: "What work can we do usefully in advance without making it feel as if we have just taken for granted that this is going to be approved?" Clearly if we put a lot of effort into this, it is redundant. It is abortive cost. All of the officer time and

all of the partners' time who are involved in doing this work has a value to it, obviously. It is trying to get a balance between doing enough work that is helpful in the run-up to hopefully getting a permission to carry on, but if we do not get that permission to carry on then obviously we do not want to suddenly find that we have months and months' worth of work that just has to be put in a box and put away.

The Deputy of St. Ouen :

Did I understand from earlier discussions recorded in the KPMG report that the department was going to fund the clinical and professional forum chair for one day a week to devote him or herself to the system partnership board? Have I understood that correctly?

Director, System Redesign and Delivery: That has already happened.

The Deputy of St. Ouen : That has already happened?

Director, System Redesign and Delivery:

Yes, that has already happened because we needed a clinical forum, whose main role at the moment is to bring professionals together to redesign pathways across care.

The Deputy of St. Ouen :

Right, so that is just one of the subgroups whose head is devoting one day a week to this work. Surely the chairman of the whole of the board is going to be devoting a significant amount of time.

Chief Executive Officer:

The chairman is non-executive. We have to recognise that they are not trying to run anything. They are bringing a non-executive role to the table. It may work out that it is a couple of days a week, or it might be one week in 4 they come to the Island and the meetings are held during that week and they have other meetings, they meet with the Minister to be held to account. That has to be built up but there will be a reasonable time commitment.

The Minister for Health and Social Services:

I think there would be an enormous commitment at the beginning of the process because we have to establish the running of the board and get the relationships working. There would be a greater commitment at the beginning but once the board is established then there would be less involvement.

Deputy J.A. Hilton:

We understand the board is going to be financed from current monies that you have available to you. Presumably the chair and the non-executive directors will be reimbursed. I was just going to ask you a question. Obviously the directors are paid anyway through their own work. Would there be any ... I am just thinking about the time involved for the voluntary and the other group.

The Deputy of St. Ouen : Public and patient advisory.

Deputy J.A. Hilton:

Yes, public and patient advisory. I was just wondering what plans were in place or whether you had any discussions around whether there would be any resources made available to those people taking part in that. It is all time and presumably some of them ...

The Minister for Health and Social Services:

We have talked about whether it would be a salary or not. I think we are coming down to nobody should be disadvantaged by attending and so I think the route that we will probably take is that if someone has lost a day's pay because they have attended the meeting on our behalf then that would be reimbursed. Along those lines but it will not be a salary as such.

Deputy J.A. Hilton: No. Okay.

The Deputy of St. Ouen :

Your proposition estimates that the cost will be about £150,000 a year, which to me, if I may say, Minister, seems very low considering we have the salary and expenses of the chair and the non- executives and you have those additional payments to other board members.

The Minister for Health and Social Services: It is not a full-time executive board.

The Deputy of St. Ouen :

No, but you need administrative assistants to the board and administrative assistants to the forum.

The Minister for Health and Social Services: That exists already.

Chief Executive Officer:

Yes. That is part of what we contribute as a department to the successful launch of this board. We have people who will produce papers, make sure they are circulated to everybody and take notes of meetings and do those sorts of pieces of work. If the board generates a request to find some information about a service area then we have people who can go and research and bring that information back. The resources of the department will be made available to support this board.

The Deputy of St. Ouen : Yes.

Chief Executive Officer:

There will be salary-based for the non-executives. There will be out-of-pocket expenses. With the Director of Finance's guidance, we have taken a view on how much we think that will cost. Part of testing this as a pilot is to say: "Can we do it within that sort of sum?" If the sum has to increase then obviously we are evaluating this pilot because the question that we may have to bring back to the Minister is: "There are all these benefits that you can see from having this board working in this way, and there is a cost. Is there a sense that this is giving the system and the Island value for money?"

The Minister for Health and Social Services:

Having it as an educated estimate, I thought you were going to come back and say: "I think it is too much," not ...

The Deputy of St. Ouen :

Well, I am thinking there is training as well and you want a research capacity and ...

The Minister for Health and Social Services: Yes.

The Deputy of St. Ouen :

The forums are going to have their ...

The Minister for Health and Social Services:  

A lot of the resources that would provide training, that would be providing secretarial support, exist now already within the department.

Chief Executive Officer:

We service the transition steering group. That obviously would not exist if there was a system partnership board. The resource that goes to supporting the transition steering group could go to supporting the board.

The Deputy of St. Ouen :

Yes. Is there anything that is going to be removed from within the department as a result of having to fund these new roles?

Chief Executive Officer:

We think not. Obviously if it turned out to be different we would go back to that question of benefits and cost. I am a great believer in this way of working because I have been part of it in other places. I have set up many boards with chairmen and I know what it takes to do it and do it well. I know what the pitfalls are. There is a cost to it, undoubtedly, but the benefits we have received from having those sorts of devices in places have outweighed that cost because you get better quality decision making.

The Deputy of St. Ouen :

I would like to ask about holding the meetings in public, which it is said will happen. If the role of the board is to develop strategy ... "policy and development" it is called, is it not? Now, at the moment all that is not done in public. Will it be done in public?

The Minister for Health and Social Services:

I think there needs to be. To be honest, it is something we need to trial. I want to be as open and as transparent as we possibly can be. There probably will need to ... well, no, there will need to be. Not "probably". There will need to be an A and a B agenda where some work around the B issues are discussed openly and as transparently as possible, in public, but we have to acknowledge there will be other areas where it will need to be developed privately as part of an A agenda before moving on to a B agenda once it has been worked up. We want to be as open as possible.

Chief Executive Officer:

Where these boards operate in other systems, and I am not familiar with the system in England because that was the one that I worked in before I came here, all of our board meetings were held in public. There was a private part and there was a real wish from the chairman, all the chairmen I have worked with, and the boards, to put as little as possible into the private part because, again, we are committing taxpayers' money and some of those decisions that we make about what we can prioritise and what you cannot prioritise are really challenging decisions. I think for people to be able to see that and see the sorts of debates and the quality of that debate that you can have, and the resolution that you can reach, is really quite important. I have sat in meetings where I have been a member of the public because I have been curious and I have gone along and I have always found it really valuable to see how that debate comes through. You hear the political perspectives, you hear the lay perspectives, and you will see how people have to balance it.

The Deputy of St. Ouen : That would be good to see.

Chief Executive Officer: Yes.

The Deputy of St. Ouen :

Perhaps our Council of Ministers might operate in the same sort of way.

The Minister for Health and Social Services: It has done on occasion, accidentally.

The Deputy of St. Ouen :

To use an example, in response to a question to you in our written questions, we asked you for some worked examples demonstrating processes and you gave us as an example one of the forums bringing a perceived need to you that there was a gap in services for individuals with mild to moderate mental health needs. Then you describe how the board would discuss the issue, seek to develop a business case and then come back to the board with that case and decide on priorities. Would all that be conducted in public?

Chief Executive Officer: Yes.

The Minister for Health and Social Services:

I do not see why not. It is not about the individual.

The Deputy of St. Ouen : No.

The Minister for Health and Social Services: It is about services.

The Deputy of St. Ouen :

It is about all sorts of options that there might be out there to deliver service at different levels. Would the department be confident in all those options being considered in a public forum?

Chief Executive Officer: Absolutely.

The Deputy of St. Ouen :

That is encouraging, I think. Okay. Minister, can you tell us something about the ministerial role? The proposition says that it is not going to change but will it change in the States Assembly in that if States Members ask you questions about health policy or seek a debate on health policy, will you be saying to States Members: "I need to go back and consult the board"?

[13.00]

The Minister for Health and Social Services:

It will be exactly as it is now. If Members get into operational matters then I would have to go back and speak to the staff about that and it may not even be appropriate for me to be giving those answers in the Assembly, but if it is about policy and even challenging the provision of the service that we are providing, it will be no different. For me, if you think for a minute that as Minister there is no informal lobbying from all these groups ...

The Deputy of St. Ouen : Oh, I am sure there is.

The Minister for Health and Social Services:

... you would be very wrong. What I want to do is to get that lobbying into a more formal forum where it is properly debated by all concerned before it comes to me rather than ... and it does not happen very often but G.P.s sometimes ... or primary care providers, not just G.P.s, have in the past - not lately, I must admit - felt that we were doing things to them, not with them. Then they would be lobbying, and they probably would not just be lobbying the Minister, they would be lobbying Back- Benchers and all the rest of it. The Minister's role does not change. One of my passions has been around mental health so I could give a steer to the board that I would like them to look at different things from there, and then they would come back with advice. I get that advice from Julie and the team now but I would like to have richer, rounded advice. The role of the Minister, holding the Minister to account for the services provided, does not change. In fact, I think you would have a better opportunity to question the Minister because there is a lot of stuff that goes on over which I have no influence or little influence at the moment because there are a lot of private businesses.

Can I just give a personal example of acting on behalf of a third sector charity when their funding was going to be removed? I am going back a few years now, prior to yourself.

The Minister for Health and Social Services: Okay, so we are going back a long time then.

Deputy J.A. Hilton:

Anyway, I approached directly the chief executive officer of Health and Social Services with the chairman of the charity involved to question why this money, which was quite a substantial amount of money, was being removed from this charity and how we could work our way through that. To cut a long story short, the money was reinstated in that meeting. I am wondering, if I were in that position now I guess that would not apply, would it? How would it be different?

Chief Executive Officer:

What I think would be different is that because we are looking across the whole system we would be, as part of the board, constantly looking and reviewing: "How well is our system working?" We may well be then also saying: "We need to develop something different for this particular sector." Say it is Children's Services. Because that board is a broad cross-section and has all of those inputs, if we are developing some thoughts about how services might change we might take a view that we used to commission that service from that children's charity and all the evidence suggests it is not working very well or it is not giving us what we need, so we are going to stop that. That could be debated by that partnership board and obviously that charity, through its links through into that representation, could put its views on the table: what would be good about it, what would be bad about it. It might be saying: "We would like you to stop doing this but we would like you to do that instead for these reasons." You are not losing anything, you are just doing something different. It gives you a different way of having those conversations. That is not to say that the board does not ultimately design its new service for children, saying: "We do not want that anymore. We would like this. These are all the reasons why." That advice goes to the Minister. The Minister says: "Yes, I think that is probably the right thing. That is the proposal we are putting forward." That charity might still then say they are not happy with that. They still have the right to come and seek a meeting with the Minister and myself and put their case but now the Minister is in a position to say: "That has been debated by the partnership board. The third sector is represented there. You had early notice of this, you have had your views listened to and taken into account and there is a good rationale for why we are changing." He may still decide to reinstate something or say: "Let us phase the change so you have more time to adapt to it" but you would not have that sense that we are just being done unto because you have a whole process of involvement.

Would there be a way in for States Members for address the partnership board on any matter?

Chief Executive Officer:

I do not see why not. It would depend because we would have a constant stream of States Members.

The Minister for Health and Social Services:

I would like to look at that because what I would not have is the public taking part in the board meeting. They are welcome to witness it. I know States Members are not the public. I would need to think about how that would work but the intention is to make this inclusive, not to exclude people. It is just how that would work.

Deputy J.A. Hilton:

Yes. I just ask that question because ...

Chief Executive Officer:

Meetings of the board would be meetings in public, they will not be public meetings, and that is the same everywhere else. You would not end up with a Q. and A. with ... otherwise you would never get your business done.

Deputy J.A. Hilton: No, of course not, no

The Minister for Health and Social Services:

Like this meeting here. We have public with us. They may wish to participate but they do not.

Deputy J.A. Hilton:

Yes. No, I just thought I would ask. I am just interested, as a States Member, what ...

Chief Executive Officer:

I would expect States Members to still contact us the way they already do, with various issues that they want to have a discussion about. What may happen is occasionally we might say: "Well, in a couple of weeks' time the chairman of the board is over. Shall we loop them into the meeting as well so that you can get a direct feed from the board?"

The Minister for Health and Social Services:

The situation you described may from time to time occur but it would be much better understood by all concerned, including the charity involved, as to how and why that decision was made rather than just being done' to them.

Deputy J.A. Hilton: Yes.

The Deputy of St. Ouen :

Minister, you have said that you are proposing a pilot of 3 years for this board.

The Minister for Health and Social Services: Yes.

The Deputy of St. Ouen :

If it was felt to go well, what would be the future after that?

The Minister for Health and Social Services:

That will come out at the end of the pilot. To be honest, I do not ...

The Deputy of St. Ouen :

What are the possibilities? You have looked at other jurisdictions and how have other jurisdictions moved forward?

The Minister for Health and Social Services:

Some jurisdictions have a board that runs the whole service. That is not the plan at the moment but that could be an outcome very much in the future. You would have to evaluate, or it has to be evaluated, whoever is in post in 3 years' time ... it has to be evaluated against the criteria we set. Was it successful? Was it not? What worked well? What did not work well? What could work better? Do we need to tweak it? Then you would look: "Going forward, how would this look?" I honestly cannot answer that at the moment.

Deputy J.A. Hilton:

Do you mean that there is the potential to have the board as sort of an arm's-length organisation, like Andium.

The Minister for Health and Social Services: No.

Chief Executive Officer:

You could. That is an option.

The Minister for Health and Social Services: Well, you could.

Chief Executive Officer:

It is not what we are suggesting.

The Minister for Health and Social Services: Politically, I would say no.

Deputy J.A. Hilton:

OK, but there is the potential for it to go that way.

The Minister for Health and Social Services:

I do not believe there is but I suppose anything is possible.

Deputy J.A. Hilton:

You obviously have a different view on this.

Chief Executive Officer:

If I was to reflect the views of all the stakeholders when we did this piece of work, there was a whole spectrum from pretty much where we are now, which is what I think the stakeholders would call a small step, and it is a safe step. I think it is because we have recognised - we have debated this at length across the whole stakeholder group - that I think this board and the work it can do, the benefit it can have, has to be proven. I think that if this board, in the way it works together and the things it can do, proves itself to be valuable, then you will build up trust and confidence. As that builds it may well be that at some point in the future, and it could be 5 years, 10 years, it could be never, there could be a decision taken, a political decision by the Assembly, to say it would make sense for them to do more. That could go all the way down the spectrum to saying: "Let us set up the delivery of health and social services as a completely standalone organisation." You would have to have a different funding relationship. There are places where that is the way it is. One of the things that is gathering a lot of interest in the U.K., for example, at the moment, is the idea of accountable care systems and accountable care organisations. It is a recognition that somewhere along the line they got it very badly wrong. They did this whole commissioner/provider split and they ended up with this very fragmented system with lots of different organisations, all with their own boards and the money flowing in all directions, and then you come up with the idea that a person does not just sit neatly in

"they need a hospital" or "they need a community service" or "they need a G.P." Most people need all of it at different times, so the system needs to work together. They are now busy trying to put the system back together and they are starting to design themselves into things that look like accountable care systems. Some of them are still very much embedded in the N.H.S. (National Health Service), some of them are starting to be led by local government, some of them are completely standalone. You have the devolution in Manchester, if any of you have heard about that. There is lots of experimentation going on across the developed world around this, what makes for a good system and a good organisation, and it becomes ... ultimately it is a decision for yourselves how far you want to take this. It can be any of those things. There are members within the partnership who would love to be very much set up to work independently with a set of agreed objectives and outcomes and a budget and all the rest of it. Most of us tend to think that that is probably too challenging and too worrying because at the end of the day this is the largest States department, it has the biggest budget in the State and it does very challenging and important things for people on the Island. I do not think we are in a place where we would feel comfortable to say: "Shall we just float that off like J.T. (Jersey Telecom) or Andium or whoever?" You may get to that position at some point in the future but at the moment we think we can add real value by taking this leadership role around P.82 and providing that richer advice and support to the Minister.

The Deputy of St. Ouen :

Is there a risk that in 3 years' time some of the members of this board are not going to want to stay advisory? If they are investing a lot of time and effort, they will want to develop the board.

Chief Executive Officer:

They would have to make the case though, would they not, and that case would be a decision for the States.

The Minister for Health and Social Services: The States would have to accept it.

The Deputy of St. Ouen : Yes.

The Minister for Health and Social Services:

It may be a debate that would need to be had but I do not think it is a risk. It could only happen if the States wanted it to happen.

Chief Executive Officer: Yes. They cannot just ...

The Minister for Health and Social Services: I cannot see that myself, but there we are.

The Deputy of St. Ouen :

It is not mentioned in your proposition but would you speak about this during the debate, Minister, the potential ...

The Minister for Health and Social Services:

No, because that is if I spoke about it then people would think that was my intention. That is not my intention. My intention ...

The Deputy of St. Ouen :

Possible directions of travel, because ...

The Minister for Health and Social Services:

You seem to think it is more of a possibility than I do, chairman.

The Deputy of St. Ouen : Well, it is a possibility, is it not?

Chief Executive Officer:

I think the important thing is to recognise that that could not happen just by the will of members of the partnership board. That is a political decision. It would require the States to decide that it wanted a different way of delivering health and social services. I think if you cannot possibly know that ... we cannot know it because we do not know where we will be in 3 years' time. I personally think this will be hugely successful and I personally will make a big commitment to try to make sure it is, and every partner I talk to wants to do the same thing. I think we are on the right track. We are not imposing this. We are not making people do something they don't want to do. The partners want to do this and I think it will be very successful.

The Minister for Health and Social Services:

Frankly, we are having to hold the partners back a bit at the moment.

The Deputy of St. Ouen : Right.

Deputy J.A. Hilton:

Can I ask a question, changing the subject?

The Deputy of St. Ouen : Yes, please do.

Deputy J.A. Hilton:

Can you tell me how children are represented on the partnership board?

Chief Executive Officer:

Children are represented like every other type of person who lives on the Island, through all the members of the board. When we are looking at the long-term direction ... I mean, we have a workstream that is Children's Services, we always have had in P.82, and there have been a number of quite substantial investments on the back of that. You will regularly see business cases that have emanated from that to develop Children's Services and that will always be a large part of the work of that board, along with everything else they do. If you are asking for some reassurance, which I think you probably are and I would expect you to given your interest, that children are not somehow going to be lost in all of this, the department is responsible for the delivery of Children's Services and we have our own internal ways of working together through Susan's department. We have the Children's Improvement Board at the moment. There are all sorts of places that are going to be keeping an eagle eye on safeguarding the interests of children and making sure that those resources are available and those improvements are being made. The partnership board can add to that by making sure that when it is considering bids for P.82 monies that Children's Services bids are coming through that route and getting their place and getting supported. Obviously in terms of the membership the most direct support for that will clearly come from the managing director for community and social services, who of course is by default the Island's chief social worker, and she is going to make very sure of it. If she is sitting in a board meeting and she is not hearing children's issues ...

Deputy J.A. Hilton:

You are going to be sat on the partnership board?

The Minister for Health and Social Services: Yes.

Managing Director, Community and Social Services: Yes.

Deputy J.A. Hilton:

Right, okay.

The Minister for Health and Social Services:

Also, do not forget, children are going to be ... because there is going to be this huge cultural change, not just around the work that we are doing and talking about here but throughout the Island, where children are at the centre of everything that we do, so every decision will have to be looked at in the light of how it affects children.

Deputy J.A. Hilton:

Is that Council of Ministers policy now, that every decision made is going to be...

The Minister for Health and Social Services:

There is not a minute saying that but the Chief Minister has been very clear.

Chief Executive Officer:

It is part of the plan that is being developed. I think how that might manifest is that there will be a very clear recognition. When we bring papers to Council of Ministers there will have to be a section that says: "What does this mean for children?"

The Minister for Health and Social Services: Yes.

Chief Executive Officer:

We would do that and I think we would adopt that at the partnership board as well.

The Minister for Health and Social Services:

I am quite comfortable about that. I would like perhaps it to expand later on to say: "We want this to be for children and their families" because families are part of ... children are part of families and the other way around.

The Deputy of St. Ouen :

Yet the sense I get is that this board is very much clinically orientated. What represents ... how would Social Services be fully and adequately represented on the board?

Chief Executive Officer: Through the chief social worker.

The Deputy of St. Ouen :

Just the one member?

The Minister for Health and Social Services:

Possibly through the third sector, the patient forum, as well.

The Deputy of St. Ouen : Possibly?

Managing Director, Community and Social Services: Also the clinical ...

The Minister for Health and Social Services: Because it has not been ... Sorry.

Managing Director, Community and Social Services:

Sorry, Minister. I beg your pardon. I would expect there to be Social Services staff within the clinical and professional forum and I think in relation to the voluntary and community sector forum there will be many organisations in there who work with the same people that Social Services work with in terms of levels of need, vulnerability or being at risk. I think it comes up there and I think your points earlier about how to make sure the public and patient advisory group reflects the population is absolutely key to this. This does very much chime with some of the lessons from the Care Inquiry. It set out very clearly that it is about the whole system, it is about listening to people's voices, it is about doing things with people. This is a very interesting, I suppose, in relation to that.

[13:15]

The Minister for Health and Social Services:

Do not forget children use clinical services as well as the families. Children are very much a part of this.

The Deputy of St. Ouen :

Yes. I suppose I have a worry that ... well, in the light of the Care Inquiry findings that we had failed as a corporate parent and the system had failed and had not developed, it seems Children's Services were regarded very much as a Cinderella service. Will this board provide Children's Services, Social Services, mental health services...

The Minister for Health and Social Services: Yes.

The Deputy of St. Ouen :

... with full presence so that their priorities can be ...

The Minister for Health and Social Services: It is all Health and Social Services.

The Deputy of St. Ouen : Yes.

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

Chief Executive Officer:

This is one of the issues which always promotes a lot of debate in every system I have ever worked in because no matter how you construct a board, you cannot put every interest at the table. You would have a board of hundreds. I know in the past I have certainly been challenged when somebody said to me: "Well, there is no Allied Health professional on the board so how does the voice of occupational therapy, physiotherapy, et cetera, get heard?" The answer is not to put a representative on the board; the answer is to challenge the professional group to say: "How can you demonstrate you have links and you are involving those groupings?" You might have a social worker or several social workers sitting as part of the professional group, you might not, but it is the responsibility of the person who is chairing that professional group and the 3 people who are coming to that board to be able to demonstrate with evidence that they have got the voice of social work in. Personally I think we will be hearing it loud and clear but there are other groups you could say may not be get heard loud and clear. If you look at the membership of the board it is quite interesting because there is more of a voice for lay and professional than there is for managerial and that is quite right, because when you look at my top team I am probably the only person - other than Jason because obviously he is an accountant by background - who is not clinical by background. All of my other staff are social workers, they are nurses or they are various other clinical types of background, and that is deliberately so because the best decisions are made when clinicians are at the table and when the public is at the table. When you get all those interests together you can create something really special. If you leave a key interest out, you will not get the best decision.

The Deputy of St. Ouen : No.

Director, System Redesign and Delivery:

In terms of the structure of P.82, which the system partnership will oversee, that has at the moment 5 elements. It has acute services, out of hospital, primary care, mental health and children's. That will continue and they need to have equal weight, which is why, in this phase of our P.82 investment, we are investing heavily in acute services and children's services.

The Deputy of St. Ouen :

Yes. I really hope that is the case. It is just that attending the conference on Monday, Susan, you went through your 2 slides on the future and there is so much that needs to be worked through in Children's Services.

Director, System Redesign and Delivery: Absolutely.

The Deputy of St. Ouen :

So many strategies to deliver, and yet all this has to be put through the new system partnership board.

Managing Director, Community and Social Services:

It potentially gives a real opportunity. People talked about a much more broad church of views and a richness of debate. One of the things I think the Care Inquiry does suggest is that Jersey has not owned what happens to their children in a very positive and productive way. I think anything that gives an opportunity for people like me and others, as part of that system, to get our voice heard. I have absolutely no doubt that I will have my voice heard. I think that is part of my job, the way it is for others. I think that is a good thing and I think it will sit alongside other interfaces like the improvement board or the new Council of Ministers' community subgroup. That is really important because we need to get all aspects of the system working together.

Chief Executive Officer:

I think this board has a real role to play because it brings some very important people to the table to own this agenda but I think the bigger issue, and it came up at the community policy board which I think you were at, Deputy Hilton, is how we get that cross-working across the whole State.

Managing Director, Community and Social Services: Absolutely.

Chief Executive Officer:

That is the bit that needs the attention. I am very confident that this board will add to our work to improve our services but the issue of improving things for children, young people and their families across the Island is a multi-departmental, multi-organisational challenge and I do not think we have cracked that yet. That is the thing I think the community policy group could really take hold of and start to look at. How could it empower the right people to come together to give that focus?

The Deputy of St. Ouen :

Yes. Before the meeting, Deputy Hilton pointed out to me a reference in the proposition where you spoke about the board having formal links to other States departments.

Deputy J.A. Hilton:

We were wondering how that was going to work.

The Deputy of St. Ouen :

What would be those formal links that the board would have?

Chief Executive Officer:

We are still working that up. The simplest way would be simply to say to the Department of Education, the Department of Social Security and C.C.A. (Community and Constitutional Affairs): "Send a representative along" but then of course we have made the board even bigger.

Deputy J.A. Hilton: Yes.

Chief Executive Officer:

I think that is something that we are still working through, talking to those departments about what might work best. It may well be that we forge those links through some of these other relationships that we are putting in place. It may be about them being involved in the subgroups that are working on the individual parts of the strategy. I think it would be about us testing the thoughts of the board and inviting them to comment on them. It may be about inviting them for particular issues to contribute to a debate. We are still working that through and talking to them because, as I said earlier, we are trying to not be prescriptive. That is not just with our partners but those other departments are our partners too. Just to say: "We want you to interrelate in this way" would be wrong. We need to say: "This is what we are trying to do. These are our aims and objectives. You are a key partner for us. What is the best way for us to work with you?" and work it up that way.

The Deputy of St. Ouen :

Okay. In the light of the Inquiry report, Minister, there is no reference to children in the proposition at all, in all its 18 pages. Do you think, in the light of the findings that children's interests should be first and foremost and children should be listened to ...

The Minister for Health and Social Services: That was the logic for the report itself.

The Deputy of St. Ouen :

How can children be given a voice in the proposed governance procedure? We are told children must be listened to.

The Minister for Health and Social Services:

Yes. Again, we have the community involvement. Would that have a young person such as the one speaking on Monday? I do not know.

The Deputy of St. Ouen : Yes.

Chief Executive Officer:

Susan, do you have a view? I know you have been doing a lot of work with others to think about children's role.

Managing Director, Community and Social Services:

Yes. There is a lot of work taking place, particularly led by the Youth Service, who are really the professional experts in terms of young people's participation. There is a lot of work happening within the broader children's landscape around that. There is work going on with that. I think we do need to have children's voices in here. We are purchasing an app that can be used on mobile devices and it is called M.O.M.O., Mind of My Own. I think we mentioned it on Monday.

Deputy T.A. McDonald: Monday, yes.

The Deputy of St. Ouen : Yes.

Managing Director, Community and Social Services:

I do not know. As I was sitting here thinking about how you include people's voices who probably do not want to come along to a meeting and listen to the likes of us talking about things, they might want to feed in in a different way. I think some of that is about saying: "How do you use technology for young people? How do you use the Youth Service? How might you use the Children's Commissioner or children's rights? I think it is about how you bring the pieces of the jigsaw together to truly bring it in. I do think as we develop strategies and policies, as Julie mentioned a moment ago, there does need to be a challenge about: "How does this impact on children? What is the impact assessment? What is the benefit to children's life of this policy or this strategy?" I think the board has a role there. I do think for children and young people, you have to look at how they might want to buy into contributing.

Deputy T.A. McDonald:

How they want to communicate.

Managing Director, Community and Social Services: They will have a view.

Deputy T.A. McDonald: Oh, yes.

Managing Director, Community and Social Services:

There is no doubt they will have a view. It is incumbent on us to find out how best we support them to make that view known widely.

Deputy T.A. McDonald:

M.O.M.O. is very, very good. It is the right pitch, the right media.

Managing Director, Community and Social Services:

It has very good evaluation and evidence of success elsewhere. It has been quite widely used in the U.K. It is good stuff. You can use it on an ongoing basis for us with children who are looked after or you could do a broader participation engagement kind of thing. It might be something. I do not know for sure but it sounds like it could be something we might use.

Deputy T.A. McDonald:

Yes. It is getting in touch with them and getting them to feel they have been included ...

Managing Director, Community and Social Services: Absolutely, yes.

Deputy T.A. McDonald:

... and their voice is being listened to.

The Deputy of St. Ouen :

We are coming to the end of our questions and possibly the meeting. Deputy McDonald, do you have any more questions?

Deputy T.A. McDonald:

No. To be honest with you, I have learned more from Julie and what she is saying because at the end of the day, you have done this. You have been, got the t-shirt and everything else. There are a couple of notes. Is there anything else that you would like to tell us, based on that experience? All of you, I mean. You have all come from different backgrounds. Is there any message that we really need ... everybody needs to understand about where these things have gone wrong in the past or ...?

Chief Executive Officer:

I think where they go wrong is that not enough time and attention is given at the beginning to people coming together and really debating together: "What is it that we are here to do? What are our objectives? What will success look like? What are the behaviours that we need to model? What will we do if there is a difficulty? What will we do if we are doing a piece of work together and we have really disparate opinions?" What happens if you have not had those discussions and you have not worked up your behaviour, your values, and the way you interact with each other, is sometimes people just go quiet or they just go and they complain outside of the room. That is when you start to find boards becoming ineffectual. The more time you put in upfront of that, what you would call organisational development activity, growing the group's confidence, getting to know each other as people and developing those rules of engagement, is really, really important. We are very keen that rather than do this quickly, we want to do it right.

Deputy T.A. McDonald:

Yes. We are obviously at a very early stage. We are getting the people involved, the numbers, the power and everything else. Really we do need to do a lot more in the way of discussions.

Chief Executive Officer:

We do. Next year will be very important in terms of doing that piece of work, assuming that the Assembly does decide that it is a valuable thing to try. Then we will spend the early parts of next year doing all of that working together, getting the representation sorted out, helping people to come together and develop together with a view to it being a board that can work well as it moves into bidding into M.T.F.P. 3, which of course is not that far away for us, really.

Deputy T.A. McDonald: No, it is not.

The Deputy of St. Ouen :

Just to understand a bit of the timescale, if the States are happy with this proposition, when would the chair and non-executives be recruited?

Chief Executive Officer:

We have, as you know because we have shared them, some draft job descriptions and personal specifications for those roles. The Appointments Commissioner is aware that this proposition is being lodged and that there may be a requirement for them to engage with this process, and obviously they have companies that they work with to source people. I would expect that in the first couple of months of next year, assuming that this gets signed off in November, December/January time we would go through that process. I would hope by February/March time we would have the chair and the non-executives available to us. Clearly in that same 3-month period we can start to up the profile around working with the individual forums so they can start to think seriously about how they will find their representatives, so that by the time we get into late spring we can start bringing people together. I think if you were to ask me then, obviously we have the election so there will be a period of time when in some respects it will be quiet, for us if not for yourselves, and we can do a lot of that working together so that as we get towards the second half of the year the board can start meeting, it can meet in public, it can do its business and it can start to think very seriously about what role it can play in supporting a new Minister, or the old Minister. I do not know who it will be but somebody will come in and take on that role, I assume, and they will have the benefit of having that board and that chairman ready to be supportive and do the work that they are asked to do.

The Deputy of St. Ouen :

Right. Thank you. I have no more questions. Is there anything you want to give to us? Well, thank you.

Deputy J.A. Hilton: Thank you very much.

The Deputy of St. Ouen :

It has been useful, very useful, and given us a better understanding of all that is proposed. Minister, thank you.

[13:28]