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Health and Social Security Scrutiny Panel Assessment of Mental Health Services
Witness: Minister for Health and Social Services
Thursday, 10th January 2019
Panel:
Deputy M.R. Le Hegarat of St. Helier (Chairman) Deputy K.G. Pamplin of St. Saviour (Vice-Chairman) Deputy C.S. Alves of St. Helier
Deputy T. Pointon of St. John
Witnesses:
Deputy Richard Renouf , Minister for Health and Social Services
Robert Sainsbury, Group Managing Director for Health and Community Services Karen Wilson , Interim Director of Governance, Quality and Nursing (Community) Dr Miguel Garcia, Consultant Psychiatrist and Acting Clinical Director
Rose Naylor, Chief Nurse
[14:04]
Deputy M.R. Le Hegarat of St. Helier (Chairman):
Good afternoon, everybody, and welcome to the first Health and Social Security Scrutiny Panel with the Minister for Health and Social Services this afternoon. Predominantly this afternoon is about us asking questions of the Minister. I am aware that there are quite a number of other States officials here but most people that are here this afternoon have already spoken to the panel and the panel have had quite a lot of dealings and meetings with, so we want to particularly focus this afternoon on yourself, Minister. What we will do is we will introduce ourselves but we might just not introduce everybody unless we need to sort of ask somebody a particular technical question and therefore they could probably at that time say who they are and then they can answer the question because otherwise it will get a bit too disjointed for everybody out there that is listening. We have had quite a lot of opportunity to speak to most of you already anyway and obviously if there is anything at the end where people think that they want to interject then that is fine but we are obviously an hour and a half so we do not want to get too bogged down with too many people answering too many questions. Fully appraising that this is under the same rules as the States Assembly, so parliamentary privilege. I will just kick off and say that I am Deputy Mary Le Hegarat of St. Helier District 3 and 4 and the chairman of the Health and Social Security Scrutiny Panel.
Deputy K.G. Pamplin of St. Saviour (Vice-Chairman):
I am Deputy Kevin Pamplin and I am vice-chairman of this panel.
Deputy C.S. Alves of St. Helier :
I am Deputy Carina Alves of St. Helier District 2. I am a member of the panel.
Deputy T. Pointon of St. John :
Deputy of St. John , Trevor Pointon, and I am a member of the panel.
The Minister for Health and Social Services:
I am Deputy Richard Renouf of St. Ouen , Minister for Health and Community Services.
Managing Director, Hospital and Community Services:
I am Robert Sainsbury and I am the group managing director for the Department of Health and Community.
Interim Director of Quality, Governance and Nursing (Community):
I am Karen Wilson , I am the interim director of governance, quality and nursing and the lead for mental health within Health and Community Services.
Deputy M.R. Le Hegarat :
As I said, if any of the other persons that have come this afternoon have anything to say then we will get them to introduce themselves, otherwise we will spend too much time on introductions. The first question I want to ask of you, Minister, there has been considerable change over the last few months even, let alone the last 12 months. Which officers are now in charge of mental health services? Who is now in charge of the mental health service?
The Minister for Health and Social Services:
In overall charge is Mr. Sainsbury here who is taking the lead and perhaps I could ask him to explain how the organisation flows from that.
Deputy M.R. Le Hegarat :
I would prefer you to explain that to us because, as I have said, we have already had some interjection from Mr. Sainsbury so I would prefer for you to say to us, from your perspective, who is in charge and how that all pans out.
The Minister for Health and Social Services:
There is now an acting clinical director who is Dr. Garcia; leading the strategy side we have Karen Wilson here, and those are really the key personnel in the leadership positions, and of course the chief nurse has a role across all nursing but she has a role in the mental health nursing and that is the structure that we will be going forward with.
Deputy M.R. Le Hegarat :
On what basis were these changes made? So on what basis have we put that structure in, if you like?
The Minister for Health and Social Services:
It is part of the structure the department has been setting forth in its target operating model and it is for that reason. I do not know how much it differs from what existed previously in terms of organisational structure.
Deputy M.R. Le Hegarat :
You may not be able to answer this question, however if you cannot I would only like the 2 people sat next to you to answer on their own behalf, and that is: how are the people in these current positions qualified to lead the mental health services? So, if you are not able to answer that question, I would be grateful if the 2 people sat next to you would answer those questions in relation to how are they qualified in relation to leading of mental health services?
The Minister for Health and Social Services:
Mr. Sainsbury is qualified by virtue of his appointment as our group managing director. Mental health is the area under his responsibility as group managing director. But as to any further qualification may I ask him to answer and Karen also?
Managing Director, Hospital and Community Services:
There was always going to be one managing director for the service taking over the whole of the Health and Community Services structure; there were previously 2 managing directors. We had an interim director brought in to support us bringing together the position to get to one managing director
role and we have enacted that earlier because the interim director has now left. So in terms of that
leadership change that has happened over the last 4 weeks where the services have come over to my executive responsibility. I hold that with the chief nurse in her role and the medical director in his role as the accountable responsible officer for the doctors. In terms of my experience with mental health services, I have been an executive director in commissioning mental health services previously; I have worked with a number of different mental health trusts in West London, in Devon, and I have also been an assistant director and head of service for both acute services, mental health services and social care. So I have quite a lot of experience and understanding of both community and inpatient mental health services in terms of my own personal experience.
Interim Director of Quality, Governance and Nursing (Community):
So my background is as a professional nurse with a qualification in mental health and general nursing as well. I have worked as a mental health practitioner on the frontline right up to leadership positions in community and inpatient services in community and mental health organisations. I have held 2 previous executive posts as director of nursing in 2 large specialist mental health trusts, one of which was responsible for one of the 3 national high-secure services in the U.K. (United Kingdom). I have also been the chief executive of an NHS Foundation Trust providing forensic learning disability services and Managing Director of a large charity that provided mental Health and learning disability services – both were located in the north west of England.
The Minister for Health and Social Services:
Chairman, can I ask, would you be interested in hearing the experience of the medical director and chief nurse so that you know as a panel what experience the team brings?
Deputy M.R. Le Hegarat : Okay, yes.
Consultant Psychiatrist and Acting Clinical Director:
I have had the pleasure of meeting you all. I have been a consultant psychiatrist here for 10 years. I have gone to numerous leadership courses but what I have is a lot of common sense and a good understanding of what is happening here in Jersey and what needs to change. So I might not have a specific degree in leadership but I can tell you I have a lot of intelligence that can help us to shape the services.
Deputy K.G. Pamplin:
Just for a point of clarification, you were recently appointed and were you aware of that when you met us before Christmas or has this recently happened?
Consultant Psychiatrist and Acting Clinical Director:
It just happened. No, I was not aware; that happened afterwards.
Deputy K.G. Pamplin:
Did you apply or were you aware or were you approached?
Consultant Psychiatrist and Acting Clinical Director:
I have been involved as a clinical lead, in clinical lead position, for the last 18 months so it was something I could see coming, but it has just materialised in the last 2 weeks and I have accepted quite happily because I really believe the management team is helping once and for all to sort out mental health services.
Managing Director, Hospital and Community Services:
Both myself and John McInerney, the medical director, had identified that we needed a clinical director who was from a mental health background to support Karen operationally. We have also brought in a gentleman at the back there, Graham Wassel, who is an operations manager who also has a background in mental health, he has been a mental health nurse and is a general manager and it was my impression in the short time of being responsible for the services directly that we needed greater operational management leadership and support to be brought in. That is something, as the Minister said, we want to frame into the future permanent structure so the workforce know exactly who is in charge for the long term of the service.
Chief Nurse:
I am Rose Naylor; I am Jersey's chief nurse and I have experience in Health and Social Services in the last 13 years, that I have worked in Jersey, both as a director of nursing and then as the chief nurse. In relation to my professional role, my responsibilities extend to all nurses in Jersey who register with the Nursing and Midwifery Council, so I work with the operational areas and support those with the clinical expertise in fulfilling their duties in relation to the nursing profession.
Deputy K.G. Pamplin:
Minister, we understand that a new Mental Health Improvement Board has been established, we started alluding to it, how do you see the purpose of this board working?
The Minister for Health and Social Services:
To focus on the very clear needs that we have and the role is in the title; to ensure that we make improvements and meet people's needs.
[14:15]
Deputy K.G. Pamplin:
We understand the board is made up of officers. How does the board report and how does this work in practice? Who do they report to and what is the practice following that procedure?
The Minister for Health and Social Services:
It will be reporting to the management executive board and therefore the director general.
Deputy K.G. Pamplin:
So will the board be made up of other people, for example people with lived experience of poor mental health or an experience in the community, working for health-based charities or nursing backgrounds, what is the sort of makeup of the positions and the roles, their experience?
The Minister for Health and Social Services:
I am not aware that is the plan at the moment. That sort of user interface I would hope might come through the user body that we intend to establish with the new governance board that we are going to be setting up shortly. We want a user group in that, which I anticipate would include those sorts of people you have just spoken of.
Deputy K.G. Pamplin:
I guess the point I am getting to is the board, who those people are and, as we started with everybody's relation to mental health, what their role is, what their background, what can they contribute on their position as a board member?
The Minister for Health and Social Services: On the mental health improvement board?
Deputy K.G. Pamplin: Yes.
The Minister for Health and Social Services:
Yes, it is a management function; it seems to me, focused on delivery.
Managing Director, Hospital and Community Services:
The board was set up to drive the mental health strategy in all honesty. We felt that we had gone so far with the mental health strategy and we needed to focus it on real improvement and it does have community representation, so Mind are a part of it; we have brought in some service users to the board so we can hear their experience of the service. That needs to be built upon and where we are now is that, while the board was set up for strategic delivery and improvement, we need to
address the operational improvement requirement, the here and now of the service challenges, and so the board is going to inevitably change its focus as a result of that and it is going to have to deal with how do you improve the services right now and deliver your future mental health strategy? So it has changed in context and Julian Blazeby, director general for Justice and Home Affairs, is our independent chair of that board so that he can provide scrutiny to us in terms of our development and our progress in relation to that. It does link to the management executive committee and the new structure of our new H.C.S. (Health and Community Services) board it will feature through to that. We have not started that board yet.
Deputy K.G. Pamplin:
Sure. When is that likely to start?
Managing Director, Hospital and Community Services:
We are hoping to hold the first board by March and we want to tie it into the appointment of our new director general because it would be good to have that timeline adhered to. But we are looking at March; potentially April if we cannot get the date sorted in March. It depends on when our director general can be released.
Deputy K.G. Pamplin:
Just picking up on what you just said there about the director general for Justice and Home Affairs, we know he is with us, Minister, just curious about your opinion on this, why someone from Justice and Home Affairs is chairing the board, albeit from an independent point of view, just interested to hear your view on this?
The Minister for Health and Social Services:
I think it is valuable because it underlines the fact that this is a service that cuts across so many departments and aspects of States working, so Mr. Blazeby brings his experience within the police service and the justice system, which have that crucial role within mental health issues as well. It means that I hope we can work better or have a better overview of all needs within the service.
Deputy K.G. Pamplin:
So a sort of, as Mr. Sainsbury was saying, scrutinising role, which we are all familiar with, but not one to bring across as defining policy and influencing policy, but is there to see the operation model and in that role.
The Minister for Health and Social Services:
Certainly, as operational, and it is great, is it not, that we could have 2 director generals involved in this work?
Sure, good to get clarity, thank you.
The Deputy of St. John :
Minister, thank you for coming in. I am going to ask you about the means by which you get information from your officers. Could you describe the reporting mechanisms that exist between you and your officers that give you a feel for what is going on?
The Minister for Health and Social Services:
Yes, once a month, or perhaps not exactly once a month, but they are ministerial meetings at which I meet with various heads of service within the department and I receive briefings on all that is going on and we discuss issues of importance. I also receive the agenda and background papers for the management executive and am able to ask questions. I have regular meetings with the director general and with Mr. Sainsbury and of course there is just the normal day-to-day inquiries that we make, the emails that fly between us, the casual meetings or more organised meetings about specific subjects. So there is a lot of activity.
The Deputy of St. John :
Those emails, so given that you seem to have a lot of communication with your officers, what would be your impression of the current state of the mental health services?
The Minister for Health and Social Services:
My impression is of a service that has been put under very great strain and is obviously, we know, not staffed as fully as it should be at the moment, but nevertheless those who work in it are producing excellent work under a lot of pressure and are dedicated people and care deeply for the people they have under their care. But they need support, better support, and we need to complement them with additional appointments and to bring our numbers up. That is clearly the greatest pressure we face at the moment I believe.
The Deputy of St. John :
Support begins firstly with Government, does it not, in the sense that you, the Minister, are the facilitator and part of that is obtain sufficient in revenue cash to be able to fund posts that have been vacant perhaps for a long time?
The Minister for Health and Social Services: Yes.
The Deputy of St. John :
What is happening in relation to obtaining those funds?
The Minister for Health and Social Services:
So I understand that the staff complement that is allocated to mental health services is agreed and I do not think there is any question that there are not enough posts; I think it is question of there are not enough people filling the posts at the moment. I stand to be corrected if others feel differently. Therefore I think the budget is there to meet the salaries for the posts that are in existence, so the budget is there to recruit and pay the staff that we should have.
The Deputy of St. John :
So what do you think are the hurdles to get over given that the budget is there, hurdles to get over to bring more people into the posts that are available?
The Minister for Health and Social Services:
The first thing to understand is of course that this is not particularly an Island problem but it is a problem that is incurred throughout the N.H.S. (National Health Service) from where we draw most of our staff and I think throughout many other jurisdictions that there just are not the mental health practitioners there to meet current need. That is partly because there is an increased understanding of mental health issues, people are seeking help where they might not otherwise have sought help, and also there is the problem of us growing older and mental health issues arising as a result of dementia pressures or the like. There does not seem to have been the training or the resources put into training mental health nurses Europe-wide in the past. So we are recruiting in a very limited pool and we are recruiting to an Island that has its attractions and is a pleasant place to come and live but it is also an expensive place to live. So at first sight I understand salaries may be attractive but when staff begin to investigate the costs of housing here then sometimes that means that they turn down any offers of a job.
The Deputy of St. John :
What is the ministerial group doing to address that?
The Minister for Health and Social Services:
Training. If we could train locally that would begin to help I believe. We have seen it in general nursing and it can help in mental health nursing. I know there are some initiatives that our chief nurse can perhaps talk more on, but we are now going to be able to offer financial help to people who wish to train here to qualify as mental health nurses. We are also talking with Guernsey about undertaking a training course here, or it might be in Guernsey, I do not know, but between us offering
the lectures and the training programme in Jersey or Guernsey, which I think will help a great deal.
This year there are 5 local nurses training in mental health but we can grow that capacity and I really hope we do. That is a big step forward.
The Deputy of St. John :
How will you increase your experience base? These people will not have experience, will they, they will be very much newbies to the game.
The Minister for Health and Social Services:
Yes, so I do not know whether in the course of their training they would undertake practical experience elsewhere, because ...
The Deputy of St. John : I'm sure they would but ...
The Minister for Health and Social Services:
... I think the practice at the moment is that they run the academic training in Chester but often come back to Jersey for the practical side of things and I do not know whether that could be reversed. Our chief nurse might be able to help with the specifics.
Chief Nurse:
So, as the Minister said, we have 5 nurses on the programme at the moment. Our intent is that we offer more nurses locally the opportunity to have some assistance with funding to start the programme in September. Our aim is to have a Channel Islands programme in 2020 and also to do something over the course of this year, which will enable some of our experienced healthcare assistant workforce an opportunity to access the nurse training programme, as you know, which is now a degree-based programme. So we are just putting the detail together around that and our divisional lead is helping us with some of the funding around that. In terms of bringing in experience, you are quite right, we need to have a mixture within our workforce of experienced nurses as well as newly-qualified nurses, so we do have a number of initiatives that we are introducing at the moment in terms of some recruitment incentives to attract people from off-Island to come into Jersey, but also really exploiting our C.P.D. (Continuous Professional Development) opportunities that we have here for nurses. So we are able to provide degree and masters level programmes locally. They are accessible to any nurses but I do not think we necessarily promote them as well as we should when we go out to recruit, so again alongside some additional recruitment incentives we will be exploiting the C.P.D. opportunities for nurses.
The Minister for Health and Social Services: For the public, C.P.D. is ...?
Chief Nurse:
Sorry, Continuous Professional Development opportunities.
The Deputy of St. John :
Thank you for that. That is informative. Then finally in relation to this question, what is the ministerial group doing about the need to level salary and income with the increased cost of living and housing?
The Minister for Health and Social Services:
Yes, so there are initiatives, there is a group looking at key worker accommodation and I understand that we are in a position now where we can address, for example, one issue about bringing in people who would begin on a probationary period of say 6 months but who might be in a position where they can only lease premises for 3 years; that puts them in a difficulty, they do not have that assurance they would pass their probationary period. I understand from the chief nurse that there is now a means of ensuring that we can overcome that worry for them about having been lumbered with 3-year lease if they cannot get past their probationary period. There are premises coming through that are available now to key workers. I had a look around, is it still called Convent Court? Plaisant Court, is it not, that is right, in Val Plaisant, which has been refurbished for key workers, including families, because many of the people that do want to come over are family people so we must provide that accommodation, and that was very pleasant accommodation it seemed to me? I would certainly be happy living there. So again can I ask the chief nurse if she would want to add to anything that I have mentioned about key workers?
[14:30]
Chief Nurse:
It just so happens I am on a few groups that the Minister is talking about so there is a States-wide group, which is looking at key worker accommodation and we had some work done around focus groups, so real experience with staff who have recently been recruited. The report came in from the company that was commissioned to do the work in December and we met earlier this month and there are 3 key workstreams that are coming out of that. So one is around the 6 to 9-month offer, so when somebody first comes to Jersey they are put in accommodation on a temporary basis while they find their feet in Jersey. There is work that we need to work up around how staff can access affordable housing in a more settled status than they have at the moment, so this is the offering around the leased properties, so securing longer-term leases that give staff that security; our staff have a lot of churn through the private rental market but also working with social housing providers to support that as well. There will be work required around the gateway on that. Then the third piece is around the affordable housing offering in terms of how we can encourage and support staff
to buy properties to settle in Jersey and again there is quite a bit of work up that needs to be done around that. In addition to that there is a piece of work called Welcome Jersey, which is about the outward-facing welcome to people who are looking to come to Jersey. That piece of work, along with a provisory location package and 2 local companies who will help onboard people, so they will contact individuals once they are offered jobs to assess their housing needs, whether they have children, they will help them get their social security number, all of those things that are quite difficult for people to navigate will be done by some on-Island organisations in the future so they will have a single point of contact. It is anticipated that will all go live in March so we are very close to that. However we are hoping that we can pull some of that forward to support some of the staff we have in the system at the moment.
The Deputy of St. John : Sounds encouraging.
The Minister for Health and Social Services:
That last point really chimes with me because coming to Jersey is different from just moving up and down the U.K.
The Deputy of St. John : Up and down the motorway.
The Minister for Health and Social Services:
That is right. But we just have different systems here and being an Island is perhaps a different way of life, different, and travelling to and from the U.K. is something we have to get used to. So to have somebody who can explain the social security system, who can explain the education system to people wanting to come here and all those minutiae of life, which we are used to and we do not think are a problem because we are here, but when you are trying to move here with a family will be complex. It is the sort of service that was offered to the wealthy residents that we were bringing in and to the high-level civil servants who have come in recently and it is deservedly now going to be offered to our key workers.
Deputy C.S. Alves :
I am not sure if you can answer this, Minister, so bear with me, how do you manage the performance of your mental health services?
The Minister for Health and Social Services:
We do need some key performance indicators. I am not a manager so I am not looking at key performance indicators as such; I am looking at it more from a political point of view, so perhaps this is a question I can ask Mrs. Wilson ?
Interim Director of Quality, Governance and Nursing (Community):
There are a number of indicators that we focus our attention and our performance, and clearly they are really activity-based indicators at the moment. We would like to shift to more outcome-based information that helps us drive our performance improvement. So the areas that we look at are things like waiting times, referral to treatment times, we look at some of the public health data in terms of prevalence, we look at incidents, complaints. We also have in some areas feedback from service users and carers themselves about their experience of care and support. The key things I think for us are about focusing on measuring how accessible we are, how responsive we are, and also how financially and clinically effective we are. So some of our indicators also relate to some of the clinical performance measures around the effectiveness of some of our care, so how people recover and how soon people can get out of hospital to lead their usual life. So things like how long they stay in hospital, bed occupancy, length of stay, those sorts of things will drive a review of how we understand performance of the service as it stands.
Deputy C.S. Alves :
Do you benchmark the services with other jurisdictions?
Interim Director of Quality, Governance and Nursing (Community):
We do. We are part of the N.H.S. benchmarking club. Our data is not as robust I think to provide full comparison, so in the areas where we can compare that is where we submit to the benchmarking.
Deputy C.S. Alves :
This is something that was just touched on by Deputy Pointon earlier about finances so I just want to ask the Minister: do you think that the mental health services require more financial investment?
The Minister for Health and Social Services:
The priority at the moment I think is to achieve our staffing complement, and we work with a number of partners. The answer to that must be yes because I think there is a great need, there is increasing emphasis on people's mental health and people seeking help. So perhaps additional finance, not necessarily within the services we provide but also to be directed towards the partners in the field. I know that the likes of Mind and the Jersey Recovery College have an understandable concern that they are only funded for very short periods at the moment, and that is the difficulty about the way we operate as Government and States, is it not; we have these plans which last for a finite time. But I
can see how much more secure their services would be if we could say: "You have guaranteed
funding for a period of time" and they can bring great user experience, expert experience by reason of their stories they have, to help people with mental health difficulties.
Deputy C.S. Alves :
So is there a plan for that and, if so, by when? Is there a kind of time ...
The Minister for Health and Social Services: Yes.
Managing Director, Hospital and Community Services:
There needs to be more investment undoubtedly. We need to shift our transformation funding into the mental health remit. The area where we have identified we would probably do that is crisis prevention and intervention. We think that is quite sizeable, it is over £1 million, potentially up to £1.2 million that we would need to invest. I just need to caveat that with: we cannot establish these services until we have addressed our overall staffing deficits because you would just be taking staff from a really hot area into another area, making it even worse; so we have got to get our vacancies sorted. We then, once we have done that, can then start to build on those kinds of transformation approaches. We could do some stages of it, the listening lounge and other things that are part of the spec, but it really comes down to people and we need to invest in more roles to support that prevention agenda and then the intervention agenda when we get to the point of crisis. That will take time but the recognition is that we will have to allocate money for that.
Deputy C.S. Alves :
Is that money that is already available or is this money that we are seeking to ...
Managing Director, Hospital and Community Services:
So that is a financial allocation that we have made for 2019. I do not think that is able to be realised in 2019 because I do not think we can address all of the vacancies that we have for that. I think we can do part implementation; I think it is key to the current approach we are taking because it is a bit different what we are trying to do in recruitment now and how we are trying to incentivise people. Once we have got an idea for that I think we will then get an indication of how much of that we would draw down. We would not lose that for 2019, we would continue for 2020. We have identified within P.82 you have to shift that funding to mental health, and that has been my priority in establishing the budget for 2019. In addition to that we have also identified financial allocation for an alternative environment potentially for some of our mental health services, physical environment, and that could be up to £2.4 million that we have identified. So this would represent the most significant transformation funding within our department, more than physical health, but obviously a big part of it relates to staff.
Can I just pick up on a couple of points made about the measuring of performance? I heard "data not robust", I heard "we do need one", I heard "transition". So how can you measure and how are you measuring the progress to deliver the mental health strategy which was started a few years ago, and really identify the progress to match what you are talking about financially? How are you doing that if you are telling us the data is not robust and the key performances are not there?
Interim Director of Quality, Governance and Nursing (Community):
So we are measuring what we can measure and I think what we have identified is that there are gaps that we need to work through as part of an improvement agenda. So that is why the benchmarking information is really important because that gives us an opportunity to understand how we are performing against similar others; they are very clear benchmarks that can be reported on. I think what we need to do is also think about producing outcome-based information, performance information, which I do not think we are collecting in the way that we need to at the moment. But I think this is part of our assessment around what improvements need to be brought to the table around that.
Deputy K.G. Pamplin:
Just digging into how that works; you talk about benchmarking, is there a place that is like the current service available that we have encountered at Orchard House in the United Kingdom, when you talk about benchmarking?
Interim Director of Quality, Governance and Nursing (Community): Yes.
Deputy K.G. Pamplin:
So again I think it is fair to say there are elements there that are woefully in place, so how does that work when you are trying to benchmark about what is being done which is very different in the U.K. where they have mental health facilities? Just to dig in to explain to people how that works.
Interim Director of Quality, Governance and Nursing (Community):
So really in terms of what you look at are the indicators or the key performance measures that you can collect data about. So I talked about bed occupancy, so it does not matter which inpatient unit you choose to collect data on, if you can collect that data around the number of times people occupy a bed you compare that with another similar organisation or similar service. It is the same in terms of admission rates; you can compare those sorts of things. The things that I think we are talking
about in relation to outcome measures should answer the question are we better or worse in helping
people recover in a particular period of time, and what does that tell us about our effectiveness in terms of how good our interventions are, how good our broader service arrangements are. I do not think at the moment we can offer you that because that needs quite a bit of work to be done around it, so what we are able to offer is the activity-based information that is driven through what we would call a minimum data set. So everybody who comes into hospital has a record of when they came in and when they went out, which allows us to calculate things like length of stay. Everybody who comes in has an assessment of whether or not they are detained under the Mental Health Act or not, so we can report how many people are detained under a legal article, how many people are informally coming into our service. So we are measuring what we can measure at the moment but I think when we are talking about the overall improvement we have not really identified what the outcome requirements will be around that improvement plan because it is still evolving as we speak.
Deputy M.R. Le Hegarat :
All of us on this panel have been to the facilities in relation to mental health. What is the government plan in relation to updating and improvement the mental health estate?
The Minister for Health and Social Services:
So there is work being carried out on Orchard House at the moment, complying with the statutory notice that was served on the department, but the medium-term intention is that Orchard House should be closed and that we should create a new facility across the road at Clinique Pinel and there are plans being worked up to create that facility. There is a wider or broader plan to move all those facilities presently in St. Saviour to Overdale, but I think at the moment we have kind of put a pause on that because you cannot do too much at once and I think we have got to make sure that Orchard House is safe and improved for the very short term, and then we have got to concentrate quickly on getting the work at Clinique Pinel done.
[14:45]
Then of course the question of the Future Hospital does also impact upon mental health services and that issue has arisen. So I think for the moment plans to move everything across to Overdale are not vigorously pursued. The plan is there and I think we are just concentrating on what is more urgent at the moment; is that fair to say?
Managing Director, Hospital and Community Services:
It is fair to say. I guess what I would add is we do have to do a feasibility assessment for that, so our thinking is Clinique Pinel is an option but Overdale could also be an option. But the Minister is right, we have got to think about the longer-term component of that. But in our alternatives we will be looking at the Clinique Pinel and Overdale as potential alternative inpatient facilities that we can
provide, because we just do not believe that the environment is offering a therapeutic condition for our inpatients.
Deputy M.R. Le Hegarat :
When will the work be done in relation to getting Orchard House into the right place? When is that likely to be complete?
The Minister for Health and Social Services:
Work is going on at the moment. I have seen sort of a table with all sorts of individual pieces of work. Can you assist with the last piece of work to be completed?
Interim Director of Quality, Governance and Nursing (Community):
Yes, I can. So we have got a time bound action plan which takes us up to June/July this year to realise some of the improvements that we can as far as practically deliver, given the constraints of that overall environment. That has to be planned for in relation to the decisions that we take about the option around moving to Clinique Pinel or Overdale. So there will be a point at which it will be not cost effective or even clinically effective to continue to make those improvement works because we want to retarget and redirect the investment to those new arrangements. But our priority and the plan really is to keep that unit safe as far as can be achieved, and also to make sure that where we are developing a much broader offer that we are providing service arrangements that prevent admission to hospital. So the plan is to develop a very strong focus on prevention, early intervention, so that the need for hospital admission starts to be reduced. For that, that requires us to work in a much greater partnership with our other stakeholders to look at what are the options and what are the capacities across the Island to be able to do some of that work. But the Minister and Rob alluded to earlier some of the developments around community services and connections with community- based partners, particularly around Mind Jersey. We have already shown and seen evidence of the work that we have done in relation to the development of psychological therapies that we developed in partnership with them. There is capacity to expand that even further in relation to the proposals we have got around the listening lounge, and then in terms of trying to stop people from coming into hospital our plan is to put arrangements around alternatives to admission which include a place of safety so that people are not always having to go to A. and E. (Accident and Emergency) for support, or alternatively being detained by the police and being treated and supported in a police cell.
Deputy M.R. Le Hegarat :
Do you, Minister, think that all mental health services should be located in one place?
The Minister for Health and Social Services:
No, not necessarily. There are some patients that we look after who have lengths of stay of more than a year. For them perhaps the best, most therapeutic place would be somewhere very quiet with pleasant surroundings, not too crowded. So there is no easy answer that it should be one or the other, and the truth of the matter is you should probably provide some mental health services within a general hospital because there will be people with needs that are physical and mental and there will be those acute needs too. But there are also needs that could well be better served separated from a general hospital.
Deputy M.R. Le Hegarat :
So on that basis you would not necessarily think that mental health should be co-located with a hospital?
The Minister for Health and Social Services:
I imagine it could be and perhaps in some places it is that all mental health services are delivered in combination with a general hospital on one site. So it could be; it does not mean to say that outcomes are affected, but I do not think there is one rule that says one scenario has to be.
Deputy K.G. Pamplin:
I am going to talk about people in crisis but just picking upon that point, and you have mentioned Overdale as an alternative to Clinique Pinel, for argument's sake, if the States Assembly reject Gloucester Street as a site, the debate comes back and Overdale theoretically is chosen, what does that do to the impact of what you are talking about of creating a separate mental health service? What could be the possible impact there?
The Minister for Health and Social Services:
Well I think we would then need to look at the delivery of a general hospital and mental health facilities at Overdale; is it possible to combine the 2 there?
Deputy K.G. Pamplin:
Is that not curious then because the benchmarking against the N.H.S., they are very much separate, they have mental health hospitals that are separate and there are hospitals but they do not appear as hospitals, but for people with varying different levels of health needs they do not want to come into that mental hospital setup, they want to come into a safe holistic environment to help their well- being. So there is a bit of a confliction going on here. If we are going to benchmark against the N.H.S. and where they have separate places where people can get well, yes, the general hospital can help and support and stabilise patients to refer into the next stage, so it is just clarifying the impact that if the hospital is rejected where would the mental health services go then? Would we have to restart the whole process again?
Managing Director, Hospital and Community Services:
No, that would not be the plan because you would still be able to ... I think the key point could be around the colocation. So there will always be a shared care part of the general hospital anyway, and I think that will grow, I think we will see that. But if that becomes the site that becomes of choice then you would be able to still develop plans that would mean that the general hospital function could be the general hospital and you could have a collocated mental health facility. You are right that they need to have ... they are slightly different. Some of the indicators might sound the same around length of stay and admission but they mean different things. So that would not prevent us from being in that situation, we would be able to adapt that plan.
The Deputy of St. John :
I think that most of you have experienced the model in the U.K.; I wonder if you could give us the benefit of that experience and explain how things are done in the U.K.?
Managing Director, Hospital and Community Services:
It varies, I mean in the N.H.S. Wales experience there are a number of hospitals where they have joint facilities. So the new hospital in Caerphilly is an acute general hospital and it has a mental health wing which is part of it, so there is a dedicated unit but it is part of the physical building. There are other hospitals; if you look at Exeter, they have a general hospital and then you cross the pathway and you are in the mental health facility. There are other facilities which are standalone which are miles away from a general hospital facility. I think the Minister is right; there is not really ... I think there is mixed opinion about the provision of those services. I think there is a recognition that for some patients, being in a certain environment which is less busy and is not part of the intensity that you can have in a general hospital can be a good thing. Then for others there is the benefit of course of recognising that physical and mental health are of parity and they should not be separated. So I think there are varying views around this, and we have both experienced different models. I am sure you are the same, Karen.
Interim Director of Quality, Governance and Nursing (Community): Yes, absolutely.
The Deputy of St. John :
I wonder if we could bring in the contribution of the newly appointed director.
Managing Director, Hospital and Community Services: Yes, I think that would be really good.
Consultant Psychiatrist and Acting Clinical Director:
A couple of things come to mind. I have worked in Australia, in Melbourne and in Queensland, and in both places we had the main hospital and mental health in a campus next to each other. It really helps to deal with mental health and physical health together and remove the stigma. In my opinion that would be one way to look at it. I think that having been in Jersey for 10 years and being aware of it, I have seen quite a number of patients and there is so much stigma attached to St. Saviour 's. I think we really need to move away. Younger generations have heard from the older generations. Older generations have experienced it themselves. It is there, it is deeply ingrained and I think we have to recognise it. I am mindful that we cannot do it without a feasibility study but I think that it is a point that really needs to be considered. In any case, we need to make sure that mental health and physical health are treated equally. If it is being separated geographically that it is not going to helpful.
Deputy K.G. Pamplin:
That leads us into the crisis thing and I am glad you have come forward again. What are the plans for improving the care pathways for people experiencing mental health crisis and where do they start? We will start with the Minister first.
The Minister for Health and Social Services:
I think we lack a provision that is open 24 hours and we clearly need that. As has already been mentioned, there is work going on with the hope that we can deliver something. Personally I like the talk about a listening lounge. It is not an emergency department, it is not a police station. It is a place where people can go, it is non-threatening, and receive some therapy, some help. But again there are staffing implications for that. Obviously it is something that we want to achieve very quickly and there is the issue as well of having a place of safety for people who are in that immediate crisis. That is being created now, a place of safety is being created within the hospital, not part of the emergency department. But there are plans, which we hope to have operational by June, that we can deliver a place of safety, so there is a comfortable suite that people can see their needs addressed.
Interim Director of Quality, Governance and Nursing (Community):
I think that also the 24/7 offer is not just about what statutory services can offer. Part of our plan will be to develop some of those models of support and care with other agents who are already starting to come forward and saying: "We would like to be part of that." The other thing is about how we use technology. We will be building that into our plans because particularly there will be differences about how people respond to their own particular crisis, depending on their age. We have talked to young people and we have heard that they quite like the idea of using technology to assist them, to direct and guide their own need for support. That might not be the case for somebody like me or some people in the room, but I think what we have got to be able to do is be able to offer a menu of 24/7 support that is sensitive to the needs of Islanders going forward. The part that we have not got played in at that moment, because we are focusing on what we can do as a statutory service, is to broaden that out so that we develop this in partnership with others and use the technology developments that will be available to us.
Deputy K.G. Pamplin:
I am glad you said that because that is picking up my point that the place of safety at the hospital you have described is good but is that not creating the same problem? If you put young people in with elderly people and people conflicted with different levels of mental health or abuse problems and you are putting them all in the one place, does that not just transfer the problem? How will you safeguard if a young person of 15 years old is coming into this safe place but at the very same time you have got a middle-aged man who is in all sorts of ... how are you going to safeguard this safe place so it is separated, so we are not seeing what we are seeing in other places, people just jammed in and not separated?
Interim Director of Quality, Governance and Nursing (Community):
I think it is really important that we define what we mean when we say "place of safety". Under the ordinary sort of technical guidance, if you like, that defines what environment you need for a place of safety, it has been based on the specification that is aligned to dealing with high risk, highly complicated needs, those who present to services that may require assistance from police or an additional medical intervention/detention. Place of safety to young people, when we have talked to them, is about a house that is anonymous that they can go to and feel safe. So I think we have to prioritise where we address those needs. I think that does not mean to say that a young person who is in crisis and in need of detention or in need of medical intervention and support is prevented from going to the place of safety that we have defined that is aligned to the hospital. Our safeguards around that will be to put in the right staffing and supervision arrangements and make sure that there is a place where young people can be supported in that environment on an individual basis.
[15:00]
So, working with a whole-person-centred approach is a philosophy that also has to be driven through the service offer that we make. Place of safety can also mean somebody's home and that might mean that we can start to remodel the way in which our community responds, shapes up as well. So I think when we are talking about place of safety, we are talking about a number of things on a number of levels, but I think the part of the service that we have not got in place at the moment is the service that we need where we have got high-risk individuals presenting in A. and E., where we have got people being detained in police cells where it is not conducive to their therapeutic support at that time.
Deputy M.R. Le Hegarat :
Just from my own perspective, how will you resource this? How will you resource having a 24/7 available place of safety in the hospital for example? How will you find the resources for that?
Managing Director, Hospital and Community Services:
We need staff for that. We have got the space, the room. We have sorted that. We have a capital plan around that, but the limitations are you have got to have staff who are able to respond to a crisis, do the assessment, provide the support required and then support the pathway, wherever that would be. That is why our plan for the place of safety, similar to the crisis prevention initiative overall, is so intrinsically linked to how we address the current issues with staff across our units, not just inpatient but the community as well. You have got to sort that first before you can offer that kind of a service.
The Deputy of St. John :
On the matter of a place of safety, especially for adolescents when they require admission to hospital they are currently going into a general medical-surgical children's facility, which causes all sorts of disruption there. Are there serious plans afoot to provide accommodation for children who are being admitted to hospital?
Managing Director, Hospital and Community Services:
We are looking at that. We have some additional support who has just joined us to provide a review, I guess, of our needs. We have a commissioning need around this service. You are quite right, we do not have a facility at the moment that can be used and we are using the physical hospital environment a lot and we are seeing that growing. We need to be mindful that there are children who will have physical and mental health needs and that environment might be right for them. However, there are cases whereby that is not the right environment and we are undertaking a review to establish what is the right pathway. It might not always be on Island. Where possible it should be on Island, but I think we are in the same position around that requirement as we are with some of the adult requirements. We need a new facility and we will need additional capacity to provide that kind of an environment. We just do not have it at the moment and we have not had it for a long time.
Deputy K.G. Pamplin:
It sounds like you are creating a Tardis. You have got this building and you are trying to find spaces and stuff but what you are also saying is that it is not acceptable for a 15 year-old teenager who has tried to take her own life and is in severe crisis but is in there with a sick young 6 year-old patient. That is not acceptable and that is what is going on. How do you change it? Does it mean the pressure is therefore to put back on the fact we need a new hospital? How do you manage that, as the chief of the hospital, knowing that is happening right now?
Managing Director, Hospital and Community Services:
It is very challenging and very difficult. Our staff are working in difficult conditions and they are managing those risks day in, day out and they are presenting daily challenges for us in that circumstance. I think we do have some changes we can make within the current estate, look at how we could configure the unit a bit better within the Robin Ward , but I do not think that will eradicate the problem and I think you have got to the heart of the point. We need to factor that into a new facility within the general hospital, recognising the shared-care requirement, but then we probably need something else as well outside of the hospital, and that is what the review is going to try to flesh out for us.
Deputy K.G. Pamplin:
Trevor has got questions about the separation of children and adult mental services, so that leads in.
The Deputy of St. John :
Minister, in your written response to the review you set out some risks and benefits associated with separating child and adult services and managing each through different departments. In the risk section you repeatedly state that the risks will be mitigated by utilising a governance framework. How so far have you been involved in developing that framework?
The Minister for Health and Social Services:
I have been receiving reports on work that is being carried out at a high level by officers, because there is a lot of thinking going on. It is a medical service, is it not, that we are offering in the most serious cases therapies and medication to children and should not this be offered within the health service? The thinking has been that there could be governance arrangements that would allow the service to be placed within children and young people but still be governed within the health service structures and the professional structures that exist. In the same way perhaps, or in a similar way, that has happened around the ambulance service, because the ambulance service has now transferred into Justice and Home Affairs but there are good governance arrangements, which means that the paramedics keep all their professional links with those they are working with in the health service. That has happened there and I think the hope was it could have happened in this scenario, but I am comforted that there is a lot of work going on with the patients at the centre of it. It is not a case of how does this best fit within a government organisation but it is what is best for these children.
The Deputy of St. John :
That is a concern, because when you separate services and you do not have good communication and good oversight from a professional group you are likely to have stumbling blocks.
The Minister for Health and Social Services:
It is quite possible, is it not? So I do not believe that we are heading towards a total separation at the moment, but again it is a work in progress. But perhaps I could ask Mr. Sainsbury to respond because he is the one working on it and thinking.
Managing Director, Hospital and Community Services:
We have had continuous dialogue with the children and young people's services about this position and I think where we are is recognising that there is going to be an intrinsic connectivity between the clinicians and the service professionals within the C.A.M.H.S. (Children and Adolescent Mental Health Service) service. I do not think it is right for either portfolio to believe that they own that service in entirety in any way because they should work together, the Department of Health and the Department for Children, Young People, Education and Skills should be working together to address how we provide good mental health services for young people.
The Deputy of St. John :
How do you get over that problem of people wanting to own what they are doing?
Managing Director, Hospital and Community Services:
Yes, indeed. We need more partnership focus but there needs to be accountability and I think that that is where we have to recognise that for parts of the C.A.M.H.S. we are going to need to keep accountability for the way that people perform their duties within portfolios. They need to know who they are accountable to and it is really clear that the medical fraternity needs to be part of our medical fraternity. It cannot be anywhere else, and that is the same within the nursing context. However, I do think what we have got to focus on is how working together with children and young people drives a better pathway for people, but I think that is a journey. The service has not transitioned at the moment. We are talking about a joint board arrangement to monitor how that goes. This is different to the ambulance position and I think we need to feel our way with how that is going, because it is again a pressured service and we need to stabilise it a bit before we start making huge changes to it, would be my view.
The Deputy of St. John :
What is the timeframe involved, do you think?
Managing Director, Hospital and Community Services:
It is ongoing is what I would say at the moment. We have not set a definitive date for transfer. We had a clear date for the ambulance service and we worked to that. The Minister is quite right, the governance arrangements can be applicable across multiple portfolios in the way that we can continue to provide professional support, clinical interface, but this is a bit different because a high volume of this activity has been retained within our physical environment and within our professional staff groups. So we need to get to a position whereby we are confident that the service is stable, that we can drive it through a partnership agenda. At the moment we need to continue to drive those changes and we are working really closely with children and young people's services around that. So we have not set a definitive date for transfer at this moment.
The Deputy of St. John :
During all this discussion, do you think there is any risk that people might become so preoccupied with the discussion that they do not apply themselves to the work that they are supposed to be doing?
Managing Director, Hospital and Community Services:
I think that is a fair challenge and I think it has dominated focus and I think it has become problematic in a perception of how the service is governed and the service is run. We face a recruitment challenge in this area also and I think people need certainty around who they are working for, who their boss is and where they live and where they sit. So I think we do need to shift the focus away from what department are we in to what are we trying to do and who is responsible for doing that. I think our new leadership arrangement is able to strengthen that but I think that is an ongoing development, would be my assessment in the short time that I have been responsible.
Deputy C.S. Alves :
You mentioned that C.A.M.H.S. is one of the services that is pressured, under pressure at the minute, and we have seen that also Talking Therapies is one of them that has a very long waiting list of 12 to 18 months. So what plans are there in place to try to reduce those waiting times across the whole of the mental health services?
Interim Director of Quality, Governance and Nursing (Community):
When we have looked at the activity around the Talking Therapies service the demand has just exploded and I think that shows a demonstration or rather demonstrates the actual need that there is for talking services. Whether or not the demand that has been created is the right kind of demand for what the service offers is the discussion that we are having at the moment, because what we have identified is that there are some people who might benefit from some other kinds of talking therapies that are fairly low-level interventions. We have already talked about the listening lounge and we mentioned technology before. We have not explored the capacity for online applications that might help and provide some support for people in that way. So our plan is to look at how that activity is organised and what the needs are that people are presenting with and to refine, if you like, the thresholds for the service in terms of what the offer is and make that a lot clearer, a lot more defined. The success around that would be the relationships that we develop with our primary care colleagues and also with again our third-sector partners, who are all in a position to be able to offer some service arrangement around this so that the Talking Therapies service can concentrate on achieving its intended outcomes, which is really to work with the more complex talking therapy intervention than cannot be provided elsewhere.
Managing Director, Hospital and Community Services:
You mentioned access overall there and I think that covers a critical point that is relevant to Jersey Talking Therapies. In the position we are in with the workforce challenges that we have, it is inevitable that our staff are having to do too much activity, so their caseload that they are holding is too high. We are not able to release them to undertake proactive assessment in the way that we would like. The volume of activity that is coming through needs to be managed in a different way. What we are finding is that our very precious specialist mental health resource is being used predominantly for lots of assessments, whether it be the hospital or the community. This means the very pressured workforce are not always able to get to the things they really need to get to and focus on because they are having such high volume of activity. We have an ability to address that in some of the services we provide and that is what we want to do for our new operating model. We want our physical health services to recognise they should not just blanket refer everything to mental health. They have got a role to play and they can sometimes manage the situation. A lot of our clients within the service have issues that are not just around mental health. There may be social problems that could be addressed by other professionals. Then we need to work with other partners as well. We know that we need to improve our risk and our assessment of people in crisis so we can start to focus our practitioners where they are really needed. That is a cultural challenge that will take time and leadership, particularly medical leadership, to start to address.
[15:15]
Deputy K.G. Pamplin:
I am glad you mentioned that right now. Talking Therapies, we have been there above the bus station. They were supposed to be moving somewhere to be more accessible but they are not. So what you are talking about is this cultural change, accepting it. Is it not the immediate danger,
though, if they are still feeling very disconnected and keep getting this blanket referral service, unless
they get brought into a system more accessible, into town, into a location that is all linked, as of today, tomorrow, next week they are still facing the same pressures? How do we fix that in the short term quickly?
Managing Director, Hospital and Community Services:
We are looking at the location. It is not the case that that has stopped. We are continuing to look at the options that we have around that because we accept that that is not quite right. I guess the point I was making was broader than Jersey Talking Therapies. I think it is symptomatic of all of our mental health services in terms of the volume is so high that it is not enabling them to get through, but I do think the accessibility thing is a bit different around the physical environment.
Deputy K.G. Pamplin:
Yes, and to achieve that you are talking about it needs to be brought in. At the moment it feels very drifted apart and distant and you go and speak to the people there, like we have done, in the environment. It needs to succeed now to start this process. You talk about looking for places. Where do you identify where it can go quickly? Another room in the hospital or do you have somewhere in mind?
Managing Director, Hospital and Community Services:
It could be. So we are looking at what estate options we have and we will look at the total estate for that. I think we recognise that it is not quite right at the moment, so that is part of the work that we are undertaking. That is all captured within our estates plan around what we want do to for these services. We are developing these services.
Consultant Psychiatrist and Acting Clinical Director:
I think things are already happening via education and working together with primary care. I think it is not much about having a place as opposed to really treating mental health issues like anything else, so people can go to their G.P. (general practitioner) practices, as already is happening, and they can have their mental health needs looked at. I think that will really help. So I think it is not so much a building but being spread into the community and really working in partnership with the third sector. That is really the key. So really we focus on what we need to focus on because we are having cases that we should not.
Deputy M.R. Le Hegarat :
You have all mentioned partnership working and I will start with the Minister in relation to this. We have heard that Government is increasingly relying on the private and charitable sector to deliver a range of mental health services. What are you doing to support these organisations on which we
are increasingly relying? What are you doing to support those organisations?
The Minister for Health and Social Services:
Well, there is the financial support. I mentioned before they would like that to be increased and offer more services but also to have the security of knowing that is for a reasonably long term. Part of what Mr. Sainsbury has mentioned is that the pressures upon staff mean that staff do not always have the time to fully engage perhaps and liaise with our partners and that needs to be something ... that is crucial. If they are our partners, we need to be in constant communication with them and talking about how we deliver services together. So upping our staffing levels is crucial to that, but I believe that all staff do understand and are very willing to work with our partners and will try to do that as often as they can. I well remember my visit to Jersey Recovery College and how inspiring I found that and their willingness to take on work and to help people through problems, not because they have gone through a university course and 7 or 8 years of training but because they have lived experience of mental health issues and they can give so much to the people that might come through their doors. We want to encourage that. I think for kind of lower level need, enhancing all that work that they are prepared to offer us is something we must concentrate on.
Interim Director of Quality, Governance and Nursing (Community):
I think we can add to that. One area where we have been really successful is with the Recovery College. We are looking to build our relationship with the Recovery College because they offer an approach called peer recovery work. That is bringing people with lived experience of mental health to talk about some of the educational ways in which they have learned how to manage their own mental health and to share that with others. The evidence base suggests that that does make a meaningful contribution to things like people needing less professional support over the longer term. So we are just going through a review with Jersey Recovery College at the moment to try and work out how best we could optimise their contribution. We have also previously talked about some of the work that we have done with Mind, but there is also some work going on in the Parishes to try and start to see how you can tap into some of that community capacity that helps communities look after one another, so to start to detect the way people might start to fall ill or what might be contributors to their ill health through social isolation, unemployment or whatever. Part of our approach will be to connect with those developments in the community to make sure that we can start to link up some of that work with some of the statutory work that we are doing in terms of service offer.
Deputy K.G. Pamplin:
That is encouraging as we dip into early intervention here because I have heard Mind Jersey spoken about 8 times, I have noted, and Recovery College, but we have to be mindful, do we not - and this is somebody who worked in the charity sector - that they are charities and rely on fundraising? There
are 340 charities in Jersey, all vying for that funding, and there is a pressure that comes with that.
It is fantastic and we have been screaming out for it and they have been screaming out for it for many, many years. We are all here doing this thing and now it is finally being recognised, but is there not a cautionary point that if there is too much burden put on the charity sector, they are charities at the end of the day. They could go tomorrow if that funding suddenly drops. So there is a pressure that comes between ... we need more Government funding, so then the Government is funding a charity. Is it, therefore, a charity and do we have to have a raw discussion of what we should be providing as a state with charity support, not what seemingly is the other way round? I am curious what your thoughts are on that and also their involvement on promoting good mental health because they are so key to helping early intervention.
Managing Director, Hospital and Community Services:
I was just going to add on to that point. There are lots of examples whereby charities are able to sustain their charitable status while being rewarded and recognised that they are an intrinsic part of the care system. They are treated as an equal partner, funded and have the security and the support through working with a statutory provider. I think we need to think about how we develop our relationship differently with this sector. There is something, as the Minister mentioned, about long- term commissioning and funding and contracting, but there is also something then about how we drive towards shared ambition and where these partners are able to be incredibly supportive for us. In providing the support that they do, they need to be recognised that they are providing over and above, and how do they feature within our service planning more prominently? I think you can do that without compromising their charitable nature. I think you just need to have a different relationship in your contracting and commissioning discussion with them, and there are lots of ... whether it is an accountable care system or a shared care system or a joint venture, there are many mechanisms we could adopt to start to develop that relationship with our charities. I think that is what we need to think about.
Deputy K.G. Pamplin:
Then the key part of that is with G.P.s as well because, as you have mentioned earlier referring to Talking Therapies, when a system is provided by a charitable sector that could be the first port of call while you are waiting for this long referral, but that is not seemingly happening.
Managing Director, Hospital and Community Services:
I think it is exactly the same for G.P.s. They can also be part of a system approach and I think we could also have a different arrangement with primary care that ensures that we are having mutual benefit from the services and the way they work together. There is too much interface to simply have separation of the systems and we have to think flexibly and with more agility about how we are going to start to think about our service interface, whether that is funding, people, contracts, accountability. We have to think differently to what we have at the moment. It is a very traditional contracting/commissioning function that we need to change.
Deputy K.G. Pamplin:
Sure. So, Minister, what measures are there to promote good mental health going forward now and to help problems being more severe? Can you see upcoming promotions or however you want to describe it?
The Minister for Health and Social Services:
Can I just pick up on something that Mr. Sainsbury has said? I think we need to recognise that in Jersey we do not have a national health service which is provided by Government. We have a number of different players, of which Government is one. We have a primary care system in which G.P.s are independent practices. We have a huge voluntary sector which is contributing towards healthcare, and then historically Government stood in and said it would provide an acute service. That has grown as different needs have emerged, but there perhaps has not been a consistent plan into exactly what Government's role is. But we have to recognise that we are all sharing, as Mr. Sainsbury has said, in the delivery of health services to the Island so we do need to work together. Government must not take the attitude that: "We are the one that drives it." We must have proper regard to the services that charities and the third sector wish to introduce, and there may even be a role for the commercial sector. Because there are firms growing up now that are offering health services on a commercial basis.
Consultant Psychiatrist and Acting Clinical Director:
Yes, it has already started. G.P.s are getting together and starting to develop their own well-being services with emphasis in providing lower intensity mental health services, but that is going to be a great help. The other thing about the third sector and charity is that we can also support them, not just simply financially, by deploying all our resources, by educating them, by supporting, by co- producing, by establishing clear pathways that will help management. So those are things that can be done and improved on.
Deputy K.G. Pamplin:
Interestingly, is this sustainable, though, long term? Because for a lot of people, their first intervention is going to see the G.P., which starts at least sometimes a referral process instead of coming from absolute crisis into hospital. But you have to pay generally to see your G.P. We are starting to see trends come along where people are choosing not to see their G.P. because they do not want to pay that money, so they miss that early intervention where they could be picked up and referred on to a service. Is it not fair to suggest while this is the model you have described at the
moment but in the long term are there plans afoot to say is this really sustainable? Is this the right
approach for Jersey? How do we change what we are seeing to help people who are not making that first step because they do not want to pay the average fee of £40? Therefore, this all comes crashing down, people do not come down, and an alarm bell goes off if people are then having to start paying everywhere to get services, to have to go to the hospital, have to pay for that, have to pay for this. Surely we have to learn from the N.H.S. but fit a model that works for us. Is it sustainable is what I am asking?
The Deputy of St. John :
Do you think that it is worth putting the social security contribution up to a more realistic level in order to change the route by which payment is made to G.P.s and for the different services?
The Minister for Health and Social Services:
It is one option but there may well be people who will still say that whatever the level is I cannot afford it, even a smaller payment.
The Deputy of St. John :
We have already introduced a long-term care charge. Is there not a case for increasing the charge for services for people under the age of 69?
The Minister for Health and Social Services:
There is an argument, certainly, Deputy , but my view is that I would want to keep our system of G.P.s working as practices, independent practitioners, because people value that relationship with their G.P., I believe. But we want to ... insofar as payment for G.P. services is a difficulty we can find ways of changing that, perhaps, so that it does not impact on people on affordability, that we can ensure that G.P.s are able to deal with people ... most of the people they will see will have long- term conditions throughout their lifetime and if we can ... instead of seeing your G.P., who refers you to the hospital and then you are into waiting lists and appointments at the hospital, if a G.P. can see those sorts of people with lifelong conditions, be responsible for their care, drawing on expertise that might be within the hospital or specialist nurses, but all the time the point of contact is with the G.P.
[15:30]
We do not ask the patient to pay £40 every time they see their G.P. but instead we fund the G.P. by saying: "We will pay you X thousand pounds to manage a cohort of patients who have this condition." Say it is diabetes or say it is skin conditions or something, we will commission them to look after the people in our Island who have that sort of condition and they will develop their expertise. Because I think we see that now, that a lot of G.P.s are willing to take an interest in a specialism and develop that and assist their patients in that way. There are many models that could be considered, but that is where I hope we might move towards.
Deputy K.G. Pamplin:
But what we are saying is whatever your entry point is, whatever your age, there needs to be a place that is open, that you do not feel you are coming into a place where you are going to be sent off to St. Saviour or you are condemned or the stigma approach, because it is a massive moment in someone's life to step forward and ask for help.
The Minister for Health and Social Services: Absolutely, yes.
Deputy K.G. Pamplin:
That might not be a doctor, it might not be a hospital. It needs to be somewhere but then is linked up so it becomes part of the system. That is what we are exploring here, is it not? So, yes, the G.P. model ... curious to find, and maybe, Robin, you can explore that model a bit more openly.
Consultant Psychiatrist and Acting Clinical Director:
It is already happening that psychology counsellors are going to private practices at no cost, but I think if we look at the bigger picture, the emphasis should be on education and people taking responsibility. It is everybody's business but it is also our own responsibility. We really need to make everybody aware of how things damage your mental and physical health and for people to start making healthy choices. That is really what is going to produce visible changes looking into the future. There is this expectation that we have to take a paternalistic approach and be providing for everybody, but without education we take the risk of people not really ... we are not really helping them to promote their right of autonomy and I do not think that really will pay off in the long run.
Deputy K.G. Pamplin:
For those people who are in crisis, though, as you alluded to last time you were here, they want to know that there is help there and they are not going to be told: "Oh, you have a medical condition so you will get a medical waiting list." They just want to know that there is help there and they are going to be treated like a human being, because they have lost that ability to do it for themselves because that early intervention ...
Consultant Psychiatrist and Acting Clinical Director:
Yes. For sure, the way forward is an emphasis in the community. What we should aim for is that admission is the very last resort and it is rarely happening. Whatever you need ... it should be a unit that will be above anything flexible so that at this moment in time these are our needs, but looking into the future I am hoping that our bed occupancy will be reduced by half because we have been able to be more effective in the community. It is going to be about education and about really everybody working together to make everybody aware that this is everybody's business, not just ...
The Deputy of St. John :
It is interesting you talk about everybody working together. We have heard on several occasions during the process here of alternative approaches to care of people with mental illness that involve the team actively working together with individuals and with groups. We have particularly identified an approach called Open Dialogue developed in Finland, now utilised in the U.K. and other parts of Europe. There are other approaches of care largely developed in Scandinavia on the dark nights, you know. But we were wondering whether or not the service is giving attention to alternative approaches in dealing with the difficulties that people have rather than the medical model.
Interim Director of Quality, Governance and Nursing (Community):
I think as part of our planning, we should build these into the overall offer going forward. We have not described those in terms of our current pattern of service. I think the challenge around sustainability is really important because we are going to have to have a different dialogue with the public about how to improve mental health and well-being. The public is employers, local communities, the media. It is Islanders in general because that kind of open dialogue really is good at starting to raise the spectre of whether or not what we currently invest in is giving us the productivity that we are looking for, is giving us the outcomes and the results. It will challenge the whole system to think very differently about what we might want to do for the future. Some of the alternatives will be about technology. It will be about different kinds of partnership arrangements that we have talked about around the duty and responsibility of employers, for example, the whole educational and health promotion approach, the role of the media in that. These are the things that we will be building into our thinking going forward.
The Minister for Health and Social Services:
If we could go back to the Government's strategic policy, health prevention is key to that as a high priority. Of course, that will include mental health as well.
The Deputy of St. John :
I am wondering if there has been any research undertaken by the department to look at alternative means of approaching mental health in the Scandinavian countries, for example, in Wales, for example, where there are especially education approaches that are beneficial for children and society.
Managing Director, Hospital and Community Services:
We are. I think there is a societal approach, is there not, that we need to adopt? There is a context here where the Department of Health and Community has a role to play and is able to do what it can do, but we are really asking all departments to be supporting this agenda beyond Government. I think it is that that Karen is describing. We need to think about how our strategy of caring for ourselves and caring for each other becomes an Island context and we apply that to mental health and we take it into the banks and the press and the employers and that we really start to drive that cultural change. I think if you cannot do it in Jersey I am not sure where you could do it given the strength of what we have.
Deputy M.R. Le Hegarat :
Have you spoken to J.T. (Jersey Telecom)?
Managing Director, Hospital and Community Services: No.
Deputy M.R. Le Hegarat :
Because we have and they gave us ... we had a public meeting with them and what they have done within J.T. is exceptional. That is obviously ... they have certainly gone and spoken to others as well, so that might be worth your while speaking to them. Because I must admit I was not ... until this, I was not aware of that, what they have done, and it is exceptional what they have done.
Deputy C.S. Alves :
They have had other businesses approach them as well.
Deputy M.R. Le Hegarat : Yes.
Deputy K.G. Pamplin:
That is a really key point, is it not? It is all these things going on across Jersey, doing different things. I think this is the end point for us today: how do you, Minister, pull this all together to help Islanders? I think another key area that Rob just mentioned was it is great looking at all these models, the N.H.S., Scandinavia, but really we need to find something that works for Jersey because we are an Island and we have to find a model that works for us. Because the uniqueness about Jersey, you cannot escape and go across up to ... and get on a train and get out of the area and escape somewhere. You are on an Island. You are going to bump into your social worker. You are going to bump into your neighbour. You are going to bump into somebody that you have seen with problems. So is it not the key point that we have to find something that is unique and works for Jersey that comes within Jersey? How do you achieve that and what is the message to send out to people who are listening right now that that is achievable?
The Minister for Health and Social Services:
It has to be about making it the norm to speak about mental health, to have procedures in place in the workplace, for example. Everyone understands a workplace will have a first aider but more workplaces are now having a mental health first aider. There are awards being given for firms that address well-being among their workforce. So this is growing in people's consciousness and we need to continue that work, to talk about it in the press, to concentrate on people's well-being, which begins with them looking after themselves, how we can best avoid the traps and signpost ways of seeking help if people are beginning to feel that they are running into difficulties. There should be easy ways. For some it will be online, for others it will be a visit to the G.P. Straightaway they should be able to access the help that they can get. We must make those pathways clear and easy to access, it seems to me.
Deputy K.G. Pamplin:
When can we see the first moves of all we have discussed in the last hour and a half? When will the public start to see things happen? Can you explain right now? I know we have touched on a few dates, March and things. When will people really start to see that something is happening?
The Minister for Health and Social Services:
It is such a huge piece of work. It is not a thing that I think you could give a launch date to because you have heard that work is going on currently and steps are constantly being taken. Clearly, staffing is critical and I commend all that is being planned at the moment with regard to putting key personnel in place. There is an urgency about that. I hope you detect that. There is, certainly in my mind, a very great sense that we do need to address these issues. It is not just me as the Minister for Health and Social Services. It was the Chief Minister and it is everyone who has been involved in the elections and the whole ... all States Members. We recognise that imperative to improve people's well-being and mental health. That is one of our 5 key objectives of the common strategic policy, to improve our well-being and our mental health.
Deputy K.G. Pamplin:
I think it is fair to say that is why the first thing we did 2 weeks after the election was to ...
The Minister for Health and Social Services:
Indeed, so your report is part of that increasing awareness and drive. We await your recommendations, really, because we want to embed your recommendations in our plans going forward. We do not want to set out plans, have a scrutiny review of it and then receive recommendations which would just tinker with a plan. We want your recommendations and all the evidence you have unearthed to contribute to our plans and to be part of the action points we will take going forward.
Deputy M.R. Le Hegarat :
I think what you said was right. If we cannot get it right, then you have no chance anywhere else. Because let us be honest, we have a really good third sector here. Partnership working on an Island of this size should be so easy, really. There is no excuse for it not to work. So I think that there has to be a positive for us moving forward, without a doubt. Okay, that is us done. Thank you very much, all, for coming.
The Minister for Health and Social Services: Thank you for receiving us.
Deputy M.R. Le Hegarat : Thank you very much.
[15:42]