Transcript - Government Plan Health and Social Services - Health and Social Services Minister - 17 September 2019

Health and Social Security Scrutiny Panel Government Plan Review: Health and Social Security Panel

Witness: Minister for Health and Community Services

Tuesday, 17th September 2019

Panel:

Deputy M.R. Le Hegarat of St. Helier (Chairman) Deputy K.G. Pamplin of St. Saviour (Vice Chairman) Deputy T. Pointon of St. John

Witnesses:

Deputy R.J. Renouf of St. Ouen , The Minister for Health and Community Services Senator S.W. Pallett, Assistant Minister for Health and Community Services

Mr. S. Mair, Group Finance Director, Health and Community Services

Ms. C. Landon, Director General, Health and Community Services

Mr. R. Sainsbury, Group Managing Director, Health and Community Services

Ms. R. Naylor, Chief Nurse, Health and Community Services

Mr. J. McInerney, Group Medical Director, Health and Community Services

[09:02]

Deputy M.R. Le Hegarat of St. Helier (Chairman):

Good morning, everybody. This is the scrutiny panel meeting in relation to the Health Department. We are going to be discussing the Government Plan this morning and we welcome members of the public that have attended. I am Deputy Mary Le Hegarat of St. Helier and I am the Chair of this panel.

Deputy K.G. Pamplin of St. Saviour (Vice Chairman): Deputy Kevin Pamplin and I am the Vice Chair of this panel.

Deputy T. Pointon of St. John :

I am Trevor Pointon, Deputy of St. John . I am a member of the panel.

Deputy M.R. Le Hegarat :

We have apologies from Carina Alves , Deputy of St. Helier , who is currently away on business. I will just ask the members of Health to introduce themselves so that if they speak the public are aware as to what their roles are, please.

The Minister for Health and Community Services:

I am Deputy Richard Renouf , Minister for Health and Community Services.

Assistant Minister for Health and Community Services:

Senator Steve Pallett, Assistant Minister for Health and Community Services.

Group Finance Director, Health and Community Services:

I am Stephen Mair. I am the Finance Director for the department.

Director General, Health and Community Services:

I am Caroline Landon. I am the Director General for Health and Community Services.

 Group Managing Director, Health and Community Services:

I am Rob Sainsbury. I am the Group Managing Director for Health and Community Services.

Chief Nurse, Health and Community Services: Rose Naylor, Chief Nurse.

Group Medical Director, Health and Community Services: I am John McInerney, the Group Medical Director.

The Minister for Health and Community Services:

Chair, can I give apologies on behalf of Deputy Hugh Raymond who is out of the Island on States business and Deputy Jeremy Maçon who is involved with other meetings?

Deputy M.R. Le Hegarat :

Thank you. We will start because we have got a fairly heavy agenda this morning, as you will appreciate, because we are looking at the Government Plan at the moment. Firstly, the overall funding allocation for your department in 2020 is £211,387,000. I think that is right with all the zeroes that we have here. Where does the budget now sit for the Ambulance Service and C.A.M.H.S. (Child and Adolescent Mental Health Service) and how has this impacted on your overall budget?

The Minister for Health and Community Services:

My understanding is that we no longer hold the budget for the Ambulance Service and the money for C.A.M.H.S. may still be with us but it will be being transferred.

The Deputy of St. John :

That is very interesting because the Government Plan shows this amount of money, this lump sum that Mary has referred to, in this financial year. If you go back to 2017, it was a very similar sum and that similar sum included a provision for ambulance.

The Minister for Health and Community Services:

That is perhaps just coincidental that they are similar sums.

The Deputy of St. John :

But coincidentally the budget for Home Affairs was in the same region as the budget predicted for Home Affairs this time.

Group Finance Director, Health and Community Services:

If I may, Deputy , the Ambulance Service has been moved precisely as the Minister said. The H.C.S. (Health and Community Services) budget will have changed for a number of reasons. For example, inflation might have come in during the year. I do not have the exact figures, so it will have gone up for other reasons other than the transfer of the Ambulance Service and that may have offset the loss of monies due to the Ambulance Service. We can get you an analysis if you wish, separately, but there are other factors other than just those 2 transfers.

The Deputy of St. John :

But I do not understand why it does not show in the Home Affairs budget.

Group Finance Director, Health and Community Services:

It should show in the Home Affairs budget. I will have to check with colleagues for you and find out for you.

Group Managing Director, Health and Community Services:

If I may, the budget period you reference would have included all of the children's social services that we had within what was H.S.S.D.(Health and Social Services Department) in the date that you have highlighted. That all went over to Children, Young People, Education and Skills before 2018, so a big chunk of that would have been the former children's social worker services that we previously ran.

The Deputy of St. John :

I will not labour this, of course, because the accountants will tell us what is going on but the Home Affairs budget does not seem to have increased commensurately to cater for the needs of ambulance.

Group Finance Director, Health and Community Services:

I will have to check with colleagues, but I can do so and I can get you a note through if that is helpful.

The Deputy of St. John : Thanks very much.

Deputy M.R. Le Hegarat :

Moving forward, preventative diseases, R.91 states that: "To bring about sustained behavioural change, education and public health messaging must be accompanied by strong policy that ensures our local environments and the context in which we make everyday decisions are supportive of health." Do you intend to amend any existing policies to ensure the above aspiration can be achieved?

The Minister for Health and Community Services:

I think we need to be clearer and firmer on alcohol and that is a piece of work that we intend to develop over the period of this Government Plan. We want to enhance the smoking cessation programme. We want to do more work in schools, particularly around food and nutrition and weight management. Prevention is not just the province of H.C.S. It is cross-government, so it is all about helping low income families, housing conditions, environmental matters. It is a huge programme that we will try to address across the Government.

Assistant Minister for Health and Community Services:

I can probably add to that as well. We are currently progressing a health and wellbeing policy framework that will link all those policies: smoking cessation, alcohol policy, food and nutrition strategy. All of those need to be linked in an overall strategy that links them all together. In fact after this meeting today I have got a meeting to look at the first draft of that framework. I have got it with me here. What it will do is give some guidance to all the departments involved as to what we will be expecting from each of them, working together to produce a policy and a framework that will link all those together. Some of the work that we will be doing, for example, will be within the Economic Development, Tourism, Sport and Culture Department through Jersey Sport, which will be an Active Jersey strategy. That will form part of the work we will do to prevent diseases, reduce obesity, see improving health with young people, all those type of things. But at the moment we do not have an overall policy strategy that links all those together and we are hoping to have that finished and produced by Christmas.

Deputy M.R. Le Hegarat :

There is significant increases in the budget in relation to those things and you say you have got a draft. Obviously from our perspective if some of that information was available before you come to having the debate on the budget in relation to your department, do you not think that there would be a benefit to that being available for that debate so that people can see why it has gone from 300 to 2,800, so people can understand what the increases are and what the money is going to be spent on?

Assistant Minister for Health and Community Services:

I think there is always going to be a lead-in period. When we are moving from a policy in the past that has looked at treating illness and disease towards a more preventative type policy, there is always going to be a lead-in period. I think the first year is very much putting some building blocks in place, really thinking about where the strategy is going to lead, making sure all those link in before we start to bring in some of the programmes and policies that will support the people who want to give up smoking so we can put support in schools and support families into healthier lifestyles. You look like you are going to ask a question.

Deputy M.R. Le Hegarat :

I am when you are finished. What I was going to ask was, should you not get the budget that you request, are you, within your strategies, doing a prioritisation of what you are going to do first?

Assistant Minister for Health and Community Services:

I think the answer is yes. There is certainly adequate budget there to change the culture in regards to making sure that we look at prevention in a serious way. I do not think in the past prevention has really had the priority that it needs to be given. Within this Government Plan I think it is. But one of the things that the Chief Executive of Jersey Sport said to me a few months ago is that it will take time to build some of these programmes. Throwing money at it on day one is not going to solve the issue. I think we need to be clever with what we spend and we need to spend it wisely. The wise thing to do is to get your programmes in place and then the funding will follow from that. That is why in years 2, 3 and 4 the budget is increased quite considerably.

Deputy M.R. Le Hegarat :

You mentioned smoking cessation. In relation to that, within the plan you are asking for £579,000 over 3 years. Are you able to give us any indication of how you intend to spend the money? What do you intend to do with that money?

Assistant Minister for Health and Community Services:

That is a little bit outside my remit. I do not think I can help with that one.

Director General, Health and Community Services:

Part of the work that we are doing is we are working collaboratively alongside other government departments, particularly C.Y.P.E.S. (Children, Young People, Education and Skills), around how we can get the smoking cessation and smoking prevention message into schools. We are also looking as part of the work we are doing around the Jersey Care model at harnessing community efforts that we have across the parishes so that we start to get a more educative process happening out within groups that are touching people every day and are able to speak to them quite informally. I think some of the work that Martin Knight is going to help us with around the health promotion is how we start to get messages that are less punitive and much more dynamic and reactive to people's circumstances, which are very different across Jersey as well. But the smoking cessation framework is always very difficult unless you target them appropriately. John, I do not know if you want to comment about the conversations that we are having about how we can best maximise that resource, if that is okay, Chair.

Deputy M.R. Le Hegarat : Yes, of course it is.

Group Medical Director, Health and Community Services:

Smoking cessation is a priority, if you think about the diseases that are associated with that, but I will not go into that. It is not just schools. That is smoking avoidance. Smoking cessation is also directed at adult smoking, those adults who unfortunately are addicted to cigarettes and nicotine. We have a new care prevention for families and primary care, which we need to give our primary care colleagues, both pharmacists and G.P.s (general practitioners), funding for outcome of the measures so they can convince and assist their patients to stop smoking.

[09:15]

A lot of the funding will go into the community where it is best served rather than being used to pay for colleagues in the hospital, secondary care, to deal with the complications. There is also legislation around vending machines and parks and so forth, like other jurisdictions are doing. Most of the funding will be shared with C.Y.P.E.S. through smoking avoidance, but smoking cessation is really about those unfortunate adults that already are addicted.

Deputy K.G. Pamplin:

Just curious about my smoker's cough there, but it was not on purpose. This next line of questioning, it will be no surprise to you, is focusing on mental health. I just wanted to say thank you, Minister, for the response to our written questions. That has proved very helpful. Let us start with our mental health report. Your response to the recommendations in the report makes various references to workforce improvement and retention, which is a subject matter we have talked about a lot previously, the need for a workforce strategy. Does the request for additional funds include any consideration of investment in existing staff?

The Minister for Health and Community Services:

I believe it includes training programmes and educational programmes, indeed, yes. That is my thought. Our staff as well need to be fully au fait and able to work within the new legislation that we have. They need to be able to know about assessment of capacity and the rules around our mental health treatments, and all that is a continuing education. I do not know if perhaps Mr. Sainsbury could add something.

Group Managing Director, Health and Community Services:

That is correct, particularly with mental health. Normal legislation is already funding that we had to apply this year for that because that had to be trained. The other area where we have to invest in the existing staff as well as new staff is the crisis prevention service that is going to be working in a different way. It is a completely different specification to the current psychiatric liaison service. Those psychiatrists and psychiatric liaison nurses have to work in a different way and will need a lot of training, support, education and professional development to help them to do that, and they will need a revised on-call arrangement as well.

Deputy K.G. Pamplin:

I am also aware of the changes in the government team as well and the new lead of mental health as he sets up his team. Is that covered by that, the additional cost, so if Dr. Garcia is requesting additional resource as he puts his team together going forward, is that included in this investment or is that separate?

Group Managing Director, Health and Community Services:

That is separate. We have already made the investment into Dr. Garcia's leadership team. He has the biggest team across the whole of our Health and Community Services, what we call our tier 3 and tier 4 leadership. So he has a dedicated improvement lead, a dedicated lead nurse, a dedicated lead social worker and a dedicated lead allied health professional. We have already made that investment in 2019 for those additional people. We do need to continuously monitor that and if we do need to make further adjustment we would address that through our target operating model as it goes forward. We have to review is the team adequate, does it need something different, but that is not a cost in the Government Plan.

Deputy K.G. Pamplin:

That is really clear. Thank you. Do you plan on using any of the requested funds to assist in housing mental health professionals? Going back to previous hearings, we were told that the accommodation options would be brought forward before December 2019.

The Minister for Health and Community Services:

I do not believe the Government Plan allocates money for housing. I think that is within the Andium Homes programme, but I think our Chief Nurse might be able to assist with that.

Chief Nurse, Health and Community Services:

Yes, we are working at the moment with Andium Homes, the Housing Department and J.P.H. (Jersey Property Holdings) around a scheme that will bring 45 properties online towards the end of this year. Following on the success that we have had previously working with Andium it will give us additional single occupancy properties coming online this year.

Deputy K.G. Pamplin: That is 45; is that right?

Chief Nurse, Health and Community Services:

Yes. There are further to come online next summer. I would need to get you the total amount.

Deputy K.G. Pamplin:

Just as a rough breakdown: are they one-bedroom, 2-bedroom?

Chief Nurse, Health and Community Services:

They are predominantly one-bedroom, quite large apartments.

Deputy K.G. Pamplin:

Would there be any additional requests for money? Say there was somebody exceptional in mental health that wanted to come with his family and you would have to go to Andium and say: "We need something quite unique, we want this person, we want them here but he or she comes with their family who obviously would not want to get into a one-bedroom flat."

Chief Nurse, Health and Community Services:

From an employer's point of view, we do everything we can to support individuals coming out to work here. In terms of the broad piece of work around housing that is happening across the Government of Jersey at the moment, that is a broader question than I am able to answer in terms of that, but we would do everything that we could to support the individual. We would make that happen for mental health, absolutely. Mental health is our number one priority within our management team, so we would make that happen.

Deputy K.G. Pamplin:

In that instance if you are fundamentally wanting somebody exceptional in mental health, they would be saying: "We need this person, we want this person, they come with their family; one bedroom is not going to do it, Minister." Therefore, as Minister would you then go to the Minister for Housing and Andium Homes and say: "I have got a bit of money and we really want this person"?

The Minister for Health and Community Services:

We would do everything we can to find a way, because if this person is key to enhance our services and fill a much-needed gap then we want to get him in and we will find a way.

Director General, Health and Community Services

We have a relocation package that we are able to flex if needs be, which is an upfront payment that we can give to people but also helping them to find accommodation that suits their needs. I am confident that we would be able to make that happen.

Deputy K.G. Pamplin:

So rounding all up the funds within the Government Plan and the budget going forward, is there money in there to do that?

The Minister for Health and Community Services: Within budgets.

Director General, Health and Community Services

Within our overall budget we would make that happen. Indeed, we have made it happen, have we not, Rose, for people who have got children and we have had to sort out housing?

Chief Nurse, Health and Community Services: Yes.

Deputy K.G. Pamplin:

We understand that £5.4 million, the requested money over the 4 years, is for use to fund the crisis response team of 14 F.T.E.s (full-time equivalents). How many of those are new positions?

Group Managing Director, Health and Community Services: For crisis prevention, they are all new.

Deputy K.G. Pamplin: Every single position is new?

Group Managing Director, Health and Community Services: For crisis prevention investment?

Deputy K.G. Pamplin: Yes, the response team.

Group Managing Director, Health and Community Services: Yes, all of the full-time equivalents that are identified are new posts.

Deputy K.G. Pamplin:

Is that a mix of off-Island and on-Island, do we know?

Group Managing Director, Health and Community Services:

It will probably be a blend. We are talking to the existing psychiatric liaison team and there are some members who would be willing to move into the future crisis prevention service. There are some people who do not want to and they do not want to work out of hours and they do not want to do on- call work, so we are working through and we need their skills in other areas as well. So it will probably be a blend of off-Island and on-Island.

Deputy K.G. Pamplin:

When would that be operational, do we know?

Group Managing Director, Health and Community Services:

We expect full implementation by quarter 3 in 2020 but there are elements of the service that we would be able to deliver before then, depending on recruitment. Part of the specification would incorporate street triage. We think we could probably start to do that by quarter 2 next year. We think that the psychiatric liaison nurse element of it could start to transition in quarter 1, so some of the specification will be able to be delivered, but we do have to have successful recruitment for full implementation of the specification.

Deputy K.G. Pamplin:

Obviously we are talking budget and efficiencies, so what efficiencies do you foresee the crisis response service generating, talking about budgets going forward?

The Minister for Health and Community Services:

I would just say if we can address mental health issues at an earlier stage then of course crisis point, we hope, will not be reached and that would achieve an efficiency. It is exactly the same with the listening lounge, but as to the detail, Mr. Sainsbury can help.

Group Managing Director, Health and Community Services:

There are 2 expected real benefits in terms of efficiency. The first is around prevention of admissions into our in-patient unit, into Orchard House and what will be Clinique Pinel. The second is that if we start to manage crisis prevention and we are stopping people getting to an escalated position then we would expect that to impact on our prevalence of off-Island activity, which is really expensive. When we have to send clients to the U.K. (United Kingdom) for treatment pathways, we would expect this service to be part of a broader specification that starts to impact on that. In-patient volume and off-Island activities are direct targets of what this service would do.

The Deputy of St. John :

Minister, you used a very telling term there, "hope", you hoped. How definite are we that we will be able to recruit the people we need to recruit and that we need to get into post to be able to introduce an effective crisis intervention service?

The Minister for Health and Community Services:

We have had success around recruitment in recent months and efforts to recruit continue and we have got an existing team, some of which will want to join that crisis team. So, yes, I said "hope" because I cannot say it will definitely happen that our acute facility will be empty but this is the health model, is it not? It comes back to what we were talking about before, the preventative programme. If we can prevent harm at an early stage then that serious harm will not occur down the line if we had ignored the circumstances when they presented themselves.

The Deputy of St. John :

Yes, I understand crisis intervention. I was responsible for a crisis intervention team myself in the late 1970s.

The Minister for Health and Community Services: Yes, of course, I recall, Deputy .

The Deputy of St. John :

It is, however, difficult to find the right type of crisis intervention service.

Director General, Health and Community Services

Deputy , I think what we are trying to offer here is a real wraparound mental health provision within Jersey. With the listening lounge, with the crisis support, particularly with the complex trauma, we are investing in staff that do provide that and not just for our patients that present with mental illness but across the board for patients that come into our care that we are touching. We hope that that almost mental health campus approach that we are taking will encourage staff to apply and come here to Jersey. As you probably know, it is an endemic issue everywhere, particularly in the U.K., but I think here because of our geography what we are offering is very unique. We are trying to do that wraparound, keep people where they need to be and only have an acute intervention when we absolutely have to. That is our aspiration and that is what we hope the staff will be attracted to.

Assistant Minister for Health and Community Services:

It is about trying to find the right staff to staff these crisis prevention teams but it is not just about that. The listening lounge is not just going to be staffed by government staff. It is going to be staffed by third-sector organisations, which we will be supporting. It is that better collaboration between government and private sector I think that will be part of the solution to the issues that we have currently got. It is too easy to put it down to one issue or one area where we get it right. It needs to work across the board and I think the fact that we are building on closer relationships with our third- sector partners, such as Mind, Samaritans, Recovery College, is a real key element of making sure this works moving forward. We are going to have to fund them and support them in a better way than we currently do now if they are going to provide us with the assistance that we need. In terms of what is in here, I have got absolutely confidence that we will find the right people to staff this crisis team, as I know Kevin - Deputy Pamplin - has, in regard to our lead in mental health. I am sure we have got the right people in the care group that are going to absolutely ensure that we are putting the right packages together to support people in crisis in Jersey. I have no doubt about that whatsoever. It is not a hope for me: it is an expectation that we will deliver on that.

Deputy K.G. Pamplin:

Good stuff, and you can call me anything you like, Senator. Okay, cracking on. During our review of the mental health services that we conducted - for those listening and watching it is available online - we found that for the majority of respondents one of the biggest issues is waiting for actual services for what most of them considered an unacceptable time, and I think all of us would agree as well. Do you propose to use any of the requested additional funds to help address what is clearly one of the most significant problems, the waiting time?

The Minister for Health and Community Services:

Yes, because we are remodelling, essentially, our mental health offer. The listening lounge will be available to people to receive help as opposed to just sitting on the waiting list.

[09:30]

Deputy K.G. Pamplin:

Drilling in for a bit more detail, for example Talking Therapies; is there any additional funds going into that? I know it touches into recruitment but just for a bit more detail could you elaborate on that?

Assistant Minister for Health and Community Services:

I will start and maybe the Director General can add. Having spoken to our lead on this, Dr. Garcia, he needs to do a review of Jersey Talking Therapies to see what our current capacity is and how we can improve on that. There are a lot of really important issues that need to be resolved within mental health at the moment. Dr. Garcia is working through these. Jersey Talking Therapies I think is probably the next one on his list to get to grips with and we are going to have to find resource for that. The waiting lists for Jersey Talking Therapies are too long, we accept that, and we need to bring those waiting lists down. Some of the funding that is within the Government Plan will need to be used to bring those waiting lists down. Maybe if I stop and the Director General may add.

Director General, Health and Community Services

It is not just mental health. Across the whole of Health and Community Services the waiting lists are too long. Rob can give you more detail around Talking Therapies but the whole ethos that we are doing with our associate medical director is before we invest we need to absolutely understand what the need is and how we can support that need well. The mistakes we have made in the past we have invested without any analysis of need and then we have not understood what we invested in and what those key indicators are to ensure that we are getting a return that is being impacted by outcomes. What we are asking is across all of the services to understand where is that linkage and how that is going to impact positively on outcomes and part of that is addressing waiting times. I will ask Rob to talk in a bit more detail around the work that they are doing.

Deputy K.G. Pamplin:

Just before Rob does, you just said there about the previous setup and how you viewed it of making mistakes that have led us to this place, because the curious thing about Talking Therapies is it was introduced obviously a few years back on the demand of need that was a mental health strategy created as part of this. Our review clearly identified the waiting times. Going back a little bit further, in the first 2 weeks of our career last year we went on a tour and we saw the room that was set up downstairs in the hospital. There was a review that had been going on related to the Talking Therapies in strategies 2 and 3. I am a little bit concerned about how many more times is this going to happen, because the waiting lists go on.

Director General, Health and Community Services

It is not about management bureaucracy. Absolutely we recognise that we have to invest in mental health and in the mental health needs for Islanders and just making sure this time that we get it absolutely right. Talking Therapies is fantastic but the waiting times are too long and so we need to understand that and we need to understand how we allocate resources totally or how we can move resource around to deliver service differently. That is what we are asking all of our teams to do. Echoing what Steve said, mental health is not just about our mental health provision. It is across all of our care groups and how we work collaboratively in delivering health, because what we are trying to get is the whole thing of mental health and physical health. I will leave Rob to give you more detail around what is happening with Talking Therapies.

Group Managing Director, Health and Community Services:

The reason why the listening lounge is quite critical to this ... I think you previously as a panel identified that we needed to have different models of access to services provided like Talking Therapies, particularly open access. Our view of what the listening lounge is offering is an element of some of the pathway that you would expect to go into Jersey Talking Therapies. So we need to see what that impact is and that is why we are at the moment going to do a 3-month review on the activity for the listening lounge because it could be quite big and if it is then we would have to repurpose how we would support that initiative. There is also in the complex trauma pathway a number of the staff being recruited to within that pathway are psychologist staff, so they will be able to predominantly support those individuals who need support for complex trauma but there is an element of this activity that we think we could direct into Jersey Talking Therapies as well. The team is working through that with the lead psychologist about how we might be able to do that. There is a third element, which you might not be aware of but we have invested £300,000 into a G.P. cluster pilot for social prescribing in mental health and a gentleman called Lee Bennett has started in that service at the moment with a G.P. cluster. The support and the service that he is providing also previously might have found its way going into, referring to J.T.T. (Jersey Talking Therapies). There are those 3 components that we think we have got to look at, we have to see what we get if these go in, how people want to access the service and how we need to then change it. I am not sure if we were remodelling J.T.T. we would set it up in that way now. It would be much more of an open, direct access route that you want to wrap around primary care and interface between our mental health services. It was set up very purposefully to follow a U.K. model and I think in Jersey we probably need something that is a little bit different from that, and that is what Dr. Garcia is looking at.

Assistant Minister for Health and Community Services:

Not wanting to move away from Jersey Talking Therapies, because I know it is of great interest to you, but one thing I did ask Dr. Garcia to do, which is public facing and I think is really important - and again I have seen the first draft of it and I think it is excellent - is a road map of mental health services in Jersey so that the man or woman in the street or young person can clearly identify who they can go and see and what step that ... as somebody that came into mental health services quite blind to the complex areas that it is, if you had asked me where would I go if I had an issue, I would not have had any idea whatsoever. So how would the man on the street know where to go if he had an issue at work or a family issue or a bereavement or something that caused him a mental health issue? What we are going to produce is a clear map of if you have got something that requires a relatively low intervention, somebody to talk to, where you go. A lot of it might be the G.P. but the listening lounge will be one, Jersey Talking Therapies is another, but we need to make it clear to the public where they can access those services. I do not think it has been clear in the past. I think a lot of people have been put into stress and further crisis because they do not know where to go and what I want to do is make sure that everybody out there is clear about what is available to them, and Jersey Talking Therapies is one of those options. It should not be listening lounge. It needs to be listening lounges, because it is not going to be one, in my view. I think it is going to be a multiple group of listening lounges around the Island so that people can access them easily. That is my hope, if I want to use the word "hope". But it has to be accessible to the public and the public need to understand where they are.

Deputy K.G. Pamplin:

I could not agree more. Just backing this question up from the review finally realising that Talking Therapies needs the investment urgently, much like other mental health services, that we do not come back in 6 years and do one of these again and say that nothing has happened. Will you be reassured that you can go and get the additional funds for, just off the top of my head, Talking Therapies, where it is at the moment, not in the best location, above the bus station for accessibility where it is. If the review comes back that Talking Therapies needs to be here to be accessible, will there be additional funds, will you see that through, will you get that money?

The Minister for Health and Community Services:

Yes. You have seen, Deputy , the substantial sums going in to the Government Plan to support mental health. It really is our priority.

Assistant Minister for Health and Community Services:

Can I just stress one thing? Dr. Garcia needs to know it is in the right place, resourced properly, got the right people and he knows how he can bring those waiting times down, and that work is currently in motion.

Deputy K.G. Pamplin:

Again, because we are focusing on the budget from next year post November, is that additional fund, you will be able to resource that, where does it come from? It is the details on that.

The Minister for Health and Community Services:

There is an existing budget for mental health. These are additional funds. There is money around and we will make sure that there is a budget, is there not?

Deputy K.G. Pamplin:

There is money around now but what I am trying to get at is if you are saying that the money is around but when you go to look for that money and that money is not there ...

Group Finance Director, Health and Community Services:

Just to help, if I may, we spend about £22 million at the moment on mental health, so there are monies that colleagues do access to facilitate this and, as you say, when we get the additional funds in November, which is 2 months away, then we can take that and accelerate the activity.

Deputy K.G. Pamplin:

We have heard about this a few times now. We have obviously listened now. Over the 4 years of the Government Plan, £1.6 billion has been identified to provide the listening lounge, or possibly lounges. You advised the facility will be located in a non-clinical physical space. The first question first is: have you identified the location for the listening lounge?

The Minister for Health and Community Services: Yes, it is identified.

Deputy K.G. Pamplin:

Okay. Can we just dig into the detail again about this money over the next 4 years, how this is going to work? Is it a government contract with a third party, charity, service provider? How is it broken down, just so we can understand the detail?

The Minister for Health and Community Services:

First of all, the listening lounge will be and can be a physical place but there is also a sense in which there could be a digital listening lounge and we must not forget that. But I understand there are premises that have been identified. Now, whether all that fine detail has yet been bottomed out I do not know, but I can pass it to my Assistant Minister who may know more.

Assistant Minister for Health and Community Services:

Has a place been identified? Yes. Have we got to a position where we have signed a contract? No, which is why I am a bit hesitant about saying where exactly those premises are. I think it would be wrong to undermine those discussions that are currently taking place. Do I think it is going to happen? Absolutely, yes, because I think we are so far down the line with it I think it would be ... I would not say it was going to happen if it was not going to happen. But I think while we are still having those contract negotiations I think it would be wrong to undermine those negotiations. It will also include, as I have said, third-sector organisations that will be part of it as well and they are also in the discussions. It also includes and had to include lived experience, and those with lived experience to ensure that whatever we are providing is going to work for them. The only way you are going to find out whether it works is by getting those who have been through crisis involved in that process, as I have tried to highlight in the past. It is important that that is part of it. We are about to go to contract. I think it is days if not weeks before we are going to announce what that is, but it is going to happen and it is going to happen very soon in town, in a town centre location.

Deputy K.G. Pamplin:

In the full business case it states that the listening lounge will initially be a 2-year pilot project, so why are you then requesting money to fund the initiative over a 4-year period, is the question I have?

The Minister for Health and Community Services:

We do not want to be in a position after 2 years that there is not a budget to continue that work. We are convinced that that is something that is needed but it may be that after 2 years there will be some fine tuning to be had. Of course, with the third-sector involvement that may be part of their wish also to see how they fit in and what role they have over the 2 years, because this is something new for the Island and new for our partners too, new for us.

Deputy K.G. Pamplin:

I think you can all see where I am getting at with this comparing to the Talking Therapies situation we have just referred to, when Talking Therapies was put in place, as the Director General has alluded to, the data analysis, the needs, so we do not end up with another service that cannot match the demand because the budget is not there. Equally, a slight concern with my background with health-based charities: is the money in the budget fully for the running of the services or is it just used to support the third sector or another outside company to provide the service financially or is it all funded, all be run by this budget or is there additional money that will come from a charity or another company? I am just curious because obviously, having done these things in the past, a pilot scheme is introduced, a charity starts running it, a charity turns round and says: "We have had a bad year fund raising wise. We do not have the full resources to carry this over." I am just curious again about the forecasting of the budget and how it is going to work financially.

The Minister for Health and Community Services:

I believe it is fully funded from the Government Plan. It is.

Group Managing Director, Health and Community Services:

It is and any of the third-sector involvement is committed funding to the third sector and it is set funding. We are working through the specification and the service level agreement with all of those partners now.

Group Finance Director, Health and Community Services:

The money is totally intended, as colleagues say, for internal resources so you will not have that risk and that is what the plan is at the moment.

The Deputy of St. John :

We have a situation currently that the Minister knows about and I brought this to his attention last week, that there are disturbed children waiting for respite care

[09:45]

Money is allocated to fund respite care but the people are not in the system to provide that respite care. Is there a danger that this might happen in relation to the increasing reliance upon the third sector, that they are recruiting in a marketplace which is generally speaking the lower paid marketplace and they find it extremely difficult to attract employees? For that very reason the reliance upon the third sector to provide the support for people in the community might be a difficult thing to achieve.

Director General, Health and Community Services

What our work has done around the emerging Jersey care model has demonstrated to us that we do not have a commissioning strategy around care in the community. You are absolutely right, one of the dangers of that is that as we move work into the community and rely more on the third sector, if the third sector is fishing in the same pool as we have been fishing in, there are going to be challenges around that. But one of the reasons we have identified that the pool is so small is because you can get as much money going and working in Voisins as you can providing care for somebody within their home. We have a big piece of work happening at the moment across H.C.S. and working collaboratively with partners around what we can do to change that situation. But you are right, it is not going to be a quick fix. It is work that is probably going to take us 12 months to get that market strategy right so we can encourage people into care. What we are doing is we are sitting around the table with other providers to work out that strategy but also to try to understand how we can manage the current demand with a very limited workforce. Some of that is around the work that the care model has shown that we need to start moving some of our staff around to work flexibly across the community until we get that market strategy right around carers. We are particularly challenged here because we have not got a town up the road or another county that we can go to and we cannot compete with other counties to offer more money, which again is not the right strategy but is the standard strategy. We have got to get that right for Jersey. We think we can but it is a big piece of work.

The Deputy of St. John :

This panel is concerned, of course, that if we cannot get it, right all of the aspirations for a new hospital might be thrown into some disarray, given that the plan relies very heavily upon transferring care into the community.

Director General, Health and Community Services

Much of the new care model is about moving care into primary care and putting it in more of the larger third-sector providers. It is absolutely open to all the providers, who already have a fairly robust infrastructure. Again, that we are all fishing in the same pool still remains but we are very clear that money will follow activity in the new care model. But the challenges that you allude to are very real and are risks and risks we have identified in the care model work because of the workforce challenges that we have across the Island.

The Deputy of St. John :

I am going to let Kevin go on in a moment but I just saw an opportunity there, Kevin. I do apologise. You mentioned primary care. We all know what the big issue is with primary care and that is that the doctor only gets paid for facing with his patients. My wife went and had a toenail removed by her G.P. the other day, £240. I had advised her to go to A. and E. (accident and emergency) but she refused to do that. She was supporting your efforts but the idea that many of the people in our community just cannot afford to do that ... how are we going to get over that? What work is being done and how far down the line are we to addressing that?

Director General, Health and Community Services

Sorry, I am probably being obtuse. Are you talking about work coming out of the acute or are you talking about now when you have to go to a G.P.?

The Deputy of St. John :

Well, there are both issues. You go to your G.P., £50 subsidised by Social Security. For many people that is a disincentive to go to their G.P. If you are going to be increasingly relying upon G.P. services to provide services that are currently provided in hospital then a lot of people are simply not going to access the services.

Director General, Health and Community Services

We do not want that. I will ask John to tell you about the current work, but this is a common concern that has been aired, that if we move work out of the acute people are going to be charged for work they previously had done in the hospital. That is not the case. We are developing a commission framework; money will follow activity. If we ask the G.P.s to manage frailty, the money that we currently spend on frailty will move. Now we need to have a conversation about that. So what we would want and I hope everyone will share our aspiration on the Island is we would want to be able to deliver it at very least for the current money we are paying for it. Hopefully we would be able to deliver it for a bit less because we do have significant overheads, but it is not about that. It is about getting the care where it needs to be and we will absolutely be funding that. You will get the same service now that you get but you just will not get it in that building on Gloucester Street.

The Deputy of St. John :

We hope it is going to be available elsewhere.

Deputy M.R. Le Hegarat :

I think we might need to move on.

The Minister for Health and Community Services:

In the same way Mr. Sainsbury has just mentioned the G.P. mental health cluster, that is an example of the funding from the department going into primary care.

The Deputy of St. John :

To be clear about that, you would have a group of G.P.s who are specialists in psychiatry whom you would move funds out to so that the patient does not have an upfront charge?

Director General, Health and Community Services

We would commission that service, but what we hope to do is also be able to have our staff working collaboratively so it is not just: "I am a G.P., I work in primary care. I am an acute physician, I work in the acute. I am in the third sector." Our aspiration is to get a model where the delivery of care is across the Island regardless of whose hand touches the patient. There is big work going on with the current challenge about going to your G.P. and what that looks like, that very useful conversation that G.P.s feed back to us as well, about how we can start to offer that service in a way that is more appropriate for the needs of the people on the Island who are economically challenged.

Deputy K.G. Pamplin:

The final bits from me, moving on to the capital project fund for mental health improvement. Is the additional funding as quoted in the Government Plan here sufficient enough to ensure the project meets its aims and , more importantly, the deadlines that are included, as we have talked in great length over the recent months?

The Minister for Health and Community Services:

Yes, I am often questioned about this and I am assured that as much as possible that has been precisely calculated, although of course the contract still has to go out to tender, and the timelines are tight but they are manageable. I am really looking forward to getting the planning application in for the work we need to do at Clinique Pinel.

Deputy K.G. Pamplin:

Back in June the States Assembly was told, again following on from our review into the service, that the ongoing remedial work to Orchard House would be completed by the end of 2019 and the transfer to Clinique Pinel by the end of 2020. Are we on target to meet those dates as of today and what changes could possibly happen in the coming months, and talking about the Government Plan, if it is delayed, if there is an issue? Could you just give a bit of an insight there?

The Minister for Health and Community Services:

We are on target. Is your question what might disrupt that programme?

Deputy K.G. Pamplin:

Yes, risk analysis, budgets and so on. What would happen if the Government Plan got delayed, what is the impact?

The Minister for Health and Community Services:

Yes, if the money was not voted by the States Assembly Members, if there was some problem with the Planning Department, although this has been discussed and this is an existing Health estate so I hope there will not be a problem and the Planning Department do understand our need. The contract is still to go out to tender. Those I would see as possible risks but they have been taken account of. Where we are now is where we would want to be having taken account of those risks and moved forward in the light of them. Perhaps Mr. Sainsbury can add something.

Group Managing Director, Health and Community Services:

I agree, everything looks to be on track, but I am aware of the history of capital programmes on this Island and there are lots of variables. It seems that ordering window parts and different things can take a lot longer, but we are assured that the surveying and the work that has been undertaken is to a realistic timeframe. There is just one caveat in relation to the end of 2020 period. We know that providing the building is in the position we need that we can start to shift the activity and we would see that throughout 2020. The full occupation and the full closure for Orchard House is dependent on the activity. If we found ourselves in a position where we needed the capacity then that might spill into the first quarter of 2021 or slightly beyond. That is not what we predict, looking at our current occupancy, but that is a risk and we need to outline that that could be something that we experience. But we should see our first patients moving within the 2020 period including the new place of safety suite as well.

Deputy K.G. Pamplin:

Just to be clear, because we talked about it in our hearing previously and we talked about the kind of work going on in Orchard House following the interim health and safety report. I know this is something I have talked about a lot. Is that work continuing now that the budget is there?

Group Managing Director, Health and Community Services: Yes, it is.

Deputy K.G. Pamplin:

That will be completed by the end of this year?

The Minister for Health and Community Services: Yes, rest assured.

Deputy K.G. Pamplin:

You are requesting close to £4 million in the Government Plan for mental health improvements. How much of this money is going towards the development of the place of safety, another area that came up in our review and we have talked about previously? How much of that £4 million is going to be used towards developing a place of safety? Can you give us a figure and a bit of detail?

The Minister for Health and Community Services:

The place of safety, I understand, is planned within the Clinique Pinel facility. How much is the place of safety and how much are other facilities? I do not have that detail.

Group Managing Director, Health and Community Services:

It is part of the overall cost for the relocation. It has been factored as part of what will be the intensive care suite in the new area of Clinique Pinel and the place of safety is part of that. I do not have the breakdown for what that specific bit is. We could ask. It is to the full suite expectation that is set within the U.K. standard, so we can get a cost indication to you. In addition, we will have psychiatric liaison suites at the general hospital as well and these will be hugely helpful.

Deputy K.G. Pamplin: What is the timeline for this?

Group Managing Director, Health and Community Services:

The place of safety suite could be one of the earlier parts that we adopt within Clinique Pinel. It could come to fruition in Q3 to Q4 next year because that section of the upgrading, the higher dependency area, is one of the first areas that we are doing. That could be before the rest of the whole in-patient unit comes over. That is a 2020 aspiration.

Deputy K.G. Pamplin:

Is the money previously put aside for the development of the place of safety, because we began this journey with being told it was going to go to the hospital. In fact, at our last quarterly hearing at the beginning of the year we were even told it was going to be open in late June, July in the hospital. Obviously that has not happened. We are now September and my issue here is it is very similar to the previous Minister for Health's assumption on the front page of the  Jersey Evening Post: "Overdale is going to be a brand new mental health facility" and here is where we are. We have talked about the place of safety opening up in June. People are very tuned into this topic, obviously. It has not come about in June and this is where we are coming from. If we are going to say something and it does not happen in the world of mental health, people can be affected by that. Before it comes online in 2020, we know we need this, we were told this in our review, the police have said it, the doctors have said it, hospital staff have said it, patients have said it. Where do people go now and how can we address this? That is why I bring it up now.

Assistant Minister for Health and Community Services:

We have a current place of safety. Let us be clear, we have a current place of safety. In terms of the one at the general hospital, when the associate medical director reviewed that proposal he did not agree with it and he wanted to review it and he has reviewed it, which has led to the change of direction into having that at Clinique Pinel. That was his decision. He is the head of mental health, our mental health lead. That was one of the first things he came to me with and said: "Steve, I am sorry but I do not like the direction this is going. I think we are going to struggle to staff it and I do not think it is the right place for it." So we have taken that on board, but we do have a current place of safety and, as the Group Medical Director said, it is one of the things that will be delivered probably sooner than later. It is not a perfect scenario and I do not like saying things we do not deliver on because that is not good government, and I accept that. But in terms of are we going to build what we say we are going to build, absolutely, because mental health has been in a bad place for a long time.

[10:00]

Deputy K.G. Pamplin:

You are right, and this is why I raise it. I think the Director General has hit the nail on the head, it is doing this work previously so we know exactly what we need, then delivering instead of going down a pathway and then somebody comes in and goes: "This is totally wrong." Good that it has happened this time so we do not build another service that cannot match the demand but

Assistant Minister for Health and Community Services:

We have got a care group now lead by an associate medical director that I have a lot of faith in and I see no reason why that team will not be together for some considerable time and take us through this quite transitional difficult period in time. They are all in place. I think they are functioning really but it is a new team and as the associate medical director said to me: "I want my team together in September" he has got them together in September. I think he is very optimistic now we are going to move things forward on time and within the realms of what we have said within the Government.

Director General, Health and Community Services:

I think, Deputy , you have hit the nail on the head in that Miguel came to see me as well and what we are doing is we have reacted. There was a crisis and we have reacted and the room was wrong. It was in the wrong place and it was wrong. What we needed to do is step back but we were in the spotlight and so we just leapt into a decision. That is exactly what I was trying to say earlier, I really get your point, we are not trying to delay or full it with reports and review, because we absolutely are not that kind of team, but it is just about getting it right so that we spend the money right the first time.

Deputy K.G. Pamplin:

That is the point, is it not? That is what we are here to doing, discussing the Government Plan. That is our role to scrutinise it so we this bit first and then we have not spent money and have to go and do it again.

Assistant Minister for Health and Community Services:

Could I just add one thing? All of these issues, all of these developments will be on trackers that we will watch and monitor and share with you on a regular basis. They all come under and are discussed at the risk assurance committees and quality performance committees. We will share and we will speak to you on a regular basis about trackers and when things are not moving forward as quickly as we would want or when they are moving quicker than we hoped they would. But they will tracked. In the past they have not been and, again, that is not good governance within H.C.S. and that is now part of the governance regime. Something that C. and A.G. (Comptroller and Auditor General) has wanted for some time and that is now in place. It is not mature - I think is probably the right word - we are learning in terms of how that assurance will be given, both internally and externally to yourselves and the public, but at least we are working towards that.

Group Medical Director, Health and Community Services:

Can I also assure Scrutiny and the public that we did a risk assessment, the work that has been done in that area next to the Emergency Department is not going to go wasted, it will still be used to assess patients but not at the level that they for a really agitated patient it was felt not to be safe enough and that is why we repurposed and put it into Clinique Pinel. That work that has been done in that area has still been set aside for mental health patients and the mental health team are going to use that to assess patients with slightly lower acuity.

Deputy K.G. Pamplin:

That is reassuring. That is it on the mental health

Deputy M.R. Le Hegarat :

Sorry, could I just ask a question, because this has been bugging me? It is a bit off-piste I have to day, but for us to be able to move Orchard House in to Clinique Pinel, and the other services, are you saying that Clinique Pinel was underused?

Group Managing Director, Health and Community Services:

We have had lower occupancy in Clinique Pinel, yes. We have had it consistently having empty beds there on both levels but we need additional capacity as well. So it is part of the existing building with an extension element that we applying for, so that it is bigger.

Deputy K.G. Pamplin:

That is it. It is just a curious observation, thank you again, as I started with the information and the data, there is much more detail here than in other areas which I will hand over, but, again, thank you because it just shows how scrutiny and government can work. We will continue to monitor it, thank you.

The Deputy of St. John :

We are going to move on to the Digital Healthcare Strategy now. I am just trying to reference the papers. We noted and we sent you a written question about the fact that for 2020 you do not include any budget for digital healthcare. You advised in the reply that you would be funding from 3 sources: slippage in the H.C.S. capital programme, slippage from the overall programme and slippage from the overall investment in I.T. (information technology) set out in the Government Plan. It does not sound a very secure means of funding, slippage. What do you mean by that?

The Minister for Health and Community Services:

Digital is complex, I acknowledge, Deputy . There is a huge budget for digital and innovation within the central operating office, which is working across all government departments to deliver the digital strategy. That is working to deliver it within the Health and Community Services Department without necessarily that money flowing through the H.C.S. budget, especially in 2020. There is an ambitious programme which is being rolled out over the period of the Government Plan. We want to move forward to have that patient record digitised. Immediately we are finalising projects that are currently -  I love this expression - in flight. We are looking forward to having e-prescribing and communications that are handled electronically in terms of G.P.s requesting tests to be carried out and receiving the results. So all that is being funded at an early stage through the Government Plan. Yes, I acknowledge the complexity needs to be read across the whole piece but I do not know if any other officers here perhaps the Finance Director can add

Group Finance Director, Health and Community Services:

Yes, certainly, Minister. There is very significant investment through the Chief Operating Office into I.C.T. (information and communication technology). The Government are keen to adopt a corporate approach while also taking full cognisance of service impacts. We are very closely linked with that. We are working with them, we are discussing with them to make sure H.C.S.'s requirements are at the forefront of that money. There is a considerable investment in that area. We will make sure H.C.S. is fully protected and fully part of that process. What it needs, we will make sure it gets through that field.

The Deputy of St. John :

I do not quite understand what the relationship is between a tax programme and a healthcare programme.

Group Finance Director, Health and Community Services: Sorry, a tax programme?

The Deputy of St. John :

Yes. We have learned recently that the Tax Department are having problems introducing their new I.T. service. I have not heard anything in relation to Health in terms of the development of a healthcare I.T.

Director General, Health and Community Services:

We have to have a lot of investment in our health digitally. One of the pluses of having it held centrally is so at the moment we have a lot of investment in E.M.I.S. (emergency management information system) so we able to talk to G.P.s and G.P.s are able to talk to us, not as much as what we want but we are getting there. E-prescribing and e-ordering and order comms, all this is helping our G.P.s to break down that wall. We would also like to break down that wall between services like Social Security, because we would like to be able to have a free flow for information, absolutely with confidentiality and we have of course got rules, so that we can start to talk to other departments that impact upon people who come to us for service. One of the reason that the budget is being held centrally by the C.O.O. (Central Operating Office) is so that we are not purchasing systems in isolation. We are going to do a big purchase over the next few years of an electronic patient record, but if we buy that just for Health because we are looking to move Health Island-wide and because we are looking to link much more closely with C.R.S. (common reporting standard) around how we can interact across those departmental boundaries, the C.O.O. is holding on to that so they can ensure that we buy a system that enables us to talk to each other. What we have been guilty of in Health in particular is adding multiple systems that do not talk to each other. At last count I think we had about 45 of them that just service clinical needs. The clinicians have to John, when you go into clinic do you not go into about 5 different systems. Having Health centrally will hopefully enable us to spend the money wisely. I am not a digital expert but that is the intention.

The Deputy of St. John :

Right. Last year I spent a whole month's holiday in Edinburgh Hospital and I got to know their healthcare programme relatively well. Putting in a specific health programme almost bankrupt the trust, I gather. Theirs was not perfect. Where are we going to find a system that is not going to bankrupt Jersey?

Director General, Health and Community Services:

That is the challenge and that is why we have elected to we were coming to the end of our current contract and were engaging with people around different contracts so they are completely understanding what we need for Health. That is why we stood back and renewed our contract with our current providers, bartered them down to 3 years, so that gives us time it sounds like a lot but it is not in digital terms, we are already a couple of months into it. So then we have time to sit back and understand what it is that we want. But none of us are digital experts so for us it is beneficial to have that central resource that is looking across government and is able to advise us. We are good at - well, hopefully trying to be good - delivering health, we are not that great at delivering digital. So having that external support helps us to avoid doing exactly that.

The Deputy of St. John :

The idea of having an integrated healthcare programme means that you can, as you say, communicate across the piece. Justice and Home Affairs have, for their Government Plan, allocated £667,000 for the year 2020 to specifically introduce a digital system. Given the level of development that you have in Health and in the wider sphere thus far, would it be suitable for J.H.A. (Justice and Home Affairs) to go ahead with a digital system for the Ambulance Service when you will not know what they are talking to or what system is going to be purchased elsewhere?

Director General, Health and Community Services: So my understanding is sorry, John.

Group Medical Director, Health and Community Services:

Having worked with the ambulance there is an electronic patient report form that you would want to integrate and have access to. That is why it, again, comes back to the need for C.O.O. to integrate our systems so we do not have a bespoke system in Justice and Home Affairs and a different system that will not interact in Health.

The Deputy of St. John :

The question I am asking really because you still have governance responsibility for the ambulance, is it a bit premature for Justice and Home Affairs to be going ahead and purchasing an electronic system?

Director General, Health and Community Services:

I think we need to have a conversation with Justice and Home Affairs about that.

The Deputy of St. John :

Were you aware that they were putting one in?

Group Medical Director, Health and Community Services:

They would have to update their C.A.D. (computer aided dispatch) and their control centre, so that needs updating but they were working on a patient report form which would integrate with the other departments. Again, we need to continue those discussions because electronic prescribing, as well, which we are introducing next year again, if we could introduce that to the Island that would be fantastic. But you are right, we need to have integration and that means collaboration across One.gov.

Director General, Health and Community Services:

But there are conversations happening. All of our digital needs we have a digital health need, J.H.A. have a digital need, they all meet regularly with the C.O.O. apologies I do not know the guy who heads up their I.T. there now the other guy has left. So they all meet up regularly, because I know Bernie our expert does, so I would assume that those conversations are absolutely taking place because that is why we have ceded authority and funds to that central reserve, so that we can pull down as we need but they can also have that oversight and governance around spend.

Group Medical Director, Health and Community Services:

The other thing is we are hoping that Justice now goes away and has the discussion because my portfolio is quality and safety, our datex system, which looks at when errors happen, the ambulance have it and we want to make sure that police maybe not police but fire also have that so we will share our systems with them. You are right, we need to make sure that the budgets are aligned.

Director General, Health and Community Services:

We meet with Pete, Rob and I met with Pete recently because we recognise we are all, you know, first responder services so we work really closely together supporting the Ambulance Service because they support us immensely in the work that both they bring to our door but also the work they keep away from our door. I will keep linking with our digital lead to make sure those conversations are happening now. I am confident they will be.

The Minister for Health and Community Services: Yes, can we undertake to update you.

The Deputy of St. John : You certainly can.

The Minister for Health and Community Services: The programme has to start somewhere.

The Deputy of St. John :

We will definitely be asking questions of Justice and Home Affairs so I do not want to trouble you further with any of the questions we have on another panel. Digital stood out as being an important facet of the relationship.

[10:15]

Director General, Health and Community Services:

It is absolute driver for the new care model. If you were to ask us what we need, we need to be much more digitally enhanced.

The Deputy of St. John :

I am going to read this statement because I am not sure I understand it myself. Within R91, page 39, it states: "It is assumed that the 2.7 million will be available to H.C.S. in 2020, along with a recurring impact of the 2019 schemes of 0.9 million." Why is it only assumed at this stage? Have discussions not taken place about the availability of these funds? We have got a list of funds, additional funds, to toward the development of P.82.

Group Finance Director, Health and Community Services:

Discussions have taken place. We have basically the monies were previous management had an arrangement that for 2019 the monies would be used to fund something else. Discussions have taken place. We are expecting those to come back and will be approved through the Government Plan, obviously subject to the Assembly's actual approval.

The Deputy of St. John :

Okay, I have a supplementary there because the figures over the 4-year period are all the same.

Group Finance Director, Health and Community Services: Yes.

The Deputy of St. John :

Given that inflationary pressures exist, why is there no annual increase anticipated?

Group Finance Director, Health and Community Services:

The Treasury holds an allowance for inflation centrally for contractual impacts, et cetera, and that will be dealt by the Treasury and then allocated out to departments as they go through the following 4 years.

The Deputy of St. John :

You do not have much certainty in your financial plan.

Group Finance Director, Health and Community Services:

Yes, we do have certainty in the financial plans as far as we can within the confines of where we are but the Treasury holds centrally the money for inflation. It is not the departments that hold the money for inflation, the corporate Treasury holds it and then allocates it out. That is normal practice.

The Deputy of St. John :

The hospital pre-feasibility study, there was a vote for that pre-feasibility study, 5 million in 2020, 1.6 million in 2021, why is there less money requested in 2021?

Group Finance Director, Health and Community Services:

The plan is to get the bulk of the work done during 2020, therefore we will not need as much in 2021 for the pre-feasibility. Obviously the financing of the actual hospital itself will be a separate issue that will come through separately once we have done the pre-feasibility work to work out what will be needed.

The Deputy of St. John :

In the Government Plan you suggest that the long-term revenue plan requires the States to withdraw from the commitments made to the transformation programme. What do you mean by that?

The Minister for Health and Community Services: Sorry, requires the States to withdraw?

The Deputy of St. John :

To withdraw from the commitments made to the transformation programme.

The Minister for Health and Community Services: To draw from?

The Deputy of St. John : To withdraw.

The Minister for Health and Community Services: To withdraw. Sorry, where is that to be found?

The Deputy of St. John :

This is an additional question I put in and I do not have the reference, I am afraid.

The Minister for Health and Community Services: I do not recognise that phrase.

Director General, Health and Community Services: I do not recognise it.

The Deputy of St. John :

Given that I cannot reference it, perhaps we will talk about that in writing at some stage.

The Minister for Health and Community Services: Certainly, yes.

Deputy M.R. Le Hegarat :

We will move on to maintaining health and community care standards. The summary business case states that the plan identifies some potential funding sources which relieve pressure on central contingencies. What are those potential funding sources which you refer to?

Group Finance Director, Health and Community Services: Is this the 4,179 in 2020?

Deputy M.R. Le Hegarat :

The 4,179 in 2020 and it goes up to 21,513 in 2023.

Group Finance Director, Health and Community Services:

It does. Yes, this goes back several years and approximately £5 million a year has been invested through yourselves into the Health service over the last few years. This comes through the Government Plan, the funding source is yourselves, it is the Government that funds this and the figures are as we show there. They are indicatively set out as to what the department might spend them on, working with the Minister on that. They are not precise lines with precise figures against them, they are an indication of what it might be. The funding is the Government Plan.

Deputy M.R. Le Hegarat :

What pressures were you referring to when you talk about pressures on the central contingencies? What pressures were you talking about?

Group Finance Director, Health and Community Services:

The pressures the service has faced in the past, faces now and is dealing with now include demographic change, which obviously can have quite a significant impact; the continuing developments in the medical world, new systems, new processes, new approaches to get the best for the Island it can; new treatments. The costs of meeting professional standards, the continuous improvements required of our professionals, we have to finance that. Off-Island services, U.K. placements has been a pressure as you may have seen through the month 6 monitor that we publish, the services dealing with that. Insurance costs tend to rise, there is a rather tightening of the market at the moment. There can be other things as well. It is not saying it is precisely those, it is what the service would consider to keep a top class health service running.

The Minister for Health and Community Services:

My understanding is that this has been an allocation that is now historical because it was made during the previous Administration and is, in essence, a contingency fund for health-related issues, which for some purposes, administrative, it was separated from other contingency funding of the Government because it was recognised that there were some particular factors affecting a health economy.

Deputy M.R. Le Hegarat :

Would you share the detail of targets you expect to achieve in the 3-year period you describe?

The Minister for Health and Community Services:

In this allocation? I am not sure there are targets as such. There is a summary business case which we have shared with you. There are percentages as to estimates as to inflationary costs or costs of new treatments. There are probably some figures

Group Finance Director, Health and Community Services:

If I may, Minister? The figure is a total, we have indications as to where it will go. Clearly that will be worked up. Yes, we can issue some supplementary information when it is done.

Director General, Health and Community Services:

If you are talking about performance standards around how are we intending to deliver service differently next year, so next year of course is particularly about addressing waiting lists. We can share some of how we think we are going to do that and how we are going to try and move away from just as part of our standard business bedding capacity. We could share that information around those standards that we are trying to work to for the next 12 months, which we are currently working through in our business plan, if that would be helpful?

Deputy M.R. Le Hegarat :

That would be perfect. Along with that, and I think this is probably where Deputy Pointon got his question from, would you please also explain the transformation and modernisation programme and what that has achieved so far? That would also be very helpful to us moving forward.

Director General, Health and Community Services:

We have a whole piece of work that we have done around what P.82 has done so far, what we have delivered, what we have not delivered - because we have not delivered a significant amount of it - and what we intend to deliver. The Jersey care model in effect is P.82 plus, plus, plus. It is just a 7 year one. We can share that with you, that piece of work.

Deputy M.R. Le Hegarat :

Yes, that would be perfect because a number of our questions in relation to this area were to do with us basically having an understanding of what you have, what modernisation you are doing and what you are doing moving forward. That would be perfect.

Director General, Health and Community Services: We can do that, yes.

Deputy M.R. Le Hegarat : Thank you.

The Deputy of St. John :

You do refer to a well-developed efficiency programme. Can you describe some of the elements of the efficiency programme?

Director General, Health and Community Services:

We have been looking in detail, as we have started to get our data more robust, around how we can deliver care better. As I think we spoke to the panel about before, we talked about the Jersey plan, the Jersey health plan, and so some of the work we have been doing is looking at our variable costs, so the spend that we have on agency staff and on bank staff and how we roster staff across our areas, do we do that according to demand. We do not always do that. Do we manage our most expensive resources as effectively as we can do? Do we schedule appropriately in theatres, do we have the right patients in I.T.U. (intensive treatment unit)? Do we have the right number of beds open and closed and staffed appropriately? The basics really of a healthcare economy. A lot of the time we are do really well and we deliver very good care but there are significant opportunities across H.C.S. - and I think I have talked to the panel before - to take money out and spend it differently. That is the work we are doing. We are looking at resource allocation, we are looking at utilisation, particularly of our most expensive capacity, and we are looking at our variable spend. We are putting in place a performance management framework which is supportive but is also about holding our leaders to account around the money that we spend and how we spend it.

Deputy M.R. Le Hegarat :

I am conscious that our scheduled time is 6 minutes away from completion. We have a couple more areas that we would like to ask, is it possible to extend slightly the time?

The Minister for Health and Community Services: I am happy to do that.

Assistant Minister for Health and Community Services: I have got 30 minutes left.

Deputy M.R. Le Hegarat :

That would be perfect because obviously it is quite useful for the public to be able to know, bearing in mind this is to do with the Government Plan. Deputy Pointon has another section he would like to ask about.

The Deputy of St. John :

As mentioned in the Government Plan, a 6-facet survey undertaken in 2019 identified the need for £40 million of work in the current hospital over the next 4 years. Another survey undertaken on the non-general and acute estates identified work costing a further £9 million in the period of the Government Plan, however, only £5 million per annum over the next 4 years has been requested. Why the disparity?

The Minister for Health and Community Services:

Because it is necessary to prioritise the work essential to keep patients safe and our staff in adequate conditions but the budget has been increased from the amount that was proposed had we kept to the Future Hospital Plan and proceeded with that. Now that is not to happen so we need to keep the existing hospital running for longer so there is an increased budget there. The work has been carefully prioritised. In light of the survey I have received a briefing on it and it is felt that that is the amount required to keep the hospital safely operational in the period.

The Deputy of St. John :

The £40 million was in fact an overestimate?

The Minister for Health and Community Services:

No, no, that is work that could be done but it is a case of assessing what is essential work to maintain the hospital in a safe condition and what would be a "nice to have" perhaps if we were continuing in that building.

Director General, Health and Community Services:

Also what we could do on the Island within the constraints of the workforce we have and the access we have to it. We would not be able to deliver that amount of work because we would not be able to access the suppliers. What we have done over the past few months is that we had really we risk assessed the work but we had risk assessed it according to the risks of the building. If that wall falls down, it is not very nice, so we risk assess it at a certain level but we have not done is risk assessed to if that wall falls down and falls on a patient. The piece of work we have been doing is looking at the risk register and assessing the impact upon patients - patient experience, patient outcomes - and prioritising according to that, not just according to the building needs. Now, there are some significant building needs that we have to address that would put us at risk of breaching regulation, and that is part of this money to ensure that we do that. We could not spend the amount of money that we needed to spend because we would not get the contractors.

The Deputy of St. John :

In the development of a maintenance programme, what level of consultation with clinicians is there?

Director General, Health and Community Services:

That is the work we are doing now around saying: "What is the work that needs to be done because we need to do it for the building and what is the work that needs to be done because not doing it would impact upon the delivery of care and the experience and outcome of patients?" That is the work that we are doing through committee structure and our new governance structure around assessing that. What we have not been great at is making business decisions based on risk and which, I think, the C. and A.G., very clearly identified; that is what we are trying to do now.

[10:30]

Our risk register is becoming our business manual and it is how we make decisions and how we spend money and how we allocate resource. We are still embryonic but that is what we are trying to get to.

The Deputy of St. John :

Okay. I think you have covered all the points I would have asked. I have got a question here, which is when is the prioritised delivery programme mentioned in the Government Plan due to be finalised?

The Minister for Health and Community Services:

I have seen some very detailed programmes of work, so I think the work is identified; am I right?

Director General, Health and Community Services: Is this estates, around the estates?

The Deputy of St. John : Yes.

Director General, Health and Community Services:

We have a really clear plan around the work that we need to do and the timeframes we need to do in order to be able to deliver that work safely. We have prioritised it according to our current risk register, which is around building need. We are in the process of doing the previous piece of work. Again, we are subject to the vagaries of sourcing contractors and being able to deliver that business within a decent timeframe but we have prioritised that work. We went through that yesterday at the Quality and Performance Committee, which is chaired by Senator Pallett, and went through our top risks, which are 25 that are deemed as catastrophic risks and what we were doing to mitigate those. The Senator very clearly challenged us as an executive team around what that timeframe for delivery was. I do not know, Steve, if you wanted to elaborate.

Assistant Minister for Health and Community Services:

Just in terms of the estates, the conclusion we came to at that meeting is we need an updated priority list of things that are of the utmost importance, based on patient care and safety to patients. I think at the next meeting in October we will have an updated priority list, which I think we would be quite happy to share with the Scrutiny Panel as to the things that are of utmost importance and need to be carried out as a matter of urgency.

The Deputy of St. John :

I did have a question about I.T. but I think you covered that previously.

Deputy K.G. Pamplin:

Just so I am clear, in all the I.T. projects and everything we are referring to ... and I know we touched on it earlier but having spent 24 hours in that building, there is still no digital public records of patient records. It is hindering what you said about delivering care. Where is that in the Government Plan? Where is the money? Is it there? Is it coming and when can that be online? Listening to the staff, listening to the nurses, listening to the doctors, in 2019, with the fastest broadband speeds in the British Isles, with incredible infrastructure, we still do not have digital access for our staff records. It took on average a porter - well, in the time I spent with him - 10 minutes to go and get a patient's record from the basement on paper. Where is the oversee? Where is the funding? When is that happening?

The Minister for Health and Community Services:

I am not a digital expert but I am assured that within the Government Plan it is proposed that we will reach the point that we will have a digital patient record. But there is so much to do ahead of that before we can arrive at a point where all our patient records are digitised; that is my understanding. It is not just something you quickly buy a product off the shelf and say: "This is what we are going to do." There is so much to co-ordinate. I am not the one to speak about how it is worked through to reach that point, I am afraid, but that is the

Director General, Health and Community Services:

That, again, is to do with the electronic patient record that we are sourcing. We have signed a 3- year contract with our current provider to enable us to understand how we can get to that. I would say that it is going to take us another 3 years, which is not great. But in order to be able to digitise the records we need to then have a system that works alongside that digitisation, so that you have that crossover. We also need to be able to ensure that providers outside of the organisation can access that record. This is complex, not because of any intention but we are starting at a really, really low base. As you witnessed in the hospital, it is really challenging for our clinicians; all credit to them delivering in that environment. We are pushing ahead as quickly as we can to get that achieved over the next 3 years. Having that contract termination in 3 years forces us to do this. I would expect E.P.R. (electronic patient record) in 3 years and digitisation within the next 2 years.

Deputy K.G. Pamplin:

Finally, going back to the opening question on this £40 million of work in that identification, was it essential maintenance work? If the hospital - again presumptuous here - does not get approved in this Assembly, we are looking at a 10-year or possibly longer period that this hospital needs to continue to be running: new generators, new power supplies, new facilities. I am just curious where we are heading.

The Minister for Health and Community Services:

I do not want to think about what might happen if we do not approve any

Deputy K.G. Pamplin:

With the greatest respect, Minister, I am sorry but with our track records in this Assembly of getting this decision right there is a lack of faith until we deliver this. But what I am saying is part of risk management strategy, when you are talking about long-term capital project, is every scenario is covered.

Assistant Minister for Health and Community Services:

You are absolutely right around risk management and from what I saw yesterday there is a comprehensive list of improvements that need to be made. Again, I will stress this, what I have asked for is a prioritised list of things that need to be done as a matter of urgency and those that can wait. There are clearly some things on that list that need to be done as a priority. Some of them are unfunded and we need to find where that funding is going to come from. But there is a balance to be struck between how we communicate that. What I do not want to be doing is scaremongering to the public that things are fundamentally wrong with the hospital, where they are things that need to be dealt with in a prioritised way, but they will be dealt with by next month and we will expect to have that list in front of that board.

Deputy K.G. Pamplin:

I think what is really key is we do not want to get to a States Assembly debate where Members are standing up and saying: "There is £40 million, we have to do this or the hospital crumbles." We need to make sure we have the facts of what the reality is so it is not used in a political way to ensure that the hospital ... whatever we get to that debate. Do you know what I mean?

Assistant Minister for Health and Community Services:

I think that argument needs to be depoliticised, but the Minister is absolutely right that we need to make sure that the hospital is safe for patients over the next let us hope it is 5, 6, 7 years and not longer than that. But, clearly, there are some things that are going to have to be addressed. There are things that have been put off, I think that would be fair to say, because we thought we were going to achieve a hospital in a 3 or 4 or 5-year timeframe. We are going to have to be honest enough to say we are going to have to spend nobody wants to spend that money because we would like to see it in a new hospital but we are going to have to. But it should not be used as a tool in a political debate to beat the Government over about timeframes and things like that. We have got to get the hospital right and that is the future hospital right.

Deputy K.G. Pamplin:

The whole point of this here today is the efficiencies in delivering a better service. We are hearing we are not going to get digital paper records for another 3 years possibly.

The Minister for Health and Community Services:

But we are working towards it. There will be things happening within 3 years. It is a huge project that you build up to.

Assistant Minister for Health and Community Services:

Kevin, just on the digital side, because I had a little bit of involvement with that in the previous Government around how records could be produced and around personal digital I.D. (identification), for example, patient records are owned by the patients, or should be owned by the patients, and should only be given to who the patient wants them to be given to. As I said, there is a level of governance that is involved with that and there are security issues with that as well, all of which we have not resolved yet. I think, as a Government, we need to resolve those issues, so that patients are comforted that their records are safe and given to those that they only want them given to. It is a really complex issue but one that has been solved elsewhere and needs to be solved here, but our record on it has been poor, I hope with Deputy Wickenden in charge, or certainly overseeing some of those digital improvements, that they happen in good order. But they need to happen through government and not just in a single department. That is the problem, is it not, that it only happened in individual departments?

The Minister for Health and Community Services:

In the case of Health and Community Services, it goes beyond a government department. We want all our partners to be able to access the same record: the voluntary sector and in the G.P. surgeries and the like. That does add a complexity that you have got to be careful about and get right.

Director General, Health and Community Services:

I think our governance, Deputy Pamplin, is that through our framework and the work we are doing around our risk register, we hope at the end of the year that we are able to present you with our risk register, which is us, as officers, being held to account, as we rightly should be, by our Ministers and not officers holding officers to account, as previously. Then you, as scrutineers, have our risk register that has gone through a process of clinical risk assessment, officer risk assessment, ministerial scrutiny and comes to scrutiny, so that you absolutely have that transparency of information to question us about this. The one thing that the Minister said to me when I came into post was that he wanted assurance that the care we delivered is safe. That is this process we are going through and that we will be able to give to you at the end of the year, as we committed to in our last quarterly hearing.

Deputy M.R. Le Hegarat :

Okay, the sort of final hurdle, for the learning difficulties capital project, in total you were requesting £6.8 million over a 3-year period, 2021 to 2023. You have estimated that the Aviemore solution will cost between £2 million and £2.5 million. How will the remaining funds be spent?

The Minister for Health and Community Services:

I think, initially, we will be engaging on a feasibility study as to exactly how we might provide for these individuals with learning difficulties. There are options. Personally, I do not want to keep those premises; I do not think that would be a good use of funds. I think we should try to secure new premises, but all this should be looked at carefully. Then, depending on what option is eventually chosen, there will be different costs involved, I believe.

Deputy M.R. Le Hegarat :

Where do you plan on relocating the 4 individuals that you have referred to in the business case summary?

The Minister for Health and Community Services:

That is a huge challenge when they need to be relocated and we have to work on that.

Director General, Health and Community Services:

Again, we talked about this quality and performance yesterday. It scores high on our risk register because the property is incredibly challenged around the state of it being habitable for our patients and we have just agreed a piece of work around maintenance on that building. It is going to be done in 4-hour periods so that we do not disturb the patients in there. But we have a challenge around the relocation of those patients because we have no other facility. There is a daily discussion as part of the exec team, it is escalated to Q. and P. (Quality and Performance). It is going to be escalated to September board because we do not have anywhere currently to put those patients, unless we move them off-Island, which we would not want to do because that would not be therapeutic for those patients.

Deputy M.R. Le Hegarat :

What is your timeline for the re-provision then of Aviemore?

Director General, Health and Community Services:

I do not know, Rob, if you wanted to broaden that conversation.

Group Managing Director, Health and Community Services:

We are in discussion with multiple options around this. There is one client that we have a potential housing solution with, with a partner. There is another client that we are seeking whether or not there are existing providers on the market who might be able to support us. Our objective would be to try and vacate the top floor of Aviemore in the first instance; that is the area that needs most attention and work. The ground floor has had more investment and is a better environment. If we could have the movement of 2 of our clients, that would give us that ability. But it is very difficult because we do not want the revised setting to disrupt the clients and we have had that experience with other clients when they moved into new builds; they had been there for a long, long time, some of them. It is very closely connected to their day services because it is co-located. We are working through all the options with that now. We are trying to look for an immediate option for 2 of those clients now and working on that in 2019.

Director General, Health and Community Services:

We approached multiple providers to see if we can find alternative provision. As of today, we still do not have alternative provision but it is at the top of our priority list as an exec team.

Deputy M.R. Le Hegarat :

You have included £250,000 in a pre-feasibility vote to fund the feasibility study for the long-term solution. If this is approved, what will the feasibility study involve?

Director General, Health and Community Services:

It is about understanding the needs. We do not meet the needs on the Island and for us we need to understand exactly what they are and we need to understand what that therapeutic environment would look like. Ideally, when we talk about it as a team and when we talk about it with physicians, it is a purpose-built unit for L.D. (learning difficulties) and is fully supported and embraced within the community. It is within a community setting but is purpose-built accommodation. That is the intention and that is around the feasibility work that we need to do around that. The mistake we have made at Aviemore is that we just did it.

The Minister for Health and Community Services:

We bought at one stage a residential house and put people into it with very specific needs, which the premises could not accommodate.

[10:45]

Director General, Health and Community Services:

It is a different time, so it was difficult to take decisions at that time but we want to get it right this time. But, again, it is at the top of our priority list. It is one of our biggest challenges currently.

Deputy K.G. Pamplin:

I think we are coming to the end, but I think there is an overall view of taking everything that we are saying today, Minister, there is a lot and I think you have heard us pick up with the words because we are all about the detail in this panel: slippage, assumptions, assuming, hope. A lot of the budget in this Government Plan is for feasibility studies and looks in investigation. You go to the mental health side of things, there is a lot of detail there. There is a lot of identified projects, this is happening, that is happening. Is it fair to say, Minister, that our concerns coming from the scrutiny side is - and, again, thank you for the written answers to some of the questions - the sense of where we can zero in where the taxpayers' money will go to the end of this term, 4 years? The taxpayers will say: "I can see where my money was spent and I can see the improvements", instead of going into another world of we have had a review, we have had another strategy, we have this. Just looking at it, it is the detail of where the money is going and where the improvements will be made for the services that are in demand. A fair assumption or would you like to expand?

The Minister for Health and Community Services:

I would accept that the mental health programme is the more developed because of the priority that we have given to mental health, to try and achieve that parity of esteem, which I believe we are reaching. I am thrilled that we have been able to do that. We are able to be precise about where we are spending that money. But I would not say our preventative disease plans are just a matter of a finger in the air or a hope agenda. These are monies that the Council of Ministers has agreed will be put towards addressing our long-term issues, so that we do not develop a population with chronic illness that needs intensive care in the community or in the hospital. There are plans for new staffing levels; there are plans to bring forward new strategies. Yes, there is a lot of detail still to be worked on but I believe our direction is quite clear.

Deputy K.G. Pamplin:

Have you any concerns where you will be standing up the most? Obviously this has all got to go to the Assembly debating. We are doing our work and you are doing your work. What is your key part of this if you stand in the Assembly to ensure the key parts of your budget that you put forward, that you fought for around the table with the other Council of Ministers, is there, is going to be in this plan? Is there anything you really want to zone in on?

The Minister for Health and Community Services:

Our priority must be to deliver the mental health quality improvements, to invest in our programme of preventative care and to deliver our new care model and put that out into the community and begin to roll that out, so that we do not get caught in this problem of putting everything into a building and bringing people in with acute illnesses, that we can address their health needs at an earlier stage.

Assistant Minister for Health and Community Services:

I take your point around something like the preventative health agenda. We should have had a health and wellbeing policy framework in place by now. It was due for the last Government and it was not then and we did not deliver on it. We are going to deliver on that very shortly. What will flow out of that will be a lot of preventative health programmes, some of which I have had a lot of input in in terms of the Active Jersey Strategy, for example, and getting the Island more active and reducing obesity with young people, and in fact through the whole of the population, but you will see this very soon now. I do like the word "hope" because it is a positive word. I take your point you need to see something that is happening and things that are being delivered, but they will be delivered and they will be delivered shortly. But in terms of the preventative stuff, it needs to be revolved around a policy. At the moment we have had a lot of separate policies on smoking and alcohol, all sorts of other areas within government, and they are not being linked up. I think within the next 3 months we will link all those up and we will have a very clear way forward.

Deputy K.G. Pamplin:

I think that is the other concern if you look at it, as we hear efficiencies, efficiencies, efficiencies, that could be interpreted as cuts and cuts and cuts. We just want the assurance that you will have what you need to deliver the health service we need and make all the huge investments in the services, changes that we need. Where I was getting to is this efficiency driver that we are hearing across the board, we know how essential it is, but we also need to put in faith and insurances in the hard- working staff who deliver our services. But that does not mean loss of jobs, that we are going to farm it all out to external sources. It is just that surety that we are looking for and that is where the detail is. When we see stuff like slippages and assumptions and things, we are just trying to get that detail and that reassurance of what it means that you can deliver the health service we need.

The Minister for Health and Community Services:

I am absolutely with you. It is not about cutting for the sake of achieving a figure. It is about keeping patients safe and giving them better health outcomes. I would hope that we have managed to show you today and the previous times we have met that this is what the department is working to. It is not being driven by an agenda where we have got to slash budgets; it is about directing our resources to better outcomes. If we can make savings along the way by, for example, the Director General has mentioned, using our theatres in a better way, then we can apply that money to efficiencies, which means we can have that money to do things in the public areas.

Director General, Health and Community Services:

Forgive me, Minister, there is no headcount reduction in our efficiencies programme.

Deputy M.R. Le Hegarat :

On that note, I think we will finish because that is a very positive note to finish on.

The Minister for Health and Community Services: Yes.

Deputy M.R. Le Hegarat :

Thank you very much all for attending.

The Minister for Health and Community Services: Thank you.

[10:52]