Transcript - Minister for Health and Social Services - 28 June 2019

Corporate Services Scrutiny Panel Population and Migration

Witness: The Minister for Health and Social Services

Friday, 28th June 2019

Panel:

Deputy J.H. Perchard of St. Saviour (Chairman) Senator K.L. Moore

Witnesses:

Deputy R.J. Renouf of St. Ouen , The Minister for Health and Social Services Ms. B. Sherrington, Head of Nursing and Governance

[14:08]

Deputy J.H. Perchard of St. Saviour (Chairman):

Thank you for coming. Obviously we are inquorate but we, as a panel, have made a decision, while quorate, to go ahead being inquorate. We have double checked the procedure that we could do that. We are a bit depleted but we have made the quorate decision to do that. If I could just draw your attention to the witness notice and could you please confirm that you are happy with it?

The Minister for Health and Social Services: Indeed, I am aware of that and I am happy with it.

Deputy J.H. Perchard:

Thank you, and just for the sake of the record we will just introduce ourselves. I am Deputy Jess Perchard. I am a member of the Corporate Services Scrutiny Panel and I am taking the lead on this population and migration review.

Senator K.L. Moore :

I am Senator Kristina Moore . I am the Chairman of the Corporate Services Panel and a member of this review.

The Minister for Health and Social Services:

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

Head of Nursing and Governance:

I am Becky Sherrington, Head of Nursing at Jersey General Hospital.

Deputy J.H. Perchard:

Thank you. Minister, just to start off, firstly, thank you for your submission, which we have received and looked at. How are you contributing to the work of the Migration Policy Development Board?

The Minister for Health and Social Services:

I have not been asked to make a specific contribution as yet, but I am very willing to meet to engage with the board, as they might wish. To the best of my knowledge, I do not believe they have contacted the Health and Community Services Department for any input as yet.

Deputy J.H. Perchard:

But do you expect that will be the case as they progress their consultation?

The Minister for Health and Social Services:

I would expect so because the department does bring in a lot of people to the Island for their specialist skills. It is part of the issue we have around migration, is it not?

Deputy J.H. Perchard:

Do you have any indication as to when you might be engaged or are you just

The Minister for Health and Social Services:

No, I do not believe so. It is perhaps early days on the part of the board. I do not know their schedule or timetable.

Deputy J.H. Perchard:

Sure.

Senator K.L. Moore :

Clearly we have big questions to answer in terms of the infrastructure and services we provide to the community in the context of a rising population. Health is an important factor of that. I recall at the time of the debate of P.82 that much reference was made in the Health Department about the use of the plus-325 figure in terms of planning for service provision in the future and the size of the hospital also. Does your department use that same equation of plus-325 still when looking to the future and planning?

The Minister for Health and Social Services:

I think the last time these sort of projections were made was in the outline business case for the future hospital and I think the projection there that was used was plus-700 as a sort of benchmark but there were calculations either way below that and above that. But I think the outline business case took the 700 on the basis that that had been the average over a period, perhaps it was 10 years or something at that time, 2016. Currently we are looking at the model of care, again in the context of the hospital project but also generally how we deliver care in the Island. So we want to do that and I do not think we have yet got to the stage where we are we have got to that detail where we choosing which figure we might use to project population forwards.

Deputy J.H. Perchard:

You very helpfully, in your letter to us, quoted the O.B.C. (outline business case) and showed that, just quoting: "Analysis shows that as demand increases beyond 2026 further increases in F.T. (full- time) numbers will be required. At 2036 the total increase on 2016 will be some 266 staff. A further 167 will be required by 2046." Do you anticipate that that increase in F.T. will be in the form of people moving to the Island or do you have plans to fill those requirements from within or how have you projected forwards to meet those requirements?

The Minister for Health and Social Services:

I think wherever we can we would recruit locally. Purely on economics that is the better option, the cheaper option, so we train locally where we can. But there will always be skills that we cannot train locally and there will always be a difference between the people we can bring through locally and the needs of the health service, I believe. I think now we should exercise some caution around that figure or those sorts of figures. We have yet, in the future hospital new project, to appoint the team that is really going to drill down and make these sort of projections and assess what we might need in the future. There is talk about also delivering care differently and not having one person doing a single job, because I see this happening, that we drag people into the general hospital for a physio appointment and then the next week they will be in for something else whereas maybe that one

person could attend to all their needs. But if I could invite Ms. Sherrington to speak to that because she will have the detail about future possibilities.

[14:15]

Head of Nursing and Governance:

We always need to think about smarter and different ways of working, so we always need to look around what we do with different roles. Rather than having a single role for a single person, we would have blended roles and we would have different ways of working with different healthcare professionals. As the Minister said, if we look at O.T.s (occupational therapists) and the way that they could perhaps work differently with physios and registered nurses and there is different models of care that are already happening within the U.K. (United Kingdom) and within Europe that would be a really exciting opportunity for us to do over here. By doing that we would be able to attract other members of staff from the U.K. who would want come and work somewhere that is adopting new ways of working. So we are working up through it that way. We also need to look at the way in which we employ and support our non-registered workforce and that is going to be really essential for looking after those with frailty going forward. They might not need highly skilled professionals but need people with unqualified roles to support them around their frailty needs, so we are doing that piece of work too.

Deputy J.H. Perchard:

Thank you. That is really helpful.

The Minister for Health and Social Services:

Can I just add that we also want to work in better ways with G.P.s (general practitioners) in the Island. I think people relate to their G.P.s very well and G.P.s can take a substantial part of people's care and deliver it in their surgeries in the community that leaves the health service to address the more acute cases. As we said, we do not need to be bringing people in for check-ups constantly when G.P.s can do that, for example.

Senator K.L. Moore :

There has been an area, however, where there has been considerable negotiation and discussions since 2014 when the sustainable funding mechanism for primary care was supposed to have been implemented, yet it still has not been.

The Minister for Health and Social Services:

No, I know and it is a difficult one. We are still in discussions. I think there is a clear recognition on the part of the G.P.s that we all need to move to different ways of working, but it is the funding around that that is the difficulty and we are continuing to talk and try to resolve that.

Deputy J.H. Perchard:

We have seen quite large population growth in the last 4 years in particular, net plus 1,000 since 2015 where it peaked at 1,500, which is obviously quite a lot. The projections we have seen from Statistics Jersey look at the population growth at net plus 1,000 and that we will double our population by 2092. Would you say that the vacancies that I have just quoted to you are a direct result of population growth in general or is it the result of a greater need and a certain demographic, the ageing population specifically, or are people getting sicker? What is it that is driving these increased requirements?

The Minister for Health and Social Services:

It is not just general population growth, because I would guess that the increased numbers coming to the Island are more likely to be younger people who do not have a great need for health service as yet. The pressures come more in the ageing demographic, so people who are already here and are living longer because, thank goodness, we can keep them living and healthy and curing illnesses so that they do enjoy, we hope, a good old age. But they come to the stage where they are living with a number of conditions and those need to be managed and the numbers of those people are growing, so it is there that the pressures take effect in the short to medium term. I suppose looking at the longer term, the people that have been coming in in recent years as young people are going to grow old, so there will be a greater number with those sort of long-term conditions or frail and just needing support and assistance. So we must plan for that occurring.

Deputy J.H. Perchard:

Is it your view that bringing in a younger workforce to support the ageing population is an appropriate response to the needs of an ageing population or should we be looking at other creative or different ways to support an ageing population temporarily so that we are not creating a problem that just kind of exponentially grows?

The Minister for Health and Social Services:

Yes. The difficulty is there is no easy answer, is there? Yes, if we can look at other ways of supporting an ageing population a great deal of faith is being placed in technology, for example, and there are definitely ways that would help staff to manage an increasingly ageing population. Can you add to that?

Head of Nursing and Governance:

This is a debate we have often and we are looking at this. Rose Naylor, the Chief Nurse, is working with Paul McGinty about how we have a relationship with the third sector, with our charitable organisations, because people will engage and work with charitable organisations far more than they will do at the moment. We are looking at getting charitable organisations to do it in the community hubs. One of the schemes is called Closer at Home in which charitable groups go to the parishes and they deliver advice and support and that is co-produced at the moment. People are working together with the community and charitable organisations, so when you are there you get advice about exercise or your medications but also you might get advice about your mental health too. A lot of this is around social isolation as well. As the population gets older and is on their own they become socially isolated, which means they may access health not inappropriately but that may not be their actual need, so by doing Closer at Home schemes people are able to go and talk about socially isolation, do a bit of exercise and get advice about healthcare needs as well. So that is a scheme that is being developed and started to run already. That is a piece of work that at the moment is going on to try and talk with other charitable organisations about how we support them to support our community too.

Senator K.L. Moore :

In the past issues have arisen in working with the community and voluntary sector before proper memorandums of understanding or service level agreements have been bottomed out. Is that process underway and have those service level agreements been formulated?

Head of Nursing and Governance:

I could not tell you exactly. I could not find out how many service level agreements are in place. I know that many are but I could not tell you the numbers of them, but I know that Paul McGinty and Rose are working with charitable organisations to work through some of the issues that they come to us to say we need to work in partnership and we can do and should be able to do that with them.

Senator K.L. Moore :

It is somewhat off topic of the population and migration review in any event, but I think the interest for us and the focus is about the funding and the projections going forward. The Minister spoke of long-term care and the impact of that, potentially, looking to the future. That has been subject to actuarial review along with the Social Security Fund. But what work has Health done to look at the increasing demographic and the changes that that puts on funding the healthcare system, particularly in light of the fact that agreement still is not met on the primary care bodies and of course that we are still on that path to implementing community care as we agreed in 2013 on the P.82?

The Minister for Health and Social Services:

Sorry, your question was about what work around funding?

Senator K.L. Moore :

This is really about funding, yes. What will the impact be on your department? Is that being properly provided for? Do you feel secure that looking into the longer term your budget is secure and properly provided for any increased burden due to changes?

The Minister for Health and Social Services:

I think because there are such fundamental changes going on in our model of care, we have not set out and got that vision for funding in the longer term on exactly how it will happen. So, for example, if we want the G.P.s to do so much, then it will be a different funding. It will not just be a lot paid to Health and Community Services. It might come through

Senator K.L. Moore :

Yes, but your predecessor, Deputy Pryke, had the foresight to bring forward P.82 and a model of community care and so this work should have been heading in this direction, because it was agreed by the Assembly in 2013. Despite the fact that the primary care body is still not in agreement with the department, what work and what security do you have as Minister that this work is progressing and looking to the future properly and adequately?

The Minister for Health and Social Services:

Well, the work with the G.P.s is progressing and very regular meetings are held and we are engaging well with them, but the way we fund G.P. services is an issue that is very difficult. There are different ways it can be done but we have not yet settled on a way which we were in a position to put to the States Assembly to make any changes. Those discussions are ongoing and involve the Minister for Social Security and the Health Insurance Fund also. Funding healthcare in the longer term will also very much depend on the model of care that we adopt and how much we can deliver in the community which might save

Senator K.L. Moore :

We adopted a community-based model of care in 2013, so there has been ample preparation time.

The Minister for Health and Social Services:

The principles were all there. We are not departing from the principles of P.82 but I think the outworking of it is really now being developed, it would seem to me, particularly with community partners, the voluntary sector for example, which you asked about before. So treating them as partners rather than a separate organisation to which we pay a grant which might not be allocated according to exactly what we are doing but because somebody chose the figure or somebody asked for a figure, but we will be able to discuss exactly what we would like that voluntary organisation to deliver and provide funding against it with some key performance indicators and that clearly written into a service level agreement with them.

Deputy J.H. Perchard:

Do you have, Minister, projected scenarios in which you look at if this particular part of the population increases in size by this much by this year, our service provision will need to increase in these areas by this much by this time? Do you see what I mean? Do you have those different scenarios projected forwards based on changes to demographics, the ageing population and population generally?

Head of Nursing and Governance:

We recognise that that is something we need to do. We have got a new Director General who has recognised that P.82 gave us the first stepping stone to changing the way in which we deliver care and that has been put in place. Prior to that we did not have specialist nurses working on some chronic lung problems, we did not have cardiac rehab. So there are lots of things in place that P.82 enabled us to do but going forward now, now we have got a new Director General, there is a few things that we need to gives us a chance just to look at it even bigger now and look at this more radically. Part of the target operating model has been a reorganisational structure change and part of that is to look at modernisation and there will be a head of modernisation. My understanding of that role will be to look at ways in which we work differently and start to look at what our healthcare needs are that are being projected.

Deputy J.H. Perchard:

Yes, because of course while everything you have said is welcome, it is hard to design a direction of travel or new policies or even new ways of working without that data underpinning your goals.

The Minister for Health and Social Services:

Yes, and I am seeing a much greater emphasis now on the collection of data and the planning of services for the future that perhaps was not there before or just could not be collected for various reasons.

Deputy J.H. Perchard:

Aside from a medical emergency, population growth and particularly the growth of the ageing demographic is possibly one of the biggest threats to the Health Department in terms of its ability to provide, so I would have hoped and assumed that that was at the forefront of your planning, having those projections in front of you and planning accordingly. Would you think that is a fair comment?

The Minister for Health and Social Services:

It is, yes. The ageing demographic is a blessing but it is also a risk in terms of the resources that are needed to keep people well in old age. It is a priority. We are perhaps not yet at the point that you would hope we might be but it is certainly the intention that these services are backed up by resilient data and we plan our services for the future.

[14:30]

Deputy J.H. Perchard:

One of my concerns, having had the hearing with the Chair of the Development Board recently, is that we asked: "Which alternative measures are you considering as part of your review, aside from just expanding the number of working age people?" which as I say just kicks the problem down the road. It does not address the ageing population problem at all. My question to you is the same but specifically through a health lens: what creative and innovative policies are being discussed aside from simply growing the middle-aged population to deal with the ageing demographic in health?

The Minister for Health and Social Services: Yes, aside from bringing people in, as it were.

Deputy J.H. Perchard:

Well, aside from bringing in permanent residents who will then become part of the next ageing population.

The Minister for Health and Social Services:

Yes. I do not think we regard that as the go-to answer.

Deputy J.H. Perchard: That is reassuring.

The Minister for Health and Social Services:

I think it is about different ways of delivery; it is about involving more people, involving community groups, parishes and indeed families. I think we have all got to understand that families have responsibilities in this or should do and should be involved in the care of elderly members of families. I mentioned briefly technology as well, which I think has a great role to play in, for example, just monitoring people at home. You can monitor people's blood pressures or heart rates or something without having people to call on them to take those tests.

Head of Nursing and Governance:

We do have the Digital Health Team who are looking at those innovations. We have digital health nurses attached to that team as well, looking at how we transform delivery care, also the care available to people to prevent from all types of things.

The Minister for Health and Social Services:

Yes. There is the scheme, which I think is great what is it called?

Female Speaker: Call and Check.

The Minister for Health and Social Services:

Call and Check. Thank you very much. Health is supporting that financially and otherwise and I think that is a good model for the future, so recognising that we want to keep people living independently in their own homes but instead of having health professionals call on them to monitor them, you can have the postie, who has no health qualifications but has a level of training, just to answer a few questions and make an assessment of whether that person is managing or has any specific needs that week or that day. That is about community care rather than elevating it to a specialism that needs nurses or doctors going in.

Deputy J.H. Perchard:

You have talked a lot about what I would suggest are kind of reactive things. What about prevention of ill health in old age?

The Minister for Health and Social Services:

Yes, that is key and is one of my great emphases. We have to pay much more attention to that and put more money into preventative services because if we can keep people healthy as they pass through life then that will diminish the effects in later years. It is about diet and exercise. It is about ensuring that people are vaccinated and receive tests at appropriate times to catch early signs of any disease. In mental health it is about talking about stress and mental health issues and making sure that those are not left to fester and become a more serious problem. Absolutely, prevention will solve many of the not all but will help people as they grow older to avoid some of the difficulties that we see arising now among the older demographic.

Senator K.L. Moore :

When this Council of Ministers withdrew the population policy that was due for debate last year, were there any elements of that policy that from a health perspective you wish to see followed through by this new Assembly?

The Minister for Health and Social Services:

Gosh, can I pass on that because I have not read it for a long time? I have concentrated more on specific health policies rather than what was contained in that proposition.

Senator K.L. Moore :

Is there anything from a health perspective that you wish to see in a new population policy as it is implemented?

The Minister for Health and Social Services:

We must always have the capacity to bring in the specialist skills that we need, I believe. Otherwise, if we cannot, that means we have to refer people off Island and that would be a shame, I think, and Islanders would not like that and it would add to increased costs. So there will always be a need to bring in those specialists but I think we want to increase training opportunities for people who are here and upskill them, talking about healthcare assistants and what more they could do and give opportunities for more nurses to train, yes, if I can put it that way.

Deputy J.H. Perchard:

What are your main concerns about the future of health in relation to migration and population?

The Minister for Health and Social Services:

Well, that we reach a stage where the health service as a whole cannot cope because of the numbers seeking its services, so that might not be an immediate concern but in the future as people grow older we would need to be able to service their needs in terms of managing long-term conditions, which can be quite intensive sometimes, and addressing issues of frailty where people can be living for years but have difficulty staying healthy and independent. A lot of resource can go into that. If we can address things now that mitigate those issues we would be in a better position.

Deputy J.H. Perchard:

In the migration policy that was subsequently pulled by Chief Minister Le Fondré after the election, there was written a statement along the lines of that the new hospital would reach capacity within 10 years should the population continue to rise by 1,000 net a year. Obviously a lot has happened since then regarding the new hospital and migration policy has been withdrawn, but what consideration has your department given to the impact of population growth on the capacity of the new hospital and when we will need another hospital?

The Minister for Health and Social Services:

Obviously you can project scenarios depending on if you do nothing except adopt the current model or if you implement change and deliver care in different ways and that is what we need to do. I do not want to see a hospital that is built with a huge capacity for beds because we will need that in a couple of decades. It is far better, I think, just to address people's care needs where they are in their homes and in their communities and have a hospital that is reserved for emergency treatment and for acute care needs rather than more routine and generalised care. We know that keeping people in hospital is not good for health. People lose mobility as they get older and they need to be and I think it is just dispiriting if you have to spend a week in hospital and then get back into your routine at home. I think a lot of elderly people just lose some capacity over that sort of time period. So if we can keep people out of hospital and address their needs at home, that is what we should be aiming for.

Deputy J.H. Perchard:

When do you think we will start to see results of the changes that you have outlined today?

The Minister for Health and Social Services:

As part of the hospital planning, one of the key appointments to be made is a clinical director who will be researching and consulting on the needs for the community in terms of how it delivers its healthcare, which will ultimately inform how large the hospital should be in terms of availability of beds and other departments. That appointment has not been made yet but it will be going through the process shortly and it will be that person, I think, who will be leading the work that needs to be done.

Deputy J.H. Perchard:

Pertaining specifically to the hospital or

The Minister for Health and Social Services:

It is one healthcare system, is it not? So he or she will be looking at how realistic is it to deliver the care in the community that we have been talking about. He or she will have the expertise, the knowledge, because of the skills that we are seeking, to assess that and to say: "Can it work in Jersey or do we need to bring everyone into the hospital?" So I am looking forward to working with that person and getting that piece of work done.

Deputy J.H. Perchard:

When will that appointment be made?

The Minister for Health and Social Services:

We are hoping it has to go through the recruitment processes but it just depends on whether that has to go out to advert or whether it can be done through just looking at C.V.s (curricula vitae) and making a selection and then interviewing and things like that.

Deputy J.H. Perchard:

We have reached the end of our half hour, so thank you very much. Apologies again for the late start and we very much appreciate you coming. We will close the meeting.

The Minister for Health and Social Services:

Thank you for asking us to attend and speak to you about the health service.

[14:41]