Letter - Director General of Health and Community Services to Public Accounts Committee regarding Revised Responses to C&AG Report on Health and Social Care Governance - 13 January 2022

3rd Floor West Wing, Peter Crill House Gloucester Street | St Helier

Jersey | JE1 3QS

13 January 2022

Dear Deputy Gardiner

PAC requires further action and clarification on the Executive Response to C&AG's Health and Social Care Governance Report  

The Public Accounts Committee requests specific further details on the following matters:

1. Some revised responses do not include target dates for implementation – please provide.

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Updated document embedded.

2. Please briefly explain how you expect the Integrated Governance Framework to influence and impact upon other areas of the Government of Jersey, as well as the whole Island health and social care system'. Please provide specific expected outcomes to evidence your answer.

Health and Community Services (HCS) can influence & impact other areas of Government of Jersey as well as the whole Island health & social care system by evidencing the highest standards of quality, performance & safety, assured through the framework.

HCS cannot impose its governance structure on services which operate as independent businesses (Dentists / Community Pharmacists / Charities). However, there will be areas which can be influenced through,

• Island-wide strategy development

• Contracts & service level agreements, HCS will continue to define its expectations from commissioned services

Governance arrangements will be an essential part of future service level agreements with contracted services within the Commissioning Framework. For example:

• The Maternity Strategic Improvement Programme which will lead on the development & implementation of the Maternity strategy for Jersey, will require a governance framework that incorporates service providers external to HCS.

• The intermediary care services delivery which will consist of internal HCS services and community services such as Family Nursing & Home Care (FNHC).

1. How will the progress of the Framework be tracked?

The areas of government referred to by the Comptroller & Auditor General in the report, will be invited to attend the HCS Board.

2. Please advise whether you expect to modify the Framework to account for the whole Island health and social care system, or if it will be embedded' from the outset. If it is to be modified, what changes will it undergo and what quality assurance will you seek to ensure that the changes are suitable?

The development of the framework is an iterative process and modifications will be made as required following regular assessment of its effectiveness. The use of expert independent members to the assurance committees (who will attend HCS Board) will commence in Q3 of 2022. The assurance committees will set the quality standards going forward when in place.

3. Please provide an updated timeline for the revised response to Recommendation 4 and advise how this will impact upon other work programmes within Health and Community Services.

HCS accepts the recommendation by PAC to produce the Board Assurance Framework by Q2 2023.

This revised timeline will not impact upon other workstreams within HCS.

4. Your revised response to the PAC's Comments in respect of Recommendation 5 does not appear to include consideration of our request for an Annual Quality Account in 2022. Please confirm that an Annual Quality Account is planned for, and will be published, in 2022.

HCS is committed to preparing an Annual Quality Account starting in 2022. In line with the local financial year, this will run from January 1 – December 31, unlike the NHS who run theirs in line with the 1 April- 31 March financial year. HCS will publish the 2022 Quality Account by the end of Q1 2023 in order to have time to collect end of year data and for the document to be internally verified.

1. What impact will the new Director Quality and Safety have on taking this work forward on an annual basis?

The Director of Quality and Safety will work in conjunction with the Medical Director and

Chief Nurse to deliver our Quality & Safety agenda. This includes but not limited to:

• Design and support the implementation of HCS Quality and Safety Strategy by developing and embedding a culture of continuous Quality Improvement across the organisation

• Provide assurance relating to compliance with standards in order that HCS services are supported and able to consistently deliver safe and effective care

• Leadership and management of the risk management process for HCS

• Play an integral part in embedding a Quality & Safety improvement culture throughout the organisation and create a culture for continuous improvement

2. What responsibilities will they have regarding the publication of Annual Quality Accounts?

The Director of Quality and Safety will have Executive responsibility for the Annual

Quality Accounts

3. Please explain the rationale for your timescale of Q4 2023 (nearly two years) to implement a regular Annual Quality Account.

I believe this may have been an error, it should read the end of Q1 2023. Quality

Accounts report on a 12-month period so data cannot be finalised until at least 28 days from the end of year. This is in line with relevant HCS/Government policies such as the Government of Jersey Customer feedback policy which allows 25 days for a response and Patient Safety Learning Event Policy (2019) which allows 28 days for an investigation to be completed. Data would need to be cleansed, collated, and prepared for the writing of the report.

5. Please confirm whether an internal report will be drafted on the exploration of the use of other Government of Jersey Boards to understand their arrangements on responsibility, accountability, and renumeration to advance Recommendation 6, and, if so, please advise of the completion date of this work and provide the completed report (in confidence, if necessary) to the PAC.

HCS can confirm that an internal report will be drafted.

Initial advice has already been sought from Government of Jersey Risk & Audit Department & the Law Officers Department (LOD). The completion of this work will be end of Q2 2022.

a.  What legal and third-party advice will the HCS Department source to further understand the use of independent members on the Health and Community Services Board, and what case studies will it consider from other jurisdictions?

A further meeting is planned with the Law Officers Department.

HCS is exploring other jurisdictions, particularly those with a comparable health & political context.

6. Please provide an outline to the PAC of the proposed changes to the Government of Jersey's People and Culture Programme relating to how it will impact upon Health and Wellbeing, and how it forms a long-term strategy to deliver this.

The People and Culture Programme plans across Government are designed in response to the outcomes of the staff survey. Initiatives will be co-designed with staff to deliver improvements in the key areas identified in the survey. This includes all the work supporting Health and Wellbeing.

The HCS plans will be developed and implemented in line with the wider Government of Jersey People Strategy with Wellbeing a key part of the My Experience commitment. In line with the People and Culture Programme there is an increased access to management and supervision training and development, this development of managerial capability will facilitate improvement in the culture across HCS and will lead to a positive impact on the wellbeing of the workforce as manager expertise is enhanced and supervision.

There is also a greater awareness of the well-being data provided on staff absence and this is being utilised at an early stage to support staff with their well-being.

It is anticipated that these wellbeing initiatives will lead to lower absence figures, shorter periods of absence, higher morale, and improved staff survey outcomes.

1. Please confirm that the Government of Jersey's performance against the Strategy outlined will be reported publicly, and will include consideration of Government, Health and Social Care services and key partners.

We can confirm that the Government of Jersey Performance against the Government of Jersey People Strategy will be reported publicly as part of standard departmental reporting requirements

2. Please confirm that the Strategy will be linked against public measures within the Jersey Performance Framework and the annual operational plan of the department.

We can confirm that the Government of Jersey Performance against the Government of Jersey People Strategy will be in line with metrics outlined in the strategy document and will be reported via the staff survey outcomes.

3. Please explain briefly how multi-disciplinary models currently used in HCS will aid in building the capability and capacity for on-Island provision'. Please advise how this impact on staff wellbeing.

Priority work will commence in Q1 2022 to develop the detailed programme plan needed to establish how best to create a long-term strategy for health and wellbeing across the island that is to be delivered by Government, Health and Social Care services and in association with key partners. Some limited, preliminary work was conducted during the summer of 2021 to gauge appetite and potential but, due to the status of the renewal of the existing Occupational Health Contract provision, coupled with a lack of resource and capacity at this time, there has been limited progress. Those contractual and resource issues have now been remedied and we are now in a position to start developing the detail of the programme of work needed. A key outcome of this work will be to ensure that there is a robust offer that will support the improved health and wellbeing of all Jersey public service staff.

4. You refer to utilising the People and Culture Strategy in your response, but do not refer to the Group Director for People and Corporate Services as a Responsible Officer. What impact and responsibilities will the Group Director and his function have in implementing Recommendation 6, and how will his work feed into that of the Head of Organisation Development and the Associated Chief for Allied Health Professionals and Wellbeing?

The Associate Director of People – HCS is a direct report of the Group Director for People and Corporate Services and is a member of the PCS Senior Leadership Team where the impact of the strategy is discussed and works closely with the Associate Director of Organisation Development as a peer and colleague. The Associate Director of People in HCS is also a member of the Executive Leadership Team and the Senior Leadership Team of Health and Community Services and works closely with the Chief of Allied Health Professionals and Head of Well Being on developing Well Being activity.

The role of Chief of Allied Health Professionals and Head of HCS Wellbeing involves leading the  strategic, operational,  and  professional  development of the  HCS  staff wellbeing programme and wellbeing services. This includes leading as HCS liaison with government-wide corporate wellbeing initiatives and ensure HCS' wellbeing programme and work is fully aligned to them. A HCS Wellbeing Committee meets quarterly to co- ordinate and agree HCS Wellbeing activity. This Committee reports into the HCS People and Organisational Development Committee. The HCS Associate Director of People and GoJ Corporate Wellbeing Consultant are members of the HCS Wellbeing Committee.

5. Please provide a realistic timeline for your revised response.

A detailed programme plan of the work needed to create a long-term strategy for health and wellbeing across the island that is to be delivered by Government, health and social care services and in association with key partners, will be developed during Q1 2022 and will be available for review by 30 April 2022. It is anticipated that the work needed to build the detailed business case could take 6 months due to the research required, complexity and component parts.

7. What is the timeline for completion of improvements to the Patient Advice and Liaison Service?

The improvements to the Patient Advise and Liaison Service will be complete by the end

of 2022

1. Please share the final report of the PALs service review with the PAC and indicate how the findings and recommendations of the review's report will feed into the improvement of performance within Health and Community Services.

The review of the PALs service has been completed and recommendations accepted.

In terms of improvement the information relating to the experience of patients and visitors will be directly used to make changes to services. The report will be shared once signed off by the Medical Director and Chief Nurse.

2. Please advise when a permanent desk at the Gwyneth Huelin site will be established for the Patient Advice and Liaison Service, and when staffing requirements will be fulfilled.

A desk has been set up in the Gwyneth Huelin site, and proposing to formally star staffing

the desk during Q1 2022 on a part time basis. The full staffing requirements for the service based on the review recommendations will be fully implemented by 31/12/22.

8. Please provide an indication of when the Jersey Nursing Assessment and Accreditation System (JNAAS) will be included in all new or renegotiated contracts, and how have guidelines been revised to ensure its inclusion.

The inclusion of the JNAAS will be considered for all relevant contracts that will be commissioned from 2023 and discussions with providers on requirements will be undertaken in 2022.

a.  How will community providers be informed of how to operate the Jersey Nursing Assessment and Accreditation System, and how long do you expect it to take for them to be incorporated into JNAAS?

The Chief Nurse Office will work with community providers on a service by service basis to familiarise them with the JNAAS standards and process of assessment. There is a website dedicated to JNAAS which contains a lot of information about the standards and the process, all with a focus on improvement.

Preparation to full assessment can take between 6 months to a year if services haven't worked with the standards before (250+ standards). There may also be some additional bespoke work that needs to happen as some community providers deliver specialist services. In these instances, work will be undertaken with the provider to ensure that any relevant clinical guidelines are included.

9. When will a new Quality and Safety Director (and his/her team) be appointed?

HCS is currently in the process of recruiting to the Director of Quality and Safety, one round of recruitment has been completed and we have been unable to appoint. We are committed to completing this work and will continue with our attempts to recruit to the position.

1. What is the timeline for the implementation of Recommendation 15, given your revised response?

The HCS Quality and Safety Strategy will need to be fully embedded within HCS prior

to further work being carried out across other Government of Jersey Departments. Work on implementation of this strategy will be complete by the end of Q4 2022.  

2. When do you expect the comprehensive quality and safety programme across all health and social care services to be published?

We are awaiting the appointment of the Director of Quality and Safety. This person will

lead on the Quality and Safety Programme. Until they are in post, we are unable to give a timeline for the publication.

10. How regularly are benchmarks examined and revised to ensure that the Island is benchmarked against high-performing but operationally comparative and relevant jurisdictions?

We have an annual cycle of review for all indicators and standards. We set all indicators and performance standards for the year in the final quarter of the previous year. Quality

performance indicators are discussed monthly at the Care Group Performance Reviews (CGPR). They are also reviewed, by Quality and Risk, Operation Performance and Finance, and the Executive Board before being published quarterly in our Quality and Performance report on GOV.je. However, as the governance process has still been maturing through this year, we have had some flexibility and had changes through 2021.

a.  How do you ensure that standards are appropriate for Health and Community Service's remit and size where certain areas of NHS standard reporting may not be directly comparable?

Standards are set based on benchmarks against other jurisdictions where possible and

using the latest available data point. If there is no suitable comparison in terms of either indicator or jurisdiction then a standard can be benchmarked against our own historic performance with the standard set to engender improvement in our service and care delivered. If new data becomes available e.g. another jurisdiction publishes/shares information that informs our service improvement then this would be taken into consideration outside the annual review process if appropriate.

11. Why  did the  Government  of Jersey's Government Enterprise  Risk  Management  site  not consider the requirement of Health and Community Services before its implementation?

The requirement of including Health and Social Services risk registers was considered as part of the change request and tactical implementation of an Electronic Risk Management (ERM) SharePoint Tool. (accept poor wording in previous HCS response).

The strategic vision for a one-stop shop for risk management is articulated below:

Limited integration has been achieved in terms of a data extract of the HCS risk register from Datix to SharePoint. The functionality of SharePoint was limited, and out of support with Microsoft. Evaluations with Modernisation & Digital and Commercial Services took place to agree a suitable replacement. We now have a revised SharePoint site based on new Microsoft 365 functionality and using Microsoft Power BI. Due to the limited functionality of the existing site, poor risk management culture and the complexity of the risk landscape that Jersey was confronted with, including compound risks around pandemic, winter pressures and business continuity, this system had to be developed quickly. This tactical solution was implemented and has successfully become embedded across Government of Jersey except for HCS.

Government of Jersey will need to come to a decision on a longer-term strategic solution in due course, once it has reviewed risks around enterprise architecture and the technological estate.

1. How is risk currently tracked and monitored within Health and Community Services? Risk is tracked & monitored through,

• Service / Care Group governance structures

• Executive Performance Reviews

• Risk Management Committee

• Assurance Committees

• HCS Board

A framework has recently been developed by the recently appointed HCS Risk Manager

which describes the management of risk at various levels within HCS. This will be presented to the Risk Management Committee at its next meeting (20th Jan 2022) for discussion & approval. The Terms Of Reference (TOR) for the Risk Management Committee describe its functions in detail.

2. How are those methods aligned with wider Government methodology?

The Terms of Reference for the HCS Risk Management Committee broadly reflect the Terms of Reference for the Government of Jersey Departmental Risk Group to ensure alignment of processes & reporting. The purpose of the committee is to ensure a consistent approach to risk management within HCS that aligns to the Government of Jersey Risk Management Strategy & supports the objectives of the Enterprise Risk Management Strategy (ERM).

3. Why and how were Health and Community Services' risks treated separately to the rest of the Government of Jersey?

The HCS risk management aligns with the ERM Strategy. However, in terms of systems, HCS historically uses Datix (a system widely used in the NHS). As previously stated above, integration of Datix with SharePoint has proved difficult, and still does not meet our needs. The ERM SharePoint is currently a tactical solution until the time that a full strategic solution can be implemented.

HCS has regular monthly meetings with Risk and Audit to review risks captured on Datix. Risk and Audit officers also provide support to HCS through workshops and other training in risk management.

4. What are the alternative ways you are using to report on Enterprise Risk Management until the department is fully integrated?

It is unclear at this stage whether HCS (Datix) can fully integrate with the GOJ Enterprise Risk Management system. A weekly extract is taken from Datix which feeds into the ERM & provides the Government of Jersey Head of Risk visibility on all HCS risks.

Whilst this is being determined, HCS Risk Manager is exploring the use of Microsoft Power BI to extract high level risk data which can be used within ERM reports. Where possible, HCS has added fields within Datix which highlights specific information in the ERM e.g., Health & Safety risks. As stated previously, HCS regularly meets with Risk and Audit through monthly 1:1s and quarterly Accountable Officer meetings to discuss risk and treatment.

The development of the HCS Board Assurance Framework will further support reporting.

5. Has  the  implementing  of  Health  and  Community  Services  into  the  Government Enterprise Risk Management been marked as a high priority within the Government's own Recommendations Tracker? Please provide details.

The vision is to align in due course as stated above subject to interdependencies.

6. Which officers have responsibility for this work?

The responsibility for this work sits with the HCS Risk Manager.

Yours sincerely

Caroline Landon

Director General of Health & Community Services

D +44 (0)1534 442357 / 442272