Health and Social Care

Restructuring the funding of health and care

Although it was not a headline event, the policy letter on the restructuring of funding for health and care was a potentially hugely transformational decision. This is the speech I made in the debate.

Sir, 

Navigating the health and care system can be difficult, whether you are on the outside trying to access a service, or on the inside trying to provide a service.

The system is complicated, fragmented and slow. We know that, and we know we need to deal with it. The less efficient and timely the care we provide, the less effective it can be and the less there is available to invest in frontline services and new ways of working. That is what transformation is about.

And The proposals set out in this policy letter will enable a step change when it comes to transformation of health and care and discharges the resolution in the Partnership of Purpose policy letter this Assembly approved a year and a half ago.

Whilst it seems quite dry and just a transfer of responsibilities from one Committee to another, it opens up huge opportunities to transform health and care through greater flexibility and simplification of the current system. By doing so it will help meet key aims of the new model of care, including fairer access, a universal offering and a focus on quality.

Now, what I don’t want members to get the impression of from this policy letter is that the problems we face are because of silos. All too often we are told there are these silos that stop things happening. That is not the issue here. We are very grateful to ESS for the support they have provided and we have a good working relationship this term. It has been  essential to enable us to achieve what we have already this term, from extra support for the primary care practice in Alderney, to Medevac contract and the introduction of the free contraception for under 21s.

No, this is not about silos. It is about a system structure that is dated, inflexible and restrictive and past its sell by date.

I think it might be useful to give just a few examples of the problems with the current system and the obstacles currently in our way.

Just last week the Committee approved the requirement for 2 new anaesthetists – to manage growing demand and current best practice. These consultants will need to be paid out of the GHSF. However, an anaesthetist is not much use without the theatre staff and they come from a different pot –  general revenue. Not only does this mean 2 separate bids having to be made to 2 different Committees, but it also makes it harder to track total costs of acute care as well individual operations.

Another linked example is in respect of Orthopaedics. As I just said, the GHSF can be used to pay for an anaesthetist who works for the MSG, but it can’t be used to pay for treatments off-island. We have needed to use off-island providers to deal with the backlog and meet the increased demand, which has meant we have also had to make a bid for funding from P&R.

But then, the complications continue as for those people who have to go off-island for treatment, HSC book the people for that care, but ESS book the travel. This isn’t ideal for the patient or us.

As I have mentioned before, drugs in community are controlled and paid for separately depending on whether they are dispensed in the hospital or by community pharmacists. At the moment every drug added to the white list in the community has to be added through ordinance. The same drug will be added in the hospital but that requires no approval. More on drugs in a minute.

And on that, I wanted to give reassurance regarding the removal of statutory benefits and address any concerns there may be. Some members such as Deputy Merrett have contacted the Committee in relation to this. I did reply to her but it is useful to raise this aspect now. 

Members should be aware that the vast majority of services currently provided in health and care are done so on a non-statutory basis, most obviously, the hospital of course. 

It might be argued that the best way to protect the public is to put everything we provide on a statutory footing, instead of taking the current statutory provisions away. But early this term, the States debated the bowel cancer screening service and agreed to return control of the service to HSC, rather than tying it up in States Resolutions, as it had been before. We continue to provide the service, but now have the flexibility to introduce new technologies and modes of screening as scientific knowledge evolves & we understand what works best for patients. AND that is what we are doing now.

Any service that’s tied up in law doesn’t have that flexibility – including those currently funded by ESS.

Now, proposition 9 makes it clear that HSC will provide services to a standard equivalent to that currently provided with future changes aligned to the Partnership of Purpose and P&R Plan. It also states that changes must be subject to the same requirements for consultation and, if necessary, approval by resolution of the States.

Now I’d just like to elaborate on what that means in practice and what can be expected in relation to those benefits that are to be transferred.

Firstly, medical benefits – basically the £12 and £6 grants. A review of primary care, including future funding is the subject of active work and there will be considerable consultation before proposals comes to the States, hopefully by the end of the year. All States Members approved our policy letter when we said that primary care needed to be put on a fairer and more affordable footing, and this was reinforced during the In-Work Poverty debate. To do that, we need to change the system we currently have and we will need a States’ debate to do so.

When it comes to drugs dispensed in the community, there is unlikely ever to be a time when no pharmaceuticals are made available. Remember, the actual right to specific drugs is set in policy, not law and members will be aware that HSC will shortly be publishing its policy letter setting out proposed changes to current policy and funding options. Also, do not forget that prescription charges will continue to still be set in law. Again, this law only governs drugs provided in the community; drugs provided by HSC in hospital aren’t covered by the same legal framework. 

The Law with regard to Specialist Medical Benefit sets out what services can be paid for from the Fund ie secondary health care services, secondary physiotherapy services, visiting consultants and primary mental health. Apologies for the double negative, but there is unlikely ever to be a time when these services are never going to be needed.  The actual services provided eg obstetrics and gynaecology, Ear Nose and Throat, gastroenterology, for example – are set out in separate contracts not the law. Even if the legal framework falls away, HSC is bound by the terms of our contracts with MSG and others, and would have to use usual contract management processes to change any part of those services.

In relation to Alderney Hospital Benefit, It is worth noting that ESS and HSC have actually been providing services that go beyond the Law.  We have a general obligation to provide health as a transferred service, and will continue to do so in dialogue with the States of Alderney and the local medical practice. A review into primary care there will help to inform future provision, as will any review of the Reform Law and transferred services.

The Travelling Allowance Grant, to primarily fund the cost of travel for off island appointments, is provided from the Guernsey Insurance fund and has statutory standing under a different piece of law. The Partnership of Purpose has equity of access at its heart. It would be nonsensical to remove this such that someone is referred for off-island care but can’t access it as they can’t afford to get there. Not just nonsensical but politically unpalatable.

The trial of Free contraceptives for under 21s is also met from the fund but doesn’t have any statutory basis. This was a service the ESS President and myself were determined to get up and running, and we did so as a pilot because that allowed us to get funding out of the GHSF pretty quickly.  The policy letter will enable us to formalise it. This has already proven to be a great success and it would, again, be nonsensical to stop it now.

It’s also important to provide assurance on the issue of appeals. Under the current statutory regime, entitlement to health benefits under the Health Service (Benefit) Guernsey Law are determined by the Administrator of Social Security, against whose decisions the claimant has a right of appeal. But this is not about whether someone is happy or not with a particular treatment, or should have access to a particular drug. But rather relate to binary issues such as whether they qualify for free treatment under the secondary care contract.

Of the handful of Health Service Benefit appeals that have made it to a Tribunal in the last 25 years, these were cases where people had signed their consent to be treated as a private patient, but on later receiving the bill wished to revert to being treated as States contract patient.      

HSC has in place a single Complaints Policy with the MSG which ensures that there is a joined-up system to enable service-users to complain or raise any criticisms or concerns to be investigated further. A Customer Care Team receives and triages all complaints and an Investigating Officer is appointed to report on findings to the Clinical Governance Group, which maintains an overview of the process and further investigates concerns, where this is necessary. Where a complaint is not adequately resolved to the satisfaction of the complainant, the Policy allows for the issue to be referred to an Appeals Panel. This comprehensive policy can easily be adapted to include those areas to be transferred to HSC.

Of course, there is a lot of work to do to get the new system in place. Some areas will be easier to manage than others, with some changes being able to be brought in sooner than others. 

What will be important is to ensure that we do not get so bogged down in process that we can’t respond to crises that arise. This term ESS and HSC have worked very closely to ensure that things could work as smoothly as possible. We’ve also consolidated part of the drug approval process. 

What is needed is flexibility in approach. Whilst, I suspect sums will be set out as part of the budget setting process from now on, there is a need to understand that, although we are the largest area of the States, we are still a small health and care organisation with little resilience when unexpected events occur. We have seen that most recently with radiology and orthopaedics. Not only does it require action on a timely basis in other words you can’t wait for each new year to make changes, it also needs consideration of funding on a longer term horizon. I would hope that this consolidation of funding would enable that to become a reality sooner rather than later. Looking at expenditure as distinct chunks of 12 months and comparing one year directly with another can hinder progress and build in delay. Anyhow, that is for the future.

You know we spend hours and hours on issues we think are important, or things we think the public believe important, but often those policy changes that make a fundamental difference are those that don’t make the front page headline, but that enable great change to happen. This is one such policy letter. Through increased efficiency, flexibility, transparency and consistency it will enable considerable transformation of health and care and at the same time the reform of the public service. I am therefore pleased to support it.

Future funding for disability aids and equipment

I laid an amendment to the policy letter on the restructuring of funding of health and care which sought to ensure that support for aids and equipment was considered by the States in relation to future funding. The amendment passed, and this is the speech I made.

Sir, the purpose of this amendment is 2 fold;

Firstly, to lay a marker in the sand to ensure that a review in this area is undertaken and secondly, to receive agreement in principle that the responsibility for the provision of benefit in relation to aids and equipment is transferred from ESS to HSC.

Now, I understand why P&R did not want this aspect dealt with in the policy letter as the source of funding and law in relation to it are different from those 

BUT we, and by we, I mean HSC and ESS as the ESS President and myself are proposing  the amendment on behalf of both Committees, believe that the principles are the same as for the services dealt with in the policy letter. 

Members will have been provided with quite a detailed background appended to the amendment, kindly put together by Deputy Yerby. This sets out clearly the issues with the current structure and why a review is needed. I won’t repeat all that is in it now other than to say, the system is not transparent and requires transformation for 2 reasons;

Firstly to fit with the principles of the new model of care and more specifically fairer access to care, a universal offering and user-centred care. And secondly, to align with Article 26 of the UN Convention of the Rights of Persons with Disabilities which states how governments should enable people with disabilities to attain and maintain maximum independence.

S10 of the Income Support Law, a law that is 48 years old now, allows ESS to fund disability related equipment, aids and adaptations. It is not restricted to those on benefits as it is recognised that some equipment is prohibitively expensive. ESS can provide financial support in whole or in part, by grants, loans or both.

However, it is discretionary, with no rules around it, such that individualised decisions can be made, resulting in a lack of transparency with people unclear whether they can expect support or not.

As things stand, whilst HSC provide an occupational therapist who will undertake an assessment as well as a wheelchair service, we don’t order or pay for equipment. This is left to individuals and their families. If people can’t afford it, their options are to go to ESS or various charities. And on that I should like to thank all those charities who do provide such support in the community. 

BUT this is very different from when you are prescribed a drug and know that it will only cost £4 per item, however much that drug actually costs the States. This can be a real issue for those families with children with disabilities and degenerative diseases where needs change over time. 

Members may question the deadline date of June 2022 which seems a long time away. However, that is because we don’t want to raise expectations at this stage, especially as it is not part of the P&R Plan and both Committees will be maxed out between now and the next election with what is set out in that Plan. However, it will enable successor Committees to consider and determine whether they wish to raise up the order of work or stick to the date set.

Sir, this is an eminently sensible amendment to lay at this time, will be achievable without spending any money on outside consultants, and I ask members to support it.

Carers’ Action Plan

This is the speech I made on the launch of the Carers’ Action Plan.

The Carers Action Plan identifies areas for change which can be delivered during this term of government to improve support for people who have a significant unpaid role caring for family members or friends. 

I will tell you in a moment about what has already been achieved from a Health & Care point of view, but first I want to emphasise that this plan is for all organisations in the Bailiwick who have contact with carers. It helps us to work together, as a Partnership of Purpose, to support the health and wellbeing of carers and their participation across society. Health and Social Care has a role in delivering some of the plan, but partnership means that the community has its part to play too. 

The plan represents the first step on a journey of change towards a society that is more inclusive and supportive for people who have caring responsibilities. 

So, what has HSC done so far? 

We recognise that currently respite services are not all that they could be and we have been making changes to improve provision. 

There will be increased funding for the Respite at Home service, and increased availability.

HSC has employed a respite coordinator based in community services whose role is to help people with pre-booking respite in advance or in emergency situations and to help them navigate the system. This means that there will be one point of contact, a one-stop shop if you like, for carers who need a break. The respite coordinator will help carers to find placements for planned and emergency respite for all adult services, with the exception of respite for people who have learning disabilities, which is already well established. 

The Short Break at Home service, historically known as the ‘sitting service’ and senior carer service has seen recent investment and recruited new staff. The senior carer service has been able to provide respite at home for a number of people as an alternative to respite in a care home in an emergency.

We understand the need to offer a carers assessment and to acknowledge the carers’ needs alongside the cared-for person. We are therefore trialling an approach where all carers who care for someone for 35 hours a week or more, will be given the opportunity to have an assessment of their own needs. The introduction of carers’ assessments is a really positive step.

We are in the process of recruiting and have had funding approval for one full-time social worker, based in the adult community team, whose role will focus on carers assessments and case work management that arises from that assessment. We recognise that carers who are providing 35 hours a week or more are the people most in need of support themselves as it’s likely they are caring for those whose needs are more complex. 

We recognise that these people are providing a higher level of care and may, by definition, require a higher level of support in their own right. 

HSC’s responsibility is to work in the areas where people have most complex needs. The social worker whose main role will be in undertaking carers assessments will be helping us to refine our approach in identifying those who most need those services and initially the focus will be on those people who are in receipt of carers allowance.

We have made a commitment to include carers in the development and review of care plans and discharge plans for the person or people that they are caring for.  We know how important this is to carers and it is something that they told us they wish to be involved in, particularly at key points such as when they are discharged from services, or at the transition from children’s to adult services.

We are developing a new reablement service. This is something the Committee has been wanting to establish for nearly 2 years but it has taken a while to secure the funding. Reablement involves providing personal care such as help with daily living activities and other practical tasks, usually for up to six weeks, in the home of the service user. This encourages them to develop the confidence and skills to carry out these activities for themselves and continue to live independently at home. Reablement services tend to be provided to people who have just been discharged from hospital or who may be risk of entering the care system following a crisis. This is relevant for carers who are caring for someone who may benefit from reablement after being admitted to hospital or due to a worsening of their condition. We have only been provided with funding for a year, which is a concern but we hope that, as the benefits are seen that it can become permanent.

HSC’s proposals for health and care regulation were approved by the States in February. 

Regulation seeks to ensure, as far as is reasonably possible, the safety of those accessing and using our health and care system, including the most vulnerable islanders.

The proposals include the setting up of an independent regulatory body or commission.

The Commission will be established under a new Enabling Law – a piece of primary legislation – which will govern the regulation of those working within the health and care sector as well as the premises and systems.  The emphasis throughout has been on an approach which is both proportionate and appropriate to our size. It will not be a replica of the incredibly complex regulatory systems in other larger jurisdictions, most notably England.

The proposals were formed following a review of local regulation which identified key areas of risk in terms of public safety through the lack of regulatory oversight.

I must emphasise at this point, that the proposals do not affect those providing care for relatives or friends.  Any concerns relating to care provided on this basis should be raised through existing safeguarding channels.

A top priority will be addressing what is known as the “unregistered workforce” – this includes carers, domiciliary care workers or those who work within people’s homes, as well as Care Support Workers working in residential and nursing homes, extra care housing, and clinical settings such as the hospital.  

There is significant concern over the potential for harm to those receiving such care.  At present there is no legal requirement for Carers and Care Support Workers to undergo criminal background checks, mandatory training, to be insured, or supervised.  This is what we are seeking to address.

We recognise that responsible employers in the care sector already ensure that their employees are suitable, have background checks and training.  Indeed HSC, itself ensures that its employees are subject to enhanced DBS checks before working with vulnerable adults. We have also recently introduced the Care Certificate as part of the induction of carers which assesses employees over 15 standards including dignity in care and hydration of clients over their 6 month induction period.

During the formation of our policy letter on regulation, we met with many providers of health and care across our islands and will continue to actively consult with care providers when the standards surrounding the unregistered workforce are drafted, as well as how it is funded. This will be done with providers, relevant government Committees such as Employment and Social Security, third sector, and users of health and care services.  

So, HSC is not standing still. This is not just a document that will gather dust on some virtual bookshelf. We have a big part to play in making the Plan real and are committed to doing so as I hope I was demonstrated. 

In addition, we will shortly be publishing our first Joint Strategic Needs Assessment on the over 50s. Work on that has fed into this Plan, but it does provide the bigger picture which will help inform what will become the universal offer across health and care.

There is more to do of course and I think a key area of work has to be in signposting. This is a critical aspect of the new model of health and care. We need to be able to make it far easier for people to know what is out there. However, we need to do this in a far more coordinated manner so we can provide, for want of a better description, a single version of the truth. There is a lot of information but it is all over the place in leaflets, on various websites and what is worse than having no information on services available is having a jumble of information, often not updated, not enough and not in one place. 

I’ll just finish by saying that, from a personal point of view I have seen the impact of having to care 24 hours a day for a loved one can have. I have seen it cause mental stress and physical illness. I also know how difficult it is for someone looking after their loved one to see themselves as a full-time carer, especially where it happens gradually over time. That is why I think government can and must do more, to provide support. However, I also saw how others who come into contact with carers and those who they are caring for, could do more.

As I said at the start, this is not just an HSC, or a States of Guernsey issue for that matter. We all of us need to work together – States Committees, GPs, consultants, third sector and the wider community if real positive lasting change is going to happen and that rings as true for the Carer’s Action Plan as it does for the wider world of health and care.

Thank you.

Hospital modernisation

In March 2019, HSC presented a policy letter to the States of Deliberation setting out its proposals for the modernisation of the PEH. It was unanimously supported by the States and we now embark on an exciting new chapter in its history.

Sir, It was in 1949 that our future Queen officially opened the building that was to bear her name, the Princess Elizabeth Hospital. In those intervening 70 years the hospital has played an increasingly important role in the protection, promotion and enhancement of the health and wellbeing of islanders. The work undertaken 24/7 behind its walls has contributed in no small way to residents having amongst the highest life expectancies in the world. 

The hospital, or as we all know it, the PEH, has had such an important part to play in our community since it was opened. It is where life begins and ends. It is where lives are saved or improved, it is where we learn what it is to be a mortal human being and who and what are most important to us. 

We should be proud of having such a facility on such a small island. There must be very few places in the world that could boast a hospital providing such a range of services for such a small population. There is a tendency to take it for granted but we should not. We are very lucky indeed.

And that is because over the years previous Boards and Committees in various guises have seen the need to adapt it in an ever changing landscape. New innovations in medical practice, advances in scientific understanding, medical research and technology, have all helped to improve outcomes but they have also put increased demands on the physical infrastructure.

There has probably not been a time when the need to expand and adapt the infrastructure of the PEH has not been either discussed or implemented. Now a few months back I read a piece about post war period of health care in Guernsey written by the much respected Dr Brian Seth-Smith who spent a lot of his working life working at the hospital and who sadly died in January. In this article he talks about Plans for Phase 1A and B to create a new Children’s Ward, operating theatres, central sterilisation department, pharmacy, post-mortem room and supporting service area which were first drawn up in 1966. Apparently, these were thrown out by the then States as being too grandiose, with one speaker stating that he didn’t want a mortuary, as he didn’t see why we should spend money on the dead. 

But, plans were eventually accepted in 1971 and that first phase of development was completed 15 years later. Dr Seth-Smith made the comment though that, whilst an excellent design, it was unfortunate that x-ray and receiving room were at the Vauquiedor end, far from the theatres and wards.

The most recent developments covered off the new clinical block completed 9 years ago now, and the Oberlands Centre that was opened in 2016. 

Just as it has been a focus for our community over the last 70 years, the PEH Campus has a big role to play in the development of our new model of care – the Partnership of Purpose. We see it as the backbone of the system, with the long term intention that it should be the focus for the delivery of secondary health care, including the acute hospital, mental health services and diagnostics.

However, we are struggling with what we have now. The design is inflexible and makes it difficult to implement new technology and new ways of working. Some of the areas are very dated and costly to maintain. Just recently we had to close a theatre because of a water leak into the air filtration system which followed a more serious leak last year. Added to that there are the problems with asbestos in various areas which mean that when repairs are needed, say in the plant room under theatres, staff have to wear full protection gear and the whole process takes much longer than if it was a benign environment. 

We are unable to meet various building regulations and standards because of the layout and parts of the site do not support those with a disability, nor provide the best working environment.

The 10 year modernisation programme that we are presenting to members today is an essential catalyst for change enabling greater integrated patient centred care in a modernised hospital that is safe, flexible to meet future needs and which ultimately will improve patient experiences and outcomes.

The programme is divided into 3 phases to minimise the impact on the delivery of services. At the same time it spreads the capital cost over a number of years and should benefit the local construction industry. Details are provided in the policy letter and I won’t repeat all that is said in there.

However, I think it is important to focus on a few points relating to Phase 1 for which we are seeking funding approval today.

Various reviews, including that by the NMC in 2014 into maternity services, have highlighted the issue of the distance of Loveridge, the maternity ward, from theatres. At the moment staff have to undertake drills to ensure they can get women who need an emergency caesarean section from to the ward within 20 minutes. The main risk area being the fact Loveridge Ward is on a different level to the theatre block and therefore a lift is needed. The plans seek to address this issue.

However, this won’t be just a simple lift and shift of Loveridge and Frossard, the children’s ward, but address other limitations of our current offering. This includes a dedicated area for children and young people presenting with mental health issues, space that is more suitable for adolescents and a means for treatment away from the wards. 

Now, the backlog with regard to orthopaedics is well known and thanks to support from ESS and P&R and an incredible amount of hard work by HSC staff, we are now actively tackling it. However, a key limitation to us and what needs to be tackled if we are to minimise the risk of this happening in the future, is the infrastructure.  A real pinch point that is impacting on the number of operations that can be undertaken and causes a higher numbers of postponements than we would like is the number of critical care beds. This is an increasing problem as the age of those we operate on rises. Whilst in the past we may not have operated on 70 and 80 year olds, this is becoming more and more common. Those patients are more likely to have other underlying health conditions which means they need more care post-op in the critical care unit beds. We currently only have 7 such beds, which means we are very vulnerable to any emergency or trauma cases that arise. The plan is to create enough space that will enable us to start with 10 beds and later to 12. 

The plan is for a new theatre block, to include critical care unit to be built that will enable the latest technology including robotics to be introduced, whilst reducing the problems we are currently experiencing in terms of maintenance.

As part of phase 1, work will be undertaken to identify the most suitable location for MSG staff and consultants. This will then enable any building works to be undertaken in phase 2 and within the 7 year deadline when their current leases expire. Having consultants on site will be conducive to greater integrated and patient-centred care.

Throughout the programme we will be building in better support for those with a disability. This will include signage that will support those with conditions such as dyslexia and dementia, as well as new facilities such as changing places toilets.

The overall anticipated costs for the programme are between £72.3m to £93.4m. The first phase, due for completion by 2021, will cost between £34.3m to £44.3m. It’s probably worth noting that Jersey has spent a similar sum just trying to identify where to put their new hospital. We are fortunate with the site we have.

It is for phase 1 that we seek funding support for now. We will be coming back to the States In respect of Phases 2 that will cover orthopaedics, day patient unit, relocation of MSG, equipment library and private wing, and Phase 3 which will include pathology, pharmacy and emergency department as the programme progresses.

Finally, I can’t finish without mentioning transport and parking. The Committee understands the frustrations for those visiting the PEH who find it difficult to park. It impacts us as we don’t have dedicated spaces and our friends and families. Seventy years ago the PEH had 20 parking spaces. 50 years ago it had 120 spaces. Today there are 750 parking places across the Campus. Those are the official ones, not including people parking across grass verges and down side roads. And still it’s apparently not enough. Whilst at peak times we are around 50 spaces short, outside of those times there are plenty of spaces going spare. 

We will shortly be adding 80 additional temporary parking spaces that will help as works get underway. However, we can’t just look at pouring more tarmac over the site. History has shown it just doesn’t work and is not value for money. Thanks to the support of E&I a travel strategy has been developed for the Campus and the Committee will receive the report very soon. We hope that this, combined with the development of new staff changing facilities which is currently underway, will help in the creation of a more sustainable long term solution.

Sir, in summary, the overriding aim of the hospital modernisation programme is to improve the experience of anyone needing our services. From the moment that they arrive on the PEH Campus, get the care they need when they need it and leave. We want that experience to be as stress free as possible and with the best outcomes as possible. But more importantly we want it to be a joined up part of an overall seamless experience of community care for all. 

Health & Care Regulation

In February 2019, HSC presented its proposals to the States of Deliberation on the future regulation of health and care. These were overwhelmingly supported. This is my speech opening debate.

Sir, As members will know, a key aim of the partnership of purpose is proportionate governance: ensuring clear boundaries exist between commissioning, provision and regulation. In the policy letter setting out the new model of health and care, the Committee for Health & Social Care stated that it is likely there will always be some overlap between those who decide what kinds of services should be provided and how they should be paid for, those who provide these services and those who regulate the services to ensure safety. However, there needs to be, in particular between commissioning and regulation, a framework which is proportionate to the size, resources and requirements of the Bailiwick, to ensure appropriate separation.

This Assembly supported that policy letter and the proposals in front of members today support that key aim as well as being a priority of the Policy & Resource Plan.

The current system of regulation is fragmented and has evolved over many years. What we are seeking to do is not destroy it and put in a huge great regulatory structure in its place, but build on it and develop a more robust independent regime. There are areas where there is a lack of professional regulation such as in domiciliary care, lack of systems regulation – such as for the majority of States services, a lack of flexibility to respond to evolutions in health care provision, insufficient emphasis on safeguarding and a lack of regulatory independence. These are what we are seeking to address.

As Prof Dickon Weir-Hughes states in his report for the Committee, the subject of regulation in any sector often gives rise to concerns about cost and proportionality, especially amongst taxpayers. However, as he says, ‘one of the key benefits of providing health and social care in a relatively contained island community that is not burdened by the bureaucracy of larger jurisdictions is the opportunity to develop regulatory approaches that are both world leading and proportionate.’

Now, when we say world leading, we don’t mean gold or platinum plated. It is not about how much money you throw at it and how complex you make it, but how effective it is. Those are not necessarily the same thing as the 2008 financial crash showed.

Fundamentally, the Committee was determined that such regulation should be appropriate and proportionate to the size of the Bailiwick. What does that mean?

Well we did not believe that replicating the regulatory system for the financial services industry would be appropriate and neither did we believe adopting the hugely complex system in the UK would be proportionate. Ultimately we need to consider proportionality in terms of risk.

And in doing so, we don’t want to reinvent the wheel. There are a wide range of internationally accredited schemes, such as CHKS for GP practices and Magnet for hospital services that exist around the world. We will evaluate those that make sense for our community and adopt where necessary. Where there are no ready-made schemes seen to appropriate we will set our own, again taking an appropriate and proportionate approach.

We are proposing that regulation will be the responsibility of an independent commission. This is important to ensure there is no political interference and it can equally hold the public and private sector to account. But, perhaps more importantly, having that independent function will support continual improvement.

We are not proposing that the Commission will have a heavy inspection system but one that ensures compliance with standards and schemes, but that it will have the power to step in and inspect or take other action where concerns have been highlighted. Neither are we proposing it will employ a large team of people. The complexity of the system would not justify it. Instead, there will be a core team that will bring in expertise as, and when, required.

The aim will be to develop an Enabling Law to establish the Commission and give power to the States by Ordinance to prescribe or authorise adoption of designated accreditation schemes or local standards and other appropriate regulatory measures.

After that, the individual standards will then be set and approved by the States, with a focus on those with the highest priority, being the unregulated domiciliary care workforce and acute hospital services.

We have been working closely with Jersey in the development of this policy letter, and whilst they wish to adopt a more heavy inspection system and have other priority areas in terms of regulation, we both believe there is an opportunity to share the Commissioner function and will continue to work with them if this policy letter is approved to ensure that our Enabling Law makes a shared Commissioning function possible and how we can put it into practice.

No one really likes regulation. And I have stood up in this place more than once raising my concerns. Most recently on Data Protection. But, it does seem to me that there are some who, possibly understandably given the extent of regulation that has grown over the years, lost sight of a core purpose – to protect people from harm – be it financial, social, environmental, physical or mental. Surely nowhere is regulation more justified than in matters of life and death. 

I’d ask those who think this is just another piece of unnecessary regulation, are they happy that anyone, without any police check or any qualification, can enter the home of their frail and vulnerable mother or father to provide very personal care? Are they happy that their 14 year old daughter can get their eye lids lifted or lips botoxed from a hotel room? Are they happy that their depressed wife or husband can get self-styled counselling from someone with no recognised qualifications?

There are some who think we don’t need it for ‘an island of our size’. Does that mean we don’t need finance regulation too? Or is money more important than our people? An island of our size wouldn’t have a general hospital the size of the PEH. Are those same people saying we ought to close it down? To those who believe a priority should be a sound foundation for health and later life care’, I would say, it is difficult to think of a sounder foundation than ensuring appropriate standards  through professional and systems regulation in the health and care sector.

Now, we estimate the total costs will be around £368k, although not all the costs are new. How this will be paid for and how much those who will be licenced will have to pay will be the subject of further engagement but I would point out to those who believe this is too much to spend on regulation, it pales into comparison with the extra £800k members supported for another regulator only a few months ago – the Data Protection Authority and represents 0.2% if the total health and care spend.

It’s also worth pointing out that the lack of an independent regulatory regime was a stated concern of the NMC when they undertook their review in 2014 and with whom our nurses and midwives are registered. They expect that their members to be working in a regulated environment. Were it to be decided today that we do not a proportionate and appropriate system of regulation, that we are happy not to protect our workforce then at the very least, it will not be looked on favourably, at worst, they may consider nurses may not be revalidated whilst working here. Not only that, it could mean that we are no longer able to provide on-island training of our nursing workforce. These are very real risks.

Let’s also not forget that this is also welcomed by those in the health and care sector, with whom we have had extensive engagement. Regulation may be seen to just add to bureaucracy but it can have benefits. And one particular area is in terms of post-Brexit preparedness with the European Commission, having recently published a report on the increasingly important role of health care assistants and with it, the importance of having an overview of the knowledge, skills and competencies they need. As they say, such an overview can help patient safety while at the same time facilitating professionals’ mobility.

So, sir.

I understand those who say, not more regulation. But let me ask those naysayers, if you had a list of all those areas that are currently regulated, would you say care regulation is less important than all of them? If you do think this is one piece of regulation too many, then is it not better to repeal those pieces of regulation that you believe are unnecessary red tape?

Appropriate and proportionate care regulation is about the Bailiwick being a mature, credible and economically attractive jurisdiction. 

It’s about people getting the service they need not stifled by bureaucracy or wary of punishment so they don’t innovate.

It’s about people knowing what to expect and what is expected of them.

It’s about promoting quality, minimising harm and strengthening trust in the health and care service.

Our proposals are innovative, cost effective, sustainable and most importantly, have the potential to improve health and care across the Bailiwick.

For all those reasons I ask members to support this policy letter.

In-Work Poverty

I made the following speech when we debated the Scrutiny Management Committee’s report on In-Work Poverty.

Sir, 

In-work poverty is something that Government should address and I really believe it is a worthy topic for a Scrutiny Committee to investigate.

But the debate so far really hasn’t really explored it. What it is, how people get into it and, more importantly what do we do about it. There just seems to have been a focus on the propositions and the amendment to them, which I find a bit of a disappointment to be perfectly honest. That’s not what this debate should be about. 

So much of what we have heard is, the propositions are fine cos all they do is tell Committees to do something and if Committees aren’t doing it well we’re telling them to do it, but if they are, well what does it matter. Kind of misses the point.

Frankly it is as inappropriate for a scrutiny committee to instruct principal committees on what to do and when as it is for government to tell SMC what it should review, even if there are times, when I’d like to. Indeed, this debate has made me think whether there is any merit in a requete to do just that. 

Deputy Lester Queripel spoke at length about the Children’s services review. I agree it was a good report by Dr Marshall and it, as well as the  Parry report, have made a difference. However, what he is missing here is that it did not come to the States, and the recommendations were not resolutions of the States. That was completely unnecessary.

You can’t have a Scrutiny Committee produce a policy letter either, it is a report.

However, am I bothered? No not really because it is all pretty meaningless.

Now, Deputy Merrett laboured the point about when members would see something. She didn’t know. Deputy Fallaize went big on this as well.

The Committee for HSC wrote to the President, SMC, in October 2018 to provide its feedback on SMC’s draft Policy Letter, emphasising that ensuring fair access to health care, including primary health care, is fundamental to the Partnership of Purpose and is central to most, if not all, of the workstreams currently ongoing under the transformation programme. We also said we would be reporting back this term through a series of policy letters including proposals for the future structure of and funding for, primary care in Guernsey. Not only that, and what makes it even more galling is that, although the Scrutiny Management Committee quote the P&R Plan of 2017, they do not acknowledge the 2018 update in which the Committee set out as one of its key areas of focus for 2018 and 2019 was work on establishing more equitable funding and charging arrangements for primary care.

And At the last States meeting, in my statement to the assembly I stated, ‘The Committee is also progressing a review of the future structure and funding arrangements of primary care, incorporating the Emergency Department, to ensure that cost does not prevent people getting the treatment they need.’ Is also progressing… note.

Whilst the SMC have been spending time putting together this report telling us what they think we should do, we have developed the Partnership of Purpose, had it approved, secured the resource to undertake the work and will be considering a first draft of the policy letter later this month. 

Had we not been doing anything these propositions wouldn’t have been achievable anyway. The time taken to get the resource, if free, and have time to do the work under the cloud of Brexit would have made it almost impossible. Far from needing to be told what to do, we are ahead of the game.

This isn’t just about the propositions that relate to HSC being unnecessary and adding little value, we are also concerned that SMC have looked at things in a piecemeal way when it comes to health which is reflected in the 2 propositions. The reality is you can’t separate emergency care from general practice in this context.

You can’t just recommend that under 5s go free without taking into consideration how this will impact on GPs. As has been seen in an island not so far away, unless you do the same thing in GP practices, people will turn up to ED and cause real strain on the service, when they really should be dealt with by a doctor or nurse in primary care. This becomes a more obvious issue out of hours when the GP is based right next to the ED.

The propositions also don’t recognise that it is not just the cost of primary care that needs to be considered but the model. We have a demand based system, GPs acting as gatekeepers for other services. Just looking at the funding doesn’t address these fundamental aspects that impact on the care people receive. That’s why the grant system is unsustainable. 

At the same time, any recommendations that will result in changes to the ways in which health and care services are funded will impact on the Committee’s budget and its relationships with private providers, and as such must be examined closely and managed in a cohesive way.

Fair access to health care, including primary health care, is fundamental to the Partnership of Purpose and is central to most, if not all, of the workstreams currently ongoing under the transformation programme. We want to reduce the barriers to accessing the right care at the right time. However, in order to do so, we have to have an idea of the problem we are seeking to solve. 

That’s why the Partnership of Purpose policy letter also emphasised the need for better health intelligence to define need, guide decision making, set goals and targets and to monitor progress. 

Winston Churchill has been quoted a few times recently. He’s always good for a quote isn’t he? and here’s another one; ‘You must look at facts, as they look at you.’

HSC has invested time and money collecting and analysing data that will ensure we benefit from structured, evidence-based decision making when recommending changes to health care policy.  Indeed, shortly we will be publishing the first KPI’s on secondary healthcare for the first time.

Now SMC say how they support the need for more evidence on which to make decisions. However, this report does rather give the impression of ‘do as we say, not as we do.’

Because what disappoints me about it is that there is a lot of opinion but not much in the way of fact. For example, we are told that, ‘The Cost of visiting a GP in Guernsey is a major issue for a large section of the population.’ 

No one is denying that the cost of primary care is an issue for a proportion of the population, which is why we want to do something about it, but it is essential that we have a better understanding of the extent of the problem in order that we can understand the most appropriate solution. What is a large section? If it is 75% then that may require a completely different approach than if it is 25%, for example. And, who struggles to pay and who just doesn’t want to pay? 

I think it is also important to get the phraseology right here. Paragraph 11.1 speaks of the relatively high costs of accessing medical and para-medical cover. However, I think you will find the hourly rate of a GP holds up well compared to the cost of an advocate, although I’m sure Deputy Ferbrache would advise they are good value for money.

Again, ED, although charging its services, operates at a loss of around £1.7m and of course St John Ambulance can only survive on a state subsidy.

Really I think what is being said is that the costs are high for a proportion of the population not high for the quality of service given. I’ll expand on that in a minute.

But before I do

I do need to correct a couple of errors in the report which Deputy Merrett has repeated today.

Firstly, it is not correct to say that invoices from PCCL doctor charges were paid for and rest of hospital staff were effectively free. It really it is not as simple as that. HSSD charged PCCL for the cost of staff. They also had a multitude of ancillary charges. 

When HSC took over we simplified the structure and made it more open and transparent. Now, at least you know exactly what you are likely to be charged – I knew it would cost me £155 etc

We have not hiked costs up as was implied by a quote from a couple of Constables of the St Peter Port Douzaine, used in the interim report. 

The actual truth is we now have an ED Department not run by GPs but Emergency Care consultants supported by highly qualified nurses. A team that has also achieved the nationally recognised Blue SCAPE Award that takes years to achieve.

Now Deputy Merrett & Roffey refer to the low throughput. An average of 2 people seen an hour. Well firstly, it’s implied that they’re sitting there saying, hey that’s 2 people coming to see us! It does not take into account how long it takes to care for that person, stabilise and treat. Remember, the majority going through the doors of ED are the more elderly and frail in our community with complex morbidities. Also, the demand is rising.

Let’s not forget we absolutely have to provide an emergency service. If we are to provide such a service we have to meet clinical best practice. That is what our community expect. That is what the regulatory bodies expect. And that is what we have. We didn’t have that for years, but we have it now. It comes at a cost.

The simple truth is we do not benefit from economies of scale. 

Whilst the impression given is that ED can just be another GP service, that is not the case anymore. The world is more specialised than 10 years ago. That is the problem we are facing not just in primary care, but secondary care too. We are a tiny population in the scheme of things and the increase in specialisation is just one of the reasons why the costs to the community are increasing. We can’t just add more and more specialists on-island. 

However, that doesn’t mean we are not looking at innovative ways to enhance the service provided. We are, but I don’t think it is for the Scrutiny Committee or this Assembly to tell clinical staff what they should be doing.

But that’s not the real issue here. That’s just about how much we charge people, not about whether we charge people for emergency care.

Personally, as I said at the Scrutiny hearing, it makes me very uncomfortable that I have inherited a system going back decades where people have to pay to be treated. I am only alive because of the NHS who saved my life. Dr Blood he was called.

That is why I want to do something about it. That is why it is rather irritating hearing those say, well we hear what you say, but it is not a resolution so we need to make it one, so we know you will do it.

As I’ve said, we are DOING it. 

The report suggests various options for the funding of primary care, which reflect various systems currently in place. I’m not going to go through them now as we will cover them off when we put forward our proposals. However, given the current ratio of GPs to the population is approximately 1 in 800 compared to 1 in 1,600 in England Wales, I don’t think having another entrant into the market is the solution. 

Saying all that, it is important to separate the weaknesses of report from the subject matter itself and I am truly of the opinion that the issue of in-work poverty is something that needs addressing. It has a considerable impact from a health perspective after all. 

The poorer in our society are statistically more likely to need our support. Life expectancy is lower the poorer you are, you’re more likely to be overweight, drink and smoke. And there is a direct causality between financial worries and poor mental health. 

Now, a couple of days ago I watched an interview given by the Prime Minsiter of New Zealand, Jacinda Arden, and how refreshing it was amongst all the rubbish we are hearing from other leaders across the world at the moment.

She spoke about how NZ was projected to have 3% growth, unemployment was 3.9%, things should be great.

But, homelessness was at staggering rates, NZ has one of the highest rates of youth suicide in the OECD and mental health and wellbeing aren’t what they should be.

She spoke about how stagnant wages in developed countries is a concern. People’s quality of life is not improving. The importance of addressing this gap through how we measure success and broadening out what success is ie beyond economic indicators. How this gets to heart of the current political crisis and the populist agenda.

She went on to say, if you are somebody at home listening to a politician say, well according to GDP we are now in a recovery phase and yet you are sitting there and don’t feel it, your situation is not improving, then that means you have a disconnect and an increase in the lack of trust in your institutions and lack of democracy.

She finished by saying if you want to start looking at politics through a lens of kindness, empathy and wellbeing then it doesn’t matter what just happens in a political cycle, it matters what happens over decades.

But that should not be news to us here.

We are, in theory at least, already ahead of the game.  We’ve agreed we want Guernsey to be one of the happiest healthiest places in the world. We have agreed that we should consider health in all policies. That’s not just health policies, all policies. Fiscal, economic, social and environmental. The wider determinants of health that we cover at length in the Partnership of Purpose policy letter – for a very good reason.

But NZ is going further. The plan is, if you are a minister and want to spend money, you have to PROVE you are going to improve inter-generational wellbeing.

I think that is something we really do need to consider here. Members will remember, although not referenced in the report, that as a result of a successful amendment to the budget by the P&R President  I believe prompted by an earlier one by Deputy Hanxmann Rouxel, it was resolved amongst other things;

‘the Policy & Resources Committee to publish every December an Annual Monitoring Report addressing the adapted OECD Regional Wellbeing Framework indicators set out in paragraph 4.6 of this policy letter with the aim of contributing to establishing if government policy is influencing key measures as desired.’

That is a start, although we haven’t seen it yet . By measuring what we care about we can then make a difference that matters to our community. 

But then we need to do something about it.

Now, the proposals in the report in respect of ED charges – free for under 5s and cap of £100 would cost around. £1m. However, there is no suggestion as to where the money comes from. Deputy Laurie Queripel says the headline ‘scrutiny review plucks uncosted proposoals out of thin air’ was something he felt quite comfortable about. All that says to me  is it’s a real shame we don’t have a Public Accounts Committee any more. 

Because that really is the elephant in the room here. Whatever we do to make primary care more accessible will cost money. Making everything free, providing all NICE drugs and treatments, reciprocal health agreement will cost eye watering amounts. This is in addition to the projected increase in HSC costs if we don’t change our model of care and the cost of long term care. We’re talking tens of millions of pounds, annually. Not just a one-off cost like the Alderney runway. Who is going to pay?

If people want more, expect more, that has to be paid for. You can’t have one without the other. 

Back in 2002 at the time of the Townsend review,  two thirds of the population said they would be prepared to pay more tax to help end poverty in Guernsey. Well, we have more taxes and higher social security contributions since then, but I don’t get that warm fuzzy feeling people want to pay any more.

And be careful if you think businesses should pay. Don’t forget that most people are employed by local small businesses who have also felt the squeeze over the last 10 years.

However, if we want free primary care, no, if we want the services we currently have in the next 10 years, the money is going to have to come from somewhere. The report talks about increasing personal allowances for the less well off, but where is the cut off point for those who will then have to have a lower personal allowance, that is unless we have different tax rates, something I tried last term and was told I had gone to the dark side. As Deputy Gollop is wont to say, you can’t have the penny and the bun.

This is a lazy report. It tackles one side but not the other. It makes us all feel good and we can pat each other on the back by supporting the propositions and say we care about those hard working people who can’t make ends meet.

But HSC more than any other Committee has been tackling inequity. From the development of the Partnership of Purpose that sets out what we are going to do, to making it real, most recently through the provision of free cervical screening but also through increasing support in the community by 25%.

We will be coming to the States this year on our proposals for emergency and primary care which I hope will help reduce in-work poverty. Deputy Roffey says it has mattered to hime for a long time, well it matters to me too and was a big reason why I stood for the States back in 2012. 

But I will finish with a quote from Sir Michael Marmot, the guru on the social determinants of health. This comes from his book, The Health Gap, 

‘Virtually no one in public life in the UK or US is prepared to have a grown up discussion in public about whether a more progressive tax system , with an overall higher tax take is a price worth paying for improving the quality of people’s lives to match those of the Nordic countries.’

We can have free primary care, free emergency care, cheap social housing and other benefits, if we are willing to pay for it. That is the debate we really should be having. That is what SMC should have been considering.

Unless that is we want to continue taxing and charging the way we have done so for years and years. If we don’t all we are doing here today is playing lip service to in-work poverty, and reducing the wealth gap. 

HSC has and is being doing its bit. I think ESS ad ESC are also trying to do the same, but all we are really doing is focusing on the symptoms, not the cure. 

It is this Assembly and this Assembly alone that can improve the lives of people today and we all need to do it for the health not just of the individual islander but for that of the Bailiwick as a whole.

President’s Statement January 2019

Dear Sir

I am making this statement following the inquest into the tragic death of baby Jack Tually that concluded on 18th January. In doing so, I am fulfilling a promise I made last year. But before I begin I would again like to take this opportunity to publicly and wholeheartedly express my deepest sympathy to the parents. As I said after the verdict, I know that losing a child is every parent’s worst nightmare and I can’t imagine just how difficult it has been for the family.

From the beginning, the coroner made it clear that the purpose of the inquest was to establish the cause of death on the balance of probabilities and NOT to consider or offer an opinion on anything else. He reached his conclusions with the assistance of 3 expert witnesses in obstetrics, neonatal care and paediatric pathology. No other witnesses were called. 

A narrative verdict was given, in which the coroner concluded that, on the balance of probabilities, the primary cause of death was hypoxia caused by Persistent Pulmonary Hypertension of the Newborn, or PPHN, a relatively rare, life threatening condition. Death was contributed to by the lack of effective intubation. No other factors contributed to the death.

As I said earlier, the inquest only dealt with the cause of death and it is for this reason the coroner decided to only hear evidence from the 3 expert witnesses. He made it very clear that this was expert OPINION but if evidence was required to be tested as factual, further witnesses would need to be called. Advocates were given the opportunity to request further evidence be heard but NONE did so.

What I can say now, is that 4 midwives and 2 doctors who were involved at the time were referred to their regulatory body in 2014. Both the General Medical Council and the Nursing and Midwifery Council investigated in accordance with their disciplinary procedures. 

The GMC found no case to answer for one doctor. The other was required to retrain before they could return to practice. That doctor no longer works at the MSG and no longer has a licence to practice. The GMC completed their investigations in 2016. 

In contrast, the NMC has taken years to conclude its investigation into the midwives, resulting in a constant drip, drip of media publicity and very public naming and shaming.  It has also given the impression that their conduct contributed to the baby’s death when that was not the case. It’s also worth pointing out that there is still an appeal outstanding for one midwife, so matters have not even now, concluded.

I understand that the NMC has introduced a new approach recently that moves away from blame and punishment to learning from mistakes and preventing them from happening again. This change is welcome and I will speak more generally on that in a moment but I also hope it speeds the process up.

And that leads me to the time it has been taken for the inquest to be completed. Clearly 5 years is far too long. 

However, I can categorically state for the record that, at no time, has there been any  political interference or obstruction from the Committee for Health & Social Care in the coronial process. Neither have we, or previous Boards, ever covered anything up.  It should also be pointed out that back in January 2016, 3 years ago, the expert witnesses agreed a consensus statement that the likely cause of the baby’s death was PPHN.

Members may also like to know that there are still 2 inquests outstanding that haven’t been opened, one from 2012 relating to a death that was investigated following the Tually case and one from 2016. 

Therefore, on behalf of the Committee for Health & Social Care, I have written to the Policy & Resources President requesting that the Policy & Resources Committee consider whether any resources can be given to help reduce such delays happening in future.

Now, it is important to assure women and their families who are using maternity services that, contrary to what has been reported in the media, we provide an excellent level of service, which is comparable to the service that a small district general hospital in the UK would provide. Maternity services on Guernsey are able to give expert care to women who require both midwifery and obstetric care when either pregnancy or labour is not straightforward. We have in place a programme of care called ‘Every Baby Counts’, an evidence based tool that has been shown to reduce the number of stillbirths. 

The maternity unit provides 24/7 obstetric consultant cover to ensure that women requiring medical help during their labour have access to this in a timely manner. A senior midwife is on duty 24/7 to coordinate the maternity service, both in the hospital and the community. There are now excellent midwifery staffing levels with at least 4 midwives on duty at any time. There is an on-call system in place so more midwives can be called in when the unit is busy. There are also 4 professional midwifery advocates who give midwives expert advice when required, and this has replaced the old system of midwifery supervision. There is training in place for all maternity staff, including doctors, midwives and health care assistants. There is now a robust system of clinical governance in place to ensure that HSC is an open and transparent learning organisation.

There will always be risks in healthcare, and HSC does everything it can to minimise these risks. But, very sadly, some babies are stillborn or die in the first few days of life.

We investigate and learn from all incidents, and last year implemented a programme of work called Safer Every Day, which uses the methodology of the International Institute for Healthcare Improvement, the world’s leading safety improvement organisation. 

The stillbirth rate in Guernsey is lower than England and Wales at 2.9 per thousand births compared to 4.4. The number of infant deaths, is the same as England and Wales at 3.8 deaths per 1000 live births. Childbirth today is the safest it has ever been.

Let’s not forget that no one on that day exactly 5 years ago went to work wanting a baby to die. There was no malice aforethought. But there was a blame culture. And it was that which ultimately led to the failings found by the NMC.  Midwives going outside scope as they felt unable to say no to verbal orders and the way the death was initially investigated reflected that. Everyone can, and must, learn from what happened. Everyone.

Matthew Syed in his book Black Box Thinking which I believe anyone involved in health and care should read,  states, ‘Self esteem is a vastly overvalued psychological trait. It can cause us to jeopardise learning if we think it might risk us looking anything less than perfect. What we really need is resilience: the capacity to face up to failure and to learn from it. Ultimately that is what growth is about.’

A criticism often hurled at the States is that it needs to be more open and transparent.  Indeed, it is essential that we own up to our mistakes if we are to constantly learn and improve.

However, if that is to happen, we as a community need to understand that we are all fallible and mistakes will happen. And nowhere is that understanding needed more than in healthcare with all the inherent risks that come with it. We all need to understand that compassion and tolerance are not a sign of weakness, but a sign of strength and our community will be stronger and more resilient for that.

President’s Statement December 2018

Sir, the States gave its unanimous support to our Partnership of Purpose policy letter almost one year ago to the day and we have been making great progress.  This set out the future of heath and care services for the Bailiwick and as we reach its first anniversary, I wanted to take this opportunity to focus on what has been achieved and to look ahead to the next twelve months.

However, I should like to begin with the issue of orthopaedic waiting times. HSC has been very open about the ongoing issues experienced in orthopaedics and I should like to sincerely apologise to those who have been affected.  Earlier this year, as part of phase 1 of our plan, and as I advised in my last statement to the Assembly, a number of measures were taken to successfully bring waiting times for orthopaedic outpatient appointments to within an eight week waiting time. As expected, and also as previously advised, this has increased inpatient waiting times, but now we have outpatients under control we are commencing phase 2 of our plan.

It should be noted that orthopaedic waiting times have been a problem for many years, with 49% of patients waiting for their inpatient treatment outside the contractual waiting time of 8 weeks at the beginning of 2016 which had increased to 53% by March this year. Increased pressures have arisen since 2017 and changes to service provision have also become necessary as a consequence of Royal College reviews. In addition, an unprecedented number of emergency and trauma patients earlier in the year have led to a higher than normal number of postponements in elective surgery.  These pressures have been compounded by the limitations of the current hospital infrastructure.

Demand is increasing at such a pace that we are struggling to keep up with orthopaedic demand and the pressure on the surgeons, theatre teams and infrastructure requires immediate action. Referrals for orthopaedic inpatient surgery have increased 22% in the last year. In the week ending 25 November, 38 new patients were added to the inpatient waiting list whilst 24 patients were treated. 

Part of the demand is linked to an ageing population who naturally have increasingly complex medical issues often necessitating post-operative intensive care. In the past these patients would not have been considered for surgery. Obesity, is also a factor, which I will come to in a moment.

We intend to reduce the backlog through a number of measures which has already begun, including using off-island partners, increasing theatre utilisation and bed capacity.  As a result of taking the above action, we expect to see significant improvements in the New Year and we will update the community as progress is made.

It should be noted that HSC’s newly established Client Team has provided better health intelligence than we’ve ever had before enabling us to understand the situation better and come up with workable solutions. As I have said many times before, it is only possible to truly transform if you have the data on which to base your decisions and members will hear more about how we are making greater use of health intelligence as we develop the new model of care in just a moment.

AND the Committee continues to push ahead with many significant areas of transformation of our services that will improve our ways of working.  I just touched on the problems with the current hospital infrastructure. Over the last year we’ve been developing a Business Case for the modernisation of the site and a policy letter will come here early next year setting out a phased programme of improvement works.  This in turn will be an enabler for further transformation and will seek to ensure that acute services are part of an integrated system of care provided from a hospital that is safe, flexible and modern for the future. 

In addition, we are developing proposals for a Principal Community Hub at Les Ozouets that will bring together community services and make them more accessible and working closely with ESC to make sure that it fits in with their plans for the site.

The Committee is delighted that this year has seen the formation of the Health Improvement Commission to lead on certain health promotion activities in the Bailiwick, including the Healthy Weight Strategy and the Drug and Alcohol Strategy; important foundations for an effective health improvement strategy for the Islands. It’s importance is underlined when we look at orthopaedics. Obesity contributes to the increased requirement of complex joint replacements and research has shown that overweight and obese patients are at a greater than 40% and 100% increased risk of knee replacement surgery, respectively, compared to patients with normal weight ranges.

There has been much activity in public health with several new initiatives.  The introduction of free contraception for under 21’s has been incredibly successful in reducing unintended pregnancies in young women under the age of 18 years.  Early results are show a predicted reduction in under 18 conceptions of at least 75%, making our rates amongst the best in the UK and Europe.  

Also aligned with the aspirations of the Partnership of Purpose to ensure fair access to care, we will shortly be making cervical cancer screening free for all women.  Evidence of the financial barriers to accessing cervical screening were supported by data from the Orchard Centre, where 80% of women accessing this service for free through the Centre said that they could not afford the cost in primary care.  

The Committee is also progressing a review of the future structure and funding arrangements of primary care, incorporating the Emergency Department, to ensure that cost does not prevent people getting the treatment they need.  An important issue that was also picked up by the SMC during its review of in-work poverty.


HSC has also led on the first population needs assessment focusing on older people, which invited feedback from older people and over 200 stakeholder groups about what is important for older people in the Islands.  The Needs Assessment has highlighted how much valuable work already goes on in our community to support older Islanders but a number of urgent and needed projects have been prioritised, which will guide our future work.  

The strategic review of the terms and conditions of nurses, midwives and other health and care workers employed by the States of Guernsey has progressed well.  The review, which has considered a full range of issues such as the competitiveness of pay in relation to the cost of living on the island and any workplace cultural issues affecting recruitment and retention, has involved meeting directly with staff in focus groups to explore relevant issues.  The review, which will help us to look closely at the barriers to the recruitment and retention of staff, will report before the end of the year.

The Committee is also pushing ahead with drafting a new Capacity Law to ensure that there are safeguards and processes in place protect people who may not have the capacity to make their own decisions.  This remains the legislative priority for the Committee and many other areas of HSC’s work relies upon having this Law in place. However, we are concerned that progress is slow due to pressures on law officer time.

Other areas of activity include our vital work on developing proposals for appropriate, proportionate and robust regulatory standards across health and care to safeguard the well-being of Islanders, and a policy letter on this is due to be published imminently.  

Significant progress has been made this year on HSC’s digital transformation programme and we have been mapping out our approach to ensure that not only is it clinically led but also robustly defines our requirements for any future Electronic Health Record. In addition, work on the upgrade to our IT infrastructure through the deployment of a new Wi-Fi system and Local Area Network across our estate is progressing well. We’re now thoroughly testing applications and medical equipment in parallel with a re-wiring of the estate with some 19.5 miles of cable before rolling out the new solution during the course of 2019.  

A range of service improvements introduced in 2018 have also led to new key clinical initiatives with the benefit of early identification of problems and early treatment.

A Familial Hypercholesterolemia (FH) genetics testing pilot supports our focus on prevention and early intervention.  FH is a genetically inherited condition which can lead to exceptionally high cholesterol levels and early development of cardiac disease, unless mitigated by early diagnosis and medication & lifestyle interventions.  In addition, recent work to establish Heartflow as a non-invasive diagnostic tool in 3D heart imaging will help specialists achieve a more accurate treatment pathway for patients, as well as improving patient safety and comfort.

We continue to focus on the ‘Safer Everyday’ initiative launched in January, which emphasises patient care, the sharing of best practice across HSC and improving the governance of our clinical processes.  Most notably, there has been a 30% reduction in falls this year.  Wards have been equipped with adapted beds and new systems for recording medications that have been administered in relation to fall risks.  A ‘Thinking Differently, Working Differently’ conference held in November looked closely at patient safety and importantly how service users can become more closely involved in their care. 

Finally, the Committee believes that there is huge value in the rolling out of Mental Health First Aider training across the States of Guernsey and would like to explore this next year. As a start, we would like to work with MIND to organise sessions for States Members. We need to lead by example.

Sir, 2018 has been another busy year for HSC and, again, I have only scratched the surface in my update to the Assembly today.  Be assured that we won’t be resting on our laurels and we’ll be taking our relentless pursuit and focus on delivering the Partnership of Purpose into the next 12 months and beyond. 

Drugs, treatments and devices policy

I made this speech in the debate on a requete laid to bring in all NICE approved drugs and treatments. I laid an amendment on behalf of HSC to ensure that such a decision was not made without a proper evidence-based review as we knew the costs would be considerable and that members needed to know the impact before making a decision. It passed.

Sir,

We shall never have all we need. Expectation will always exceed capacity. The service must always be changing, growing and improving. It must always appear inadequate.

No, those are not my words, but those of the founder of the NHS Aneurin Bevan. Very wise words spoken exactly 70 years ago. History has proven him right. 

The truth is there will never ever be enough money to pay for absolutely everything.

That is why we will never ever be able to provide everything that everyone wants however efficient we become. The question is not just, are we spending what we need to spend? But how do we know what we need to spend in the first place?

The current policy, with the creation of a white list and rules around access to drugs in tertiary hospitals has its genesis 15 years ago and was designed to ensure equity of treatment across the Bailiwick population within a tight budget.  But let’s not forget, over this time, spending has increased in Health and Care and the number of drugs, treatments and services that we provide to the people of Guernsey and Alderney has also increased. However, over time, a gap has grown between the drugs and treatments available in the UK and the Bailiwick and the UK has introduced an End of Life Premium for some drugs and a Cancer Drugs Fund.

The question that the Committee asked itself at the beginning of term was, is such a gap justifiable? I don’t think I am wrong in saying that Members have felt uncomfortable about it. We wanted to review current policy and demonstrated our commitment under a resolution of the Partnership of Purpose policy letter and further by amendment to the Policy & Resource Plan in June.

Understandably, those arguing for extending the drugs and treatments available do so in terms of fairness. That it is not fair that people in the UK at least theoretically, get access to drugs not available here. However, that is not the only factor that needs to be taken into consideration. We also need to think about prevention, user-centred care, proportionate governance, a focus on quality and empowered providers and integrated teams. These are 6 of the 10 key aims of the Partnership of Purpose. Our current policy was designed before those Key Aims were developed and approved by this Assembly. We need to ensure future policy aligns with them. Members will see that these are specifically referenced in the terms of reference of the proposed review.

It is fair to say that the Committee has a lot of sympathy for the requete. It is hard not to listen to those who feel they have been let down by the current policy and hear their personal stories, not to want to do something about it immediately and I think the theory behind not asking for everything up front and looking for a minimum outcome prior to any review is laudable.

However, after giving it a lot of consideration, we just can’t support it because it is flawed. It makes no reference to funding. As things stand, if the requete was passed it could mean services elsewhere would need to be cut. It makes no reference to Alderney, although knowing Deputy Roffey, I am sure that was unintentional. 

But, more fundamentally and ironically, by trying to stop one inequality it could lead to greater inequalities elsewhere in the system. For example, if the minimum outcome is adopted then someone treated on-island would not get access to the same drugs as someone being treated off-island. It could also have the unintended consequence of consultants actually referring patients off-island who could be treated on-island.

States Members might think I’m stretching the argument to prove a point: after all, surely two people with the same condition will either both be treated here, or both be sent off-island? But that isn’t the case. One person with cancer might have an underlying health condition that complicates their treatment, meaning they need to be sent to the UK for more specialist care. Another person, with the same cancer but without the other condition, can be treated here. The first person, who is sent off-island, will then be able to access certain drugs and treatments *for their cancer*, which the other person with the *same* cancer can’t access here. So the risk of inequity or injustice, if the Requete is adopted as written, is real.

Now, we could of course come here today and just argued that members reject the requete. However, that was not good enough. We understand the strength of feeling from some in the community who feel let down by the current policy and who want to see change.

And on that I should like to thank the group of campaigners, some of whom I met on Wednesday night who conducted themselves with great dignity and it was really useful to hear from them first hand. What was clear to me was that there were issues over process that needing investigating and I have committed to ensuring improvements are made. Not only that, if this amendment is passed and Option 1 is approved by the States, we have committed to work on the basis of permissive funding as far as we can in the interim and to provide a single point of contact, not involved in dealing with funding requests, who will help people through the process.

We also didn’t want to be seen to be hijacking the requete but to produce something that took into account the strength of feeling of some camapaigners. That is why we have included our preferred option of a review, whose terms have been published for all to see, but also an alternative that says, let’s just do it.

We have listened and In particular, understand the concern about the time it would take for a review to take place. We had committed to undertaking a review by Q3 of next year. This would have enabled the review to be undertaken by our Director of Public Health, with independent support from her counterpart in the Isle of Man. However, that would of course be too late for any funding to be found for the 2020 budget. So, instead we have said we will ensure the review is undertaken by Q2 next year, by bringing in external public health specialists. These are not generalist consultants from an accountancy firm or management consultancy. This is a highly complex area needing the necessary expertise.

We have also listened in terms of the review itself. We have therefore published the terms of the proposed review. We have also stated that it should be undertaken on the presumption that we will make available all drugs, treatments and medical devices approved by NICE Technology Appraisals.

We will ensure the review fully explains the benefits and implications of adopting all NICE TAs and how that can be achieved, and the policy letter arising from the review will give States Members the option to vote to do so.  HSC can’t guarantee that the funding will be available – only that we will clearly make the financial and ethical case and ask for the necessary budget. 

We believe that we have come up with an amendment that moves us forward and will help us navigate through a very complex area.

Complexity – if ever there was a word to sum up health and care it is complexity. It is really difficult to get across quite how complex the health and care system is now. It is more complex than 5 years ago and even more complex than 10 years ago. Every year, new drugs, new treatments and new methods are invented. We have to navigate this complexity and understand where these new inventions will actually make a meaningful difference. At the same time we have a population with increasing expectation and, thanks to the internet, greater knowledge of what is available out there.

Aneurin Bevan wasn’t wrong. We will always appear inadequate, we can’t meet everyone’s expectations. However, what we can do is ensure we meet the principles we set ourselves as far as possible and justify the decisions we make. That is why I ask that members support the amendment.

Summing up

This is an incredibly complex subject and reflects the difficult decisions that have to be made in health and care every day and will continue to have to be made. I wish we had all the money in the world and could satisfy everyone’s wants. But then what would be the consequence of that?

Anyone who’s watched the film Bruce Almighty will know what I’m talking about. Bruce, played by Jim Carrey hears voices in his head and then meets God, bear with me here. He explains that the voices are prayers to God, and that Bruce must deal with them. So, Bruce creates an e-mail system to receive prayers and respond to them. However, he then finds that the influx is far too great for him to handle, even with the use of his powers. So he sets the program to automatically answer “Yes” to every prayer, thinking this will make everyone happy. Needless to say it causes a heap of problems.

What it is important to do is listen, empathise and inform. Because we can’t provide what everyone wants we need to ensure that what we do can be justified. But we can only do that by reviewing what we do periodically to ensure that we are meeting people’s needs as best we can.

We have listened and taken on board what people have been saying. I believe we have done all we can to demonstrate that we take this issue seriously. We understand and empathise with the concerns and would like to ensure that we progress to a more liberal regime. Overall, we have made it possible for all those to coalesce around the need for a review that will enable us to make evidence-based decisions that support the key aims we have set for our health and care service.

I urge members to support this amendment.


Organ donation

I was delighted to be able to bring a policy letter to the States proposing an opt-out organ donation scheme which was passed by the Assembly. Here is my opening speech.

Sir,

The donating of an organ is a precious gift. It can be life changing. It can be life saving. Every year Guernsey residents have their lives saved or improved drastically because someone took the effort to expressly agree to allow their organs to be donated in the event of their death. Their death has allowed others to live.

In the last 2 years, 3 Guernsey residents have become donors and 12 have received an organ transplant. Major operations.

Sadly though, the number of people requiring a transplant significantly outnumbers the donors. There are currently approximately 6,000 people on the UK organ donation register that includes Guernsey residents, with 400 dying waiting for a transplant in the last year.

There are a number of reasons for this mismatch;

  1. The advancement of science means that more people can benefit from a transplant than ever before;
  2. The circumstances that enable a donation to be made are very precise, with less than 1% of deaths meeting those criteria. This can be due to the nature of the death but also whether an individual is found to have any underlying health issues that may preclude donation;
  3. The fact someone has not consented to allowing their organs to be donated; and
  4. And, even where someone has consented, the family is not happy for their loved one’s organs to be donated.

In terms of the first 2 that relate to the practical aspects, it may be in the future that scientific advances will enable organs to be replaced without the need for human donors or further research may demonstrate certain underlying health issues are not a barrier to donation as they were once seen to be. Every year advances are made in both areas.

It is trying to increase the potential number of donors that this policy letter seeks to address and why we are proposing a soft opt-out donation scheme.

Under a soft opt-out scheme an individual, unless someone has expressly stated their wishes, either for or against, will be presumed to have consented to be a donor unless their family express their objection, it clearly causes distress to a family, or if no family can be found. Deemed consent would not apply to those under 18, not ordinarily resident in Guernsey for the last year, or those without capacity.

The use of a presumed consent system was supported by Nobel Prize Winner Richard Thaler and Cass Sunstein, who developed the concept of nudge theory. In their book called Nudge, they described an experiment undertaken by Eric Johnston and Dan Goldstein who found out how important  a default position  in organ donation was. Here I’m hoping I haven’t stolen Deputy de Sausmarez’s thunder!

Using an online survey the researchers asked people in different ways whether they would be willing to be donors. 

In the explicit consent version particpiants were told they had just moved to a new state where the default was not to be an organ donor. In the presumed consent version the wording was identical  but the default was to be a donor. In the third neutral condition, no mention of a default, they just had to choose. Under all three conditions the response was entered with one click.

The default mattered. When participants had to opt in, only 42% did. But when they had to opt out, 82% agreed to be donors. Almost as many did under the neutral condition. A real life example of this is in Germany with an opt in scheme has a 12% consent rate, the same as Guernsey, compared to Austria with an opt-out scheme which has a 99% consent rate.

And as advised in the policy letter, Wales brought in a soft opt out scheme in December 2015. The very latest news announced a fortnight ago is that Wales now has the highest consent after death rate in the UK at 80.5% against a maximum for the rest of the UK of under 67%. Guernsey’s rate is only 46.7%.

I think it is worth just mentioning what happens when a potential donor is identified. It’s important we all understand this isn’t a run of the mill situation. Remember, this is an incredibly difficult time for friends and family, knowing that their loved one will die, especially, which is the most likely scenario, it is an untimely or unexpected death. It is something I know very well and I can say the passing of the years doesn’t make it any easier either.

It is important that the professionals involved at such a horrid time are incredibly well trained and experienced. Due to the very small numbers involved in Guernsey it would not be possible to develop that expertise here. The Specialist Nurses for Organ Donation (SNOD’s) are employed directly by UK Blood and Transplant and are free to us.  When we identify a potential donor we phone them and they advise if transplantation is potentially possible. If it seems likely they fly over to speak to the family. Remember, all for free. Evidence is that the best consent rates are when the first contact with the family is by a SNOD with the ITU team. 

But the change in the consent system will not improve donations per se. What we need and hope change will do, is lead to people talking about what they would or would not like to happen to them should such an unlikely circumstance arise with their family. Or better still, to register their preference, either for or against. 

So, should this policy letter be approved, there will be significant publicity leading up to the introduction of legislation and we will ensure there is increased awareness in the future. Indeed, this is an area where we can pool resources with Jersey in particular, who have already been helpful in this area and I thank them for their support. This isn’t about a lot of publicity up front and forget about it. 

And raising awareness doesn’t just mean broad media campaigns but through places like doctors’ surgeries, hospital, schools and community hubs. In others words, and in support of the Partnerhsip of Purpose, by Making Every Contact Count.

There will always be the conspiracy theorists and those who have a natural tendency to distrust the state that will rage against these proposals but this is not the State taking control of our organs. This is about changing lives and saving lives. This is about us as fellow human beings doing what we can for each other.

Presumed consent leads to a greater opportunity for donation.

Now I do hold an organ donation card, but I haven’t always done so. I always wanted to but, you know, just didn’t get round to it. I actually felt guilty that I hadn’t, but hey other things were going on. Work, kids, stuff. Ironically as for most of us LIFE just gets in the way of donating in DEATH.

I am not bothered what happens to my body when I am dead and happy for any of my organs to be donated, although I doubt whether my liver would pass muster after the last few years. However, eventually I did register for three reasons, the first was how could I not in my position leading a Committee that has a duty to protect promote and enhance the health and wellbeing of the people of the Bailiwick knowing what a difference the donation of an organ makes? What a poor example I would be giving if I did not?

The second was having been thrown from my bike in a head on collision with a car which I was lucky to walk away from just a few years ago and thirdly, and probably what made me sit up and really think, was when someone asked me, if you were dying and needed a transplant, would you take it? I knew my answer. 

That is why I support a deemed consent system and why I ask members to please support this policy letter and help save lives.

The below is what I said in summing up.

Sir,

Just like to pick up on comments regarding family wishes. Really it would be impossible to ignore family at such a very difficult time. David Shaw writing in the journal of Intensive Care stated that even in an opt-in situation the family can cause an objection of around 10%. However, that does include the fact they provide information about a donor that makes it unviable. But the last thing anyone would want to do is make their distress worse. What is important, as I said when I opened debate, is that there are Specialist Nurses who talk with the family. Evidence shows that where you have such a professional consent rates are higher than when you don’t.

Those against presumed consent argue that this is undemocratic. Of course, we could spend hours debating this point. However, it is also the case that there is a presumption in both opt out and opt in system. In either case a proportion will be wronged by having their autonomy violated. It is also the case that those opposed to organ donation are more likely to opt-out under a system of presumed consent than someone who wished to opt-in Aunder an explicit consent system. Those objecting the most are more likely to have strong moral or religious objections of which they are very much aware and are unlikely to neglect to opt-out. In this regard, we need to determine whether the moral mistake that saves other lives is preferable to an equivalent mistakes that in addition costs lives. What we need is for organ donation to be seen as the norm and that we allow the sick to be left to suffer through a desire not to harm the potential autonomous will of the dead.

WE have heard views for families not having a voice and others that do. Perhaps like baby bear’s porridge it means we have got it just right. It is important to avoid further distress to the family at an already difficult time but is also, we need to avoid any negative reputational issues associated with transplantation services which may result in people generally losing faith in the systems and choosing to opt out. 

Sir, members today have had a brief insight into the world we inhabit in Health and Social Care. Issues of life and death are an everyday part of what we have to deal with. We know that we can’t please everyone all the time and that difficult decisions have to be made. More on that in a couple of weeks’ time. However, today we have an opportunity to improve people’s lives and save people’s lives. Not just HSC but the whole of the community. Ultimately it is of course, working together that we will create a more sustainable healthcare system and improve the outcomes of the people of the Bailiwick.

I therefore ask all Members to support this policy letter.



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Email: heidi@heidisoulsby.com