Finance and Taxation

Fiscal Framework

The fiscal framework has been due to be debated by the States with the 2020 Budget. However, it becomes obvious that what had due to be presented did not reflect the financial situation that was being faced with Committee bids far exceeding the funding available to an extent not seen before. Instead, the policy letter was presented in January 2020 with an express proposition recommending a review of taxes in the next term. This is my speech in that debate.

Sir, A fiscal framework provides a structure and control that, for a small jurisdiction which can’t run up a national debt and for whom political, social and economic stability is crucial for its future, is absolutely essential. It may not have been in the past when life was simple, but in today’s complex world it absolutely is.

And really there is little that can be fundamentally be challenged in what is set out in this policy letter when it comes to the framework. 

BUT what is missing from this policy letter is any connection between the principles laid out and what sort of society we want. Principle 5, setting the aggregate amount of States revenues as a % of GDP is really where this becomes obvious. We are told in paragraph 5.13 that this governs the aggregate size of the public sector providing a limit on the maximum amount of money it is deemed appropriate to take out of the general economy to be directed at the provision of public services.

There is reference to pressures such as from the ageing population and the need for fiscal discipline. The need to set a limit that is, supposedly, challenging but achievable’ but nothing about what our long term goal is. 

BUT we do have a long term goal and is something referenced by  P&R in its letter of comment on the policy letter we will be debating shortly – that is to be one of the healthiest and happiest places in the world. 

We have a Policy & Resource Plan that is meant to determine how we get there.

BUT there is no connection between the P&R Plan and the Fiscal Framework, which seems odd given that the development of both is the responsibility of P&R.

The policy letter is written in such a way that it makes out the Principal Committees are just doing their own thing without any direction. 

Paragraph 2.2 is symptomatic of the mindset where it states, and I quote, ‘each policy brought forward for debate is undoubtedly done so with the best of intentions’.

This completely ignores the fact that the Committees have been following the direction of the States. Through the Policy & Resource Plan. 

Of course, the problem is the Policy & Resource Plan itself where everything is a priority. Every key strategy is treated as a priority and that is where it has gone wrong and which I said at the time phase 1 was being developed. Instead of recommendations from key strategies being prioritised, the strategies themselves have been. 

It really should not have been a surprise to P&R that the fiscal pressures are now becoming apparent. Just looking at ESS’s mandate – all their big ticket items they have brought and will bring this term have arisen from strategy decisions from last term – SLAWS, Disability & Inclusion, SWBIC, secondary pensions. No one expected to come without a hefty price tag.

Public sector pay, in particular equal pay for work of equal value, has been an issue for many years and just not addressed whilst it was clearly apparent that the situation was getting more and more indefensible.

Neither should the pressures on health and care come as a bolt from the blue. This was clearly referenced in our policy letter on the Partnership of Purpose and proposition 21, which became a resolution directed P&R to consider, as part of future budgets, what steps, if any, are required over and above transformation of health and care  to ensure the sustainability of funding for health and care. 

This policy letter just references what was provided in this year’s budget. And on that, I need to correct what is stated in paragraph 2.33. HSC was not awarded £6.2m to meet above inflation pressures on baseline costs. HSC was given £6.2m to reflect its true staff costs and inflation. It does not take into account growing demand.

And this takes me back to the point I am making – we have a fiscal framework and we have a policy & resource plan but nothing linking the 2.  The fiscal framework all seems very dry and it hasn’t had much interest in the media. But it really is important. It feeds through the Medium Term Financial Plan which in turn determines the budget Committees receive. It has meant that before HSC made its budget submission for this year, it had already cut £5m from the requests that came to it and then what we received was £3.6m less than the Committee applied for. We are in a completely unsustainable situation.

Now I was interested to read the Better Life Indicators Report that came out last month which showed Guernsey has the 5th largest household income and 6th highest life expectancy compared with 30 OECD countries and second only to South Korea for broadband access with such good news backed up by the latest economic and financial stability overview. All excellent stuff.

And then we have the Gini Coefficient, the measure of inequality in a society. We are told in that report that Guernsey has a Gini Coefficient of 0.37, which seems quite close to the OECD average of 0.32. However, this is a classic example of where using a mean does not reflect the reality. Having looked at the Gini Coefficients of all the OECD countries it is evident that, rather than being somewhere in the middle which is the assumption you could make from the scoring, Guernsey comes in as the 6th most unequal compared to the 36 members of the OECD. Only, US, Lithuania, Turkey, Chile, US and Mexico being worse than us. The median is .307 similar to Ireland and Luxembourg.

The importance of this? As all the work done on the Social Determinants of Health shows, there is a direct correlation between wealth and health.  Conversely, the greater the public expenditure on health care and education the higher the human development index – an index the UN uses to show that societies that spend more on schools and health care are those societies that score better on education, health and income.

This does not mean throwing money at social policy. It does mean targeting funding where it will make a difference and empowering people to live better lives. It is not about government meddling in everyone’s lives either. The saddest thing I read about that Better Life Indicators Report, which was backed up by the recent Joint Strategic Needs Assessment HSC undertook on the over 50s, was how poorly Guernsey performed in terms of how people perceived their social network – whether they felt they had people to turn to when they needed help – we are 7th from bottom. This is backed up by the recent health and wellbeing survey where those living in affordable housing, including social housing are more likely to be emotionally and socially lonely. 50% of whom felt intensely socially lonely. The younger you are the more likely you are to be intensely socially and emotionally lonely. We also see that the greatest causes of stress are work with 36% always or often stressed by work and 30% by money and financial pressures.

I want to quote again what Jacinda Aherne the Prime Minster of New Zealand said- 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.

Joseph Stiglitz, Nobel Prize winning economist and former Chief Economist at the World Bank wrote in his book the Great Divide wrote that growth is not just a matter of increasing GDP. It must be sustainable and inclusive. At least a majority of citizens must benefit. That trickle down economics does not work: an increase in GDP can actually leave citizens worse off. But that there does not need to be a trade off between growth and inequality as governments can enhance growth through inclusiveness – education and social protection. He references Singapore that has prioritised social and economic equity while achieving higher rates of growth demonstrating inequality is not just a matter of social justice but economic performance. Ultimately he says how inequality actually restricts growth, which has become increasingly apparent since the 2008 crash which is hitting the young in particular.

This is why we have made under 21 contraception free, why we have made cervical smear testing free, why we are seeking to restructure primary care funding and why we are proposing changes to our drugs policy. It is because they make sense for future growth and sustainability.

It is why any review of the tax base is not only necessary to consider future funding pressures, but is also an opportunity to take into account that current inequality and really help make us one of the happiest and healthiest places in the world. 

Budget 2020

The 2020 budget debate wa very different from 2019 which has been dominated by the public sector reform changes made by the Chief Executive. This year the focus was around the unsustainability of the current finances. My speech was centered around what had been achieved by Health & Social Care to live within its budget but also to make it clear – again – that there are growing challenges and demand that need to be funded in the future.

Sir, normally and in past years I’ve covered off a range of items in the budget. BUT the truth is I can’t see anything more important in respect of the States finances than the cost of health and care – what we provide and how we pay for it.

The development of this year’s budget has been incredibly difficult for the Committee for Health & Social Care. Over the last 3 plus years, HSC has improved its financial controls, financial reporting and financial analysis. Processes have been introduced to ensure that all recruitment requests are scrutinised before approval. A framework for the pricing of agency staff has been introduced to control such expenditure. A prioritisation process has been implemented to ensure that all service redesign initiatives are properly costed, reviewed and assessed and positive steps have been taken to agree clear contractual arrangements with NHS providers, enabling more reliable off-island services for patients at more predictable, stable costs. HSC is more efficient than ever before.

We have made savings and underspends totalling £8m as a result of service improvements and wider transformation. Indeed, we are the only Committee that has already made the recurring savings we identified we could for 2019, totalling £945k. Without these collective actions, HSC’s quarterly expenditure would be over £5 million more than it is today. We have consistently made more savings than any other Committee this term, such savings that have helped out other parts of the States undertake initiatives that would have not been possible otherwise.

However, growing demand, growing medical advances and growing expectations are putting real and huge pressures on the service. In my last update to the Assembly I stated that we would overspend our budget this year by £5m not due to lack of financial control but because of real and tangible increases in demand. 

Given one amongst us wrote a letter to the Guernsey Press saying he didn’t believe it, I thought it would be worth providing a few examples. Occupancy in the PEH has increased by 10% in the last year alone. The critical care unit has been full to overflowing this summer, which is unprecedented. Radiology has seen an increase in demand of 25% in the last 12 months. We are forecasting a 23% increase in Emergency Department attendances since 2017. Mental health services and community services are all seeing increased demand for their services.  We have had to employ agency staff in adult community services whilst we wait for an additional 43 permanent staff we have recruited to become available to meet growing and complex needs. 

Off-island care has seen a 10% increase in cases translating into an increased spend of £1.5m

In addition, successful recruitment efforts across acute services, combined with the introduction of super-numerary posts to help retention, as well as unpredictable events requiring expensive locum cover have meant we have eaten into the vacancy factor that has been used in the past to keep the budget down and enable funds to be freed up for other Committees. 

It is against this backdrop that HSC’s 2020 Budget needs to be understood and the requested increase not be seen as unexpected. 

Our submission totalled £130.5m, representing £12.24m over the indicative adjusted cash limit. It is proposed that we receive £124.7m, with £2m of separate annualised service developments. Now, it has to be said that the development of the budget is something of a black art and it took some time to reconcile one with the other. I’m not going to explain it in detail right here, but the upshot is, the proposals are £3.6m less than we applied for, or £2.1m excluding items which we have been advised can be funded from elsewhere.

Our submission covered £10.4m of what we consider essential funding. That is funding required in order that current services could be maintained and current demand met, with £1.8m of items we believed should be funded to meet gaps in service provision.

In the event, the cash limit increase, excluding service developments and alternative funding, totals £6.6m. This covers £1.1m inflationary increases, with the remaining £5.5m mostly reflecting an adjustment to our base staff costs to reflect their true cost. Yes, that is right, to reflect their true cost. Various adjustments have had to be made, reflecting prior year under-budgeting as well as the elimination of the vacancy factor for frontline staff which is no longer justified. So basically our cash limit just covers off maintaining what we have. It does not deal with increases in demand or any gaps in provision which are both, oddly,  defined as service developments.

It is proposed that we receive £2m in annualised service developments, which is £1.5m less than expected. 

Let no one think that this was a speculative wish list. It is a carefully considered submission which has been subject to extensive assessment, review and prioritisation by both officers and the Committee. From an initial list of over 60 proposals with total costs of around £8 million, we brought that down to £2.1 million essential bids, and a further 14 requests totalling £1.1m which we believed could be delayed but would put strain elsewhere in the system. These are pro-rated costs, not full annual costs by the way.

Every proposal has been subject to extensive internal scrutiny. HSC’s Finance Business Partner has a simple phrase pinned prominently above his desk; “Every pound wasted is a patient’s lost opportunity”. This message encapsulates the approach taken to financial management across HSC, recognising the need to maximise the value of every pound available to the community.  

And here’s the proof – [raises budget papers] what that’s about 7cm of paper and I can assure members there are plenty more documents on this laptop as a result of the whole summer being spent trying to arrive at a realistic budget.

I don’t intend to go through in detail each of the prioritised requests in turn but will provide a few examples which will, subject to members’ approval, be funded in 2020;

  • The initial stages for a Mental Health and Wellbeing Centre. The need for an accessible,  community-based service for those experiencing stress and distress was identified as part of the gap analysis of all mental health and wellbeing services provided across the Guernsey and Alderney;

My Committee is determined to ensure that when we made a priority of the P&R Plan that Mental health be given equal priority and consideration as physical health that this should not be hollow words. 

  • An improved diabetic retinopathy screening programme designed to increase the number of service users accessing it;
  • A Consultant Community Paediatrician to cover services such as Safeguarding, Autism Assessment, neurodisability services, school clinics, and support for the Child Development Centre. This is an essential post if we are to abide by one of the central tenets of the Children and Young People’s plan that every child should be safe and nurtured.

However, those areas that, at this stage, will be unfunded, include;

  • The expansion of the Community Speech and Language Therapy team to respond to the 75% increase in out-patient referrals and increased complexity of the caseload;
  • The recruitment of a Falls Practitioner to work across HSC to provide support in reducing falls and ensuring effective treatment and rehabilitation for those who have fallen;
  • the development of Health and Care Regulation to provide independent assurance around safety and quality of public, private and third sector services. 
  • And Increased provision for the Children’s dental service to manage increased demand.

We do appreciate the difficult decisions that P&R had to make in developing the 2020 Budget. We have not wanted to make it difficult for them. HSC has done its bit over the last few years to make their life easier and continues to do so through transformation which I will spell out in my next statement. But whilst a focus on prevention and improving the general health and wellbeing of the population may reduce the scale or complexity of future demand, and earlier intervention and more integrated care will improve efficiency and effectiveness, the overall costs will continue to rise. KPMG made it very clear that, even making transformational changes, there will be a funding gap in health and care of £20m by 2027. It should therefore not be a surprise to anyone that we are where we are.

Whilst we can be more efficient and are always seeking to improve, anyone who still thinks that the funding gap can be managed by cutting out waste clearly has no comprehension of the pressures currently being faced. In any event, any multi-million pound savings are really only likely to be achievable through digital transformation and that isn’t going to happen overnight.

Sir, We are very lucky to have the breadth and depth of health and care provision that we do in the Bailiwick and my Committee is proud to represent all those who provide such an amazing service. But this Budget indicates that the time has come for a wider conversation over what the community is able and willing to pay to maintain our services. The current arrangements are unsustainable if we are to meet growing expectations, be it in how long we have to wait for surgery, how much we have to pay to see a GP, the drugs and treatments we want or the level of care we desire in the community. Something has to give.

All the savings that HSC has made over the last 3 years have been made without cutting services. We’ve done it through thinking differently and working differently. The time has come for all of us to think and work differently and think and work together to find the best solution for the people of the Bailiwick because decisions need to be made and made now.

Fair and equal Pay

The issue of equal pay for work of equal pay has been longstanding and not addressed by successive governments to the extent that dealing with it now will come at considerable cost. Deputy Le Clerc and myself sought to lay an amendment to the 2020 budget changing the wording used by Policy & Resources Committee to ensure that greater assurance was given that this would finally be addressed. After discussion with that Committee, we agreed to an amendment that would do that. My speech on the amendment is set out below.

Sir, I thank Policy & Resources for listening to Deputy Le Clerc and myself in order that we could arrive at an amendment with which we are both happy.

I actually have some sympathy for Policy & Resources. The issue of fair and equal pay  is not new. Previous administrations over decades have failed to grasp the nettle and address the inequality in pay scales.

The problem now is that the inequality between various public sector workers, and not exclusively those under Agenda for Change, has grown such that it is likely to come with a large price tag and will take quite detailed planning and a number of years to put right. 

But, something has to be done. The current situation is not sustainable and is actually costing us money. We have people leaving hard to recruit areas and taking up other better paid public sector roles which require less qualifications, we have agency staff who would like to become permanent staff but can’t afford to. 

The problem is assurances have been given in the past but nothing has been done. That is not the case now with the Royles review in respect of Agenda for Change which came out of the Partnership of Purpose policy letter and the wider work by Kojima that has been commissioned mapping and benchmarking terms and conditions across the States. That is certainly a step in the right direction. But that is only part of what needs doing. I was pleased that Policy & Resources agreed to put in a proposition with respect to equal pay but was disappointed with how it was worded.

‘To endorse the intention’, which seems to preface a number of propositions this year, just did not seem enough and it concerned us that we may end up not having a debate before the end of this term. I am pleased that P&R have agreed to this more robust wording. I suppose the only issue I have with the amendment in front of us now is the ‘if appropriate’ which begs the question when would a timeline not be appropriate in respect of fair and equal pay. However, I am happy to live with it in the spirit of cooperation and think it better than the original proposition and would ask all members to approve it.

President’s Statement July 2019

Sir, 

The Committee has achieved major milestones in moving the Partnership of Purpose forward since my last statement, receiving the green light from the Assembly to proceed with the introduction of a proportionate regulatory framework for health and care and a commitment to invest in the infrastructure of the PEH.

Together with the Reform of Health Care Funding, these projects are crucial enablers which help us to lay the foundation for further transformation and the new model of care.

Work is ongoing to deliver a new model of primary care focused on greater equity of access and enhanced partnership working across the health and care system. 

The Review of Drugs and Treatments, which we aim to publish by the end of this month, provides the evidence-base we were seeking to recommend changes in drug funding policy and the Committee is working with ESS and P&R to ensure that we have a workable proposal to bring to the Assembly in the autumn.  

In the recent debate on the Future Guernsey Plan, Members supported our aim to address the identified gaps in mental health services and to place a greater focus on early intervention and prevention.  I am delighted that as part of this commitment, HSC’s application to become a signatory to the Prevention Concordat Programme for Better Mental Health has been accepted.  This is a significant achievement and reflects the huge amount of effort that has been carried out to map our services and to work with our community partners to promote good mental health   .

In children’s services, levels of early help have increased, those on the child protection register for over 2 years have fallen significantly and the re-registration rate within two years also remains low.  Generally, long term trends also indicate a decline in looked after children. In addition, joint working with our counterparts in Jersey has resulted in the appointment of the first Pan-Island Independent Chair of the Islands Safeguarding Children Partnership and we continue to work with Jersey in other areas.

There has also been some fantastic partnership working with the Guernsey Housing Association.  New key worker accommodation at Beauville, right next to the PEH was opened last week, which, for the first time offers family accommodation.  The Autism Hub is also due for completion at the end of the summer.  Service users and their relatives have been visiting the site over recent weeks and transition planning has begun.

The first ever Joint Strategic Needs Assessment provides us with a wealth of information on the specific needs of the over 50s identifying a number of ‘urgent’ and ‘needed’ projects in Guernsey and Alderney to improve the wellbeing of the community. An excellent piece of work by our Public Health Team.

At a more operational level, in my last statement I set out the problems with respect to orthopaedic Inpatient Waiting times and plans to reduce the backlog. Since then we have made good progress through a combination of on and off-Island initiatives.

The introduction of periodic Saturday operating lists, off-island operations through Peterborough NHS Trust, Spire Hospital Southampton, and Jersey has helped to reduce the waiting list even though we are seeing significantly increasing demand. 

We expect added momentum over the coming months with an extra anaesthetist now on-island and additional contracts with other off-island providers. A ‘short notice’ list is also being trialled where the longest waiting patients are being offered the opportunity to prepare for surgery should a last minute slot become available. We also have contractual service redesigns for orthopaedic surgery and theatre management planned for later this year.

However, living longer inevitably means more procedures and whilst the PEH Modernisation Programme will increase capacity in the longer term, we also need look at prevention and how we can do things differently. With regard to the latter, a review is currently active and we expect a report in the next few weeks.

The ageing demographic, as shown by orthopaedics; a growing demand for increasingly specialist services, together with general developments in modern healthcare are having a very real impact on the bottom line.  

We know pressures arising from the ageing demographic result in an additional expenditure of £1million. Now none of the above is new. 

However, ironically a major reason why our budget is under very real pressure this year is because of our own success. For the first time in many many years we have been successful in stabilising the permanent staffing within acute services. 

At the end of June 2018 there were 83 Registered Nurse vacancies within acute services and we are expecting a reduction to just 29 by this September as a result of an excellent recruitment drive.  A huge thank you goes to all those involved across the States who have made it happen

I’m sure members will agree this is fantastic news. However, it perversely presents us with new budgetary challenges. The reasons are two-fold. Firstly, some of those staff are super-numerary and  their costs need to be covered for the first few months and secondly, a  vacancy factor, basically a percentage cut in pay budget,  is in place on the basis that we have never been able to fully recruit before.  Clearly, as we are now in position where this is no longer the case, we need to re-think the approach in the budget setting process for 2020.  

Of course, whilst we have made such a difference in recruitment, retention is still a considerable concern. That is why the Committee would like to see resolution to the nurses pay dispute and an agreed plan of action in terms of the development of a future framework that takes account of equal pay for work of equal value, as soon as possible. On that front, I would like to thank the nurses, on behalf of the Committee,for the truly professional approach they have taken in their campaign. 

Whichever way we look at it, the funding gap identified by KPMG is beginning to be felt, and even with all the transformation initiatives we propose, it is expected to reach £20m in the next 8 years.

HSC has worked tirelessly to manage its budget well, with millions of pounds of real savings made to the bottom line without any service cuts.  In fact, to the contrary, as we have re-invested savings into prevention and early intervention measures.

This has included the introduction of free under 21’s contraception, which has exceeded all expectations in reducing unintended teenage pregnancies, free cervical cancer screening, HPV vaccinations for boys and FH genetic cholesterol testing which is to be launched shortly. These have all happened through partnership working which we want to develop more over the next few months. 

However, we are rapidly coming to a point where services may well need to be cut unless extra funding can be provided in line with KPMG’s predictions. 

So, Sir, it has been a busy six months and the rest of this year promises to be equally so with the Capacity Law being finalised, engagement on proposed changes to the Children’s Law and publication of our proposed future model of Primary Care to name but three. However, the debate at budget time will be crucial. Sticking to our usual approach, when it comes to raising revenue and allocating it, won’t work.  We need to think differently about the whole financial picture of the States, if we want to keep pace with the health and care needs of an ageing population, as well as working on prevention for future generations.  All the amazing work to lay the foundations for a better model of care could be meaningless unless the whole of this States is prepared to confront the funding challenges that lie ahead.

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.

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.

States Budget 2019

The speech I made in the general debate on the budget.

Sir, As is customary will begin by commenting on the budget in so far as it affects HSC and then speak more generally.

The headline summary of HSCs submission does not reflect the wide range of challenges and considerations that are taken into account and that result in the budget figure build which was submitted to P&R. We will therefore be publishing it on our webpage in order that those interested can get an idea of the various factors involved and Deputy Green and others can find out the considerable transformation that has occurred at HSC and what is being planned. 

Actually I hear about Deputy Fallaize say Deputy Green has been appointed the resident pessimist but I think being a new Dad and the loss of sleep that goes with it may have something to do with it.

Anyhow, Whether or not transformation is going on elsewhere I will not accept in any way shape or form any attempt to throw seeds of doubt as to what HSC has achieved. We have made millions in bottom line cash savings and considerably more in terms of cost avoidance.

Regarding capital spend and in answer to Deputy Green, like Deputy Fallaize I want to give a boost to capital infrastructure which is why HSC has been focused on the PEH modernisation and expects to get a policy letter to the States early next year which will likely make a sizeable dent in the Capital reserve. At least I expect it to happen before Jersey get a spade in the ground on a new hospital.

Now just looking at specific aspects of HSC’s budget.

The ageing population is real and hitting us like an express train. The immediate post war baby boomers are in their 70s and the numbers over pension age are expected to increase 2% pa over the the next few years. This has been calculated to drive a 1.4% increase in demand, all other things being equal. At the other end of the age range, whilst less children are being born many more are surviving with conditions that would not have been viable just a few years ago. Rising obesity is also causing increased demand on a number of services and that is why we need the Health Improvement Commission to do its bit as the current increase is causing pressures that will be costly to resolve.

Recruitment of skilled staff has become increasingly difficult in all disciplines. In recent months these issues have worsened considerably reflecting the Brexit uncertainty but also the short sighted decision of the UK resulting in declining numbers of nurses and allied health professionals.  

To strategically reduce agency, recruitment and retention costs we propose to considerably increase the intake of trainee nurses each year and have budgeted for this accordingly. This will strengthen nursing resilience in the bailiwick and provide a clearer career development path.

We have also included funding for free cervical screening, support for additional gastroenterologists and oncologists and for the Carers’ Action Plan.  The pressure on the drugs bill is rising and using the NHS inflation projection of 4.1% that equates to a cost pressure of £213,000. It is quite likely the reality will be greater.

However, members should also know that the budget incorporates planned savings of £945k. Thinking differently working differently is real and happening every day. So, whilst the headline is of £2m being given to HSC, it would be far more if weren’t focused on cost and service improvement which is now becoming business as usual. Because of that I think at some stage we need to consider whether instead of those resources coming out of the transformation and transition fund they should form part of HSC’s budget.

The one item that has come out of the budget altogether is routine capital, which used to appear at the bottom of the Committee budgets. This approach was approved by members earlier this year. However, it does appear to me that the process now completely sidelines Committees and is exclusively an officer driven process, with authorisation having to be given by a group with a title that only government could come up with: the Property Minor Capital Oversight Board. Indeed, few members here will have an idea as to how minor capital is being spent and won’t until, I presume the accounts are presented next year.

This is a concern as operating capital may seem just business as usual but such spending can have a transformational element and I don’t think that has been properly considered as part of the process.

I believe that P&R should advise members how the Property Minor Capital Oversight Board operates, its membership and the criteria used to determine what is and what isn’t approved.

Sir, more generally, the budget these days is so broad ranging and encompasses items that in the past might have been dealt with under a separate policy letter. Lots of different bits and pieces seem to have been incorporated, making it a very unwieldy beast. I think it results in certain items not being given the attention they deserve. 

And to be frank I think a lot of time is spent focused on allowances, fuel and TRP which I totally understand as they are easy to relate to and they impact directly on the pound in the pocket. But there is so much more than that in these pages that relate to significant items of revenue and expenditure. 

The number of pots have been multiplying and as they expand, the harder it is to really understand the bigger picture. General Reserve, Capital Reserve, Core Investment Reserve, TransTF, Corp Housing Prog, General Reserve Account reserve, Future Guernsey Economic Fund, Bond Reserve, Brexit Transition, Participatory Budgeting, Overseas Aid Impact Investing and then £15m of other apparently minor funds.

All have different purposes and different means of accessing them and they are all controlled by P&R. Which of course they should be, or rather a separate Treasury function should be. Something which I think, although not certain may be addressed in the new structure, which is good.

It was such concerns that led to the amendment I was proposing to lay with Deputy Yerby.

The financial structure now is incredibly complex. I thought it interesting listening to Deputy Green about his concerns over delegated authority to P&R and in the part of his speech that wasn’t as President of the Scrutiny Management Committee. Personally, I think the financial scrutiny function has been diluted under the new machinery of government, which I thought would be the case. 

But even if the structure is ok, the scrutiny function is not big enough. I was expecting that this was going to be one of the first things SMC would address this term. The opportunities were provided in the policy letter he referenced in his speech. I know as I put that in, as well as the opportunity to increase it’s annual budget quite substantially. However, we see next year’s budget will be less than this years.

I think it does ring warning bells when P&R are quoted in paragraph 8.39 as saying they commend the continued responsible financial approach being taken by SMC. That if they needed money for an unplanned review they can apply for funding. I think, given the transfer of considerably more functions into P&R, such as IT, HR, Finance and Procurement, this way of doing things really does have to change.

Sir, there is so much more in this budget that deserves more scrutiny. Another eye watering £866,000 for the Data Protection Authority which is far more than we were led to expect when the policy letter came to the States, temporary overdraft of £15m to Aurigny and more fundamentally, just whether the Medium Term Financial Plan is fit for purpose. The latter is the key here and no a requete is not appropriate, but a properly considered and informed debate in the Policy & Resource Plan next year and something I look forward to.

Health & Care Funding

I made this speech in the debate on the annual report of the contributory benefit scheme.

I’d just like to pick up on the aspects that overlap the mandate of HSC and in particular the resolutions arising from our Partnership of Purpose policy letter. 

As acknowledged in this report, the current funding structure for health is complex and not conducive to timely or consistent decision making. Indeed, I think this has been evident just in trying to disentangle what is actually in place now.

But, I believe it will make a significant difference and enable us to really push on making transformational change. I should point out that this is in no way a criticism of ESS. Far from it. Whilst some may believe there is a silo mentality in the States, this is certainly not the case between our 2 Committees which I am sure Deputy Le Clerc would agree. The success of the under 21 free contraception, being a case in point. 

But, the various structures put in place date from another era, with everything based in legislation meaning there is limited flexibility and barriers to keeping up with changes in health and care, an area of constant innovation and change. Just looking at this month’s agenda with 4 amendment regulations to Health Benefits provides a good indicator of the problem we face. Reducing bureaucratic structures means we can more easily ensure we target health and care where it is needed and when it is needed.

I therefore welcome the transfer of policy and operational control for services funded through the GHSF. 

Just responding to Deputy de Lisle and the £12 and £6 grant, as part of the Partnership of Purpose, approved by this Assembly, HSC is currently reviewing the funding of primary care and we expect to be able to report on this earlier next year. However, we need to think differently from just increasing grants which will do nothing to solve the underlying problems of what is a demand led system with no conditions around the grant that is paid to the primary care practices. The primary care model will have to change if we are to ensure greater equity of access and greater focus on prevention and early intervention to name but 2 but at the same time not destroy all that is good about the care received at the primary level. 

Now, whilst the fund restructuring is welcome from an administrative point of view, more fundamental is the need to determine how we fund health and care in the future. I’m not going to talk at length about that here, it is a debate to be had in the budget, or as part of the debate on the requete laid by Deputy Roffey later this year.

On the latter point I think it is worth just noting paragraphs 6.4 to 6.7 on the pharmaceutical service which clearly demonstrate the benefit of controlling entry on the prescribing list and the pragmatic use of generic alternatives. It’s also worth noting the joint working that has happened to amalgamate the bodies who advise on prescription matters which should cut down bureaucracy and simplify decision making.

But on the issue of future funding, we are living in cloud cuckoo land if we believe that greater efficiencies are going to be enough to keep the health and care budget within the fiscal rules of no real terms increase in expenditure. We are finding new ways of working every day and avoiding future costs by doing so. However, this will not prevent future cost increases arising from growing demand. This policy letter mentions new consultant posts – a third oncologist and second gastroenterologist, both directly linked to our ageing population. On the back of these appointments our general revenue budget submission includes the nursing support for those additional consultants. In addition, we expect that we will need to appoint additional anaesthetists in the near future.

So, it is disappointing that little if any progress has been made on reviewing future funding. We can’t fiddle around with various pots for much longer to make out things are fine. As I say, more on that in the budget debate. In the meantime, I welcome the report from ESS and the support they have given HSC over the last year.

Budget 2018

Here is the speech I made in the States about the 2018 Budget.

Sir, I will speak firstly on the budget so far as it relates to the Committee for Health & Social Care and then in a personal capacity.

Firstly I thank P&R for their appreciation in this report in relation to the savings made by the Committee to date and our commitment to managing our budget. Members will see that the Committee has accepted a £3.6m reduction in its budget from 2017. This represents £2m already banked and as set out in the successful amendment laid against the MTFP earlier this year and a commitment to a further £1.6m for next year. This represents a 3% saving against an overall savings target of 1%. The programme of system grip and service improvement has made this possible. This will continue and become embedded in business as usual.

However, we have to realise that the work done to date demonstrates that there are inefficiencies in the system, but this must not distract from the very real pressures of an ageing population, medical inflation and high expectations over the coming years. More on that when we publish our policy letter. 

I should also like to assure Members that we are committed to transforming our services and making the savings we can. However, this will not be at the expense of a fall in standards, a deterioration of the environment or, most importantly, the safety of our service users.

Just as an aside, and in the immediate future, we do have concerns over the impact of winter pressures which are likely to kick in at the beginning of the year. In particular, the bad flu season experienced in the southern hemisphere in their last winter could potentially put considerable strain on the system. 

In terms of the Policy & Resource Plan, we are pleased that the recommended priorities that we provided to P&R have been accepted by them and form part of the final 23. In particular the Health and social care regulatory policy and health and wellbeing policy will have a major part to play in moving towards a more sustainable model of health and care and which will become clearer when our policy letter comes out. In particular, we are particularly excited about what the Bailiwick Health and Wellbeing Commission could achieve and thank P&R for approving the matched funding in relation to this initiative. This will represent a significant commitment towards prevention, which is crucial to the sustainability of health and care in the Bailiwick.

Moving on to other specific areas of interest to the Committee, whilst we have not been involved in the discussions, we welcome the establishment of a social investment commission. However, whether that is enough to assure the long term sustainability remains to be seen. There is clearly a duplication of effort when it comes to back office support amongst the many charities that exist and one way of providing greater resilience would be for there to be consolidation of the sector. Another would be for government to help provide some of those resources in a joined up way. Again, this is something we will reference in our policy letter.

In terms of excise duty on alcohol and, more particularly paragraph 5.76, we have indeed received a letter from P&R since the budget was published with regard to providing a clear direction in the same way as is given for Tobacco.

I have advised the P&R President in response that the Strategy, which HSC took over from Homes Affairs earlier this year, concludes at the end of 2020 and so it is likely that a formal review will not be considered or concluded until after this political term. Therefore, we may need to look at this separately from that process.

It should also be pointed out that we consider that an increase in excise duty may well be just a blunt instrument in dealing with alcohol use. As part of the P&R Plan and included in our submission to P&R under health and wellbeing promotion we include a key initiative in relation to the D&A Strategy to be a consideration of minimum unit pricing. We think it may be worth looking at excise duty as part of that work.

In terms of a sugar tax, the principle has been considered by the Committee who wish to pursue this further and our officers are in discussion with their counterparts in Jersey to look into the application of a sugar tax that could be implemented across the Islands. The evidence for such a tax is growing but that does not necessarily mean it will take the form of that which will come into force in the UK in April next year. We need to consider what works for the Islands.

Speaking personally, aside from all the great things we are doing at HSC, the most important section of this budget is on page 20. The Economic Development Policy. Until we know how we are going to support our economy, the States of Guernsey Budget is really just an exercise in treading water. The fact we have sensationalist journalism now on mainstream media that is selective of its stories for headline news shows how important it is under the current climate.

Deputy Ferbrache has raised expectations that his policy will be radical and I do hope he is right. We have a budget balancing raising income and saving money and there really is nothing wrong with that at all, but what it lacks is the support for growth. That’s nothing new. We do little to support businesses, expect those that are State owned of course. 

I get incredibly depressed when I see considerable resources put into a GDPR paper that is basically a copy of the UK, a population management regime that was past its sell-by date before it became law, and Brexit, which may not even happen at all. A lot of time and resources spent on more bureaucracy.

What we need is a business friendly environment. I called for a red tape audit in the last term and I think this was completed by C&E after I left. Therefore, I do hope that within ED’s policy letter are recommendations to rescind unnecessary red-tape and support business the best way government can, which often means to leave it alone as far as possible. Tomorrow we will be asked to approve yet more legislation but I can’t recall the last time legislation was rescinded other than because it was being replaced.

So, we seriously need a policy that supports economic growth but at the same time a growth mindset, to put in old fashioned language, a can-do attitude. That’s not just in Government but in business and the wider community. At HSC we are doing our bit and that will hopefully become apparent when we publish our policy letter, but it needs collective effort to get the economy moving. The recent so-called revelations over so-called tax havens should be a wake-up call that, instead of focusing on regulations and red-tape which won’t satisfy anyone, we need to take a positive approach to support a thriving economy, before it is too late. 



Mobile: 07781 139385

Email: heidi@heidisoulsby.com