Transformation

Review of NICE drugs, treatments and devices

In January 2020 the Committee for Health & Social Care presented its policy letter to the States. We proposed that all NICE drugs, treatments and devices with technology appraisals be phased in over 4 years, with an interim review. Here is the speech I made to open the debate.

Sir, 

On behalf of HSC I am delighted to present our findings and recommendations following a review of drugs, treatments and devices. The Committee honoured the direction of the States in publishing its policy letter in time to meet the 2020 Budget, albeit that we are only now debating it. A lot of work was done in a relatively short space of time to get us to where we are today.

Firstly I should like to say that the Committee is very grateful to Solutions for Public Health for an excellent piece of work. Their knowledge and skills were evident at all stages of the process and have enabled us to present proposals based on detailed, impartial and expert evidence. Consultants have had a bad press and in some cases justifiably so – taking our watch, telling us the time and going away with handsome reward, but not in this case. We should also like to thank all those that contributed to the process, fellow members, those with a specific interest, as well as members of the general public. Their views have all been considered in the development of this policy.

Before highlighting the key proposals I think it really is important to say that the current policy which has, to a large extent, been in existence for the last 17 years, has been effective in controlling the rate of increase in health costs over a period of considerable budgetary restraint. Officers have done an excellent job working within this policy and, if they had not done so, health overspends would probably have been much higher and the balance on the Health Service Fund considerably lower. We must not forget that and it is something I will come back to at the end.

Understandably, those arguing for extending the drugs and treatments available do so in terms of fairness. That it is not fair that people in England get access to drugs not available here. However, that is not the only factor that needs to be taken into consideration. 

As I said during the debate on Deputy Roffey’s requete, Our current policy was designed before the Partnerhsip of Purpose was developed and approved by this Assembly and the Committee as part of that policy letter stated the need to ensure future policy aligns with it and in particular the key aims of fairness, prevention, user-centred care, proportionate governance, a focus on quality and empowered providers and integrated teams. These aims were specifically stated in the terms of reference of the proposed review.

And it is as a result of that review that we believe the current policy has created disparity between the drugs available to patients in England and those available to patients in the Bailiwick, such that the gap is now too large to be acceptable and a change in policy is necessary if this is not to worsen. Indeed, since the review was undertaken an additional 51 TAs have been approved.

A number of members spoke in the last debate about the need for people to have access to what they stated were life-saving drugs. However, it is important to note that many of the drugs and treatments approved by NICE that would become available to Guernsey and Alderney residents are life extending rather than curative treatments. As such, they can’t be considered life-saving although some of the newer treatments do have the effect of reducing often uncomfortable side effects and enable patients to maintain a greater quality of life during treatment than some of the existing treatment pathways and are expected to be one of the major benefits of adopting NICE TAs.

In summary we propose that the States should, in principle, move towards funding all drugs, treatments and devices with a  TA from NICE, including those approved for funding from the Cancer Drug Fund and hat treatments should be phased in based on a universally accepted method of differentiating drugs, known as the incremental cost effectiveness ratio. 

We are also proposing that the next Committee report back to the States after 2 years and before full implementation for 2 key reasons, firstly, additional staff, resources and infrastructure changes will all be required before NICE TAs with an ICER of over £40k can be introduced. Secondly,  as NHS Social Judgements states, advisory bodies need to make a stronger case for interventions  above an ICER of over £30k.

It is important to make clear that the complexity of the work has meant that it has been necessary to make a number of assumptions about the anticipated costs of adopting NICE TAs. It is therefore essential that members take the figures in this policy letter as best available estimates at this time. In the case of backlog costs in particular it is assumed there is no decrease in costs over time. However, it is more likely that regrettably some of those patients receiving newly introduced TAs will pass away each year and will not require treatment on a long term basis. However, determining mortality rates would be a very difficult exercise to undertake and certainly not possible in this timeframe.

A non-statutory approach is being proposed to ensure best value for money. I need to make it very clear here that this is not because we don’t acknowledge the expertise of NICE, we do and follow its published guidance on most areas within health and care in fact, but rather because it will allow for some of the bias in the NICE TA process to be neutralised. I think I should also advise that through ESS a lot of work is done to maximise the use of generic over branded drugs. 

There are additional costs if we are to extend the drugs and treatments in the way envisaged beyond the cost of the treatments themselves. It will also require additional cost and resources through communication, developing new pathways, new internal policies, audit of new TAs, new staff and new software. A lot of thought and planning will be required to ensure things go smoothly, as well as to ensure the public is aware of the new policies and that we can provide greater transparency over the processes we bring in.

Sir, we have already had a debate on the pressures on finances. We have debated the merits of spending money on one thing or another.

And I said at the start how the current policy had served the States well during considerable budgetary restraint. But the question we must ask ourselves now is, has the time come where it is not serving its people well.

And that leads me to P&R’s letter comment. 

 In it they say that the States are being asked to make a value judgement regarding the point to which the investment of resources in improving the quality of life and wellbeing of potentially small groups of individuals represents an effective use of resources in achieving the vision of becoming the “happiest and healthiest place in the world” for the community as a whole. 

Well let’s dissect that statement for a minute. Firstly, members need to understand that these are the decisions HSC has to make all the time.

BUT it is not just a simple matter of looking at the number of individuals involved. After all, we spend upwards of a quarter of a million pounds each on liver, kidney and heart transplants which benefit just a handful of people each year. Indeed, we have had a particularly high number last year that impacted on our off-island budget.

BUT these benefit a very small numbers of people. However, we do so, because of the proven clinical and cost effectiveness. It is for the same reason we are saying that NICE TAs with an ICER up to £40k should be funded, but that we should undertake a review after 2 years, particularly to determine whether it is justifiable bringing in those with higher ICERs. And it should be noted here that we are not necessarily talking about the cost of those drugs. We are not saying drugs costing over £40,000, but their Incremental Cost Effectiveness Ratio – the amount of money needed to be spent to achieve 1 additional quality adjusted life year with one medicine compared to another.

We make it very clear that funding new drugs and treatments should not be at the expense of other investments in the health service which support the long-term transformation of health and care. As I said in the last debate the current budget levels are unrealistic even before considering more drugs and treatments. Where would the funding come from? 

The easiest things to do would be to cut the off-island budget for tertiary care not provided here such as radiotherapy, complex surgery and other cases thus penalising one group for the benefit of the other. I can’t see that as being politically acceptable. Other areas that support prevention and early intervention are often the first to be cut when budgets are tight, but that is cutting off your nose to spite your face and will only lead to greater cost further down the line. Indeed, focusing on prevention and early intervention is the means of preventing people from needing many of the new drugs and treatments in the first place. Screening may give short term benefits but it is through other public health measures, such as through preventing obesity, smoking and excess alcohol consumption where we could really cut the drug bill, but we are only likely to see the benefit of that in the medium to long term.

The solution proposed, which has been agreed by both P&R and ESS is that we seek funding from general revenue until legislative changes are made that mean it can come from the Guernsey Health Reserve for the first 2 years which would mean up to £5.6m in year 1 and £8.3m in year 2.

This is a considerable sum of money, although based on a worst case scenario as I have said. However, I find it interesting that this is the first letter of comment I recall coming from P&R that compares the cost to the percentage of particular taxes. I have no problem with that. We should probably do it more often. However, I don’t recall any such comparison being made when we were asked to support a supposedly temporary overdraft facility for Aurigny of over £25m in the last budget, extra funding for digital transformation, or the £8m requested for public sector reform, none of which benefit the people of Guernsey and Alderney immediately or directly.

So much of what government does, whilst incredibly important, does not benefit our people directly. If this policy letter is approved we estimate over 3k people’s lives may be made better. That’s the equivalent of 2 colleges of 1,500 students each. Is that not enough people to care about?

I think it is also worth bearing in mind paragraph 3.5.4 of the main report where it states;

‘The long term position of late or never adoption of newer, effective interventions won’t only affect patients but may also have an indeirect, adverse effect on the ability of clinical staff to be able to maintain their professional standards or for younger doctors to take full clinical responsibility for prescribing older treatments with which they may be less experienced and, in the long term, attract and recruit clinical staff.

Ultimately, and probably most importantly, given the last debate, supporting these proposals today will reduce inequality by making available drugs that are currently only available to those who can pay.

Our proposals are expected to help thousands of people, not a handful. Thousands who may live longer, may live in less pain or be able to live independently and productively for longer.

If that isn’t considered to help us become one of the happiest and healthiest places in the world I don’t know what does.

Sir, I ask members to support this policy letter.

President’s Statement November 2019

Sir, since my last statement to the Assembly in July we have seen continued progress in pursuing the objectives of the Partnership of Purpose – an essential and collaborative approach that will allow islanders fair access to solutions that meet their health and care needs by placing the user at the centre and making every contact count.

The Partnership of Purpose is more than just a theoretical concept. It is a substantial and complex long-term programme to reshape the Bailiwick’s approach to health and care and meet the challenges of growing demand, growing medical advances and growing expectations. We are already seeing the benefits of embedding the values of the Partnership of Purpose across not only Health and Social Care but also the private and third sectors with some significant and tangible outcomes emerging from collaborative thinking and working.

Here are a few examples;

Firstly, following a review of The Acute and Community Pain Service, steps have been taken to develop a more collaborative, integrated, person-centred approach. Psychologists and physiotherapists are working with doctors and nurses to develop this new way of working. Working with the creative industries we are now exploring how virtual reality, alongside other technology, can be used to support better patient outcomes by individuals managing their pain. 

Secondly, an agreement on improved data sharing across health care providers through collaboration with the primary care sector is in its early stages but is progressing well and will make a considerable difference in being able to provide a more joined up service. 

And thirdly, the setting of a fixed tariff for certain sexual health services means individuals can go to Choices, their GP or the Orchard centre, wherever they feel most comfortable, for the same cost.

Sir, while we are still at the relatively early stage of a 10-year programme to transform HSC, the Partnership of Purpose is already more than an ideology – it is becoming part of the conversation, it is being referenced by third party stakeholders and is helping to inform decisions and service developments. Real change is happening and a wide-ranging portfolio of programmes and projects are, in different ways, bringing the transformation to life. 

Here are a few examples of projects that have already improved outcomes for islanders. Not only are real benefits being felt by patients, the transformational way people are being cared for means better value in the long run.

We’ve supported the launch of a pilot project for familial hypercholesterolaemia led by Queen’s Road Medical Practice and Wessex Genetics. This is now live and will lead to long-term savings in cardiovascular care and the avoidance of early deaths. 

There is a steady and increasing requirement for access to clinical genetics services and we are also looking to establish a visiting service comprising a consultant geneticist and a genetic counsellor. This model is a much more cost effective way of meeting the increase in demand than sending service users to the UK for consultations and is easier for Islanders. 

We’ve introduced a new diagnostic service in cardiology, using CT scans to create 3D imaging.  This has resulted in less patient travel off-island and reduced the need for invasive follow up. Also, by re-evaluating eligibility criteria, we’ve reduced pressure on the Individual Funding Request panel for expensive care designed for patients who cannot tolerate open heart surgery. 

We have recently opened two new scanners in Radiology; a SPECT-CT scanner- the only one in the Crown Dependencies- and a CT scanner. Together they will provide us with 10 years of Nuclear Medicine and CT scanning with improved clinical functionality and, importantly, resilience. 

We’ve initiated a series of guidance documents for GPs to streamline and clarify referrals to secondary care, which will result in an overall reduction in waiting list numbers and times. We’ve also clarified and updated the purpose, frequency and need for more than 700 tests currently processed in the hospital labs which we anticipate will lead to savings through the reduction of over-testing.

We’ve introduced free screening for cervical cancer which looks like it will increase take up to over 90%.

We’ve developed and published a Joint Strategic Needs Assessment for the over-50s providing an unprecedented understanding of the needs of this sector of the population; 

We’ve signed up to the prevention concordat for mental health and conducted an evidence-based gap analysis of mental health services that has fed through to our budget submission

We’ve opened the autism hub and created an Autism Outreach service that will change the lives of those in our community and mean we are bringing home those who to date have had to live far apart from their families.

We’ve developed a policy framework for the use of medicinal cannabis and produced guidance notes.

As promised, we’ve demonstrated our commitment to adopting a permissive approach towards drug funding, and I was delighted to announce earlier this month that we have been able to secure access to Orkambi for people living with Cystic Fibrosis in the Bailiwick. 

We have also begun piloting new ways of working in Alderney primary care.

Sir, these initiatives are underpinned by the values of the Partnership of Purpose, people-centred and making use of cross-sector working, making every contact count.

The work continues and there are a number of other areas where further developments will be made before the end of this year.

In respiratory services, we will have made the capital funding case for palliative ventilation equipment for degenerative neuromuscular conditions which will save hospital readmissions; ended lease arrangements for some medical equipment saving £100K per annum in the next seven years; developed a clinical protocol to support end-of-life arrangements for respiratory patients and embedded arrangements to support multi-disciplinary working. 

In Specialist Nursing provision we will have appointed specialist nurses to cover patient cohorts in Chronic Pain, Chronic Respiratory conditions, Palliative respiratory conditions, Urinary tract cancers and Bowel cancers.

In acute care, we will have conducted NHS Improvement audits in hospital wards to facilitate efficient discharge from care and multidisciplinary teamwork.

Finally, in respect of the overall model of care, in the next few months we will be announcing plans to formalise arrangements around the Partnership of Purpose itself, establishing a mechanism to accredit those public, private and third sector bodies working with us to realise the Partnership’s values. 

I said earlier in my statement that the Partnership of Purpose has become part of the conversation. Well, this conversation extends beyond the Bailiwick’s shores to our colleagues in Jersey. Published last month, the Jersey Care Model closely reflects the Partnership of Purpose in its ambition, areas of focus and driving principles. Indeed, it even references the need to create a Partnership of Purpose! Immiation is the sincerest form of flattery they say. 

I am grateful to all those involved in collaborating on the projects I’ve outlined today, especially those delivering front-line services. Successful transformation is being brought to life by our committed and professional staff AND Just last month, the urology and emergency departments won three awards at the Nursing Times Awards for their innovative, patient-centred practice.

I said at the beginning of this statement that the health and care transformation programme is substantial and complex. However, we have a firm grasp of the nettle and continue to see progress. Some of the 2017 resolutions have proved slower and more challenging to deliver than expected while in other areas we are more advanced than we anticipated. We are well on track to ensure that we have set firm foundations for the new model of care by the end of this term and so ensure that any future Committee can hit the ground running.

Sir, the Committee is dependent on the members of this Assembly to continue to support this essential programme of work. It will be achieved by cross-committee cooperation to truly deliver collaborative solutions to the Bailiwick’s health and care needs. Recognising that people’s health is determined primarily by a range of social, economic and environmental factors, the  forthcoming publication of the latest Wellbeing Survey will provide a wealth of information which all Committees can use to inform policy development and service delivery. Whether through the Integrated Transport Strategy, Justice Policy, transforming education programme or other initiatives collectively we can create an environment for health which supports a sustainable health and care system for our existing population and those generations to come.

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.

Transforming Secondary Education – Community Hub

An amendment was laid by the Policy & Resources Committee to the policy letter brought by the Committee for Education, Sport & Culture on moving forward the development of a community hub. This has been an area of intense frustration as various sites suggested have not been able to be progressed. Three years ago it was thought the site of the KEVII Hospital may be used, then Les Ozouets Campus and, as set out in the policy letter, Delancey. The latter is a compromise, which will enable new ways of working, but will only be an interim solution.

Sir, It has been known for years that many of HSC’s child and adult social services are scattered across the Island in ageing and unsuitable properties. For years, successive Committees and successive Assemblies have agreed that these services should be consolidated onto a single site, allowing for greater collaboration between teams, easier access for service users and opportunities for efficiencies combining common service. This would improve experiences for staff and service users and also enable the release of current sites.

And when I say years, I mean years spanning 3 electoral terms and at least 5 Health Boards or Committees.

The 2020 vision in 2011 made reference to a number of buildings in HSSD’s property portfolio being ill suited to the delivery of modern health and social care services or are expensive to maintain. Specific proposals were included in the Capital Portfolio at the beginning of this term to co-locate peripatetic services and a further commitment was made through the Partnership of Purpose. It is safe to say that no further commitment is needed- just action. 

The States of Guernsey has an Estates Plan. It establishes a number of Property Objectives for Estates Optimisation. First and foremost is better working locations, providing the right buildings in the right place and condition to meet current and future service delivery needs. Current community provision would fall short of this standard and it is right that action is taken to address this. 

In the context of the Partnership of Purpose, the relocation of community services is vital. Not only are some current work environments fundamentally unsuitable, they are creating a very real barrier to realising the values of the Partnership of Purpose and the adoption of new ways of working. 

The Partnership of Purpose is about achieving the physical, virtual and financial transformation of the health and care system. It is based on an ever closer integration of care which places the user at its centre and provides a greater focus on prevention and support and care in the community. The current property portfolio prevents this. Staff are forced to work in physical silos, service users are unable to access multiple services in a single visit and it is challenging to trial new ways of working. Multi-disciplinary working is happening, but it is having to overcome the fundamental challenges posed by the infrastructure. 

And I have to say it has not been for the want of trying but I until now it has felt like we were banging our heads against a brick wall. A well built one at that. I won’t bother members with our own frustrations here but suffice it to say we had lost confidence that any solution would be found. Everything seemed to be wrong, nothing seemed to be right. However, hopefully the stars are now aligned and I was pleased to hear the P&R Presidents commitment to the co-location of a number of services at Delancey. This provides a real opportunity to improve working environments and pilot new ways of working across current team boundaries. It is considered that there would be opportunity to co-locate staff from the Children & Family Community Services, the Youth Justice Team, the Youth Commission, and other services. It has the potential to enable the vacation of Lukis House and Swissville and other sites.

And I would aks members to consider this. Under the survey undertaken by Peter Marsh Consulting and set out in Section 3.1 of the policy letter, none of the buildings at Delancey were rated as good. 

But, it is a sad indictment of our current property processes that they are a considerable improvement on those currently occupied by community services. Indeed, all the work undertaken to date has indicated that it would fully meet the needs of community services.

The development of Delancey for health and care purposes is considered a vital albeit interim milestone in the Partnership of Purpose as we work towards a long term Communtity Hub. It will in the short term improve working environments, enable a number of States’ buildings to be vacated and enable new ways of working to be piloted.

That is why we want members to support proposition 6a). however, that is only an interim solution.

It is a good next step that will help transformation and free up States property and will enable us to start to make real changes. However, it is not a long term solution.

  • Because, whilst the proximity to service users is beneficial, the site is not centrally located on the Island;
  • Accessibility to the site is less than perfect with no bus route, minimal parking and being on top of a hill not the easiest for those with mobility issues.
  • Delancey will host a range of services to pilot collaborative working between statuary and charitable sectors however the site size limits the number of services that can be located there and the ability to incorporate private providers
  • The extent and scope of the long term ambition will require a larger and more flexible space, to host a community café and other facilities which Delancey will not be able to accommodate
  •  As opposed to just housing Children & Family services, the long term Community Hub will accommodate a range of services throughout the life course of our people which will need a range of in-reach and out-reach providers
  • The long term Community Hub will strengthen our approach to meeting the needs of all our service users (supporting the disability & inclusion strategy)  

In short, the site is temporarily sustainable for services relocating there, represents a better quality environment for our staff and will act as a test bed for transformational changes, but not for the longer term aspiration of a Principal Community Hub.

I think I need to go into more detail about what we mean here.

A key aspect of the new model of health and care is the physical co-location of services through a number of easily accessible sites called Community Hubs. Through these Hubs, individuals will be able to access a range of face-to face and virtual services provided by public, private and third sector organisations. By consolidating services which are currently scattered across the Islands, the Community Hubs will seek to improve access to care and enable islanders to deal with multiple health and care needs in a single visit. This approach will be of particular value to those individuals with long term conditions and will facilitate direct access to services which currently require a referral. 

While it is envisaged that there will be a network of Community Hubs throughout the Island- some of which may be developed around existing GP practices or community centres, and is something we are currently in discussion with various interested parties, it is considered that it will be necessary to develop a Principal Community Hub. What makes this different is, in addition to supporting public-facing services, it would also provide a base for shared back-office support for the public and third sectors. 

The Principal Community Hub needs to incorporate a wide range of service provisions, from across HSC, ESC, ESS and the private and charitable sectors. By combining a wide range of community services, and areas available for hire by other community groups, the site will be a valuable resource to all members of the community.  

To achieve these ambitions, a number of site requirements have been identified, which indicates that there are few available which would readily allow the envisaged co-location of the full breadth of services. The vacation of schools through the Transforming Education Programme is likely to be one of the few opportunities available to the States to the re-purpose an existing building as a Principal Community Hub, thereby avoiding the significant capital costs associated with a build. 

The Committee’s officers have undertaken extensive work to scope current provision and opportunities for the future but we’ve had to pause the progression of a Business Case based on growing uncertainty in respect of site availability.

Without the progression of this work and the associated development of the infrastructure underpinning community care, the Committee’s ability to realise the Partnership of Purpose is stymied. Without shared spaces, the ability to adopt new ways of working is limited, the development of working practices across organisational boundaries is restricted and we cannot improve convenience for service users. 

I’m not especially happy we can’t pin down where the new Hub will be and I understand the process we have signed up to but have yet to be convinced that all parties are quite aware of the roles that they are there to undertake. Inaction appears to have been the order of the day. Decisions do need to be made. That’s why I am pleased there is a deadline state, although I would hope matters can now be resolved in a more timely manner given the work that has already been done by HSC staff.

This has been going on too long. The will is there politically I believe, but process has got in the way. It needs this Assembly to make things happen and I ask members to support this amendment.

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.

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.



Mobile: 07781 139385

Email: heidi@heidisoulsby.com