In-Work Poverty

Fiscal Framework

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I want to quote again what Jacinda Aherne the Prime Minster of New Zealand said- if you are somebody at home listening to a politician say, well according to GDP we are now in a recovery phase and yet you are sitting there and don’t feel it, your situation is not improving, then that means you have a disconnect and an increase in the lack of trust in your institutions and lack of democracy.

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

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

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

Fair and equal Pay

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

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

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

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

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

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

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

President’s Statement July 2019

Sir, 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Future funding for disability aids and equipment

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

Sir, the purpose of this amendment is 2 fold;

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

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

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

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

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

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

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

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

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

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

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

In-Work Poverty

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

Sir, 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

But before I do

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

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

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

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

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

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

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

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

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

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

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

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

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

As I’ve said, we are DOING it. 

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

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

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

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

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

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

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

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

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

But that should not be news to us here.

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

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

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

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

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

But then we need to do something about it.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Benefits limitation/income support

I made this speech in this debate on non-contributory benefits.

I do welcome this amendment as I do the increases in benefits limitation. When we approved the benefits changes it was sold partly on the fact that it would bring more people into income support, which would mean they would benefit from medical support.

And that’s incredibly important. Income is a social determinant of health. The 2013 Healthy Lifestyle Survey found that, while 80% of respondents reported their general health as good or very good, the proportion of adults rating their health as very good was associated with higher income and younger age. The Survey demonstrated some significant inequalities locally, including:

26% of people who rented their homes smoked compared to 8% who owned their homes. 25% of people in low income households smoked compared to 3% in high income households;

In respect of alcohol use, adults from the lowest income category had both the highest level of abstinence (33%), and the highest levels of higher risk drinking (8%) and possible dependence (2%); and

24% of adults living in low income households had low mental wellbeing compared with 12.1% of those in higher income households. The proportion of adults with low mental wellbeing was higher among those living in States’ Housing or Guernsey Housing Association’s rental properties than those with other living arrangements.

But what is proposed isn’t sufficient in isolation and broader action, through joined up working in support of the Partnership of Purpose is needed to address these health inequalities rather than simply responding to the result of ill health.

I hear Deputy Roffey’s comments regarding possible solutions but would caution ESS spending a lot of time coming up with alternatives when, as I said in the earlier debate, HSC is looking at a fundamentally different model. I’m not sure whether Deputy Fallaize was listening to what I said in that debate to be honest. 

And on that front I don’t think this will impact on the work that we are doing. 

As such, and at this stage, I believe this amendment make sense and will be supporting it.

This is also why it is important to increase the benefits limitation on 224 families and 721 children and the benefits of short term measures and plans to prepare a further policy Letter on the bedding in of the Income Support Scheme and matters which have not been considered such as the personal allowances for those in receipt of care. It would be good if specific reference to health in all policies was mentioned as part of this work and consideration.

Budget 2018

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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



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