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.