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.