Healthcare

Summary

  • The people of Jersey should have access to affordable firstclass healthcare, most provided on-Island but some off-Island.
  • There is a wealth of evidence that Jersey is a long way from meeting the “first-class test”, particularly in respect of mental health, dental care and long-term care.
  • Existing arrangements must be made to work as efficiently as possible, which requires effective management with strong political oversight. In some areas changes to existing arrangements will be necessary.
  • The Jersey Care Model is based on reduced dependency on the hospital by expanding primary and community services. However, it is not clear how this will be delivered.
  • Charities have first-hand experience of what is working and what is not and are very willing to share that experience with Government so as to make improvements. However, full use is not being made of this resource.
  • Charities need medium term funding arrangements so that they can plan their activities accordingly. An annual funding arrangement simply does not work.
  • The hospital project is inevitably contentious. The States Assembly has decided on Overdale as the “least bad” site and has agreed a budget of £804 million. The project is now at the implementation stage. Tight control on the budget must be maintained and opportunities for cost savings pursued.
  • An insurance-based scheme should be introduced to provide dentistry services to children.
“The people of Jersey should have access to affordable first-class healthcare, most provided on-Island but some off-Island.”

Objective

The people of Jersey should have access to affordable first-class healthcare provision, embracing all forms of healthcare – public health to minimise need for medical services, pharmacy, doctors’ practices, maternity, dental health, mental health, long-term care, accident and emergency, elective surgery and critical illness.

The vast majority of services should be provided on-Island, but the small size of Jersey means that some services of the necessary quality can best be provided off-Island.  Technological developments mean that is now much easier to access off-Island expertise from within Jersey.

Issues

There is a wealth of evidence that Jersey is a long way from meeting the “first-class test” –

      • The Independent Review of Adult Mental Health Services (October 2021) found that there was a lack of senior management leadership and direction, inadequate systems to learn from serious incidents, silo working professionally and within teams, lack of a system to ratify, manage and implement policies and procedures and poor management supervision structures.
      • The Child and Adolescent Mental Health Service is significantly under-resourced and has been unable to cope with growing demand, partly as a result of Covid.
      • The Jersey Care Model is not working effectively. Expectations of what staff can do are unrealistic.  Inspections are  poor and inconsistent.  Community support is not sufficient to allow home provision. GPs are struggling to meet the work that is required.
      • Children’s dental health is poor.
      • The hospital is dilapidated and not capable of providing the quality of services that is required.
      • These are clearly some management issues at the hospital and evidence of significant staff dissatisfaction.
      • Recruiting staff is difficult partly because of the very high cost of housing.
      • Charities provide vital services but have no guaranteed income.

 

The deficiencies with health service delivery were set out in a Council of Ministers paper (P.80/2021) on the budget and financing for the hospital.  The relevant section is appended to this paper.

Approach

The basic approach has to be to get the existing arrangements working effectively. This does not require new legislation and quite possibly does not even require significant extra resources. But it does require effective management with the appropriate political support.

The brief for the Health Minister should be to ensure efficient delivery of all health services. There are officials willing to play their part in improving performance, but quite possibly some whose working practices put obstacles in the way of what needs to be done.  The Chief Minister, the Health Minister and the Chief Executive of the Government must ensure that the necessary leadership team is in place.

The Jersey Care Model and the role of voluntary bodies

The Jersey Care Model has three overarching objectives –

      1. Ensure care is person-centred with a focus on prevention and self-care, for both physical and mental health.
      2. Reduce dependency on secondary care services by expanding primary and community services, working closely with all partners, in order to deliver more care in the community and at home.
      3. Redesign health and community services so that they are structured to meet the current and future needs of Islanders.

 

These are eminently sensible and in line with practice in other countries.  Jersey has had a particularly high dependence on services provided in the hospital, which is both costly and not person-centred.  However, the second point is key – that reducing dependency on hospital services requires expanding primary and community services.

Covid has of course had a significant influence – straining all healthcare resources with the inevitable consequence of poor delivery of some services and delays in implementing new arrangements.  However, even allowing for this it is worth noting the words in the PwC report on the model: “The shift to preventative, service user-centred care and self-care is fundamental to JCM; however, how this will be systemically delivered is still unclear”.

The role of voluntary bodies and of volunteers is critical to the delivery of healthcare in Jersey.  The Government properly provides financial support to a number of charities that do essential work that would otherwise not be done or which would be done at the taxpayer’s expense.

Charities need medium term funding arrangements so that they can plan their activities accordingly.  An annual funding arrangement simply does not work.

Charities also have an important role to play in helping to formulate policies and implementation plans.  The Jersey Association of Carers has recently published a list of ten deliverables, including key points such as carers having access to the right information and the right type of practical and emotional support, and has backed this with a three-year action plan.

The plan makes a very valid point: “The Coronavirus Pandemic was especially difficult for many Carers in Jersey. They provide unpaid care to family or friends at home and many support services closed leaving them alone.”  The Action Plan is a good starting point for what needs to be done in this important part of the healthcare system.

More generally, charities have first-hand experience of what is working and what is not and are very willing to share that experience with Government so as to make improvements.  However, it is not clear that this process is working as it should, with there being some reluctance to draw on local knowledge and expertise, instead preferring to use UK-based consultants.

There is some good practice here, but the good practice needs to be universal and embedded in the system. These points were well made in the Council of Ministers’ paper referred to earlier –

      • Jersey has a very strong voluntary sector and social care market, but it could be better coordinated and is difficult to navigate, especially in times of crisis
      • Over £80m is raised annually, one-in-eight adults on the island are volunteering
      • £18m commissioned services and approved providers, although not through coordinated commissioning
      •  Duplication of services and back-office functions
      • Lack of understanding and signposting of all services
      • Carers are not adequately supported by the current system as many are supported by the voluntary sector and Parishes.

 

These points all need to be urgently addressed.

Children’s dental health

Many Children in Jersey are going without basic dentistry.  Untreated cavities can cause pain and infections that may lead to problems with eating, speaking, playing and learning.  In England, 25% of five-year-olds and 44% of 15-year-olds have signs of tooth decay.  There are no comparable figures for Jersey (itself unsatisfactory) but it would be surprising if the figures were not similar.

There is a strong case for providing an insurance-based dental care programme for children up to the age of 18, which would give children access to dental treatment to a pre-defined benefit level, accessed via any dentist in Jersey.  A number of insurance companies offer a comprehensive service.

Typically this would give a “benefit pot” of £500 for 0–5-year-olds and £1,000 for 6–18-year-olds to cover routine preventative and restorative treatments.  The cost of the premium would be around £2.5 million a year.

However, this would be good value for the benefit of significant improvements in children’s dental health.  Some of the companies offering this service also offer a helpline available 24/7 for all children with anxiety.  This is an extra benefit and can help recognise mental health at an early age.

The Alliance does not have the resources to be prescriptive about the details of such a scheme.  However, it is committed to the concept and would ensure that an appropriate scheme is developed and implemented promptly by an Alliance Government.

The hospital

Plans for a new hospital are contentious in many ways. The States Assembly has voted overwhelmingly in favour of a new hospital at the Overdale site and has agreed a total budget of £805 million. The project is now at the implementation stage with contracts having been signed, property purchased and planning applications submitted.

By the time of the Election, several significant decisions will have been taken. The Government that will be formed after the election on 22 June will have to take the position as it then stands.  It will not be possible to reverse some of the decisions that have already been taken.

The following principles are relevant and will guide how an Alliance Government would handle the issue –

      • The people of Jersey are entitled to expect first-class hospital provision.  Whether that provision is on-Island or off-Island should depend on a combination of effectiveness, convenience and cost.  Developments in technology mean that increasingly the necessary off-Island expertise can be accessed from an on-Island facility.
      • The current hospital is dilapidated and not fit for purpose. It does not provide the quality of treatment that the people of Jersey are entitled to expect.  The States Assembly took a decision to this effect in 2012.
      • There is no ideal site for a hospital in Jersey. But the “least bad” site has to be chosen. The States Assembly has decided that that site is Overdale.
      • It is accepted that the Overdale site raises issues in respect of access and planning, but similar Issues would arise with any other site and have to be balanced against other factors.
      • By the time the new Council of Ministers takes office, significant decisions will have been taken and progress made with the Overdale site. Any future decisions must be based on the knowledge that large amounts of money have already been spent and will not be recovered if there is any significant change of plan.  The more that the project is revisited and the more that the project is delayed the greater the cost.
      • A tight control is needed on the project to ensure that it remains within budget. As further work is done on the project, opportunities may be found to reduce the cost, which could mean some activities being located elsewhere.  Such opportunities should be carefully considered and if appropriately implemented.  This is standard practice for large projects.

 

Footnote – key facts.

October 2012 States Assembly voted 41-1 on need for new hospital

November 2020 States Assembly voted 37-6 for Overdale as the site

February 2021 States Assembly voted 34-11 for Westmount as main access road

October 2021 States Assembly approved expenditure of £805 million and borrowing of £756 million for the hospital

Appendix

Extract from Our Hospital – budget, financing and land assembly, P.80/2021, August 2021

Current state

Assessment has been undertaken on the current provision of health and social care services within Jersey and the following challenges have been identified:

Secondary Care Focused Model

    • The Hospital is the centre of care for the island, with the system heavily reliant on bedded capacity, particularly for older demographic care
    • There is a relatively high rate of low acuity ED [emergency department] attendances which could be more appropriately treated elsewhere
    • The theatre suites are underutilised, both in terms of scheduling and volume of day case activity
    • Long length of stay in rehabilitation beds and a high flow rate into Long Term Care (residential)
    • Outpatient new to follow up ratio is high in comparison with benchmarks.

Intermediate and Ambulatory Care

  • Rapid response services are not optimised and reablement services are limited
  • There is a lack of positive risk taking in the current service configuration
  • The current teams are not configured to manage higher risk patients due to lack of 24/7 cover and skills mix
  • Jersey runs a hospital led model where patients are brought into hospital as the default option
  • Lack of 24/7 Community Nursing means that there is no nursing cover to support people at home overnight, resulting in admission to hospital being the default option
  • Mental Health Crisis prevention service requires development to support increased demand.

Prevention, Primary, Community

  • There are limitations in the services offered due to the funding and payment framework
  • The payment model does not incentivise self-care, collaboration or innovation
  • Deskilled workforce in primary care due to secondary care focused model
  • Long term condition management is typically run in secondary care, e.g. Diabetes
  • Lack of standardised approach to how conditions are managed across care settings

Mental Health

  • Mental health services are not integrated with physical health services and people are often kept in hospital longer than they should, because ongoing care at home is not provided
  • Unscheduled Mental Health care within the Emergency Department is interdependent on the mental health service availability
  • There is a lack of community specialist resource to facilitate timely discharge from acute settings
  • There is a recruitment challenge for key skilled roles such as Registered Mental Health Nurses, Medical Staff and Allied Health Professionals
  • The current Mental Health Estate doesn’t provide a therapeutic environment of care
  • There is a lack specialist resource to provide mental health care co-ordination. However, there are good relations with external partners which supports the local provision

Community Care

  • 24/7 community nursing not in place
  • Services are not optimally commissioned and managed
  • Social Care model is over-reliant on high cost/dependency residential care
  • Limited options for Long Term Care other than residential care
  • Community mental health offering over-subscribed and needs development.

Direct access services

  • Primary care services such as Pharmacy, Dental and Ophthalmology are not optimised
  • Funding mechanisms not in place to encourage extended service provision
  • Most services are accessed/paid for directly by the public, e.g. Dental and Ophthalmology
  • Technology and information sharing are sometimes a barrier to joined up service provision.

Social Care and External Partners

  • Jersey has a very strong voluntary sector and social care market, but it could be better coordinated and is difficult to navigate, especially in times of crisis
  • Over £80m is raised annually, one-in-eight adults on the island are volunteering.
  • £18m commissioned services and approved providers, although not through coordinated commissioning
  • Duplication of services and back-office functions
  • Lack of understanding and signposting of all services
  • Carers are not adequately supported by the current system as many are supported by the voluntary sector and Parishes.

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