HEALTH & SOCIAL CARE IN JERSEY:

SYVRET IN DIPLOMACY MODE SHOCK!

The “Polite Critique” I Wrote

Of the Draft Health & Social Care Strategy

In March, 2007.

For reasons which I’ve never been able to entirely fathom, some people consider me to be chronically un-diplomatic, tactless and simply incapable of treating people gently.

But, of course such a stereotypical view of me simply isn’t fair or accurate.

When the need arises, I can subtly deliver all the periphrasis required to gently and obliquely convey the news to someone that – actually – they’re obviously a idiot and talking utter garbage.

Now, I know my average reader will know that I posses these skills – but there are still some out there who may require convincing of this fact.

So, in this posting I thought I should provide the evidence for my tremendous abilities in tact and discretion.

And do so in very topical fashion – by addressing the challenges faced in delivering health & social care in Jersey.

For various reasons, Jersey’s Health & Social Services department is in the news; lack of beds, too many redundant beds, not enough money, too much money, inability to recruit and retain nursing staff, failures of clinical governance – and, of course – all of the gross failings of the social services and child protection aspects of the department’s responsibilities.

And health & social care issues are clearly of some interest to commenters on this blog.

Coinciding with this state of affairs, the present H & SS Minister, Jimmy Perchard, was afforded a typically vast propaganda spread in Saturday’s edition of The Rag. In the interview he makes a number of assertions – which, let’s face it, are of so little substance as to be scarcely worth considering.

However, he made this assertion:

“There is no new money in the pot. I will be bringing forward funding proposals. No one has had the courage to do it in the past.”

Now, Jimmy, you see, just isn’t terribly bright – and can be extremely forgetful. He has plainly “forgotten” that when Ben Shenton and he took over at H & SS – I furnished them with a 10 page critique I had written of the early draft of the long-overdue new strategy for health & social care – known as “New Directions”.

And in that critique, I addressed the issues of funding – head-on – several times over.

And it fell to me to do this – because the “expert” senior managers in Health & Social Services – those who wrote the draft New Directions document – had utterly failed to.

And I was terribly diplomatic in doing so. As, indeed, I was throughout the whole document.

Which, frankly – required a near superhuman effort on my part.

You see, having waited impatiently several years – for a group of very highly paid, supposed experts in health & social care – at a combined cost that probably ran into several millions of pounds – to produce this new, strategic document – I eventually received a draft.

And was rendered speechless at just what a defective, inadequate, unfinished, incompetent, ignorant and wretched steaming pile of horse-dung the document was.

Just a few of the multitude of defects:

Not costed – even in general terms.

Little meaningful reference to cost-containment.

No meaningful identification or discussion of future funding streams or sources.

No detailed description of just how the oft-stated aim of “integrating health care” was actually to be achieved.

No detailed commitment to rigorous external inspection or investigation.

No discussion of how health-care spend be transparently and externally monitored, to ensure efficiency and value for money.

Not withstanding several years of discussions – absolutely zero detail on how the proposed social insurance scheme for continuing care for the elderly would be structured.

No meaningful solutions proffered to the stated problem of junior doctors and the European Working Time Directive.

No chapter on staff – an utterly astonishing omission – given that health & social care – more so than any other field of public sector activity – depends upon its staff.

Even more astonishingly – the complete omission of any chapter on mental health care.

It gets worse –

The draft had no chapter on Social Services.

And even more staggeringly – no chapter on the children’s services and child protection.

The draft document was so startlingly, appallingly bad as to be beyond parody.

And you – Dear Tax Payer – fork out many, many hundreds of thousands of pounds each year to employ these un-sackable clowns.

Having waited all this time – whilst very expensive senior civil servants “developed” the strategy – only to receive a document riddled with more defects than a States of Jersey fiscal plan – I felt my diplomatic skills being stretched to breaking point.

But – manfully, I restrained myself – and didn’t act on first instinct – which was to go and see Pollard and Co. – slap the draft document on the desk – and say what the (expletive deleted) is this pile of (expletive deleted) supposed to be?

Instead – I sat at my desk and wrote a detailed 10 page critique of the draft “New Directions” document – a critique which I reproduce below.

So before Jimmy and others try and re-invent history – read my critique – which was written on the 6th March 2007 and note the fact that very few – if any – other States members would have produced such a document – instead preferring to accept any old rubbish that our overpaid and under worked senior civil service churn out.

And pay particular attention to just how terribly diplomatic and restrained it is.

Were I writing such a document today, it would – how shall I phrase this – have a somewhat different flavour and tone.

Most politicians are lay-people in their political roles – they’re not experts – which is why tax-payers like you spend millions of pound employing a vast army of supposed “professionals” to undertake the specialist work required. I’m a carpenter – who left school at the age of 15 with no qualifications.

So when someone in my position can – and has to – deconstruct a startlingly garbage draft document – which has taken a couple of years for supposed experts to produce – the time has come for the tax-paying public to start taking a far harder look at the senior civil servants you pay so much for – and ask the question: “Are many of these people remotely capable of actually doing the job we employ them for?”

In many – not all – but many cases – the answer to that question could only ever be a resounding “no”.

Pollard and Ogley being two prime examples.

Read my critique of the early draft of “New Directions” below. If nothing else it will give you a flavour of the many challenging issues confronting health & social care.

Oh – I nearly forgot, silly me – I should also point out that back in early 2007 I gave copies of both this critique written by me – and a copy of the draft New Directions strategy – to The Rag.

Need I pose the question?

No, I didn’t think so.

The Rag completely ignored them – even though the future of health & social care is of obviously fundamental importance to the community.

Regards.

Stuart.

NEW DIRECTIONS: COMMENTS ON THE DRAFT

By

Senator Stuart Syvret

6th March 2007

The draft New Directions document is a good piece of work. Many people have contributed to it, and the issues flagged within the report are correctly identified as central to future health and social care strategies.

I have read the report thoroughly and whilst doing so I have attempted to view it from two perspectives. Firstly, as a member of the public who may have little detailed knowledge of the issues. And secondly, as though I were a politician who has no prior involvement in health care. Looking at the report as a ‘back-bencher’ helps to predict the obvious questions and issues that will be raised politically.

As the report will be subject to immense scrutiny – both informal and formal – I have tried to ask questions that we will certainly be asked following publication.

OVERVIEW

The elephant in the room which no one speaks of is money. It is true that the report does address funding issues in three broad areas. Firstly, the nightmare scenario of not addressing the demands of ill health in an ageing population is spoken of. Secondly, that a scheme should be introduced for the funding of long-term care. And thirdly, the need to modernise the co-paymenting system for GPs.

Much of the core of the report deals with the ways in which health and social care delivery needs to be rationalised, both for quality and cost effectiveness. And rightly so.

However, even with the most effective service and a very high degree of success in the strategic objective of a healthy population, no one could seriously argue that the cost of health & social care provision is going to do anything except go up.

The cost of delivering all that is provided by H & SS is already – by a large margin – the single most serious and onerous cost to the States and tax payers.

I therefore find it startling that there is not a chapter that deals with the cost of health care, how it is to be funded in the future, whether it is realistic to continue to rely on central taxation for all of the year-on-year revenue, whether we need to embrace a European style social insurance model of funding – at least partly – for secondary care. Given the funding pressures on the States because of zero-10 etc, health will come under more and more pressure when competing for tax revenue with other departments, and how is the taxation burden placed on the whole economy by health care best addressed?

My point is this: Even if we succeed in designing and delivering the best possible health service, it will still fall apart unless securely funded.

The States is presently wrestling with taxation issues and spending. Yet people will get the impression that this report is somewhat semi-detached from that debate. Surely we need to be more joined-up? Where does health funding fit in the great maelstrom of fiscal issues and policies? As the largest single cost for the States?

Where do we confront the public with the hard choices on funding?

SOME FURTHER THOUGHTS ABOUT MONEY

Health & Social Services is under great pressure and scrutiny from other States members, civil servants and the tax paying public in respect of our costs. Such pressure will only ever increase. We may be satisfied that we are delivering a service that is value for money, but others are not. We must find new ways of transparently demonstrating that we are an efficient organisation. I know we are efficient – but many people will require that fact to be proven to them time and again.

How can we do this? Should we pro-actively seek the regular involvement of the Controller and Auditor General?

As the tax burden falls more and more upon the less well off, we have to strike a bargain with the public. As our need for funding grows we must be in a position to prove just what the public are buying for that additional cost.

I get the impression that the NHS is constantly mired in controversy about where money is spent, how it is spent, whether it is being used wisely – and whether the expenditure produces value for money. I want health care systems in Jersey to transcend such arguments through evidence of appropriateness of spend and evidence of effectiveness and efficiency.

We must move away from the “you shouldn’t have any more money because you don’t need it or you are wasting it” arguments. The community needs more honest debates about the hard choices and ideological positions which drive these issues. Some will argue for ideological reasons we shouldn’t tax and spend on health; others will argue the opposite, again for ideological reasons. Such debates are good. It is honestly addressing the issues head-on, rather than pretending that health spend is wasteful, therefore investment is not needed.

GENERAL OBSERVATIONS

1: There should be a clear and brief statement at the outset as to what New Directions is seeking to achieve. Whilst the generality of the issues are explored in chapter 1, a more focused statement of the issues and the objectives needs to be put at the beginning. What are we seeking to achieve, in a nutshell?

2: I believe the report needs an executive summary. I know that some people argue against such sections as it may disincentivise people from reading the full document, but I feel the focus of a short summation could be useful. Perhaps put at the back as an appendix.

3: There should be, as an appendix, a full list of all those involved in working up New Directions. One of the inevitable questions we will face is ‘who was involved and are they conflicted?’ To put it plainly, will we face accusations that the report has been modelled by people who have a vested interest in seeing certain strategies adopted. How do we combat this perception at the outset? I realise that this is a ‘green paper’ and the public involvement starts now, but it is very noticeable that professional stakeholders of one stripe or another have been the key players. There appears to be minimal – if any – lay person involvement so far.

4: It seems strange that there is no significant mention of Social Services. The report deals with health and social care strategies, yet Social Services is only passingly referred to in the context of home-based patient care. Social Services has a far wider remit than this, and as recent headlines in the JEP demonstrate, we are dealing with very problematic social decay issues. Dysfunctional families and the children’s homes full to overflowing. Indeed, it might not be an exaggeration to describe the situation as a crisis. All these years after Kathy Bull – and we are further away than ever from being able to close the institutional emergency child care buildings. Growing alcoholism, growing drug abuse and more and more family units in crisis – yet our strategy simply doesn’t mention any of this. Which is doubly strange when one takes into account the elevated long-term health care costs incurred by people from dysfunctional backgrounds.

We must have a chapter on Social Services.

5: This, of course, leads on to child welfare and protection issues. As the Ministry which has responsibility for child welfare, it again seems a little anomalous that there isn’t a section devoted to children. Not only should we be putting children at the centre of the strategy for their own sake – but dysfunctional childhoods lead to unhealthy lives. Our strategy is a long-term project. Its keystone is changing lifestyle to produce healthy older people thus improving peoples’ lives and consequently the affordability of health & social care. If we fail in this, we fail in the strategy. To truly succeed in this area, we have to succeed in starting children on the right path. Whilst there is some reference in the report to PSE and ‘healthy schools’, I do not feel this is sufficient. I have already asked that we work towards an overarching strategy for children and childhood for ultimate approval by the States. Whilst that is a medium-term project, we should at least be describing what the problems are and what we propose to address in the children’s strategy. Indeed, the development and publication of that strategy should be one of the prime objectives in the New Directions report.

We must have a chapter on children and childhood.

6: I think we need a greater exposition on the correlation between low income or outright poverty and poor health and poor access to health care. The evidence is extremely robust on this question. Poorer people have poorer health and poorer access to health care. I feel we need to explore this whole field of ‘barriers to health’ and place it within the broader context of Jersey’s socio-economic environment and other States policies, such as housing, education and taxation.

7: If you asked the average politician or most members of the public what is the most eagerly awaited feature of this report, it is the continuing care social insurance proposal. The report does indeed address this subject, but I feel in nothing like enough detail. Basically the report says ‘we should introduce such a scheme’. Well, yes – but we’ve been saying that for at least five years now. Is it not time for a little more flesh on the bones? What do we propose to do? How will it work? What are the flaws in the Guernsey system? How do we plan to improve upon it? Will it be a new scheme or an extension of the existing social security system? I realise this is a strategic document, so one wouldn’t expect great detail, but nevertheless, I feel we need more information on the general direction we see this going in.

8: This leads on to questions about the social security system as presently structured. At present anyone who is wealthy can reduce or even largely eliminate their contribution requirement. They do this through several loopholes such as “employing” themselves and paying themselves the bare minimum thus attracting a high rate of supplementation from the tax payer. Supplementation presently costs the States over £50 million a year in supplementary payments from central taxation. This is simply not sustainable. We need to state the issues and suggest a direction of travel for the exploration of reforms. It simply isn’t credible or responsible to advocate an additional layer of social security on top of a range of existing problems.

9: Assuming we introduce a social insurance for long-term care, do we leave it at that? Given the immense financial pressures the States is under, do we need to broaden it out to provide a stream of funding to secondary care? Do we need to look to a European model of social insurance for health funding? If not, can the States guarantee meeting an ever growing demand on central taxation revenues?

10: In respect of 7, 8 & 9 above, I feel we need to provide a brief description of different funding options for public consideration. Different types and degrees of social insurance could be mooted; as could additional funding from central taxation; as could ring-fenced taxes. Given that this document is a “Green Paper” we have to explore these issues and give the public we are consulting a menu of options for them to comment on. I have a BMA report from a few years ago which describes the different funding approaches. We should also consider fairness and equity issues. We know that – in the strange parallel universe that is Jersey fiscal policy – struggling people get taxed whilst multi-millionaires turn up and claim means-tested benefits. Any new funding approaches for health must be fair and avoid such perversities.

We must have a chapter on money and the options for where it comes from.

11: Whilst on the subject of money, I feel there needs to be a little more clarity and specificity about our likely capital investment needs and plans. Whilst this is mentioned to some extent, I think we need more focus and detail, for example, the redevelopment of the Newgate Street end of the hospital. Where will our capital funding come from? Do we need to stake a claim now on a substantial part of the proceeds from the forthcoming big self-off of States assets? Are we going to re-claim some capital allocation to build a new nursing home?

12: The whole question of ring-fencing moneys or hypothecation of funds for health and social care needs to be addressed, whether capital income or revenue income. Treasuries generally don’t like hypothecation, but we need to at least explore the issues and options. This form of funding would be a social contract; health & social care would get security and its clients would get guaranteed standards – and other States departments wouldn’t be forever missing out on funding because of the growing needs of health.

13: Integration and amelioration of other States policies has to be considered. Whilst the role of the States as a “13th parish” is referred to, I feel there is too little focus on the policies of other departments. Given we have the focused forum of the Council of Ministers to supposedly deliver joined-up government, shouldn’t we be influencing, for example, T & TS in respect of transport strategies, for example more bicycle lanes and greater regulation of vehicle emissions such as PM 10 particles? What about Housing? Should we not have something to say in respect of well-designed and constructed homes which are warm & dry? Shouldn’t we be seeking to ensure Housing has regard for the social cohesion and even mental health issues which can arise because of deficient housing estates? What of ESC? Isn’t it plain that current approaches to both health education and physical activity and fitness are simply not working sufficiently? I know this is touched upon in New Directions, but not enough. As already touched upon, what of the tax and spend issues? Where is all the money going to come from? Shouldn’t the Treasury be involved?

We must have a chapter on integrating health and social care considerations into all relevant areas of public administration.

14: Charging for A & E attendances. This observation applies to some other aspects of the report. It is noticeable that we mention that we should stop A & E being used as a GP service – but that’s it. We don’t spell out precisely what we mean. We are leaving it to people to read between the lines. I would prefer we were up-front about these things. If we plan to start charging for A & E non-emergency appearances – then we should say so. Explain why and describe what safeguards will be in place.

15: General Practitioners. New Directions does deal with GPs and their development as leaders of primary care. However, I thought it was striking that a few of the key questions were not addressed. For example, are GPs to carry on being remunerated by soc-sec, or us as the case may be, on the basis of ‘fee-per-item-of-service’? If so, how de we propose to address all of the perverse incentives this causes? Or is it the case that we want to give GPs an annual contract payment for the overall service they provide? If so, how will this work and do GPs accept such a change?

16: New Directions does explore the issues around co-payments. We do, for example, recognise that co-payments are a disincentive to poorer people from seeing their GP. However, we get very vague again on what we propose should be done about this. There is reference to Income Support, but will this alone really address the problem? Such is the onerous nature of claiming Income Support that it is becoming clear many are simply not bothering.

17: Family Nursing and Home Care. This is another ‘elephant in the room’. Whilst FNHC receives passing reference in a few places, for example in respect of more focused home support for patients, we fail to state baldly what the issue are with FNHC and how we propose to modernise the situation. Again, it is hinted at if you wish to read between the lines, but not really faced up to. Whatever home care structure we advocate, there has to be certain changes. For example, if we are going down the social insurance path for continuing care, I want us to scrap the requirement that people have to pay FNHC “membership” fees, and I want us to scrap the charges people currently face for consumables such as dressings and incontinence pads.

18: I know the report specifically makes a point of excluding mental health from the present considerations, but I don’t think that is acceptable. We are trying to move towards a cultural shift in how we perceive mental health problems. We need to combat the stigma and normalise mental health as a “health” problem. By excluding it in the way we do in the report I feel we are actually going in the wrong direction. One gets the impression that mental health, like social services and the children’s service, has been pushed to one side by the stampede of General Hospital focused clinicians and GPs.

19: Although we wouldn’t expect much detail at this stage, I feel there needs to be a section on dental care and whether we include a funding element within any social insurance arrangement. Dental care costs are astronomical in Jersey so the poor tend to have very poor dental health.

20: I was surprised at how little nursing and nurses featured. Nurses are crucial to pretty much all we do. We face a variety of challenges in recruiting and retention. There is a world-wide shortage of nurses. How do we propose to strategically plan to deal with this problem?

21: I felt we needed a little more detail on the whole question of staff generally. How we recruit, how we retain. How we remunerate. How we train them. How we support them in maintaining high standards and so on. H & SS runs on its staff.

22: Whilst the report does address the issues around the EWTDs (European Working Time Directives) and what this means for junior doctors in the Jersey General hospital, I felt there was not enough clarity and detail as to what, precisely, we do about it. Whilst we speak of the “hospital at night”, and “hot zones” and so on, is it argued that these exercises alone will solve the problem? Do we foresee a time when GPs work in the General Hospital, carrying out some of the duties that are presently carried out by junior doctors? If so, how might this work?

23: There really needs to be a binding commitment and detailed explanation in the report as to just how we are going to secure and submit to external inspection. I am familiar with the saga of the Health Care Commission, but many people won’t be. We at least need to be clear about what it is we plan to do.

24: Similar observations apply to the whole issue of an independent complaints procedure. I have always been committed to this – and have been promising it for about 6 years. But we seem no closer to having a clear and readily accessible procedure in place. We really need to be stronger and clearer here.

25: I think we need to say something about patient involvement, for example, some kind of patient forum. A number of different models exist which we could look at, for example, the old Community Health Councils in the UK.

26: Should we commit to a “Patients’ Charter”? Should we commit to a “Clients’ Charter” as many of our ‘customers’ are not patients?

27: This leads on to the observation that the ‘feel’ of the report is very much that it has been largely generated by the hospital and GPs. This explains a lot about its focus and why some key areas appear largely unaddressed. There is a risk that this exercise will be seen by some simply as the clinicians carving things up as they want, with little regard to other aspects of our responsibilities or clients’ concerns. I’m not saying it is so, just that that will be the impression some people will get.

28: Reference is made in the report to the “10 high impact proposals”. This will need explaining for a lay audience. Most will have no idea what this means and there is also a danger that we will be accused of “importing failed NHS type policies”, unless we explain the relevance and usefulness of such measures to Jersey people.

29: I recognise fully that this is a strategic document and, as such, it does not attempt to address costings and so on. But I can guarantee now that we are going to spend an awful lot of time answering the same question in the States and publicly over and over again: “how much?” Whilst we wouldn’t expect the proposals in a strategic document to be fully costed, many people will expect at least some idea. I simply don’t think we are going to get away with “look, just agree to all this and we’ll work out the costs later.” If not possible to cost each element in detail, we ought to at least be including some kind of funding formula proposal; perhaps spend per patient, spend per capita, percentage of GDP etc etc. We will – absolutely without question – be barraged with these questions as soon as we publish. We need to have at least attempted to address them.

30: Targets and measurable and quantifiable outcomes. I can guarantee that we will be expected to demonstrate what our objectives are, how we plan to reach those targets, how will success look, how will it be reliably verified? Again, I recognise this is a strategic report in which one would not necessarily expect great detail, but nevertheless, we will be expected to at least indicate how we plan to develop and put in place a robust performance assessment procedure.

31: Energy strategy: Health & Social Services must be one of the largest consumers of energy in the Channel Islands. Add to this all of the other health & social care consumers of energy and it becomes clear that the services the community expects are massively energy dependant. We live in volatile times as far as energy supply and cost is concerned. Whilst it is possible to find extremes of view on both side of the debate, much respectable opinion has it that the world will hit peak oil production sometime this decade. Once that occurs, we begin moving towards the end of cheap oil. If we are serious in our ambition to deliver a strategy that sets health & social care on the right path for next couple of decades, we have to have regard for energy. If for no other reason than the cost of energy is going to rise astronomically and we just won’t have the money to pay for it at present levels of consumption. We should be going to extremes to maximise our energy efficiency, reducing our demand, perhaps looking at small turbines on some of our buildings and perhaps exploring the challenge of going ‘carbon neutral’. We could also say with some certainty that whatever global climate change has to offer, it certainly isn’t going to be good for peoples’ health.

CONCLUSION

I realise I have asked for further work to be done, some of which might be challenging. However, it is worth going that extra mile to get it right. If we don’t, we will only be sent back to the drawing board anyway, so we may as well do the work now.

In terms of the overall feel of the report, I think we should have a bullet-pointed summation at the end of each chapter.

I also think we must have a clear set of actions which will flow from the strategy, such as specific policy proposals, laid out in priority order so it is clear what our timetable is, and it is clear to the States and the public just what is going to happen when the strategy is enacted.

When the time comes, I will write a forward for the report.

I welcome any comments.

Senator Stuart Syvret
Minister, Health & Social Services.

6th March 2007

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