Healthcare

Introduction

The healthcare system in Jersey is under strain for similar reasons to those in the UK and other jurisdictions - the consequences of an ageing population, the effects of the pandemic and demand continuing to increase. There are also specific issues in Jersey because it is a small island and has a number of long-standing structural and cultural issues, identified in two recent reports. The related issue of a new hospital is covered in a separate brief.

Priorities

The Chief Minister’s Ministerial letters, published on 10 August 2022, included a letter to the Minister for Health and Social Services, the key part of which said –

I would like you to focus on openness, transparency, and accountability, especially for waiting lists, improving those for outpatients and mental health services in particular; and to work on any necessary improvements in morale and culture in your department, building trust and confidence. Complementing that, we need to drive the independent inspection of services to provide the public with assurance around standards and quality.

Looking into the future, I would like you to work closely with the new Minister for Infrastructure in the review and delivery of an appropriate and affordable hospital; and I also support your desire to review the Jersey Care Model, assessing its appropriateness, and delivering a health care service, including primary and community services, that are right for Jersey.

The chapter for the Minister for Health and Social Services in the Ministerial plans for 2024, published on 19 September 2023, set out eight priorities. In summary -

1. Securing vital governance improvements in the quality, safety and effectiveness of services delivered by the Health and Community Services Department.

2. Enabling different parts of the health and care system to better work together to improve outcomes for islanders.

3. Advancing the health and wellbeing of women in our community.

4. Advancing the health and wellbeing of people experiencing mental illness or distress in our community.

5. Advancing the quality of health and wellbeing support for those living with a health disability, terminal illness or who are need of support.

6. Advancing the health and wellbeing of all islanders.

7. Informing the programme of development for New Healthcare Facilities.

8. Developing legislation that provides for safe, effective services or supports the health and wellbeing of islanders including assisted dying, law to safeguard and protect adults, medicines law and misuse of drugs law, public health law and professional registration law.

The Jersey Care Model

On 22 September 2020 the Health Minister lodged a proposition in the States Assembly Jersey Care Model. The introduction sets out the purpose of the care model

A care model is a conceptual framework which calls for an organised and planned approach to improving patient health. It sets out the high-level design for services, incorporating all elements of the health and care system, as a guide to improve services holistically. The care model helps create a consistent narrative by which all elements of the system can understand the direction of travel and coordinate integration. Healthcare by its nature is complex and never static. HCS has not stopped evolving services outside of this programme as it has reacted to changing environments. The Jersey Care Model (JCM) will inform a delivery programme which will develop and deliver integrated services that will be designed and delivered as an evolution rather than a revolution, using the care model as its reference point.

The overarching aim of the Jersey Care Model is to transform health and social care, in order to improve Islanders’ physical and mental health and wellbeing. To achieve this, it proposes adopting a patient-centred approach whereby care is financially sustainable, safe and accessible, being provided in the places where people need it the most.

This also aligns closely with the Government of Jersey’s Common Strategic Policy – in particular to improve Islanders’ wellbeing and mental and physical health, whilst preparing for more Islanders living longer. Indeed, without the JCM, analysis suggests that the current health system would be overwhelmed as a result of the ageing population demographics and disease prevalence on the Island.

Care will be enhanced in the community and decentralised from the hospital by strengthening public health, prevention and community services to reduce the dependency on secondary care. Care will be proactive rather than reactive and will put individuals at the centre of their own care. Technology will also be fully utilised to allow people to manage their own health. A strong partnership model will be developed with valued service providers across the public, private and community sectors.

The Jersey Care Model was stated to have 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.

The new Council of Ministers instituted a review of the Model. Review of the Jersey Care Model was published on 30 November 2022. The press release announcing the results of the Review is the best available summary.

Following her review, Deputy Karen Wilson has concluded that 21 of the services under the JCM will carry on as they are, as they are providing the foundations to transforming the Jersey health and care system.

A further nine will be adapted to ensure they support her Ministerial Priority to deliver safe, high quality, patient-centred care.

Deputy Wilson has decided to stop one of the services – the Supportive Services project – as a similar piece of work is already being undertaken by Customer and Local Services.

The Jersey Care Model as a term and programme will end; however, those services and projects that fell under it will continue independently.

Deputy Wilson paused the JCM on becoming Minister so that she could review the programme and gain a greater understanding of what it was intended to achieve and what it had accomplished to date. She also wanted to review the programme’s funding to see if it continued to align with what was agreed by the States Assembly in 2020.

Since July, Deputy Wilson has been provided with details about the 31 services which made up the JCM, including information about the investment so far, activities and services implemented, and the timeframe for delivery.

Information about how the services aligned with the key objectives of person-centred care, the strengthening of preventative services, improving Islanders’ health outcomes, and moving services out of the General Hospital into the community was included as part of the review. Feedback from patients and service users who access existing services was also considered.

Deputy Wilson concluded that much of the work planned or already underway is providing the foundations needed to make the significant changes required to transform Jersey’s healthcare system.

As many of the services have only been running for short period of time or have not yet started, it is not possible to conclude whether they are providing the financial benefits set out in the original JCM business case. The Minister has asked for a formal evaluation of each service to be carried out as soon as they are fully established.

Deputy Wilson said: “It was apparent when I stood for election that there was strong public criticism of the Jersey Care Model. This criticism stemmed from confusion about what the programme was and why it was needed, concerns about cost, and questions about how the changes would benefit Islanders.

“On becoming Minister, I wanted to investigate these concerns to make sure that what was being introduced would help provide Jersey with high-quality health and care services.

“What I’ve found is that the majority of services will play a large part in helping to transform our health and care system. However, from this review alone I cannot be assured that the financial assumptions made in the original JCM business case will be realised. As such, I have asked for a more formal evaluation of each service to assure Ministers, the States Assembly, and the public that their delivery is in line with anticipated financial and non-financial outcomes.

“In the future we will stop using the name the Jersey Care Model, which has proven to be confusing to many, and does not adequately represent the investment made by the States Assembly. Each project should be considered on its own merit as a service development, rather than as part of a model.”

Review of health and community services

In August 2022 the Government published a Review of Health and Community Services (HCS) Clinical Governance Arrangements within Secondary Care by Professor Hugo Mascie-Taylor. The summary is reproduced below –

Jersey faces the challenges of a small island. (The same geography which make it so attractive.) Its population is just greater than 100,000 and it is over 160 miles, by air or sea, to the United Kingdom (UK).

It is an affluent island and all the people and patients of Jersey, irrespective of their individual financial circumstances, need and deserve high quality, safe healthcare. They must be assured that this is being delivered by the publication of bench-marked clinical outcome and management information from a proactively managed accountable organisation which has adopted the systematic approaches to safety and quality seen in other industries, and in modern healthcare, across the World.

Sadly, it is not possible to conclude that this is the current situation, and the Government of Jersey, on behalf of the people of Jersey, must demand this service from HCS and its employees, and publicly and assertively support the organisation in achieving it.

HCS must respond to the challenge by becoming an exemplar of good clinical governance, driven by openness, transparency, and internal and external accountability, as well as by a strong managed approach to systematic quality improvement.

This represents a substantial change from the ingrained attitudes and behaviours of many years, probably decades. It is and will be difficult and change may be vigorously resisted. The current non-accountable and individualistic culture, at least of some groups of staff, firmly rejects, sometimes noisily and angrily, any move in these directions, seeing them as unnecessary, interfering, and bureaucratic, and certainly not required in Jersey.

However, the potential rewards of success in driving change are very substantial. They include not only a Jersey public that receives, and is assured that it receives, services of high quality, but also a professionally satisfying and attractive place of work for all employees, both present, and future.

Inevitably as more esoteric treatments of disease are trialled and implemented there might be the need to transfer more patients (along well-developed care pathways), but Jersey should be able to provide, on Island, most healthcare interventions required, performed safely and effectively.

In addition, there may be the potential to treat patients from other jurisdictions should it have a commercial wish to do so.

The challenge then for HCS and its employees is to be an organisation demonstrably at the leading edge of healthcare delivery, not just technically, but importantly operationally, - not only as individuals, but as an outstanding team. Although in recent times there has been a considerable effort, and some success, in moving the organisation forwards, there is a huge challenge to be met if HCS is to achieve its potential. It will need consistent and robust support from Government to ensure the delivery of the quality of healthcare that the people of Jersey fund, deserve and should demand.

Clinical Governance

There are many ways of describing the components of clinical governance and making judgements about its effectiveness.

A simple but useful list of areas to consider and evaluate are these: -

• Knowledge and skills.
• Leadership, followership, and accountability.
• Information being widely disseminated within and out with the organisation, and including data analysis, comparative benchmarking, and an insistence on transparency.
• A culture of team working, embracing change and innovation. Placing the needs of the patients ahead of personal vested interests.
• Positive relationships including mutual earned respect, and deference to many forms of expertise. A lack of pointless hierarchy. Shared insistence on courteous professional behaviour and exposing and dealing with poor behaviour.
• Embracing of continuous quality improvement. Conformance with standardised and systematised processes which drive quality and safety (e.g., NICE guidelines).

Within the limits of the methodology and his own experience the author of this report attempts to make comment and recommendations in all these areas.

If the recommendations are enacted the quality and safety of healthcare in Jersey will unquestionably improve. This is not to say that there is any conclusive evidence that care within HCS is unacceptably poor, but there should always be a fierce ambition to make it better.

Unfortunately, however, the processes that provide assurance that care is good, or even acceptable, are not well-developed and need urgent improvement. The clinical governance is weak, and the risks are substantial.

In response to the review, on 26 August 2022 the Minister for Health and Social Services announced –

The Government is to establish an independent health board in response to a review which found serious issues of governance at the hospital.

The Minister for Health and Social Services, Deputy Karen Wilson, ordered plans to be developed for the new board after an independent review of the hospital identified serious concerns and made sixty-one recommendations to improve care and governance.

The Minister said: "Islanders will rightly expect that, as the new Minister for Health and Social Services, I will ensure that urgent, clear and direct action is taken to address the report's recommendations. Our health service must become an exemplar of safe and effective care, be of good quality, and its performance accounted for in an open and transparent way.

"In light of this, I will bring forward plans to establish an independent health board, including experts in health care provision, to drive reform, improve governance and address the cultural, structural and practice issues affecting the quality and safety of the care provided.

"Alongside that Board, I will strengthen policy functions to determine government policy across the whole health system."

The Minister ordered an immediate turn-around plan to be developed for the hospital while the new board is established. She undertook to order a follow-up review in one year's time to track progress.

Review of staff resources

In January 2023 the Jersey Audit Office published a report Deployment of Staff Resources in Health and Community Services. The conclusions of this report are –

The Health and Community Services Department is under significant pressure currently. Factors that are contributing to this pressure include:

• the ability to recruit and retain staff in a challenging market for health staff since the COVID-19 pandemic
• inpatient bed pressures caused by high level of ‘medically fit for discharge patients’ not being able to be discharged from inpatient care into the community
• lack of relevant data and management information to drive policy development and implementation
• uncertainty as to the long-term strategic health plans for the Island (including the future care model and the Our Hospital project); and
• sometimes poor working relationships between senior clinical staff and staff in management positions.

In order to deliver and implement an effective and comprehensive workforce strategy, issues that need to be addressed include:

• ensuring completeness and accuracy of workforce and clinical data and information
• the future direction of the care model and the Our Hospital programme
• finalising the structure of the Health and Community Services department (for example, the number and composition of Care Groups)
• agreement of future clinical operating models at specialty level
• resolution of policies in key areas affecting the workforce, including:

o terms and conditions for particular staff groups

o on-call policies and arrangements for medical staff; and

o a private patient strategy

• ensuring that enough specialist workforce planning capacity is available to support development of the strategy; and
• effective project management of the future workforce strategy project.

The Public Accounts Committee has asked the Government’s Chief Executive to respond to the report.

Public health

On 9 February 2023 the Government published Jersey Health Profile 2022. The introduction to this report states that –

The Jersey Health Profile combines data and knowledge from various available sources on health and wellbeing for the population of Jersey. Indicators are presented for both adults and children, from sources such as Jersey Opinions and Lifestyle Survey and Children and Young People's Survey.

In 2023 the Government published Seizing the opportunity: a population health prevention strategy for Jersey (2023-2027). The executive summary identified five strategic priorities –

Understand

It is important that we get a better understanding of health in the Island. Better data will help us to see how age, gender, income and ethnicity influence health. This improved understanding will help us focus our efforts where they are most needed. Our priorities include:

• Develop a strategic needs assessment of health on the Island;

• Continue to engage with Islanders from all walks of life to better understand their needs;

• Improve our ability to monitor and evaluate our work.

Protect

The Government of Jersey has a duty to protect islanders from infectious diseases, environmental hazards and extreme weather. This work is usually called health protection. Health protection services are delivered by lots of different organisations working together, with Public Health playing a lead role. Our health protection priorities include:

• Continue to lead improvements in how Islanders are protected from extreme weather events;

• Update public health legislation;

• Develop and implement an immunisation strategy.

Improve

Like most countries, Jersey has an ageing population. More people are becoming unwell with long-term illnesses like diabetes, cancer and heart disease. Every year new medicines and medical technology mean healthcare becomes more expensive.

This will make it difficult to fund healthcare in the future. One way to slow this increase in cost is to invest in prevention. Preventing someone becoming ill is cheaper than treating someone who is already unwell. It also saves considerable suffering. Many long-term illnesses share common causes, or risks. Eating well, being active, not drinking too much and not smoking, all help us stay well for longer. In our recent consultation with Islanders, people asked for more support with healthy behaviours. Our strategy will make it easier for people to be healthy by shaping the places we live, work and play. This work is usually called health improvement.

To do this, we will use several different approaches. Health in all policies can help us improve the social determinants of health, which have a bigger impact on health than health services. The social determinants of health include things like income, housing, education, work, the strength of our communities and the availability of a social safety net. We will work

with partners to make Jersey an easier place to make a healthy choice. And, in some cases, we will carry out evidence-based behaviour change programmes for people who really need them. Our priorities include:

• Work with Government colleagues to support the social determinants of health, through Health in all Policies;

• Support Islanders with healthy behaviours through a number of complementary approaches that aim to reduce harms from tobacco and alcohol and increase access to affordable, nutritious food;

• Develop preventative services;

• Work with partners to improve the prevention of mental ill health.

Work together

Preventing ill health and promoting good health is very much a team effort. Our aim is to build on the fantastic work already being done by partners in Government and in the community. Because our health is influenced by many different factors we need all kinds of people to work together; Government departments, arm’s length bodies, charities,

businesses, social enterprises, employers, communities and families.

One of the Public Health's team's jobs is to lead this collaborative approach. Our work is informed by consultation with Islanders and their communities. We also study data and evidence to see what has worked elsewhere. Then we can bring people together to discuss and agree the best way to tackle the Island’s issues. This work takes time and energy to build trust and mutual understanding. Our priorities include:

• Building and developing partnership for priority topics, such as mental health;

• Support healthcare colleagues to maximise the population benefits of healthcare and reduce health inequalities.

Innovate

For some health problems there are proven solutions. For example, we know vaccines are fantastic at preventing childhood illnesses. But some problems need experimentation and innovation. For instance, almost every country in the world is seeing an increase in illness caused by poor diet, but no one has yet worked out the best way to prevent this.

We have identified several pressing issues in Jersey that need innovation. They are:

• How to use Government and community resources so we can help everyone be healthy, not just people who are highly motivated;

• How to better support children and young people, especially those from less advantaged homes;

• How to make best use of carefully chosen digital tools that can support Islanders’ health.

Sustain

Before the Covid-19 pandemic, Jersey had a tiny team working on population health. To deliver this ambitious strategy we need to sustain a highly skilled, appropriately resourced and well-supported public health team that can work effectively with a huge range of partners. This will require training and investment. We also want to role model the focus on

prevention and wellbeing that we are encouraging others to adopt. Our priorities include:

• Developing the public health team’s ability to deliver this strategy;

• Continue to deliver a range of statutory and non-statutory activities that are the responsibility of the Medical Officer of Health.

The strategy is accompanied by a Population Health Action Plan 2023-27 which sets out the practical steps to implement the strategy.

Review of the Rheumatology Service

On 22 January 2024 the Government published the Royal College of Physicians' independent review of the Rheumatology Service.

The Government press release about the review included –

The RCP review team “found the standard of care to be well below what the review team would consider acceptable for a contemporary rheumatological service." The team also noted that in some cases there was “no evidence of clinical examination" and there was “on occasions, an incorrect diagnosis." The RCP review says “in many cases prescribing [of biologic drugs] was out with both UK and European guidance."

In addition to these findings about clinical practice the RCP review team found no evidence of agreed pathways or standard operating procedures for most aspects of routine rheumatological care, noted that both public and private patients were being seen in the same clinics and there was no meaningful explanation of how this overlap of private and public patients was managed and planned. The review team was also concerned to hear there was a lack of built-in challenge to prescribing, particularly biologics, by the pharmacy team.

The findings were of sufficient concern that the RCP recommended that HCS undertake an audit of patients on biologic drugs to ensure their diagnosis was correct. This audit has been completed and in over half the records reviewed, clinicians were not able to identify sufficient evidence to support the patient's diagnosis. Approximately one in four of the patients reviewed had their biologic drugs discontinued because these drugs were not felt to be necessary.

The review also made a specific comment about governance arrangements generally –

A recurring theme was the lack of governance, not just in rheumatology but across the healthcare organisation. Within rheumatology, there was an absence of the expected audits and benchmarking processes that would normally be associated with a contemporary rheumatological service. Forums and opportunities for discussion of activity, risks learning and training were missing. The review team found it difficult to understand, without regular data capture, how the service was performing.

Commenting on the review, Chris Bown, Chief Officer for Health and Community Services, said –

What has emerged from the RCP review and our own additional work, is a picture of a rheumatology service that none of us at HCS could be proud of. The people of Jersey deserve better, and we are deeply sorry that we did not provide a service that staff, patients and our community could be satisfied with.

We are making progress on the development of more robust clinical governance processes across HCS, including the appointment of a new, specialist rheumatologist to lead Jersey's rheumatology service, stronger governance frameworks such as monthly Care Group Governance meetings, and we have made it clear that clinicians must now follow certain additional, key clinical guidelines such as the National Institute for Health and Care Excellence guidelines.

Our task now is to make the improvements recommended by the RCP and to ensure that HCS becomes a beacon of good governance, not just in rheumatology but across the full spectrum of our health and care services.

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