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.

The Jersey Care Model

The Jersey Care Model was introduced in 2020. lt 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 Council of Ministers established in June 2022 instituted a review of the Model. Review of the Jersey Care Model was published on 30 November 2022. The Care Model was effectively ended although some of the programmes were continued.

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.

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.

Public health

The Annual Director of Public Health Report 2024 The Case for Prevention was published on 5 February 2025.

In his foreword, the Director of Public Health Dr Peter Bradley said –

This report sets out a compelling case for prevention, backed by robust evidence. It calls for a shift in priorities - from reacting to ill health to proactively creating the conditions that support good health for all Islanders. Building on existing work, we can embed prevention at the heart of our policies, services, and communities, and build a healthier future for the Island, making sure it remains an attractive place to live, work and do business.

Key points in the executive summary –

• Although treating illness consumes more than £9 out of every £10 spent on health, healthcare services only account for about 30% of our health.
• The building blocks of good health are money and resources, good housing, work, education and skills, access to good food, transport, the quality of our surroundings and our friends, family and communities.
• The aim of much of prevention work is to help create conditions where it is easier to be healthy, like making sure nutritious food is widely available, support those who want to behave more healthily and provide evidence-based interventions that we know prevent illness, like vaccination and screening programmes.
• Preventing illness is cheaper than treating it.
• A child born in Jersey today can expect to live for 83 years, roughly a year longer than in the UK and about two years less than the most long-lived countries. Women (85 years) generally live longer than men (just over 81 years), although the difference between the sexes has fallen in recent years.
• Although women in Jersey tend to live longer than men, they spend a greater proportion of their lifetime in poor health.
• Health generally declines with age. 94% of Islanders aged 16-24 report having good or very good health, compared with 66% of Islanders aged 65 years or older.
• Just 6% of economic inactivity for Islanders aged 20-24 is due to sickness or disability whereas for people aged 45-59 it is more than a third.
• Around 100 of the 800 deaths each year in Jersey could be prevented with better public health interventions.
• The more money that people earn the more they are physically active.
• People with higher incomes are more likely to drink to dangerous levels. Jersey is a “nation of drinkers”, consuming more alcohol per head than almost every other European nation.
• 29% of people working in routine, manual and service occupations smoke, compared to just 7% in senior manager roles.
• Children in urban areas or who attend non-fee-paying schools are much more likely to be overweight or obese than their wealthier counterparts, although the differences may be reducing.
• Jersey’s population is set to age in coming decades. This will increase demand for healthcare and social support. In addition, our existing population appears to be becoming less healthy, as evidenced by rising rates of obesity and a stalling in improvements in life expectancy. These demographic trends will put pressure on public finances. Improved prevention can help ease these pressures.
• As the population ages, there will be an increase in demand for health and care services, such as GP appointments and hospital bed days. Improved prevention would reduce this. Even a modest reduction in demand would achieve significant savings.
• Genetics, environment, and behaviours drive 70% of our health status. Treating sickness accounts for less than 30% but still consumes 90% of resources.
• There is an overwhelming consensus from academia, governments, society and business that investing in prevention make sense. There are strong financial arguments - healthier people are more productive. There are compelling moral arguments - since many factors that influence health are outside of our individual control. It is unfair that some people suffer worse health that could be prevented. As an Island nation, we depend on each other. Investing in our health is therefore an investment in all our lives.

Annual Plan 2025

In January 2025 the Health and Care Services Division Annual Plan 2025 was published. In his foreword the Minister for Health and Social Services, Tom Binet, set out a long-term strategy -

Following several years of relative turbulence, Jersey’s health system is at a crossroads. With four years to go until we have the benefit of an all-new hospital, we have just enough time remaining to improve our health service to mirror the standard of the new, forthcoming facility.

Whilst pockets of absolute excellence exist, moves to draw various health functions into central government, fractious relationships between various health bodies (Primary, Charitable and HCS etc.) and divisions between management and clinicians within HCS all suggest the need for a more collaborative style of leadership and a suitable structure within which all health sectors can work together efficiently.

With this in mind, we plan to establish an all-encompassing, unified, Jersey Health System. For the first time we will appoint a Chief Executive, charged with delivering a properly integrated service, guiding and overseeing the interaction of all health service providers (Primary Care, HCS, Charities, Care Homes, Home Care, Dental etc.).

This will involve the creation of a new ‘stand-alone’ health department. Separated from, but connected to government, it would encompass all health functions, including strategy, policy, legislation, public health, digital health, commissioning, procurement, and population data. Key advisory roles, such as a Chief Nurse Advisor and a Chief Pharmaceutical Advisor, would support this integrated approach.

Central to the proposal is the formation of a new Jersey Health and Care Partnership Board. Here, each health service provider will contribute equally. This structure would include Civil Servants serving in executive capacities alongside non-executive members representing private and charitable healthcare providers, ensuring a balanced and inclusive approach to governance.

Another key aspect of the proposal is the establishment of a single, central fund to manage all health-related finances, governed by appropriate terms and conditions. Collaboration with central government would be essential to build the autonomous internal framework for HR, finance, and procurement within the broader government system, along with Digital/IT which will receive particular attention.

Preventive health measures are a major focus of the proposal, including increased screening, vaccinations, health monitoring, and initiatives for healthier living from a young age. This proactive approach aims to address the root causes of health issues, thereby making the health budget more manageable in the longer term and improving the quality of life for residents.

Despite current funding constraints which limit certain of these longer-term ambitions, the proposal underscores the importance of not transferring fragmented services into the new hospital.

The plan also highlights the beginning of talks to develop a new health strategy, or action plan, both for the wider ‘all island’ service and for HCS itself. This initiative is expected to foster internal and external cooperation, improve morale, and initiate a much-needed culture change within the health system.

In conclusion, the plan stresses the need for maximizing operational efficiency whilst developing appropriate means by which additional funding might be achieved. It recognises Jersey's unique position as a wealthy island with a dedicated workforce and improving healthcare facilities, suggesting that with appropriate investment and a willingness to embrace change, Jersey could become a model of best practice in health care.

This plan aims to provide a comprehensive overview of the proposed changes, and the strategic direction needed to achieve a unified, efficient, and effective health system for Jersey.

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