HSSD Minister

Today I announced my nomination for the position of Minister of the Health and Social Services Department. In making that announcement to all deputies I sent them this letter outlining what I would seek to prioritise were I to gain the position. I feel that it is appropriate for me to publish the letter here on the website in the interest of transparency of my priorities.

I’d be equally pleased to answer any questions from the public on any matter pertaining to the role of minister of HSSD.

Dear Colleagues,

Having decided to stand for the position of minister of HSSD I thought it appropriate to share with all of you some of my views concerning the immediate future of the department. Were I to be elected I would work with the board and other departments with the aim of achieving as many of the actions below as possible whilst recognising that I would need the endorsement of the rest of the board to progress these intentions.

The PEH has been the main focus of many when talking of HSSD, but this is only one part of the department’s service offering. Mental health has gained far greater interest and attention in recent years, that is to be welcomed, but there’s scant attention given to our adult disability services for instance. Children’s services receive due close scrutiny on difficult occasions but when was the last time we heard talk of the role of the Children’s Convenor?

I’m proud that my time on the board of HSSD has been spent working closely with Mental Health and the recent organisation of Elephant Week. I’ve met every other month with carers of our Disability Services and recently attended the first meeting of the extended parent carer council, an initiative that I oversaw. I’m pleased to have been closely involved with the upcoming Sexual Health strategy, the first time we will have a strategy to deal with our high rates of teenage pregnancy and our low rates of STI diagnosis. I’ve also been diligently working with our IT department, implementing what will be a great improvement in the governance of healthcare.

The Chief Executive of the States recently circulated details of the new initiative ServiceGuernsey. Whilst I share some concern over the naming of the initiative, the principles behind it are laudable and to be welcomed. Of course in healthcare, such initiatives have long been championed under the heading of “Patient Centred Care”. HSSD is much larger than just healthcare and therefore we frequently talk of Service Users rather than patients, therefore I’d like to talk of Service User Centred Care, an equally unpalatable term, but it does describe accurately what needs to be our focus on each and every occasion, people, frequently at vulnerable points in their lives.

Some amongst you will feel that the lack of mention of finances thus far is worrying, but failure to deliver Service User Centred Care will result in similar problems, such as the current crisis that has consumed our maternity service. The cost of such failures are extensive. I will outline my thoughts on Finances later in this letter.

Maternity Service

The current crisis will be the main focus of the next board. A number of recommendations will be made by the Nursing and Midwifery Council (NMC) in their report. I’m of the opinion that a large number of the recommendations will need to be implemented without question, but for some recommendations there may be a question to ask as to the appropriate solution for a small, remote location, such as Guernsey. There’s also some questions that may need to be made as a result of Guernsey’s rather unique consultant led care with no junior doctors. This model is not unfamiliar to NHS Scotland, who have similar remote locations with a different model of healthcare delivery. I would therefore propose that the findings of the coming reports be peer reviewed by colleagues in another jurisdiction to evaluate what can reasonably be justified as not being implemented.

This is not a desire to be defensive of our services. We must recognise the failings that have occurred over a number of years and resolve to swiftly implement the findings where appropriate, but where we feel there are questions over the NMC findings we must not only act in the best interests of our population, we must also be seen to act in such a manner. A peer review allows us such an opportunity.

Part of the reason for the failings in my opinion, has been as a result of a closed environment within one of our services. This must never again be allowed to happen. I look at the partnership approach within mental health, where a number of service users call in to Albecq Ward for a discussion with service users to ensure that they receive the care that would be expected. Such visits keep our services open and transparent to the very people who’ve experienced them in the past and on occasion may need to call on the services again in the future. Specifically on Loveridge Ward, I believe there to be an association known as friends of Loveridge and I’d like to discuss a similar approach with them. We cannot rely on the medical profession alone to resolve the issues, as some of the issues are of their making.

Governance

It is evident that we cannot rely solely on the governance arrangements midwives have in place and need to improve on our internal governance arrangements. Following the incidents on Loveridge ward, the language used by the NMC and the Local Supervisory Authority (LSA) has been that of a culture. A culture of straying from procedures as being acceptable, a culture of poor relations between nurses and doctors, a culture of secrecy as a result of frequent leaks to the media. As a result of the Financial Transformation Program (FTP) two posts in the governance team were removed. We need to shore up our governance team and extend their remit, as such I would be talking about our staffing level and scope of the governance team, should they feel that an increase in staffing is necessary I would be seeking to review the staffing and skills at our disposal.

In the interim, the governance team is now looking at the individual failings in Loveridge ward and reviewing the policies across the hospital. This will give us a matrix of services areas against practice, developing a picture of where the failings lie and what actions will be necessary to tackle them.

MSG

The MSG contract will terminate in 2017 as I’m sure you’re all aware. Notice must be given in 2015 of whether the States will continue with the contract. This is an incredibly tight timeline, but given the previous reports commissioned by the department and the current crisis, I don’t believe the current contract to be a viable option. The culture of poor practice is partly borne of the current contract and the problem could be reasonably summed up in the following statement:

The Interests of the MSG are not always aligned with the interests of the PEH.

The variance of interest has already led to a culture of poor practice and the friction between senior consultants and junior nurses is detrimental to our service users.

There are different means of delivering secondary healthcare, States employed consultants, the current MSG model which could be thought of as similar to barristers in chambers, privately employed visiting consultants or a State owned company employment of all health workers. There’s also a combination of all the above that could be considered. I would seek to have a policy letter outlining the options to the States as soon as practicable, this would require a conversation with both the Social Security Department (SSD) and the Treasury and Resources Department (TRD) as the means of conducting such a review must be complementary to the benchmarking exercise that the TRD have identified in the coming budget.

Departmental Finance

The departmental budget for this year and the past two years has not been met. The proposed 2016 budget is once again lower than originally requested by the department. But whether there is an overspend or an underspend (as happened in 2011, where the significant underspend was masked by the decision of the department to undertake expenditure that should rightfully have been from TRD) the discourse is poor with only a comparison made between budget and expenditure. The context for the expenditure is simply lost and the resulting public discourse is ill informed and damaging to a department that strives to provide excellent healthcare and social care outcomes for its service users. I therefore would seek to publish quarterly financial results along with quarterly governance reporting. The number of procedures carried out in the PEH, the average length of stay, the number of hospital acquired infections, the number of service users with psychosis that we have, the number of service users with affective disorders, the number of off island complex placements and the number of off island acute placements, the number of children in our children services. When presented in that light the discourse will be greatly improved. I would therefore seek the endorsement of the States to publish such a report from the first quarter of 2015.

Capita have placed what I understand to be one of their most senior advisors to work with the HSSD for many months and have not identified any significant savings within the immediate term, even the longer term savings come with extensive caveats. This is no reason not to strive for greater savings, but the options are unpalatable. There is a fairly easy way of bringing the department back into budget and to meet a proportion of the outstanding FTP target, this would be through charging for certain services, blood tests, x-rays, parking being three obvious candidates. Jersey already employ this model in certain areas and I would seek to have a policy letter brought to the assembly as soon as practicable outlining the various charging options, but I must also state that the department may well lay the report and seek the States to reject such charging mechanisms. Neither of the previous boards this term have supported, by majority, the introduction of charging and such an outcome is conceivable of the next board.

IT

Part of the solution to the current crisis is the implementation of the EHSCR e-Prescribing module. This would tighten regulation surrounding the prescribing practices that is now overdue.

Children’s Services

The greatest risk item on the HSSD risk register remains in children’s services relating to the outdated computer system. If we are to avert another crisis we must reform the IT system and revisit working practices. This work has started, but progress is hampered by the delay in reviewing EHSCR as requested by the TRD. I know that the TRD are equally frustrated by this delay, but we must now work to release the funding and see the implementation happen as a matter of urgency.

Mental Health

Last week marked Elephant Week, an initiative to start a uniquely Guernsey week for raising awareness and tackling stigma surrounding mental health. I was the organiser of the week and brought various government departments, charitable organisations and the private sector together to deal with one of the biggest health issues we have.

The States are now working with Guernsey Mind to implement a mental health policy that should see a substantial reduction in the number of sickness days that are taken. When the Guernsey Post implemented this policy they saw a reduction of sickness days from 1,200 to 400 with 60% of that improvement seen in the first year. This is now estimated to save Guernsey Post £100,000 per annum. The opportunities for savings within the States are substantial and I believe HSSD should be at the forefront in implementing this policy.

Sexual Health

As I stated in an email to all of you recently, we need to introduce the ability to charge for contraceptive services in the Orchard Clinic. The current position of treating a Sexually Transmitted Infection (STI) and then advise service users of the need to go elsewhere for contraceptive services flies in the face of the ServiceGuernsey initiative. I believe the policy letter is written and I would therefore seek to present it to the assembly as soon as the timescales allow.

Resourcing

There are a number of promises made above, I must caveat all of them by stating that the HSSD will be tied in to a number of reviews concerning the immediate crisis in midwifery care. Throwing money at the problem won’t be a solution. The experience and knowledge of senior members will be torn between the immediate crises and the needs of benchmarking, review of healthcare and review of the MSG contract. I believe it would therefore be foolish to promise delivery of all of the above within short timescales, but I would seek to prioritise these demands with the new board and deliver to all States members a summary of the priorities and expected timescales by the end of the year.

I’d like to close by stating clearly that HSSD is facing a crisis in one part of its services. I’d suggest that what we need is experience and knowledge, when the Local Supervising Authority (LSA) described the failings as a systemic organisational failure, what the States need is someone who knows the system, understand the organisation and has a clear vision of how it needs reforming as well as the means of getting there. We also shouldn’t allow this one area to consume the board to the detriment of the rest of the department. I believe that I have the knowledge, the experience and the ability to deliver on the above and to keep all of you informed. This is not the time for us to look to an individual or a small group of five to resolve the problems, this is a time when each and every one of us need to take responsibility to the extent we can.

Thank you for your time in reading the above, should you wish to discuss any of the above or any other matter pertaining to the minister’s position on HSSD, please feel free to contact me.

Yours sincerely,

Elis Bebb.

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