| Findings | Comments |
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1 | The Peer Review commissioned by the Ministerial Oversight Group made 11 recommendations in total, many of which mirror the Scrutiny Panel’s findings and recommendations contained in its “Health White Paper” report (S.R.7/2012) | S.R. 7/2012 made 33 findings. Of the 21 recommendations 12 were accepted, 8 were noted and 1 was rejected. In producing S.R. 10/2014 the Scrutiny Panel requested a briefing from the Ministerial Oversight Group (MOG) Expert Panel but did not request a briefing from the Departments regarding their response. The Departments accepted most of the MOG Expert Panel’s findings and recommendations but rejected or questioned other findings; the Departments would have valued the opportunity to discuss this with the Panel prior to S.R. 10/2014 being produced. Four recommendation themes are similar in S.R. 7/2012 and the MOG Expert Panel report: - Data to monitor the impact of P82/2012 investments (S.R. 7/2012 finding 4, recommendation 1, 5, 16, 17; MOG Expert Panel recommendation 4). The MOG Expert Panel report recognised that “this is being addressed especially around the performance of the health and social care system and the health profiling of the population”
- Prioritising a sustainable funding mechanism (S.R. 7/2012 recommendation 2, 18; MOG Expert Panel recommendation 8). This is being progressed by the Treasury & Resources Department.
- Involvement of GPs in planning for Primary Care and community services (S.R. 7/2012 recommendation 8; MOG Expert Panel recommendation 3). The MOG Expert Panel specifically commended the stakeholder engagement and noted that the “consultation process was inclusive and thorough”
- Understanding the impact of any proposed charges in A&E on patients (S.R. 7/2012 recommendation 6; MOG Expert Panel recommendation 11). It should be noted that, at present, there are no proposed charges in A&E.
Many of the findings from the MOG Expert Panel Report and S.R. 7/2012 are also consistent: - The MOG Expert Panel recommendations strongly supported the health and social care transformation programme, as outlined in P82/2012. “The Panel was clear that the case for change was made and the selection of a new model for health and social care was the right one.” Recommendation 1 states “That the States continue with a new model of health and social care. The original KPMG analysis that produced these options was robust and the consultation taken since has confirmed that there is widespread support for pursuing this new model”. This is consistent with S.R. 7/2012 finding 3.
- The two reports agree on the size of funding required: S.R 7/2012 finding 1 notes that “The proposals contained in the Report and Proposition: “A new way forward for Health and Social Services” require significant additional funding.”; the MOG Expert Panel note that “The scale of the increase in resources required is difficult to forecast accurately but the Panel was clear that it would be substantial from whichever perspective it was viewed”.
- S.R 7/2012 also noted challenges regarding IT which the MOG Expert Panel report identified.
In a number of notable areas, the MOG Expert Panel reported positively on themes that had been identified in the findings or recommendations from S.R. 7/2012: - The MOG Expert panel report specifically commended the stakeholder engagement (S.R. 7/2012 finding 2, recommendation 10, 15) and noted that the “consultation process was inclusive and thorough”. They also recognised that “Consultation is not about ensuring everyone gets what they want but the process served to engage stakeholders and help build alignment, establish consensus and mitigate potential problems in the future”.
- In relation to Primary Care system changes (S.R. 7/2012 finding 5, 31, recommendation 19) the MOG Expert Panel findings noted that “the mixed economy model of provision is the best building block for system reform. The perverse incentives currently operating must be tackled as they present real barriers to system reform”.
The MOG Expert Panel identified a number of strengths and positive aspects of the health and social care transformation programme, including its focus on system change and progression towards a single patient record. It stated strong support for a new hospital, on dual sites, and noted that the Future Hospital programme must be delivered more quickly. “This scheme and the associated system reforms make a major statement to the people in Jersey and those outside about the nature and importance of the health agenda in this jurisdiction’s future. This should not be underestimated” The MOG Expert Panel report strongly supported the transformational change programme, but noted the size of the challenge and the capacity for change management. The report concluded that “We believe system integration is the right approach and applaud the efforts to build support amongst all stakeholders”, and recommendation 2 states “That the management capacity driving system reform should be considered and supplemented where necessary by encouraging greater involvement from clinicians, interim or external support. Resourcing this work properly must be a priority”. |
2 | The Peer Review commissioned by the Ministerial Oversight Group, were not provided with W.S. Atkins full report, its addendum or the additional studies undertaken by W.S. Atkins. The review seemed to focus on earlier work undertaken by KPMG in 2011 | The MOG Expert Panel was provided with a significant amount of information, both written and through presentations and discussion. The original KPMG report was just one document in a suite of almost 30 documents that were provided to the Panel. Given the nature of the review and the time available, the Department considered that a detailed briefing on the Future Hospital Project and outcome of the Strategic Outline Case was more appropriate than provision of these detailed reports. The MOG Expert Panel received a detailed briefing, with questioning and challenge which lasted for a full afternoon. The Panel were given the opportunity to request additional documentation but did not do so. |
3 | The original intention was to provide mental health facilities at the Overdale Hospital site. The dual site hospital proposal has impacted on this vision, and an alternative facility will need to be identified as part of the Mental Health Review | No decisions have yet been taken regarding the future location of mental health services. There may be advantages to co-location of mental health services with ambulatory care services and therefore discussions have taken place with the Future Hospital technical advisors regarding reviewing whether co-location of urgently required mental health services at Overdale is advisable. |
4 | The Council of Ministers agreed that proposals for the new model of primary care should be delivered by the end of September 2014 in order to align them with the related proposals for sustainable funding of health and social services. However the Panel has found that the new model of primary care will not be delivered by the end of September 2014 and a new date for completed has been proposed for April 2015 | Sustainable Primary Care is critical to the delivery of health and social care. Identifying the right model, with key stakeholders, is critically important and must not be rushed. During 2013 an expert partner was sought to assist in this. However, through ongoing discussions, a number of stakeholders felt that this was not the right solution. The procurement process was then stopped, and the project was re-focused with leadership from within the Health and Social Services Department. The project has therefore been delayed, however, key stakeholders are fully involved and committed, and are working enthusiastically and very positively with the Department to design and develop options for sustainable Primary Care into the future. A public consultation on a White Paper is planned for June 2015. |
5 | The development of the primary care service model has experienced some significant difficulties and yet the configuration and delivery of hospital services has a significant dependency on the nature and implementation of that model | The configuration and delivery of hospital services has a significant dependency on a range of health and social care services, not just Primary Care. This has been clearly identified in the Future Hospital planning work, and the team leading that work continues to work with colleagues in the Primary Care project and P82/2012 service developments to understand and to work through the impacts. The health and social care reform programme, of which Sustainable Primary Care is just one part, aims to ensure Islanders are cared for in their own homes wherever possible. The benefits and impacts of this will continue to be modelled and monitored. The Out of Hospital System development has one of the most significant impacts on the future hospital. The Out of Hospital system is not fully dependent on a new model of Primary Care and has already been introduced as a pilot project, with further development this year. The model for sustainable Primary Care is also being developed this year; key leaders from the Future Hospital project are involved in this, and vice versa, to ensure the model developments progress iteratively and with a good understanding of the respective plans and cross-project impacts. |
6 | Achieving the Health White Paper’s objectives requires an integrated approach to planning and developing services across the whole system of health and social care. The Panel has found little evidence that a whole system approach has been undertaken. This is concerning to the Panel because if one work-stream is developed without cognisance of the other, the successful delivery of the redesign programme is put at risk | The health and social care reform programme has taken a system-wide, integrated approach to planning and developing services from its inception. This is important because challenges and developments in one part of the system impact significantly on all other parts of the system. As presented in the Green Paper ‘Caring for each other, Caring for ourselves’ in 2011, the health and social care system faces a number of significant challenges, including the demands placed on the hospital. The analysis demonstrated that, if no changes were made, the hospital would quickly run out of beds. It also identified some gaps in community services. For these two reasons the investment in community services was prioritised, whilst the future hospital planning work was being progressed. But it was also important to ensure that the programme of service changes is manageable and realistic; changing every part of the system simultaneously is not possible. In terms of encouraging the whole system to work together, and planning across the whole system: A system-wide ‘U:collaborate’ event was held at the programme’s inception, where stakeholders shared thoughts and ideas and these were integrated to consider the system impact. Each of the Outline Business Cases and each of the detailed plans have been developed with a range of stakeholders from across the system (including community staff, GPs, voluntary sector, hospital). This helps to ensure that each part of the system ‘has its say’, and is able to challenge each of the plans on the impact that it will have on their profession, team or organisation and on their part of the system. The Transition Plan Steering Group has met monthly since December 2010. It comprises representatives from across the health and social care system, including GPs and voluntary sector, whose role is to challenge the emerging plans from a system-wide perspective. The investment priorities, the Green Paper, White Paper and P82/2012 were agreed by the Steering Group. The Health and Social Services Ministerial Advisory Panel (HASSMAP) challenged each of the plans. This group comprises independent experts from social care, children’s services, mental health, hospital and Primary Care. Each of the major projects has its own steering group or development board; these report into the Transition Plan Steering Group or directly into the Ministerial Oversight Group. Key individuals from the System Redesign and Delivery Team participate fully in these groups to ensure cross-fertilisation and integration between the different work programmes. |
7 | The Panel’s previous review of the Health White Paper found in 2012 that the current I.T. system was not integrated between primary and secondary care and was a problem which required urgent resolution. The Panel has found that this issue is still outstanding | The Health and Social Services Department has made good progress on the IT issues identified in SR 7/2012. The Department considered a wide range of issues and produced an Informatics Strategy, which was provided to the Panel as part of their review. The draft Informatics Strategy was agreed in January 2013 and is now being delivered. Ongoing delivery is subject to ongoing funding. The Panel’s reports make specific comment on integration between primary and secondary care systems. It is important to recognise the achievements to date and to note that the right progress must be made against realistic timescales in order to maximise value for money. For example, the new primary care IT system (GP Central Server) is currently being implemented; it would not be sensible or feasible to attempt to integrate or establish links with a system that is not yet in place. Whilst the primary care system has been developed and the implementation planned, HSSD has completed the implementation of an electronic ordering and delivery system for pathology and radiology tests. Initial discussions have taken place regarding how the primary care and hospital systems may be linked, and work has commenced on a business case for this. The Department is also establishing a system-wide health and social care informatics group to further progress IT integration. |
8 | Informatics and technology are essential to deliver and monitor the service changes and transformation described in the Health White Paper. The Minister for Health and Social Services acknowledged the lack of historical data and made a commitment in 2012 that work would be undertaken to address this issue. The Panel has found that little progress has been made in this area, which is disappointing particularly when the need for improved information systems was identified as far back as the 1990s | The Department has made significant improvements and advances in information technology and management over the past 3 years. In particular, the implementation of the ICR project delivered: - A replacement hospital administration system (Trakcare), ranked as one of the best in the world
- A new child health system, enabling Jersey to excel in protecting our children against infectious diseases
- Modern radiology systems across the hospital introducing electronic storage and retrieval of x-rays and scans
- Integration between Trakcare and other hospital systems
- A foundation, based on a world leading system, that is key to enabling the further developments and improvements to be delivered
In addition to, and following, the main project other significant achievements in this area include: - The Informatics Strategy was agreed in January 2013, and is now being delivered
- Implementation of the electronic ordering of pathology and radiology tests throughout the hospital
- Introduction of SMS text messaging reminders for appointments
- Implementation of a case management system for mental health services
- Implementation of a long term care assessment system to enable the introduction of Long Term Care Benefit.
- Supporting and enabling the CAB to develop and implement the Jersey On Line Directory
- Implementation of a bowel screening system
- Implementation of an endoscopy reporting system
- Agreed arrangements with Hospice to fund the implementation of a hospice based system to integrate with hospital and other systems
- Supporting FNHC to implement a donor management system
- Implementation of a traceability system in dental services
- Implementation of and environmental health system
- Upgrade of ambulance and patient transport systems including the additional of tetra location services
- Upgrade and integration of the clinical investigation system
In addition, a number of information based projects are currently underway; these include: - The development of an island wide health and social care informatics group
- The establishment of a Standard Data Set across HSSD, enabling benchmarking internally and against UK hospitals
- The development of business cases to support the next major systems developments:
- E-prescribing
- Community Information System
- Primary Care / Secondary Care Integration and Interfacing
- Hospital Electronic Patient Record
- The replacement and update of radiology system hardware and software
- The implementation of a ‘medical desktop’ solution across the department, supporting the use of mobile devices
- A Post Implementation Review of Trakcare and Order Communications
- Implementation of a system to support the Jersey Talking Therapies service
This demonstrates a significant improvement and advancement in information systems over recent years and illustrates a significant current and on-going programme of work. It is important to recognise that, as with healthcare itself, there is an almost infinite demand for information and information systems. These demands have to be prioritised and managed to deliver the best possible value for money within the Department’s overall capacity to deliver the organisational change that necessarily comes with new systems. |
9 | One of the overall conclusions contained in the Comptroller and Auditor General’s report “Use of Management Information in the Health and Social Services Department – Operating Theatres” was that improvements to management information should be seen as a priority. The Panel wholeheartedly agrees and expects the Health Minister will take heed of the C&AG’s report and its recommendations and conclusions | The thoroughness and depth of the Report has been welcomed by the Minister. Work had commenced on theatres prior to the Comptroller and Auditor General’s review. An action plan was developed on receipt of the report, with work underway to address the relevant recommendations. A formal response will be submitted to the Public Accounts Committee by 1st October 2014. Data is routinely collected on all the key aspects of theatre usage and can be accessed for audit or operational use. However the Department accepts that the methods of data capture could be improved and that greater operational use could be made of the data currently collected. |
10 | The Commissioning team acknowledged that there is a limited pool of health staff available on the Island which will have an impact on service development and delivery | The Green Paper ‘Caring for each other, Caring for ourselves’ stated that the increasing demand for health and social care in the future will pose workforce challenges. Most staff want to work in a supportive, modern and innovative care setting where their contribution and their full potential can be realised. P82/2012 offers the opportunity to redesign the workforce and introduce expanded roles with greater responsibility; this can both attract and retain staff. In addition to securing the right number of staff, motivation and retention is important. This includes: - Clear roles and scope
- Control over job performance
- Interesting career opportunities
- Good educational opportunities
- Trust and collaboration
- Recognition
- Effective communication
The Department’s workforce strategy includes: - increasing the number of nurses employed, for example through pre-registration nurse education on the Island
- expanding nursing roles to ensure nursing careers are more attractive, for example through non-medical prescribing
- training health and social care staff, such the BTech qualification in partnership with Highlands College
- delivering more education and training on-Island, for example the degree and Masters courses delivered in partnership with the University of Chester
Jersey is no different from other jurisdictions in facing a recruitment and retention challenge; a proactive workforce strategy with a combination of ‘growing our own’ and recruiting off-Island, along with a good working environment and opportunities, will help to address these challenges. Since 2010, 100 additional nurse posts have been created in HSSD. Because of the strategic approach to recruitment campaigns and local professional training and succession planning, as outlined above, vacancies have reduced - in July 2012 there were 41.5 posts vacant out of 708; in July 2014 this has fallen to 34.2 posts vacant out of 766. |
11 | Since 2012, there has been an improvement in the level of communication between the Health Department and members of the Voluntary and Community Sector | The voluntary and community sector is a key partner is developing and delivering health and social care services, and is also a very valuable and respected ‘voice of the patient’. We are pleased that the Panel has recognised the significant improvement in relationships between the Department and voluntary sector partners. This has come about through willingness and openness on both sides, and through the active involvement of the sector in whole system planning and delivery. Through the P82/2012 investments we have been able to support the voluntary sector partners with additional funding, for example to support the expansion of Hospice services. We have also been delighted to see strong delivery partnerships building, so that now organisations are working together to deliver services. We look forward to seeing relationships further improve and to working even more closely with our partners across the system into the future, delivering a choice of excellent health and social care to Islanders. |
12 | Recent mediation in 2014 has improved the relationship between the Health Department and General Practitioners. However, poor communication during 2012/2013 has caused a delay in the development of a new model of primary care | The relationship between the Health and Social Services Department and GPs has been developing over the past years. As with any relationship, there have been some challenges, but these have not been with every GP or in every area of work. The Primary Care Governance Team came into being in 2011; they have developed positive relationships with GPs, with regular communication – for example, monthly GP meetings and monthly meetings with the Primary Care Body, in addition to meetings with individual GPs and practices. We have worked together on a number of positive developments, including the GP Central Server and the Performers List, which was approved by the States earlier this year. The challenges regarding the new model of Primary Care arose from ongoing discussions and involvement of Primary Care representatives in the selection of an expert partner. As a result of the concerns raised by GPs, the procurement was halted and an alternative way forward was identified through facilitated discussions with the GPs. These facilitated discussions were open, honest and positive; they were not adversarial mediations as the Panel implies. The relationship with the Primary Care Body has improved significantly, and a Primary Care Hub has been set up, where GPs work jointly with officers from the Health & Social Services department and Social Security Department. This is further improving relationships and understanding, and the participants have demonstrated their commitment and enthusiasm to working together in an open and trusted way. |
13 | One of the priorities given to W.S. Atkins was to identify an appropriate site on which acute healthcare services could be delivered. However, their evidence to the Panel stated that they found it frustrating that they were not afforded the opportunity to participate in meaningful clinical team engagement | Initially, the site selection was largely driven by size and site development matters, and therefore the Strategic Outline Case (SOC) could not have been meaningfully influenced by clinicians. The Design Champion coordinated clinical engagement to test whether a dual site option was clinically safe and feasible. WS Atkins produced the SOC Addendum which reflected the dual site design developed by the Design Champion in consultation with clinicians. |
14 | The timeline for completion of the Full Business Cases to introduce more community services, originally due to commence in January 2013, was ambitious and due to a number of factors the timeline changed considerably | Phase 1 of the Transition Plan was scheduled for implementation in 2013 – 2015. This is still the case, and, half way through this period, the vast majority of additional services have now been introduced and are delivering real benefits for Islanders. This includes intermediate care, children’s respite, pulmonary rehabilitation, expanded services at Hospice, Jersey Online Directory, rapid access for heart failure, oxygen therapy, Community Midwifery. The new services are offering greater choice for Islanders, with reduced waiting lists, accessible information to support carers and individualised care. Excellent feedback from those using the services and their carers, and the services are continuing to develop and improve. As the Panel notes, the original timetable was very ambitious, and the timeline has changed through ongoing discussions with stakeholders and as a result of challenge from the Scrutiny Panel. The work to develop the detailed specifications, implementation and delivery plans started in October 2012, following the States approval of P82/2012. In January 2013 we undertook a ‘listening exercise’, as some stakeholders had raised concerns regarding their involvement. Working with stakeholders, we then rescheduled the work plan to ensure that we were responding to their concerns, developing plans together and ensuring the workload and pace of change was manageable. |
15 | The impact of delaying the implementation of community-based care strategies will have a significant effect on determining the size of the hospital | The initial investment into community-based investments was not delayed; it started immediately after P82/2012 was approved. Intermediate Care, end of life care and respite for dementia were all enhanced from late 2012, and have been developing and improving since that time. Long term conditions priority investments were made in mid-2013 and rapid response was piloted from May 2014. A ‘winter pressures’ project ran during 2013, bringing together services from across health and social care to improve discharge. The health and social care reform programme has taken a system-wide, integrated approach to planning and developing services from its inception. This is important because challenges and developments in one part of the system impact significantly on all other parts of the system. As presented in the Green Paper ‘Caring for each other, Caring for ourselves’ in 2011, the health and social care system faces a number of significant challenges, including the demands placed on the hospital. The analysis demonstrated that, if no changes were made, the hospital would quickly run out of beds. It also identified some gaps in community services. For these two reasons the investment in community services was prioritised, whilst the future hospital planning work was being progressed. But it was also important to ensure that the programme of service changes is manageable and realistic; changing every part of the system simultaneously is not possible. The ‘Out of Hospital’ system development has the most impact on determining the size of the future hospital. The aim is to enable Islanders to be cared for at home for as long as possible, reducing the demand on the hospital and on care homes. The services comprise reablement and step-up step down (previously called ‘intermediate care’), rapid response, long term conditions care, end of life care, a single point of access, and older adults mental health. These strategies have already had a noticeable effect on the hospital; in winter 2012, up to 60 beds were closed due to norovirus, but the hospital coped with this because the additional community services had started to be available. The services and the system remain under review, to ensure that investments are made in those services that can have the greatest impact and benefit. In May and November 2013 a ‘snapshot’ audit was undertaken of hospital bed use. This identified some process improvements, and confirmed that the further investment and enhancement of community services (planned for 2014) was required. A formal evaluation of the Intermediate Care pilot was reported in February 2014, and plans for the future service have been developed since that time. In terms of planning further forwards, the Future Hospital and Out of Hospital projects both include very detailed demand and capacity modelling. Activity modelling suggests that the new hospital requires 300 beds, rather than a 400 beds, which would be the requirement if there were no investments in community services. The hospital is being designed and ‘sized’ for 2040 capacity. It will be completed in 2024, but will have the right capacity for 2040 – so some of the capacity should not be needed at that point, which allows some degree of mitigation in the short term to the risk created by any delays in the delivery of community initiatives. |
16 | Following the implementation of the Community Midwife Service most views from GP surgeries were positive about the new system of providing an island-wide antenatal care service in accessible non-hospital settings | The P82/2012 investments are intended to improve choice for Islanders, as well as offering quality and value for money. Very positive feedback has also been received from individuals who have used the Intermediate Care service and Children’s respite. |
17 | Even though the Specialist Fostering service was brought forward to 2013, no specialist foster carers have been appointed to date | As at September 2014, 3 new foster carers and 1 new connected person carer have been approved, as well as 3 sets of level 2 specialist foster carers (where a ‘set’ is an individual or family unit). A further 5 level 2 carers will be approved in the near future. The new specialist foster carers are completing their training; children will be matched to the specialist foster carers according to needs. Due to this increase in local foster carers, no more children have been placed in off island fostering placements this year. |
18 | There is a lack of available health visitors on the Island to undertake training for the Sustained Home Visiting Programme and therefore it has been necessary to recruit from the UK. Family Nursing & Homecare are still in the process of recruiting, and they are therefore unable to implement fully the Sustained Home Visiting Programme | The Sustained Home Visiting Programme has already started delivering services. The implementation commenced in December 2013, and the service was planned to be fully available from October 2014. Two Health Visitors commenced in September. A further Health Visitor will start in October and the final staff member in November. The operational planning has progressed well whilst the recruitment was taking place; the License has been obtained, resources ordered and delivered and Coordinator/Champion appointed. Programme model training has been delivered to 50% of the current Health Visitors, and they have taken a small number of clients each to embed this training. E-learning modules have been completed, and Supervision training to support the programme has been delivered. |
19 | It is unclear to what extent the White Paper development in out-of-hospital care has been taken forward successfully. The one review undertaken by the Health Department - of the intermediate care pilot - is highly critical in that it indicates a lack of readiness to initiate the service as well as a failure to put in place systems to monitor adequately the use of these resources | The Scrutiny Panel has received a number of private briefings and held public hearing regarding the White Paper. The Panel has also been provided with a significant volume of information. Pilot projects are designed to identify challenges and issues, and to provide the opportunity to address these before the full service goes live. Intermediate Care is critical to the success of the White Paper, and therefore needed to be piloted. The pilot commenced in late 2012 and has been monitored and evaluated since, with service developments being made along the way. In terms of the development of the Out of Hospital system; from November 2013 – January 2014, ‘commissioning intentions’ were developed. These identify what services are needed into the future, and were based on discussions with key stakeholders, an understanding of service gaps and needs, and the emerging learning from the Community Intermediate Care (CICS) pilot. A formal evaluation of the Intermediate Care pilot was reported in February 2014. Also in February the Minister approved the commissioning intentions, and agreed that a whole system approach to ‘Out of Hospital’ care would be developed, integrating the Intermediate Care and Long Term Conditions developments into one co-ordinated system. Since that time, FNHC have commenced a Rapid Response pilot, Community and Social Services have progressed their Single Point of Referral (SPOR) and discussions have commenced regarding the integration of Older Adults Mental Health into the system-wide approach. The previously overspending CICS budget has been brought back under control and resources are being effectively managed. As agreed by the Transition Plan Steering Group in late January 2014, the system development will be led through a multi-agency group, with an integrated project approach. A Development Board has been set up, and a Project Brief have been produced which outlines the key elements of this, along with the governance, deliverables and timelines. The Development Board comprises leaders from the key organisations (FNHC, HSSD, Primary Care); their role is to develop and oversee the delivery of the Out of Hospital system, and to address the issues of readiness to initiate the service and the systems to monitor adequately the outcomes and use of resources. |
20 | Proposition P.82/2012 “Health and Social Services: A New Way Forward” required the Council of Ministers to bring forward proposals for investment in hospital services and detailed plans for a new hospital (either on a new site or rebuild on the current site) by the end of 2014. This included full details of all manpower and resource implications necessary to implement such plans | The Council of Ministers intends to report back to the Assembly with the outcome of the Future Hospital Feasibility Study as set out in P82/2012. This was originally intended for the end of 2014, however, S10/2014 acknowledged that there was a significant change to the proposed approach to delivery of the Future Hospital during 2013, resulting in the development of the dual site pre-feasibility concept in October 2013. The Ministerial Oversight Group has therefore approved a revised timescale for delivery of the Feasibility Study for the Future Hospital, which will now report to the States during 2015. |
21 | The Ministerial Oversight Group considered a Communication Plan for public consultation. Its aim was to confirm the preferred site through a States decision to enable detailed feasibility work to follow and design for a new hospital to be developed and procured. However the Panel has concluded that no States decision has been taken on this issue despite being the original intention of the Ministerial Oversight Group | . S.10/2014 acknowledges that within Budget 2014 (P.122/2013) the Treasury and Resources Minister set out for the Assembly details of the proposed Dual Site approach proposed within the Strategic Outline Business Case and indicated clearly that this would form the working assumption adopted within the Feasibility Study – funding for which was supported by the Assembly in approving Budget 2014. |
22 | Although the Department has undertaken some form of consultation on the future hospital, the Panel would have expected to have seen greater and more meaningful public consultation, together with a more detailed analysis of the results | A public communication rather than a formal public consultation was considered appropriate given that no decision relating to the requirements of P.82/2012 was proposed. The Health and Social Services Department and Jersey Property Holdings held an extensive public communication exercise during the period between lodging and debate of Budget 2014 (P122/2013), including: - Four public, key stakeholder and staff focus groups to gauge likely public response to Future Hospital proposals
- Five public events open to all Islanders
- Extensive promotion via social media of a Future Hospital website www.gov.je/futurehospital
- The development and launch of video promotions and animations of the Dual Site concept – these were widely publicised by written, audio and visual media
- Placing advertisements in the Jersey Evening Post, on Jersey Insight and other electronic media promoting the information available
- A comprehensive social media campaign that resulted in over 7,250 people being made aware of the Future Hospital video over 1,100 viewings of the video on YouTube.
Formal consultation will be undertaken as part of the Feasibility Study in advance of seeking Outline Planning applications and as part of the Environmental and Health Impact Assessments. |
23 | Concerns have been highlighted by the general public and States of Jersey employees about the dual site proposal in relation to operating from two sites, efficiency and transport. The Panel has seen no evidence that these concerns have been addressed | The communication exercise clearly demonstrated that the public response to the Future Hospital proposals was overwhelmingly in favour of the proposed changes. In terms of responding to concerns raised, the Acute Service Planning process has actively involved clinicians and other staff. Over 80 engagement meetings having been held to inform the design process already. Concerns raised are being addressed through the planning process: The refined concept pre-feasibility design includes almost 300 staff and public car parking spaces at Overdale. During the Feasibility Study phase, detailed transport plans for both Overdale and General Hospital sites will be used to inform a Transport Impact Assessment that will be part of the Outline Planning Application for the development. Underground parking is being considered for the site, together with further parking for the crematorium. The refined concept pre-feasibility design also includes costs for a frequent shuttle bus service between the general hospital and Overdale sites. This proposal will be tested and quantified further following the development of transport plans as part of the current Feasibility Study. |
24 | One of the reasons for rejecting the Zephyrus site (Waterfront) was the separation of the sites by the main road which would present significant obstruction to providing the necessary clinical and operational links between the sites. This is inconsistent with the later proposal by the Ministerial Oversight Group to operate a dual site hospital from the current hospital site and Overdale, which involves a substantially greater degree of physical separation | The two matters are separate but the responses given by Ministers are consistent. As part of the pre-feasibility development of the Strategic Outline Case, several combined sites were considered for development of a wholly new hospital. These included a combined Waterfront site where the current Waterfront Car Park and part of the Waterfront site south of Victoria Avenue were considered together to see whether a viable single hospital could be developed over the two combined sites. The clinical adjacency possible for this site configuration was very poor and therefore it was not progressed to shortlisting in this configuration. This is very different from the dual site proposal within the Addendum to the Strategic Outline Case which required consideration of a partially new built and part refurbished hospital. Here, the dual site proposal separates ambulatory care at Overdale and acute inpatient care at the General Hospital. UK NHS examples have proved that these two functions can be operated on different locations very successfully. Therefore the two approaches are not comparable in the way suggested in S.10/2014. The first attempted to fit a large wholly new built hospital on to a site with insufficient ground floor footprint necessitating a bridge over Victoria Avenue. The second separates ambulatory care from in patient care in a manner proven by exemplars elsewhere. The point being made by the Minister for Treasury and Resources and the Treasurer giving evidence was that combinations of sites had been considered prior to the Design Champion proposing a dual site in response to the clarification of the budget available for the Project as was evident from the Strategic Outline Case provided in evidence. |
25 | At a Ministerial Oversight Group Sub-Group meeting in February 2013, the Chief Executive of the States expressed a view that unless the cost of the scheme could be reduced down to the levels identified in R.125/2012 (between £389m - £431m), it would be necessary for the project to consider what clinical compromises were necessary to achieve a total project cost of below £400 million | This is correct, however, the Chief Executive was careful to refrain from proposing a suggested budget in the Ministerial Oversight Group Sub-Group meeting in February 2013. The subsequent approach to identify a sufficient budget involved an extensive review of other facilities, a cost challenge and the clinical engagement work, which collectively confirmed that, in principle, a budget of £297 million should be sufficient to enable the priorities for improvement identified by the Health and Social Services Department to be met. This information has been provided in evidence to the Panel. |
26 | Although the Waterfront options had attractions in terms of potential benefits, costs and ease of construction, the Ministerial Oversight Group Sub-Group agreed that any Waterfront option would be out of keeping with the existing Esplanade Quarter Masterplan and would require considerable lost opportunity costs to replace or compensate for the loss of existing uses. Furthermore, the options developed were considered likely to have a detrimental impact on the development of the Jersey International Finance Centre which would form an income stream considered essential for the development of the new hospital | This is correct. |
27 | A wide range of sites were considered by W.S. Atkins between May 2012 and June 2013 including greenfield sites, and many of these were worked up into relatively detailed costings. The preferred option that emerged was to rebuild on the existing General Hospital site. However the introduction of a reduced budget envelope necessitated a reconsideration of this choice | This is correct. |
28 | Although the preferred site option developed by W.S Atkins identified a total new construction and land cost of approximately £462 million, the Ministerial Oversight Group subsequently determined a maximum sustainable total capital funding package of £250 million (excluding contingency) | In June 2013, the Pre-Feasibility Project Board recommended that a more detailed concept for a £250 million first phase of a new hospital be presented within a revised Strategic Outline Case to the Ministerial Oversight Group, together with a package of proposals for transitional capacity and essential maintenance and upgrades and the Ministerial Oversight Group agreed. In practice it proved difficult to achieve the outcomes needed by the Health and Social Service Department within a £250 million envelope and a higher budget of £297 million was subsequently proposed by the Project Board and accepted by the Ministerial Oversight Group as has been provided in evidence to the Panel. |
29 | The design champion identified that a single investment in the General Hospital site would not maximise the benefit of the available investment and would result in a more lengthy and complicated construction programme causing significant disruption and inconvenience to patients. The Panel has found no evidence of his analysis on public record to enable an assessment of the factors taken into account or the robustness of judgements derived from it | In the Minister for Treasury and Resources evidence to the Panel the Treasury and Resources Department confirmed that there was a public record of the Design Champion’s iterative development of the Future Hospital concept. WS Atkins confirmed that the Design Champion’s proposals were sensible given the brief. Therefore an independent professional assessment has been provided. |
30 | W.S. Atkins felt that at times they were set unrealistically short timescales for the delivery of information or reports. They also felt that they were not able to engage fully with key members of the Project Board and as a consequence it was difficult to ensure that they fully understood the challenges of proceeding down a particular route or direction of travel | This may be a correct reporting of WS Atkins International’s view, however, WS Atkins accepted the brief provided to them and confirmed they could achieve the timescale set. It is true that the Project Board did robustly challenge WS Atkins’ assumptions on occasion as might be expected on a project of such significance to the States and this may be the reason for the view given. |
31 | It was not until May 2013 that W.S. Atkins were informed of the available budget for the future hospital project. While it may be appropriate that in the initial stages the contractor is not limited by budget, it should become clear very early on what the budget envelope is likely to be so that appropriate value is obtained from consultant time and expertise | It is true that W.S. Atkins were informed of the available budget for the future hospital project in May 2013. However, W.S. Atkins, who were employed as consultants not contractors, also confirmed in their evidence that it was not unusual for a budget not to be confirmed until a public authority had determined what could be afforded. Ministers took time to challenge all elements of the Strategic Outline Case to establish that the budget for a wholly new hospital was fully robust. As soon as it became clear that the cost of a whole new hospital would be unaffordable, the Project Board reviewed the available alternatives in relation to the spatial standards, cost assumptions and re-use of some hospital buildings. |
32 | A greenfield site for a new hospital would have been the best option in terms of less risk, more benefits and a lower overall cost | This is agreed, however, no suitable greenfield site was identified that would be capable of development for a whole new hospital.. |
33 | The process followed to appoint the design champion was flawed. Others were not given the opportunity to apply for the post and W.S Atkins were unaware that an appointment was being made to conduct work of direct relevance to their own pre-existing and continuing appointment | Financial Directions allow for appointment of consultants where time does not allow for a full procurement and a suitably experienced and qualified candidate is available as in this case. WS Atkins were made aware of the appointment; their own appointment had concluded at that point and it was an extension of their work that followed under a new brief to produce the supporting Addendum to the Strategic Outline Case. |
34 | Although the dual site offers a potential solution for a reduced budget, the current proposal means that 44% of the existing hospital will be new build, 30% will be refurbishment and the remainder will be existing use. This will inevitably result in a need for further capital investment in the future | It is inevitable that further capital investment will be required at some point in the future for the hospital. However, Ministers accepted collectively and in principle that the dual site concept set out in the Addendum to the Strategic Outline Case represented good value for money and an affordable investment as well as a safe and sustainable hospital provision. |
35 | The result of W.S. Atkins pre-feasibility study dated May 2013 was that a phased development of the existing hospital site offered the best location for key investment in future hospital capacity following which a draft Report and Proposition was prepared detailing the outcome of the pre-feasibility study. The Panel note that this did not mention Overdale hospital or the dual site concept | The draft Report and Proposition was policy in development and was never progressed. Instead the Ministerial Oversight Group accepted the Pre-Feasibility Project Board recommendation to develop a more detailed concept to an indicative £250 million budget. The dual site option emerged after this decision. |
36 | There are conflicting views on who identified the dual site solution. On the balance of the evidence, it seems most likely that the dual site solution had not been identified as an option until it was introduced by the design champion in July/August 2013 | This finding is based upon a mis-communication during the public hearing as is explained in response to finding 24. |
37 | During the development of the future hospital, options have been continually developing. As assumptions change the basis for comparisons also change and it is therefore necessary to present clearly what is included in the various options. This has not always been apparent in the documentation provided to the Panel and it is therefore questionable whether all option have been compared on a like for like basis | In each case where an option was under serious consideration a full feasibility cost estimate was produced in line with a consistent best practice protocol (the UK NHS Health premises Cost Guides) by a local qualified quantity surveyor. As the brief changed so did the assumptions within the cost estimates. |
38 | The proposed dual site option is not included in previous options produced by W.S. Atkins and which reflected the original brief, which in turn reflected the intention of P.82/2012. The impact on patient care of this decision to go with a lesser mix of new and refurbishment has not been made clear and is not in the spirit of the decision to provide new modern hospital facilities in Jersey | Proposition P.82/2012 “Health and Social Services: A New Way Forward” requires the Council of Ministers to bring forward proposals for investment in hospital services and detailed plans for a new hospital (either on a new site or rebuild on the current site). The dual site refined concept proposal is consistent with this proposition. Whilst a wholly new hospital has been confirmed as unaffordable, the dual site proposal includes proposals for a new hospital (the ambulatory care centre at Overdale) and new build and refurbished hospital on the current site. All of the published communication with regards to the dual site is consistent with this approach. |
39 | Although estimated revenue figures will be refined alongside the detailed feasibility work, the additional cost of operating on a dual site is estimated by the Treasury Department to be an annual recurrent cost of £1.7 million in 2019 when the Overdale site is planned to be opened. The Panel has found that as the dual site concept was identified at a late stage, a high level analysis of the estimated revenue consequences had not been undertaken when all other options were being considered | The appendices in both the original Strategic Outline Case and the Addendum include estimated revenue consequences. A significant number of sites were evaluated and subsequently discounted, and it would not have been cost effective to develop revenue costs for all of these options. All shortlisted options were analysed for revenue implications. This information was provided to the Scrutiny Panel during their review. |
40 | There is a lack of clarity around the decision-making process in determining the size of the budget and why a 100% new build hospital was unaffordable | The decision making process and the record of it have been made available in evidence to the Panel. The process followed to arrive at an acceptable budget was iterative and the result of a combination of cost challenge, challenge to spatial assumptions, benchmarking and re-analysis of planning assumptions. |
41 | The Panel conclude that although mention was made of the dual site proposal in the 2014 Budget report, no formal decision has been taken on this issue as it was not included in the proposition | Whilst the final decision on the approval of the Feasibility Study will be a matter for the States Assembly, the Dual Site concept informed the funding strategy approved by the States in approving Budget 2014 (P.122/2013) and awarding £10.2 million feasibility study funding. As such, Ministers consider that a decision of intent to adopt a dual site solution as suitable for consideration in the feasibility study has been made by the Council of Ministers and that the States Assembly was fully aware of this intent in approving P.122/2013. |
42 | The purchase of the two hotels in Kensington Place would make a sensible strategic investment for the States of Jersey as well as providing space to facilitate the development of the existing site | Strategic investments will be considered against affordability and space requirements. As the Feasibility Study develops the potential for this site will be considered robustly and Jersey Property Holdings have been instructed to establish the price for which the site might be secured to inform the Feasibility Study. |
43 | Due to the limited budget proposed by the Ministerial Oversight Group, W.S. Atkins explained that a target figure of a 15% reduction of room sizes below the UK NHS spatial guidance has been adopted | This is the assumption within the Addendum to the Strategic Outline Case and is a working assumption within the Feasibility Study. Analysis of spatial standards provided to the Panel indicated that very few UK NHS hospitals were constructed in accordance with the NHS Design Guidance and that many international hospitals, including in the USA and Australia, had reduced spatial standards in many rooms. Patient safety will be a primary aim of the Feasibility Design, and space will be assessed on this basis. If space and cost can be reduced safely this will be proposed within the response to P.82/2012. |
44 | The 1960s building situated at the current hospital site has been excluded from the planning as it is not fit for clinical use. Therefore, at the end of the hospital project, the 1960s building will still stand but it is not clear what purpose it will serve in the future, or whether optimum value from the current site is being achieved | The 1960’s building has not been excluded from planning but is not considered suitable for clinical use in the long term. The Feasibility Study is investigating whether the building can be used for non clinical support and administrative functions as part of the overall site development. |
45 | Although the plan is for the Overdale site to be completed by 2019, the overall hospital project will be completed by December 2024. The cost of the project so far totals £574,534 | There are significant risks in undertaking too much refurbishment at one time in the Island’s only hospital whilst it has to remain operational. The Feasibility Study will consider ways to reduce the construction timescale to the minimum possible. |
46 | There appears to be a lack of progress in strategic planning for acute services and services provided on-island/off-island since 2012. The acute services strategy is not complete and as with the absence of a primary care strategy, has created major difficulties for the Panel in reaching a conclusion about the robustness of the plans for the role, range and scale of future hospital services | The concepts underpinning the Acute Services Strategy have been in development for some time, and have been produced with Clinical Directors and Senior Nurses. The dual site option in late 2013 changed the emerging Acute Services Strategy. The Future Hospital Project Director was recruited in December 2013; as a clinician, his role was to engage with clinical colleagues to develop an Acute Services Strategy and plan based on a dual site concept. Developing a strategy, in partnership with a wide range of stakeholders, is a time consuming but necessary process. The Acute Services Strategy is currently being consulted on to test the degree to which the strategic principles, strategic objectives and clinical model it describes reflect the contributions made by stakeholders. |
47 | One of the reasons for the dual site concept was because of the potential disruption redevelopment of the current hospital site would cause for staff and patients. The Panel accepts that construction by its very nature does cause disturbance, but there are ways to minimise this both for patients and staff. Lessons and experience from other hospital redevelopments which have managed their levels of disturbance well could have been explored further rather than opting for redevelopment and new build over two sites | The Dual Site Option is an option that meets the HSSD Departments needs within the budget identified. As part of the planned Feasibility Study development, a comparable single site option will be prepared to demonstrate the performance of a single site option compared to a dual site alternative. The cost comparison work will be made available as a Report, with cost information provided to the Panel under commercially confidentiality protocols. |
48 | The Minister for Treasury and Resources stated that the central assumption for growth in the Strategic Reserve is based upon investment returns averaging 5 per cent over the next 10 years. The Minister also stated that with such an investment return, the hospital funding of £297 million can be fully met and the Strategic Reserve would rise to a value of £810 million. It is unclear what the plan will be if the fund does not return the anticipated sum of money when it comes to funding the capital projects | The Minister for Treasury and Resources made clear in evidence that in the unlikely event that investment returns from the Strategic Reserve were not sufficient to fund the hospital investment then adjustments would need to be made according to the prevailing economic conditions. In 2013 returns on the Strategic Reserve were such that, after taking account of inflation, £79.4m has already been secured by 31st December 2013. The Strategic Reserve continues to make strong returns in 2014. |
49 | The Minister for Treasury and Resources made a commitment within the Budgets 2014 and 2015 that the hospital project will be fully paid for by the time it is completed and there will be no cost to the taxpayer and no debt for future generations | This is correct but was caveated by the assumptions stated within Budget 2014 (P.122/2013). |
50 | The Long-Term Revenue Plan is being developed by the Treasury and Resources Department. This aims to provide a higher level of funding certainty and will enable long-term sustainable financial planning by the Health Department. It is understood that the sustainable funding mechanism for health and social care will be achieved via the Long-Term Revenue Plan by the end of September 2014 as agreed in P.82/2012 | The States has embraced longer term financial planning. The Treasury & Resources Department continues to develop a working document that helps to identify issues and potential measures that must be considered when reviewing the next MTFP period. All funding pressures and growth requests from Departments feed into this document alongside future income projections and economic assumptions. This includes funding requests identified by H&SS. How those and other pressures are funded is a policy decision that has not yet been made. That policy decision will be guided by the professional advice already received, the advice of the Expert Panel, as well as current thinking in the UK and elsewhere in the world, for example the very recent report of a Commission of the Kings Fund, chaired by Dame Kate Barker , who is also a member of the FPP. |
51 | The Long-Term Revenue Plan will confirm the level of investment in health and social services into the future. The Panel was informed that it will not propose a separate health fund in addition to the existing Health Investment Fund and Long-Term Care Plan. The Treasury Department explained health services are a public good and as such must be rationed to prevent an unsustainable impact on the wider Jersey economy | The Long Term Revenue Planning Review includes the level of growth required by H&SS for the next MTFP period. These pressures must be considered alongside all other requirements across the States. No decision has been made as to how costs will be funded. |
52 | The Minister for Health and Social Services recognised the requirement that the funding mechanisms for primary care link with the sustainable funding streams for the whole of health and social care and that proposition bii and biii in P.82/2012 link together. It is therefore unclear what impact the delay in completing the new model of primary care will have on the sustainable funding mechanism for health and social care | Each of the elements of P82/2012 link together. The Ministerial Oversight Group retains an overview of the entire programme, and officers work closely together to consider the interactions. The sustainable funding work-stream continues to be developed and it is not envisaged that any delay in completing the Primary Care model will affect the solution to identifying a sustainable funding mechanism for Health and Social Care in principle. |
53 | The work being undertaken to develop a new model of primary care and sustainable funding mechanism for health and social care is likely to impact on the Health Insurance Fund held within the Social Security Department. It is expected that an increase in contributions will be required from individuals in the future | Until that work has been finalised, it is not possible to say what effect that solution will have on any existing contributions to existing Funds, as it cannot be presumed that the current funding structure of the HIF will be maintained. What is clear is that the ageing population will place rising pressures on Primary Care as well as on secondary and community services and will require an increased funding alternative, however delivered. |
54 | The Long-Term Capital Plan, published as an appendix to the Medium Term Financial Plan 2013 – 2015 and developed by the Treasury and Resources Department, estimates that £332 million would be required in 2016 for the hospital but this figure did not reflect additional costs of construction in Jersey compared to the UK. The budget figure was to be developed once there was greater certainty arising from the feasibility work | The £332m MTFP estimate comprised £300 million for the new hospital. This was an indicative figure provided by KPMG, based upon a UK assumption that new hospitals cost approximately £1 million per bed and £32 million for transitional capacity – and was at 2010 prices. Subsequent work in pre-feasibility has established a more detailed cost estimate. |
55 | Within the 2015 Budget it is proposed that contributions to the Long-Term Care Fund in 2014 and 2015 are deferred in order to balance the Consolidated Fund | As the scheme only commenced on 1 July, at this stage it is difficult to know whether the payments out of the scheme are likely to differ significantly from the long term forecast which was developed from the OXERA model and was the subject of an Internal Audit Review. Given the above, assuming the modelling is accurate, it was agreed that up to £5 m in each of 2014 and 2015 could be taken from the previously agreed transfers and returned to the Consolidated Fund. This matter will be kept under constant review. |
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