Wednesday 29 June 2016
Delivered by Deputy Soulsby, President of the Committee for Health & Social Care, to the States Assembly on Wednesday 29 June 2016
**Note to media - check against delivery**
Sir, following my speech yesterday in relation to the 2015 results for HSSD, my statement today will cover the situation for this year, the immediate action being taken and, on the back of the President of Policy & Resources' speech earlier, set out what transformation means for Health and Social Care and steps being taken to make it happen.
As at the end of April we were, as Deputy St Pier said 3 weeks ago, looking at an overspend of up to £4.5m. This is very much an estimate. Because, whilst there has been improvement in reporting as a result of new requirements put in place by the previous Board, forecasting has required considerable improvement.
To address this, and as part of the 2016 business plan, work is underway to simplify the month end processes to ensure figures can be produced in a more timely, accurate and meaningful way. This includes ensuring that reporting from budget holders is consistent across the service. Everyone needs to understand that budgeting and forecasting is not merely the preserve of the finance function, but one which needs ownership across Health and Social Care.
The major causes of the overspend are, as last year, a result of the dependence on agency staff and a number of high cost off-island acute cases and I will now set out how we are trying to address these issues.
Members will be aware from my speech yesterday, of the budgetary challenges of using agency staff. Recognising this impact, Health and Social Care has, this month, entered into agreements with a limited range of pre-approved agency providers. This should mean that we have the required number of agency staff but at preferential rates. However, the maximum benefits will not be felt immediately until existing contracts expire.
In addition to tackling the direct agency cost, 2 weeks ago we introduced a 'challenge and sign off' system whereby service managers must formally consider whether a vacant position is absolutely necessary. Where they believe a position does need to be filled, it will also require approval at Director and Chief Secretary level. In a care environment we appreciate the opportunities will be limited, and this clearly will not apply to hard to recruit areas where we are taking action to improve recruitment. However, the system is designed to ensure managers across our services consider all options. We need to change the mind-set that we can automatically replace like with like.
Linked to this, we have undertaken a Skills Mix Review to ensure we have the right nursing staff, at the right level, better deployed to meet patients' needs. Currently we have different specialisms with different terms and conditions, different ways of working and different structures. Work has begun to implement the recommendations of the review, which should provide nurses with a much clearer career pathway, improve recruitment and develop qualified nurses for roles required for transformation. Moving to the appropriate skills mix will then give us more flexibility, which in turn will reduce the need for agency staff and potentially enable us to consider a new pay structure and an alternative to agenda for change. It will not happen overnight and is not in the hands of Health and Social Care alone, but the work has begun.
In relation to off-island acute cases, Health and Social Care is often unaware of treatments undertaken until the bill arrives from the UK hospital. There is currently no requirement under the current secondary healthcare contract for consultants to seek Health and Social Care's approval in advance of committing what can sometimes be considerable costs.
This does not mean that off-island referrals are inappropriate, but it does mean that we have little control over our budget in this area. Various long term solutions are being considered but for now work is being undertaken to find out why the number of cases is increasing and whether there is any short term action that can be taken.
In other areas, the Multi-Agency Support Hub, which enables a single point of entry for child help and support, has started to remove duplication of work across multiple agencies involved with child protection. In addition, the Communities team are exploring initiatives to enable people to be cared for longer in their own homes, which will decrease the pressure on very expensive hospital in-patient services.
This is not an exhaustive list. Other opportunities are being actively explored, but with the understanding that these need to be carefully considered to ensure there are no unintended consequences.
However, we can't get away from the simple truth that the current model of health and social care is unsustainable. It's been known for over a decade. It was formally acknowledged in the 2020 Vision 5 years ago, and whilst we have seen significant social policy strategies approved in the last States - MHWBS, D&I Strategy, SLAWS and CYPP, there is little if anything the public will have noticed that has changed.
The 2020 Vision said we would be in the financial position now if nothing changed. It is in black and white. If we continue as we are we will see costs double by 2050. The ageing population, falling tax receipts, expensive technology, medical inflation, increased regulatory burden and increased expectations mean doing nothing is not an option.
And I think it is important here to make it clear here that we are talking about the whole of health and social care costs. Whilst we have seen an increase in general revenue expenditure of 43% in the last 10 years, looking at the Health Service Fund, managed by Employment and Social Security, we have witnessed a 70% increase in secondary healthcare costs as a result of the growing number of consultants funded by the States. That is why the secondary healthcare contract needs to change.
We need to do things differently, consider new ways of working in a more integrated system of health and social care. We have a complicated mix of a system that has evolved over years as a result of singular decision making when what we now need is to ACT STRATEGICALLY.
And with that in mind, the Committee for Health and Social Care has already begun to establish rules to guide it in future strategic decision making, to set priorities and to help it develop the structure of the new healthcare model. Due to the importance in terms of the implications for change, and the difficult decisions that inevitably will have to be made to get to a sustainable model, we will be seeking endorsement of those rules from this Assembly as soon as is practically possible.
In addition, we will be looking to work more closely with Jersey. It is ridiculous that as 2 very similar islands, sharing the same issues, that we replicate so much. At the end of the last term, following a meeting myself and the then T&R Minister attended with the Chief Minister, HSSD Minister and their counterparts in Jersey, it was agreed that we would explore 3 areas of efficiency opportunities in healthcare provision, namely: procurement - both the commissioning of services and the procurement of general goods to get a better deal for the goods and services we need; care commission regulation, to develop a regulatory structure proportionate and appropriate to our distinct Islands' needs and the broader considerations and approaches to Public Health arrangements. Now the election is over, this is something we are keen to progress as quickly as we can and meetings are being planned as I speak.
In addition to the above, Health and Social Care is currently applying, later than I would have wished, for the allocated funding from the Transformation and Transition Fund that will enable us to have the resources to get a full grip on the immediate challenges, as well as transition to the new way of working. This will include the development of a needs assessment that will be used in conjunction with the Rules I referred to above, in order to redesign our model of health and social care.
Sir, BDO, in their report into the costing, benchmarking and prioritisation of our health and social care services, gave the following reasons why little progress has been made since the 2020 Vision was approved;
Lack of capacity and capability
Poor information and commissioning systems
Volatility of senior leadership
Complexity of running acute and community Health and Social Care
Powerful vested interests.
We have to overcome all these issues if we are to make transformational change and as I will continue to say, we will only be able to do so through greater partnership and engagement within and outside the states, the resources to do it, and improving communication to enable us to take staff, politicians, partners and wider public with us.