Hospital modernisation

In March 2019, HSC presented a policy letter to the States of Deliberation setting out its proposals for the modernisation of the PEH. It was unanimously supported by the States and we now embark on an exciting new chapter in its history.

Sir, It was in 1949 that our future Queen officially opened the building that was to bear her name, the Princess Elizabeth Hospital. In those intervening 70 years the hospital has played an increasingly important role in the protection, promotion and enhancement of the health and wellbeing of islanders. The work undertaken 24/7 behind its walls has contributed in no small way to residents having amongst the highest life expectancies in the world. 

The hospital, or as we all know it, the PEH, has had such an important part to play in our community since it was opened. It is where life begins and ends. It is where lives are saved or improved, it is where we learn what it is to be a mortal human being and who and what are most important to us. 

We should be proud of having such a facility on such a small island. There must be very few places in the world that could boast a hospital providing such a range of services for such a small population. There is a tendency to take it for granted but we should not. We are very lucky indeed.

And that is because over the years previous Boards and Committees in various guises have seen the need to adapt it in an ever changing landscape. New innovations in medical practice, advances in scientific understanding, medical research and technology, have all helped to improve outcomes but they have also put increased demands on the physical infrastructure.

There has probably not been a time when the need to expand and adapt the infrastructure of the PEH has not been either discussed or implemented. Now a few months back I read a piece about post war period of health care in Guernsey written by the much respected Dr Brian Seth-Smith who spent a lot of his working life working at the hospital and who sadly died in January. In this article he talks about Plans for Phase 1A and B to create a new Children’s Ward, operating theatres, central sterilisation department, pharmacy, post-mortem room and supporting service area which were first drawn up in 1966. Apparently, these were thrown out by the then States as being too grandiose, with one speaker stating that he didn’t want a mortuary, as he didn’t see why we should spend money on the dead. 

But, plans were eventually accepted in 1971 and that first phase of development was completed 15 years later. Dr Seth-Smith made the comment though that, whilst an excellent design, it was unfortunate that x-ray and receiving room were at the Vauquiedor end, far from the theatres and wards.

The most recent developments covered off the new clinical block completed 9 years ago now, and the Oberlands Centre that was opened in 2016. 

Just as it has been a focus for our community over the last 70 years, the PEH Campus has a big role to play in the development of our new model of care – the Partnership of Purpose. We see it as the backbone of the system, with the long term intention that it should be the focus for the delivery of secondary health care, including the acute hospital, mental health services and diagnostics.

However, we are struggling with what we have now. The design is inflexible and makes it difficult to implement new technology and new ways of working. Some of the areas are very dated and costly to maintain. Just recently we had to close a theatre because of a water leak into the air filtration system which followed a more serious leak last year. Added to that there are the problems with asbestos in various areas which mean that when repairs are needed, say in the plant room under theatres, staff have to wear full protection gear and the whole process takes much longer than if it was a benign environment. 

We are unable to meet various building regulations and standards because of the layout and parts of the site do not support those with a disability, nor provide the best working environment.

The 10 year modernisation programme that we are presenting to members today is an essential catalyst for change enabling greater integrated patient centred care in a modernised hospital that is safe, flexible to meet future needs and which ultimately will improve patient experiences and outcomes.

The programme is divided into 3 phases to minimise the impact on the delivery of services. At the same time it spreads the capital cost over a number of years and should benefit the local construction industry. Details are provided in the policy letter and I won’t repeat all that is said in there.

However, I think it is important to focus on a few points relating to Phase 1 for which we are seeking funding approval today.

Various reviews, including that by the NMC in 2014 into maternity services, have highlighted the issue of the distance of Loveridge, the maternity ward, from theatres. At the moment staff have to undertake drills to ensure they can get women who need an emergency caesarean section from to the ward within 20 minutes. The main risk area being the fact Loveridge Ward is on a different level to the theatre block and therefore a lift is needed. The plans seek to address this issue.

However, this won’t be just a simple lift and shift of Loveridge and Frossard, the children’s ward, but address other limitations of our current offering. This includes a dedicated area for children and young people presenting with mental health issues, space that is more suitable for adolescents and a means for treatment away from the wards. 

Now, the backlog with regard to orthopaedics is well known and thanks to support from ESS and P&R and an incredible amount of hard work by HSC staff, we are now actively tackling it. However, a key limitation to us and what needs to be tackled if we are to minimise the risk of this happening in the future, is the infrastructure.  A real pinch point that is impacting on the number of operations that can be undertaken and causes a higher numbers of postponements than we would like is the number of critical care beds. This is an increasing problem as the age of those we operate on rises. Whilst in the past we may not have operated on 70 and 80 year olds, this is becoming more and more common. Those patients are more likely to have other underlying health conditions which means they need more care post-op in the critical care unit beds. We currently only have 7 such beds, which means we are very vulnerable to any emergency or trauma cases that arise. The plan is to create enough space that will enable us to start with 10 beds and later to 12. 

The plan is for a new theatre block, to include critical care unit to be built that will enable the latest technology including robotics to be introduced, whilst reducing the problems we are currently experiencing in terms of maintenance.

As part of phase 1, work will be undertaken to identify the most suitable location for MSG staff and consultants. This will then enable any building works to be undertaken in phase 2 and within the 7 year deadline when their current leases expire. Having consultants on site will be conducive to greater integrated and patient-centred care.

Throughout the programme we will be building in better support for those with a disability. This will include signage that will support those with conditions such as dyslexia and dementia, as well as new facilities such as changing places toilets.

The overall anticipated costs for the programme are between £72.3m to £93.4m. The first phase, due for completion by 2021, will cost between £34.3m to £44.3m. It’s probably worth noting that Jersey has spent a similar sum just trying to identify where to put their new hospital. We are fortunate with the site we have.

It is for phase 1 that we seek funding support for now. We will be coming back to the States In respect of Phases 2 that will cover orthopaedics, day patient unit, relocation of MSG, equipment library and private wing, and Phase 3 which will include pathology, pharmacy and emergency department as the programme progresses.

Finally, I can’t finish without mentioning transport and parking. The Committee understands the frustrations for those visiting the PEH who find it difficult to park. It impacts us as we don’t have dedicated spaces and our friends and families. Seventy years ago the PEH had 20 parking spaces. 50 years ago it had 120 spaces. Today there are 750 parking places across the Campus. Those are the official ones, not including people parking across grass verges and down side roads. And still it’s apparently not enough. Whilst at peak times we are around 50 spaces short, outside of those times there are plenty of spaces going spare. 

We will shortly be adding 80 additional temporary parking spaces that will help as works get underway. However, we can’t just look at pouring more tarmac over the site. History has shown it just doesn’t work and is not value for money. Thanks to the support of E&I a travel strategy has been developed for the Campus and the Committee will receive the report very soon. We hope that this, combined with the development of new staff changing facilities which is currently underway, will help in the creation of a more sustainable long term solution.

Sir, in summary, the overriding aim of the hospital modernisation programme is to improve the experience of anyone needing our services. From the moment that they arrive on the PEH Campus, get the care they need when they need it and leave. We want that experience to be as stress free as possible and with the best outcomes as possible. But more importantly we want it to be a joined up part of an overall seamless experience of community care for all. 

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Health & Care Regulation

In February 2019, HSC presented its proposals to the States of Deliberation on the future regulation of health and care. These were overwhelmingly supported. This is my speech opening debate.

Sir, As members will know, a key aim of the partnership of purpose is proportionate governance: ensuring clear boundaries exist between commissioning, provision and regulation. In the policy letter setting out the new model of health and care, the Committee for Health & Social Care stated that it is likely there will always be some overlap between those who decide what kinds of services should be provided and how they should be paid for, those who provide these services and those who regulate the services to ensure safety. However, there needs to be, in particular between commissioning and regulation, a framework which is proportionate to the size, resources and requirements of the Bailiwick, to ensure appropriate separation.

This Assembly supported that policy letter and the proposals in front of members today support that key aim as well as being a priority of the Policy & Resource Plan.

The current system of regulation is fragmented and has evolved over many years. What we are seeking to do is not destroy it and put in a huge great regulatory structure in its place, but build on it and develop a more robust independent regime. There are areas where there is a lack of professional regulation such as in domiciliary care, lack of systems regulation – such as for the majority of States services, a lack of flexibility to respond to evolutions in health care provision, insufficient emphasis on safeguarding and a lack of regulatory independence. These are what we are seeking to address.

As Prof Dickon Weir-Hughes states in his report for the Committee, the subject of regulation in any sector often gives rise to concerns about cost and proportionality, especially amongst taxpayers. However, as he says, ‘one of the key benefits of providing health and social care in a relatively contained island community that is not burdened by the bureaucracy of larger jurisdictions is the opportunity to develop regulatory approaches that are both world leading and proportionate.’

Now, when we say world leading, we don’t mean gold or platinum plated. It is not about how much money you throw at it and how complex you make it, but how effective it is. Those are not necessarily the same thing as the 2008 financial crash showed.

Fundamentally, the Committee was determined that such regulation should be appropriate and proportionate to the size of the Bailiwick. What does that mean?

Well we did not believe that replicating the regulatory system for the financial services industry would be appropriate and neither did we believe adopting the hugely complex system in the UK would be proportionate. Ultimately we need to consider proportionality in terms of risk.

And in doing so, we don’t want to reinvent the wheel. There are a wide range of internationally accredited schemes, such as CHKS for GP practices and Magnet for hospital services that exist around the world. We will evaluate those that make sense for our community and adopt where necessary. Where there are no ready-made schemes seen to appropriate we will set our own, again taking an appropriate and proportionate approach.

We are proposing that regulation will be the responsibility of an independent commission. This is important to ensure there is no political interference and it can equally hold the public and private sector to account. But, perhaps more importantly, having that independent function will support continual improvement.

We are not proposing that the Commission will have a heavy inspection system but one that ensures compliance with standards and schemes, but that it will have the power to step in and inspect or take other action where concerns have been highlighted. Neither are we proposing it will employ a large team of people. The complexity of the system would not justify it. Instead, there will be a core team that will bring in expertise as, and when, required.

The aim will be to develop an Enabling Law to establish the Commission and give power to the States by Ordinance to prescribe or authorise adoption of designated accreditation schemes or local standards and other appropriate regulatory measures.

After that, the individual standards will then be set and approved by the States, with a focus on those with the highest priority, being the unregulated domiciliary care workforce and acute hospital services.

We have been working closely with Jersey in the development of this policy letter, and whilst they wish to adopt a more heavy inspection system and have other priority areas in terms of regulation, we both believe there is an opportunity to share the Commissioner function and will continue to work with them if this policy letter is approved to ensure that our Enabling Law makes a shared Commissioning function possible and how we can put it into practice.

No one really likes regulation. And I have stood up in this place more than once raising my concerns. Most recently on Data Protection. But, it does seem to me that there are some who, possibly understandably given the extent of regulation that has grown over the years, lost sight of a core purpose – to protect people from harm – be it financial, social, environmental, physical or mental. Surely nowhere is regulation more justified than in matters of life and death. 

I’d ask those who think this is just another piece of unnecessary regulation, are they happy that anyone, without any police check or any qualification, can enter the home of their frail and vulnerable mother or father to provide very personal care? Are they happy that their 14 year old daughter can get their eye lids lifted or lips botoxed from a hotel room? Are they happy that their depressed wife or husband can get self-styled counselling from someone with no recognised qualifications?

There are some who think we don’t need it for ‘an island of our size’. Does that mean we don’t need finance regulation too? Or is money more important than our people? An island of our size wouldn’t have a general hospital the size of the PEH. Are those same people saying we ought to close it down? To those who believe a priority should be a sound foundation for health and later life care’, I would say, it is difficult to think of a sounder foundation than ensuring appropriate standards  through professional and systems regulation in the health and care sector.

Now, we estimate the total costs will be around £368k, although not all the costs are new. How this will be paid for and how much those who will be licenced will have to pay will be the subject of further engagement but I would point out to those who believe this is too much to spend on regulation, it pales into comparison with the extra £800k members supported for another regulator only a few months ago – the Data Protection Authority and represents 0.2% if the total health and care spend.

It’s also worth pointing out that the lack of an independent regulatory regime was a stated concern of the NMC when they undertook their review in 2014 and with whom our nurses and midwives are registered. They expect that their members to be working in a regulated environment. Were it to be decided today that we do not a proportionate and appropriate system of regulation, that we are happy not to protect our workforce then at the very least, it will not be looked on favourably, at worst, they may consider nurses may not be revalidated whilst working here. Not only that, it could mean that we are no longer able to provide on-island training of our nursing workforce. These are very real risks.

Let’s also not forget that this is also welcomed by those in the health and care sector, with whom we have had extensive engagement. Regulation may be seen to just add to bureaucracy but it can have benefits. And one particular area is in terms of post-Brexit preparedness with the European Commission, having recently published a report on the increasingly important role of health care assistants and with it, the importance of having an overview of the knowledge, skills and competencies they need. As they say, such an overview can help patient safety while at the same time facilitating professionals’ mobility.

So, sir.

I understand those who say, not more regulation. But let me ask those naysayers, if you had a list of all those areas that are currently regulated, would you say care regulation is less important than all of them? If you do think this is one piece of regulation too many, then is it not better to repeal those pieces of regulation that you believe are unnecessary red tape?

Appropriate and proportionate care regulation is about the Bailiwick being a mature, credible and economically attractive jurisdiction. 

It’s about people getting the service they need not stifled by bureaucracy or wary of punishment so they don’t innovate.

It’s about people knowing what to expect and what is expected of them.

It’s about promoting quality, minimising harm and strengthening trust in the health and care service.

Our proposals are innovative, cost effective, sustainable and most importantly, have the potential to improve health and care across the Bailiwick.

For all those reasons I ask members to support this policy letter.

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Public Accounts Committee Legacy Report

  • Firstly, work together as a team. It has been a pleasure working with a bunch of intelligent people who have worked together, can have robust conversations, but listen and respect each other’s views and come to a consensus. The PAC has certainly demonstrated that it can be done. We live in a consensus system and it is as important for the SMC as it is for every other Committee of the States. I just hope that continues in the next term.
  • Secondly, don’t follow your own personal agenda. This will be even more important to be aware of where the whole scrutiny function is concentrated in just 3 Deputies and 2 Non-States Members; and
  • Thirdly, Remember that what you want is to make government perform better. That can mean a balance between making a quick headline and working behind the scenes to make things happen. A recent report into the effectiveness of Westminster select committees in the last term stated that whist some committees took the big bang approach, they did not necessarily produce long term improvements. In fact it can lead to the bunker syndrome. A balance needs to be struck.
  •   Sir, finally, and without wanting to make this sound like an Oscar acceptance speech, I would like to thank all those members of the Committee during this term. It has been a realtievely stable committee with changes only arising from the untimely death of Alderney Rep Paul Arditti and the departures of Deputies James and Le Clerc for an easier life on HSSD. I thank everyone for the positive contribution they have all made.  I have been honoured to represent you in this Assembly. There is an old adage that says, It should be noted that if you have something to note, then note it. Do not note that the item you wish to note should be noted. With that in mind, I ask members to note this report.]]>

    Secondary Education Report – 11 Plus

  • To give preference to students on free school meals in the admission border zone.
  • To ensure the 11+ reading test does not have a ‘middle-class’ bias.
  • To set a test that restricts the benefit of an 11+ tutor.
  • These policies have increased the proportion of childnre on free school meals who attend the school from 6% to 8% in 2015. So, it can be done. I suppose to me the most important issue is not about equality of opportunity but fairness, which is part of the criteria that the department are said to have considered. Is it fair that every child gets the same education rather than the education that its them? We don’t have a failing system. All the schools are doing very well, or so we’re told. So, why would we want to throw everything up in the air and hope that a bespke untried system will work better, when we don’t know what better is? That is the issue for me. I don’t have a strong ideological viewpoint, but I wish I did as it would make it so much easier. I just don’t see that getting rid of the 11+, or selection generally, will lead to Nirvana. For that reason I can’t support Amendment 1 but will support Amendment 2.]]>