The big spender

Committee for Health & Social Care

May 2016 deputies: Soulsby, Tooley, McSwiggan, Prow and Mooney

January 2018 onwards: Soulsby, Tooley, McSwiggan, Prow and Tindall

IT IS PERHAPS inevitable that the abiding public memory of the 2016-20 Committee for Health & Social Care will be defined by its central role in the Bailiwick response to the Covid-19 pandemic. So be it. But my task is to review the committee’s performance across the pre-Covid political term, which was only two months short of four years.

With a 2020 budget of close to £125m., HSC is the States’ biggest spender by far. With that amount of cash at stake, any assembly of States members needs to be very careful about who it hands the credit card to on behalf of the community, who in turn are entitled to look back and ask ‘what did they do with it?’

With that in mind, establishing stability and financial control across such a large and multi-disciplined organisation will have been among Deputy Heidi Soulsby’s top priorities when she gathered around her a team of first-time deputies in May 2016. Or put it this way, if it wasn’t amongst the top priorities, it jolly well should have been. It was certainly what new deputies like me expected when we elected her unopposed as HSC president. If a central duty of government is to reconcile the public’s expectations with the public’s readiness to pay for them, then it is in HSC and its political members that such a duty and its associated hard choices are most sharply personified. For me, the headline figure of £125m. is not the most interesting element in the HSC budget. Much more interesting, and more significant, are the details of how that large pool of expenditure is formed. A mixture of trickles, streams and full-flowing rivers of expenditure find their way into the pool, on occasions accompanied by the equivalent of an unexpected tidal bore, and one of the first duties of the committee members is to gain knowledge of those sources and exercise control of them. In my view the HSC of 2016-20 did just that. Having inherited a 2016 budget of £118.5m., the committee’s budget for 2020 is larger by around 5% at the end of four years during which health services have expanded while the universal rate of cost inflation within the field of health continued its remorseless upward climb far more steeply than RPIX.

The committee’s headline achievement was its Partnership of Purpose approved by the States in December 2017, the new committee having started from scratch in its construction. This innovative plan to transform the delivery of health and social care services has clear objectives and well-defined routes by which to achieve them, but it is too early to assess its progress along a journey with a planned duration of 10 years. That said, the Covid-19 emergency provided hints of the partnership in action: the health and care sectors were drawn ever closer to provide the necessary patient-centred care, while Public Health, GPs, the Medical Specialist Group and the third sector achieved new levels of close collaboration. There were other non-Covid-related signs of the partnership working well. Improved ways of working included: a Health Improvement Commission, established in 2018; cataract operations made available in the PEH; a joint project initiated with one of the GP practices to help identify people at high risk of cardiovascular disease; the first Joint Strategic Needs Assessment conducted to map the current and future needs of the over-50s; and in August this year the appointment of the first five partners drawn from the public, private and third sectors.

As I mentioned in a previous review of Deputy Le Clerc’s ESS committee, there has been excellent pan-committee work between HSC and ESS, as evidenced by joint initiatives such as: the 22 new flats and houses at Ville au Roi built by the Guernsey Housing Association to accommodate key HSC workers; the 28 new units at Le Vieux Jardin for those with severe autism and others needing extra care; the provision of free contraception for those under 21, leading to a dramatic reduction in unwanted teenage pregnancies; and the redeployment of a portion of the Family Allowance benefit towards improving young people’s access to medical and dental services. It shouldn’t be the case that inter-committee co-operation is influenced by personalities, but it has been clear to me that the personal chemistry between these two committees and the fact that one deputy was a member of both committees, has helped to oil the wheels to the benefit of the States and the wider community.

If a principal committee’s record can be judged by the amount of its own major policy letters that gain States members’ support, then HSC’s is right up there with the best. Some were uncontentious, such as the Capacity Law which offers overdue protection for the interests of some of the most vulnerable members of our community. When this was passed unanimously in the States, I added a nod and smile of approval on behalf of the late Roger Perrot who had scarcely let any month pass without pressing me for progress reports on an issue that was dear to him.

Some really expensive HSC policy letters also passed serenely through the States Assembly. £20m. will vanish from the Capital Reserve in the direction of replacing the Electronic Patient Record System; admittedly on the expensive side, but anything to make sure that the bloke admitted with a bad back doesn’t find himself on the operating table having his appendix removed. In January this year the committee – with the help of much pushing and shoving from Deputy Peter Roffey over many years – secured a 38 to one majority for its policy letter on the funding of NICE drugs and treatment. Mind you, the next States will have to find an extra £30m. or so to fund it for the next four years; apparently there is somewhere a pot called the Guernsey Health Reserve that will help get things started, but the revenue costs will be £5.6m. in the first year and £8.3m. in each successive year. Ouch! Any ideas anybody?

The States also approved, with scarcely a dissenting voice, dipping even further into the Capital Reserve to fund the first phase of a 10-year programme to modernise the PEH. Phase one is estimated to cost between £34.3m. and £44.3m. (what’s £10m. between friends, eh?) and the entire programme up to £93.4m. Election candidates please note.

Much more controversial were two further HSC policy letters on an opt-out organ donation scheme based on the principle of deemed consent (approved 23/14) and the further liberalisation of the abortion law (approved 23/13). Both debates demonstrated that few, if any, minds are changed by debating such issues, but that did not stop the exchange of some hard-hitting words on the Assembly’s way to results that were wholly predictable, given the make-up of the membership. In my view it was to the credit of the outgoing members that painful wounds opened during the debates on these tough issues seem quickly to have healed.

Hands up those who remember the disturbing revelation in 2014 that our maternity services were unsafe. Not that many I guess. Five years ago, the report of an independent review by the Nursing and Midwifery Council made it clear that there were serious, institutional weaknesses at the heart of these key services. Wind forward to September 2019 and we come across the headline ‘Guernsey’s Maternity Services have secured the prestigious national Blue SCAPE status (Safe, Clean and Personal Everytime) following three years of successful SCAPE audits’. I need say no more.

So it was all plain sailing at HSC then? Far from it. As Ol’ Blue Eyes used to tell us ‘regrets, we’ve had a few’.

Although the hospital modernisation policy letter was approved, the process of getting it started is sclerotic (there’s irony for you) and is costing shedfuls of money just to get the hugely bureaucratic business cases prepared so that P&R can give the go-ahead to the men with shovels.

A much-needed policy letter on reform of primary care never made it to the States, partly because Covid-19 got in the way but also partly because the pandemic itself may have led to revised thinking on the best way ahead. Meanwhile, the anecdotal evidence continues to grow that the cost of primary care causes individuals and families to avoid going to their GPs when ill-health demands that they should. There are similar anecdotes to the effect that the cost of admittance to the PEH via its Emergency Department has become prohibitively expensive. I think the HSC line on this is that the charges are reasonable and proportionate, but whether they are or not, there is still a job to be done by the committee to convince the sceptics.

Anyone want new knees? If they do, it is now a 15-month wait on best estimates. As in the UK, the provision of surgical services here was in trouble even before the Covid-19 emergency: now they are under even more pressure. There are no easy fixes.

Finally, there remains the risk that the euphoria over the success of the NICE drugs policy letter may receive a touch of reality. Although Orkambi is now approved for sufferers of cystic fibrosis, the policy itself is not yet in place. Who picks up the four-year price tag of £30m. and how it is to be paid is yet to be resolved by – you’ve guessed it – some of those general election candidates who have already promised nurses and other medical staff the earth if they get in. Interesting times await us.

HSC four-year rating: 8/10