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Q&A: How will the Government act on the Mascie-Taylor report?

Q&A: How will the Government act on the Mascie-Taylor report?

Friday 26 August 2022

Q&A: How will the Government act on the Mascie-Taylor report?

Friday 26 August 2022

The Government says it accepts every one of Prof Mascie-Taylor’s 61 recommendations and will take “urgent, clear and direct” action to implement them.

It will establish an ‘independent health board’ to “drive reform, improve governance and address the cultural, structural and practice issues affecting the quality and safety of the care provided.”

It will immediately set up a ‘task force’ led by Mr Armstrong and Chief Nurse Rose Naylor to implement the recommendations.

Health Minister Karen Wilson said: “Professor Mascie-Taylor rightly states that islanders need and deserve high quality and safe healthcare and, having considered his report, I must concur with him that, regrettably, the island does not yet receive the standard of healthcare it deserves, despite the hard work and dedication of staff employed in the service.”

Deputy Wilson said she would “strengthen the policy function” within Health to make sure it had the “skill and expertise required to establish the policy and governance frameworks” that Prof Mascie-Taylor has highlighted as necessary to “improve clinical governance”.


Pictured: Government CEO Suzanne Wylie will develop a 'turn-around' plan and a 'detailed accountability framework'.

The minister has also asked civil service head Suzanne Wylie to “oversee and develop a turn-around plan” by the end of next month to “address arrangements for resourcing the clinical leadership and management requirements throughout HCS, accompanied by a detailed accountability framework.”

Deputy Wilson will commission a review to be carried out in a year’s time. She is also going to ask the Council of Ministers and States Assembly for more money. 

“We must recognise that it is a false economy to fail to invest in good clinical and good organisational governance,” she says.

She adds: “I know that this report will impact the confidence of islanders, Assembly Members and staff but we will not build a better HCS if we do not hold people to account but rather if our focus is on blame. 

“We must fix the problems that Professor Mascie-Taylor identifies and that will require us to enhance existing skills, capacity and knowledge, and fix systems and processes within HCS that have led to a lack of accountability and the safety issues Professor Mascie-Taylor refers to.”

Deputy Wilson has already suspended the implementation of the £700m Jersey Care Model, which is designed to save £874m by 2036.

Health Minister Karen Wilson.jpg

Pictured: Health Minister Karen Wilson

Q&A with Health Minister Karen Wilson

Q How do you think this report will be received within the department?

"This is their reflection of the conditions under which they work and practice. What is really important is that we hear their voice.

"It reflects some of the messages that we we’ve been hearing from patients. It is deeply regrettable that this report has highlighted these issues, but I have to concur with Prof Mascie-Taylor’s conclusions that the island has not received the high quality and safe healthcare that it deserves, despite the hard work and dedication of staff in the service.

"In some ways, this is a watershed moment for people. It is an acknowledgement of the concerns raised and that is why I wanted to make it public. We must start to hear and listen to the concerns that patients and staff have about our healthcare system."

Q There are 2,500 people working in Health and Prof Mascie-Taylor interviewed 77. How confident are you that it is representative?

"I am fairly confident that there are a number themes that are prominent that affect the way in which the culture, behaviour and attitudes emerge in that working environment, and this is only a reflection of the people he has spoken to.

"One of the most important things is that there will be other people who have found it difficult to speak up and express those concerns.

 "I imagine this is not just the views of those who have managed to speak with him. There will be other staff who now feel that there is a cultural change about to take place and it will be safe for them to speak up about the conditions in which they work."

Q Prof Mascie-Taylor identifies a lack of openness and transparency internally and externally. Is this down to a failure of leadership?

"These issues have been around for a long, long time. One of the things I am trying to do by publishing this report is to prompt a cultural shift away from the idea that one individual is to blame; that someone at the top is to blame.

"This is systemic; there are all sorts of issues that impact and affect the way people work together and the way care is delivered.

"What I want to see is that we start to develop good team-working, good systems of supervision, openness and transparency about the way we work.

"That is an indication of a modern healthcare system that can reflect, can learn and can grow together and can improve the quality of care for patients.

"If we continue this culture of blaming, isolating and separating out individuals, you will never change the culture; it will always be driven underground.

"We must give us the best opportunity possible to tackle this now, and start to develop that cultural shift in the way that we work together."

Q Isn't the subtext of this report is that consultants at the Hospital have had too much power for a long time?

"Prof Mascie-Taylor talks about the way in which different professions have operated in the Hospital and I am not going to repeat those comments.

"What I want to say is that there is a responsibility on all of us to have a proper accountability framework in place that describes what people’s job is, who they account to, how that practice can be delivered, the standards to which that can is being provided, and the way in which that care is evaluated.

"What Prof Mascie-Taylor has highlighted is that there is a lack of organisation around that accountability and that is one of the things that has to be tackled so that people know that there is a standard that people need to be working to that governs safe and effective care."

Q The report mentions interviewees referring to the 'Jersey Way' at the Hospital. What is your interpretation of that?

"To be honest, I don’t give any credence to that term; I don’t recognise that.

"We are talking about individual attitudes and behaviours towards the way in which we deliver care and support to islanders.

"I think it is quite insulting and not helpful to refer to it in that way. Individual practitioners, clinical teams, managers, leaders, ministers, the Government ... all have to consider their attitudes and behaviours as a normal part of their daily working life.

"What Prof Mascie-Taylor is talking about is that there are some behaviours and attitudes that do not reflect a modern healthcare workforce and, as part of our turnaround, we must address that."

Q There have been reports before on bullying at Hospital. Is this the final report and you will now roll up your sleeves and deal with it?

"You have my commitment to actually invest in helping to bring about a different kind of healthcare offered to islanders.

"I hope that people will hear that very clear message that what drives my activity around this is that patients must be at the heart of all we do.

"We are on a journey of continuous improvement; we are not going to change things overnight so I don’t want to raise expectations. We are a human service, and with that comes all sorts of dynamics that reflect individual behaviours."

The Mascie-Taylor recommendations

Recommendation 1

The lack of availability of clinical output and benchmark information placed in the public domain must be addressed as a matter of urgency. This should be at organisational, service, ward, and consultant levels, and the information provided both at public meetings and on the website.

Recommendation 2

The consultant staff should embrace their professional role and leadership responsibility to drive system-wide (not just in their own practice) change to deliver improvement in patient safety, governance, and assurance processes. HCS should be prepared to provide them with the necessary expert support to achieve this, notably in data gathering, analysis and benchmarking.

Recommendation 3

Structures and processes need to be in place to make the line of accountability of HCS and its employees to the Government and people of Jersey explicit and meaningful.

It will be difficult or even impossible to drive approaches to quality and safety if the architecture is not fit for purpose, widely understood, and accepted. Government must hold HCS to account, and then those who lead HCS would be empowered to hold its employees to account and to drive change.

For many this would result in an improved working environment as well as, most importantly, the assurance of safe patient care.

Recommendation 4

Individuals and groups must act responsibly in the interests of all patients and consider carefully what is within their legitimate remit. They must offer constructive input and expect to be accountable to HCS for the advice which they give, and for their behaviour.

Recommendation 5

Staff should recognise that the reporting of incidents is a professional duty. If incidents are not reported, then opportunities to patient care are lost. The professions need to act with courage and with a strong focus on the patient, and not the protection of individual members of staff.

Recommendation 6

Similarly, there needs to be a low threshold for commencing objective, fact-finding investigations, with relevant help and support being sought from appropriate external sources where independence, transparency and expertise are required. An independent investigation avoids any perception of lack of openness and transparency.

While it is the role of the Executive and Serious Incident Review Panel (SIRP) to manage the process by which investigations occur and serious incidents are identified, the responsibility for enacting the change which must follow, needs to sit firmly at Care Group level.

This process must be seen as an opportunity to improve patient care and not primarily a threat to individuals. Changing any current negative perceptions will require strong executive leadership to build trust in the process.

Recommendation 7

In the absence of governmental policy, private and public patients should be managed employing identical policies, pathways, and procedures. It would be most helpful if Government could be explicit about its wishes and policies in this regard.

Clinical Leads should ensure that this occurs unless there are explicit exceptions agreed with their Professional Head.

It is a reasonable starting point to indicate that it is the policy of HCS to follow all relevant guidelines. If pressing reasons exist for not following them, and these reasons cannot be successfully mitigated, then the alternative agreed approach of HCS should be explicit.

It should be argued and promoted by the Care Group leader, signed off by the relevant Head of Profession and then signed off in summary form by the HCS Board.

The new guideline or process must be recorded, be available and placed in the public domain (through and endorsed by the HCS Board).

This explicit and transparent process would protect both patients from harm and individual staff from an obvious source of criticism – potentially both reputational and legal.

It may, though, expose HCS itself to reputational and medico-legal risk, so the process needs to be evidence-based and well documented so as to generate a defensible position.

Recommendation 8

HCS has a clear responsibility and duty of care towards its employees, and it needs to give this issue it’s full attention and to act as assertively as it can to deal with poor and unprofessional behaviour. Such behaviour is a matter not only for HCS but should be brought to the attention of the relevant professional regulatory process. For example, for doctors, the Medical Director for HCS and the Responsible Officer for the GMC.

It is the responsibility of all the clinical professions not to tolerate, and to challenge and report poor behaviour.

Recommendation 9

There appear to be areas of good multi-disciplinary team working within HCS. This approach needs to be extended to every area across the organisation, and no other approach tolerated.

Ensuring that this occurs must be clearly within the remit of Clinical Leads and is an approach that HCS leadership must insist upon.

Recommendation 10

HCS and its consultants must recognise that they have a joint responsibility for the safe care of all patients, both public and private, in the Hospital. Linked to this must be the recognition that all the metrics which are needed to assure the safe care of patients apply equally to public and private patients.

Recommendation 11

More information about HCS and individual performance should be routinely placed on the website and put in the public domain through HCS Board meetings.

In fairness, a number of individual clinicians make strenuous efforts to monitor their own practice and to benchmark their results against other clinicians. This should be applauded and vigorously supported by HCS.

The ownership of the data must be with HCS who are responsible for service, quality, and safety.

Recommendation 12

The developments briefly mentioned above should be enhanced as rapidly as possible. Clinical performance reporting is well developed in many areas of the world and Jersey does not need to reinvent these processes but to adopt the best available.

It may require technical support in doing this but the drive to do so must come from the Government of Jersey and the HCS Board.

Recommendation 13

Consideration should be given to creating a conventional HCS Board with non-executive leadership and it accounting for the performance of HCS directly, or less desirably, indirectly, to the Minister.

This widely adopted model would allow the Minister (with the necessary policy support) to hold the organisation more effectively to account on behalf of the Government and people of Jersey, and to focus on leading the development of policy.

Recommendation 14

The possibly emerging plan to have the assurance committees chaired by informed external experts could transform these processes and make them of benefit to all. Patient safety would be enhanced, and greater assurance would be provided to the Government and people of Jersey.

Recommendation 15

What should not be open to discussion is the need for the organisation to be held to account by Government of Jersey in a more rigorous and robust way, and importantly the authority of Government of Jersey transmitted downwards through the DG and Executives to bear on HCS and its employees.

Discussion needs to occur between relevant parties to design a more effective system building on the progress which commenced in 2019.

Recommendation 16

The Managing Director role is crucial and the incumbent needs to be a highly competent and energetic operational manager (who can come from a variety of backgrounds eg general management, nursing, medicine).

Recommendation 17

In the current HCS structure, the Managing Director should meet with the Chief of Service (currently known as Associate Medical Directors (AMD)) collectively at least weekly and more frequently at times of crisis. Individual meetings would also be required.

The Managing Director should chair the monthly Performance Review Meetings on behalf of the DG (this allows the DG to focus on the external environment and managing upwards). At these meetings, the Chief of the Care Group (AMD) and their teams should be held to account whilst receiving support and guidance.

The title of Group Managing Director is part of a wider Jersey model but is not a title used in hospitals. It may help understanding if the title were altered to Chief Operating Officer (COO).

Recommendation 18

There is a need to make clear again, and make certain that it is understood by all, the accountabilities of all those in the triumvirate so that no lack of apparent understanding can occur or be expressed. Close working and positive relationships with regular meetings are essential.

Appraisals must recognise the line management relationships.

Recommendation 19

The title of the Associate Medical Director is inappropriate and misleading. It should be changed to a suitable alternative. The title ‘Chief of. . .’ is used elsewhere.

The monthly performance review meetings should be chaired by the Managing Director (COO) and attended routinely by the AMD (Chief of care group). Both the COO and the Chief of the care group must require their immediate team to attend.

Accountability for safety and quality must be clear to all and the processes within the organisation must reflect the accountabilities. The accountability of the Chief of ...... is for all aspects of the function of the care group, not just those that interest them.

The role is that of a senior manager focussing on operational management and not on strategy.

Recommendation 20

One member of the triumvirate should be accountable to the Managing Director (usually called COO) and the other two account to that individual. Sometimes the individual is the Doctor but not always – they are then often referred to as ‘Chair.’

Recommendation 21

The author’s experience is that when the Doctor is placed in the Chair role and acts appropriately and competently, then this model is probably the optimum. It is an operational management role and usually requires at least 50% of the Doctor's time.

The care group will continue to require business partners and expert professional advice in other areas, most obviously, but not exclusively, Finance and Human Resources, Health and Safety, Infection Control, Training and Development.

The fact that a range of skills is required to manage a complex group should not generate confusion as to who is accountable for all aspects of performance within the care group.

To discharge their responsibilities, the chief of the care group will need to meet regularly, at least weekly, with their teams and meet with them individually on a regular basis.

Recommendation 22

At service level, there is frequently a similar triumvirate of doctor, nurse, and manager. If the doctor i.e., clinical lead, is the accountable manager, then the role will require at least one day a week.

If either the nurse or the manager is in this role, then they may well be able to undertake the role in tandem with another service role or other managerial work.

The responsibilities and accountabilities of the role must be spelt out with clarity, understood by all, and then managed.

Recommendation 23

All of those in management roles within the organisation need training and development consistent with and targeted at their current and future roles (as agreed with their line manager). Much of this could be provided in house.

For example, lead clinicians and most nurse-managers not at executive level do not need training in strategic management but in basic managerial competencies including finance, HR, holding others to account, and having difficult conversations with colleagues.

The drawing up of a series of competency frameworks could well be useful and aid selection and development processes.

Recommendation 24

It should be made clear that the Quality and Safety function is to support the general management structure by organising investigations and audits.

Enacting the recommendations is the responsibility of the AMD (Chief of Care Group) who is accountable to the Managing Director (COO).

Recommendation 25

There is an innovative opportunity to bring the expertise in Health and Safety to bear on other quality and safety functions.

Recommendation 26

HCS is a small organisation with limited capacity, and it must surely be the case that the overall strategic direction for Quality and Safety is placed in the hands of one executive director, preferably a new appointment of an individual capable of marshalling the available resources as effectively as possible, but if this is not achievable, then under an existing Executive Director.

The function of the collective resource should be to work through (not around) the core general management function, to improve overall quality and safety improvement. In this model, the leader of each care group is responsible and accountable for the quality and safety of staff and patient care in their areas, being very actively supported by a coherent corporate safety and quality function.

If a Director of Quality and Safety is appointed at Executive Director level, then the available resource should be placed at their disposal. The Director would need to collaborate closely with the Chief Nurse, Medical Director and Director for Improvement and Innovation but importantly work through the Managing Director (COO) in driving the agenda.

Recommendation 27

The HCS and Executives must make it clear that failure to report incidents is unacceptable to the organisation and is unprofessional.

Sadly, there is a need to make it abundantly clear that those reporting incidents will be protected from any form of intimidation and that anyone attempting to stop reporting will find themselves in serious difficulty, both managerially and professionally.

It would be useful if those with professional regulatory responsibilities made this clear.

Failure to report a potentially serious incident is to directly undermine patient safety and staff should be held to account for this failure.

The triumvirate leadership of the Care groups must understand their role in this important domain and be performance managed in delivering it.

Recommendation 28

Further evaluation of alleged intimidatory behaviours is needed, and this should be followed by clear and measurable remedial action if indicated. It should be made clear to all the employees that bullying is unacceptable and will be vigorously dealt with by the organisation through appropriate processes.

Whilst most reported the quality of nursing to be usually acceptable, areas which require attention are effective communication with relatives (training for both doctors and nurses), and consistent and accurate monitoring of sick patients with timely escalation of problems.

A proactive auditing approach would be desirable to allow the scale of the problem to be quantified and, if necessary, remedial action to occur. The threshold for escalation may need to be lowered and then escalation met by medical staff with an understanding that it is in the interests of patients, even if it proves, in retrospect, to have been unnecessary.

Recommendation 29

The author found it difficult to evaluate these points relating to recruitment and retention and would ask that Human Resources give a written report based on exit interviews and other intelligence. An expert external view might be helpful.

Recommendation 30

The solution to the difficulties in the admission from Emergency Department process is first to make it clear to all doctors that when they are asked to see a patient in the ED, then they must do so and failure to do so should be documented in the notes and the doctor held to account.

A second and highly effective approach is to give the unfettered right of admission to the hospital to ED consultants. The author has seen this work to very good effect despite fears expressed that ED consultants would be unable to differentiate between different clinical problems and would admit patients inappropriately.

In practice they performed better than predicted by their peers and this was very rarely a problem.

The concern sometimes derives from a feeling that beds within the hospital are the property of doctors or groups of doctors. This is not the case. The beds belong to the institution which employs the doctors.

If a genuine problem arises over inappropriate admissions, then this is appropriately dealt with by constructive discussions between groups of medical and sometimes nursing staff but not by denying patients care.

Recommendation 31

The solution to any lack of clarity about the availability of consultant staff is straight-forward and long overdue. Robust job plans must be in place for all consultants and made widely available.

Not only would this facilitate the hospital running more smoothly it would also have a direct and positive effect on patient safety. Importantly it would end any unwarranted criticism of consultant staff whilst making explicit any gaps in the service.

Recommendation 32

Medical Staffing is an issue of some concern to many, and which is highly likely to have a direct effect on patient safety.

The role of middle grade doctors needs to be fully assessed in a joint piece of work between the Medical Director’s and the HR departments. This must result in a written report for the HCS Board.

The report must include details of the hours worked by middle grade doctors, how their competence is assessed, and the extent to which the Consultants directly supervise them. (It may be that external support is required to do this piece of work).

If the concerns expressed prove to be upheld, then the solution will be to employ more consultants and move to a consultant-based Service.

Apart from the obvious direct benefit of having procedures undertaken by fully trained practitioners there are other benefits to this approach:

  • A more comprehensive rostering will be possible without placing onerous demands on consultants.
  • There will be more opportunities for a degree of sub-specialisation and the importing of techniques to the Island.
  • Multi-disciplinary team working would be enhanced.
  • There will be fewer lone practitioners.
  • Consultants will be able to leave the Island for Continuing Professional Development
  • Teaching and research would be improved, as would the quality of academic meetings on Jersey.
  • Consultants would be available to take part in quality improvement initiatives. 

Recommendation 33

There must be a physician of the day who is competent and available to manage or advise on the management of acutely ill medical patients on the medical wards, acute admissions unit, emergency department, surgical wards, and the intensive care unit or indeed anywhere else. The rota must be published, and contact details made clear.

Recommendation 34

There are a variety of models available, but one solution to whom is responsible for the care of patients in ICU would be that patients are under the care of an Intensivist who should be immediately available at all times. The referring consultant should visit at least daily and more when requested or wishes to do so.

Many of the patients on ICU have complex medical problems and the safety of care would certainly be improved by having a Physician of the day (see acute Medicine) who was available to provide a rapid consult service.

The Medical Director should ensure that ITU joins the national benchmarking process as soon as possible (Intensive Care National Audit and Research Centre (ICNARC)) and the results of this process placed in the public domain.

Access to ICU beds should be based on clinical need and no other consideration. This determination is the responsibility of the intensivist in charge who is, of course, accountable for their decision making.

Recommendation 35

The small number of births in Maternity makes the need for clear patient pathways and standard operating procedures very pressing, and the requirement to develop very precise benchmarks of performance. There would be benefit in a close linkage with a larger unit which could include joint audit, joint benchmarking, and a rotation of clinical staff.

The recommendations of previous reports should be enacted at pace.

Recommendation 36

The recommendations of the Mental Health report should continue to be implemented as quickly as possible.

Recommendation 37

The recommendations of Theatre Review should continue to be enacted at pace.

However, there need be no delay in making it clear that lack of adherence to safety processes, failure to start lists in a timely way and bullying will not be tolerated and, if necessary, individuals held to account.

Recommendation 38

There is a need for HCS and Government to address the vexed question of the degree of advantage to be enjoyed by private patients – an issue which generates strong and divisive emotions. These divisions undermine team working and therefore inevitably impact on patient safety.

Recommendation 39

It would be straightforward to conduct an audit to clarify whether the alleged focus of consultant staff on private patients is in fact the case.

If it is, then, apart from the policy decision outlined above, the quality of care given to those patients who do not receive consultant-based care needs to be closely monitored and transparent.

To be clear this is not a criticism of middle grade medical staff but merely points out the greater degree of assurance required. The consultant must remain accountable for the quality of care delivered by those he or she supervises.

Recommendation 40

The relevant AMD / Chief of care group needs to work with the lead clinicians to ensure less individualistic behaviour and greater systemisation in the management of surgical patients. Standard operating procedures, consistent timings etc. will make the management of surgical patients safer and easier for all staff groups.

The job planning process will address some, but not all, of these issues.

Recommendation 41

The recommendation is that radiology, in common with all other specialties, should follow National and College guidelines unless there are convincing reasons which cannot be mitigated. When this is the case, alternative guidelines should be developed as described above.

The constructive discussions between the lead clinicians which have commenced should continue.

Recommendation 42

To reduce concerns about inconsistent timing and conduct of ward rounds, and insufficient MDT working, the first step is to introduce robust job planning and the second, to follow National Guidance on the conduct of ward rounds (see RCP / RCS / RCN) Modern ward rounds, RCP London.

If there is uncertainty about these processes, training might usefully be given as a mandatory part of CPD.

Recommendation 43

The organisation should recognise its responsibility to assure itself that patient volumes are at acceptable and adequate levels. The RO should engage strongly with this area so that good professional practice is driven through the appraisal and revalidation process. Good metrics are essential and should be presented at appraisal.

Given the inevitability of its disadvantages then HCS and its employees must do everything possible to mitigate the potential problems which could emerge. Improved consultant staffing, as described above, would improve the situation.

At an Executive level, HCS should consider forming a closer relationship with a major centre. This would allow all forms of academic activity (which is a driver of quality and safety) to be undertaken in partnership.

Such a partnership may have other advantages both for training and service delivery, potentially to both parties.

For individual clinicians, the challenge is to keep up to date and have evidence that they are up to date. Many clinicians recognise this, but some do not. Individual clinicians CPD must recognise this challenge and address it directly. One way of doing this would be to routinely spend one or two weeks a year working in a relevant service at a major centre in the UK or elsewhere.

Again, relationships which this would forge could have benefits for service delivery and training.

To be clear, this is a challenge for all clinical professions and requires the development of suitable published strategies. This may well assist with recruitment and retention of staff.

Recommendation 44

There is a delicate balance between destroying current referral pathways to UK centres and creating more robust links with Southampton. Whilst a link with a single centre might remove some difficulties it could lose other real advantages, and so it is best to have a permissive approach but to ensure effort is made to mitigate the disadvantages of the current approach.

To facilitate this increasing linkage with a tertiary centre, similar to that seen across the UK and elsewhere in the world, the executives should engage in early and meaningful discussions with their counterparts in Southampton.

This should lead to robust clinical pathways being developed and followed, ready availability of clinical advice, opportunities for training, audit, CPD, rotations etc. This would reduce the isolation currently experienced by HCS and its employees and so inimitable to safety and quality.

Recommendation 45

HCS should look closely at the paediatric model and evaluate its strengths and weaknesses. This potentially would further inform discussions with Southampton.

Recommendation 46

The Medical Director should assess the need to provide a more structured approach to support those wishing to go down the CESR route and, if indicated, HCS would be wise to place the organisation of this under an appropriate Deputy Medical Director and HR business partner.

There may well be similar approaches in the other clinical professions.

Recommendation 47

HCS must develop and publish a mandatory training policy and insist that its employees complete their mandatory training.

If they fail to comply, they must be held to account.

In most organisations it is the responsibility of the local manager to ensure that this process occurs and is documented.

If the individual is within a regulated profession, then the failure must be reported to the regulator.

In Medicine, it should be made clear by the RO that it is not possible to complete a successful appraisal while ignoring mandatory training requirements.

Recommendation 48

Consultants should be open about the CPD work done in their SPA time, which should be defined in their job plans and are as such, a contractual commitment.

The organisation must insist that SPA time is used effectively and constructively. The activities undertaken should be documented and reviewed at appraisal.

Recommendation 49

Mechanisms must be put in place to demonstrate that public money is being used to benefit patients.

One additional way in which SPA time could usefully be used would be to spend time working in a major centre in the UK or, with good reason, elsewhere. There is no doubt that some consultants would welcome this opportunity.

SPA time should also be used in a transparent way to attend clinical audit meetings, mortality and morbidity meetings, and other activities which drive quality and safety. Mandatory training should also occur during this time. This should all be part of the job planning process and performance managed. 

Recommendation 50

Attendance at clinical meetings which drive safety and quality should not be optional and such meetings should be included in job plans.

Recommendation 51

All patients, both public and private, should be included in audit processes.

Recommendation 52

The RO should insist on a review of the audit of “whole practice” in guidance to appraisers and appraisees.

Recommendation 53

The degree of sub specialisation versus generalisation needs to be constantly monitored and managed by clinical leaders. When subspecialisation is possible (to increase the volume of patients managed by doctors with skills in a particular area) it should occur.

It is legitimate to recognise that the opportunities for sub specialisation in Jersey are less than in larger institutions, but it is not legitimate to avoid sub specialisation to enhance private medical practice. Again, this needs to be actively managed by clinical managers and the RO.

Recommendation 54

The financial arrangements of the management of private patients should be clarified and made transparent so that the benefit to HCS is clear and the public can be assured that care of public patients is not compromised, but hopefully is enhanced.

Recommendation 55

Allegations that the management of private patients is at the expense of public patients are very damaging – a point made by several consultants - and HCS must audit the situation thoroughly to assure itself that the management of patients within its purview is equitable and equally safe for all. (Assuming that this is the wish of the people and Government of Jersey).

If a robust audit is not reassuring, then the Government should make its position clear and HCS respond immediately to remedy the situation.

This issue should also be a matter for the HCS Board, should it be reconstituted along more conventional lines.

Recommendation 56

Many consultants themselves were concerned not only about patient care but about the tarnishing of their reputation and it might be most helpful if the issues were discussed in an open and transparent way at the Medical Staff Committee (MSC).

This is of course a matter for the MSC, which is not a management but a representative body, but can and should play an important constructive role.

A robust job planning process would provide consultant staff with protection from reputational damage.

Recommendation 57

A crucial point is that it should be always clear for all patients which consultant is responsible for their care - at all times, and available to see them when needed.

Recommendation 58

It is the role and responsibility of the organisation to provide safe high-quality care, and to be certain that its employees are doing this, as well as performing clinically and behaviourally to a satisfactory standard. This applies to both public and private patients, when these private patients being managed within its purview – in the hospital using hospital employees and facilities.

Equally, those employed by the organisation must understand that they are employees of an organisation that is clearly accountable to the government and people of Jersey.

To put it another way, they work for the organisation not at it.

It is the role of the regulatory bodies to regulate individual professionals. This includes the clinical competence of the professional, their behaviours and that they are conducting their affairs with probity.

The two roles are therefore linked and should be symbiotic, but the presence of a regulator does not remove the responsibility of the organisation to provide safe services and the accountability of its employees to it.

When confusion exists about these issues then the danger is that the lack of clarity and accountability has a direct and damaging effect on the effectiveness of the organisation and patient safety.

The medical appraisal and revalidation process is well embedded in the UK and adopted in Jersey.

It should be conducted to a high standard and the responsible officer should be rigorous in their assessment of doctors requiring revalidation, looking at and seeking evidence about all aspects of good medical practice including clinical outcomes, appropriate behaviours, organised and documented CPD and probity. These processes will clearly add value and a degree of assurance.

It is rumoured that Government in the UK may produce a more comprehensive picture of a doctor’s performance which could be used at appraisal, and it would be worth monitoring this development.

In any event, HCS should seek to support the appraisal process by providing as comprehensive a picture of the doctor’s performance as possible, including both public and private patient outcomes, details of complaints and compliments, use of SPA time, etc.

Whilst not diminishing in any way the role of the employer, the GMC and the Responsible Officer have a key role in maintaining medical professional standards and assuring the public that the requirements of Good Medical Practice are met in full.

An active dialogue between the Medical Director and RO would be useful in driving the recommendations of this report.

The informatics department should be of considerable assistance in this process and must also assist in obtaining good quality benchmarking data.

Recommendation 59:

The job planning process for consultants needs to be undertaken and completed as a matter of urgency by clinical line managers driven centrally from the Medical Director’s Office. The Medical Director should chair a high-profile steering group charged with driving the process through the organisation at pace.

Job planning could also be a useful process for other groups including middle grade doctors, some of whom are said to work excessively long hours of 15 PAs or more. There is a well understood argument about the effect of excessive hours on patient safety and these hours need to be reduced (with the appointment of more consultants to provide an increasingly consultant-based service), as is common elsewhere.

If the hours quoted are a true representation of the workload, then it is likely that more consultant appointments are required.

Recommendation 60

The recruitment processes need to be both timely and robust. For both locums and lone practitioners, the best mitigation is good induction and then close monitoring of performance. The development of suitable metrics (many of which can be lifted from elsewhere) is central to this.

It may be worth obtaining external advice on recruitment and retention. It is not the author’s area of expertise.

Recommendation 61

The Medical Director should issue a clear statement as to where the responsibility lies for signing off results from radiology and laboratories.

The responsibility for ensuring that this is done, and appropriate action taken, sits with the Consultant under whose care the patient is being managed.

This does not mean that those in service specialties should not continue to raise issues with clinicians directly and immediately if they are concerned about a result or a finding. Their expert opinion is invaluable in driving safety and good care.


IN-DEPTH: "How much evidence does Jersey’s health service want?”

FOCUS: Another review identifying more failings in Health

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Posted by anthony turmel on
never mind all the faff,its the rich getting preferential treatment...the rest of us have to suffer and wait and wait and wait......
Posted by Esporta Johnson on
Recommendation 62. Invite Care Quality Commission to review our Health Department. Do not spend taxpayer money on freelance experts selected and paid by director general.
Recommendation 63. Interview front line doctors, nurses and healthcare assistants including those who left Jersey recently. Read the results of Be Heard survey.
Posted by Esporta Johnson on
Culture will eat the 61 recommendations for breakfast.
Posted by Aston Francis on
Together with the 100+ recommendations from the theatre service review, 29 recommendations from maternity service review and those of mental health review we have now well over 200 recent recommendations. It is hard to say if we have more recommendations or more managers in the Health Department. Looking at the actual recommendations - some of them address the same points multiple times, many are wishful thinking, general ideas e.g. the recruitment processes need to be both timely and robust. Everyone knows it, I would add that people of Jersey should be healthy and happy. We did not need to spend 80k to have it stated. Perhaps the author could have shared his findings why the recruitment process is slow and ineffective. Why competent consultants and nurses do not want to work in Jersey? Why so many experienced consultants left our hospital in recent years being replaced with short term and very expensive locum doctors? People read press and talk to colleagues. They know about the toxic culture and incompetent, heavy-handed management in Jersey. Calling it Jersey Way seems to be an understatement. More than 20 of the 61 recommendations can easily be abused by the existing leadership to further bully, intimidate and silence the frontline doctors and nurses not agreeing with the leadership or those raising legitimate safety concerns. We don't need another non-exec board, another committee or new directors and managers. Why would we need more NHS-like triumvirates while the existing triumvirate at the top (director general, medical director and chief nurse) have failed to deliver in such a spectacular way. They have to GO and so should GO the 'general managers' who allowed the waiting lists to swell to highest ever levels. No more money spent on anecdotal management consultants please - the 80k we spent on the latest review would pay for two experienced nurses. The 500k spent on Kim Hodgson would pay for several consultants or middle grade doctors. The previous health minister accepted the endless reviews and recommendations used to buy time by the director general and her triumvirate. Let's hope that the new minister will do the right thing.
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