T Y N W A L D C O U R T O F F I C I A L R E P O R T
R E C O R T Y S O I K O I L Q U A I Y L T I N V A A L
P R O C E E D I N G S
D A A L T Y N
HANSARD
S T A N D I N G C O M M I T T E E O F T Y N W A L D O N S O C I A L A F F A I R S P O L I C Y R E V I E W
B I N G V E A Y N T I N V A A L M Y C H I O N E A A S C R U T A G H E Y P O L A S E E Y N E R C O O I S H Y N K I A R A I L Y T H E A Y
DEPARTMENT OF HEALTH
Douglas, Monday, 9th July 2012
PP103/12 SAPRC-H, No. 1
All published Official Reports can be found on the Tynwald website www.tynwald.org.im/Official Papers/Hansards/Please select a year:
Published by the Office of the Clerk of Tynwald, Legislative Buildings, Finch Road, Douglas, Isle of Man, IM1 3PW. © High Court of Tynwald, 2012 STANDING COMMITTEE, MONDAY, 9th JULY 2012
Members Present:
Chairman: Mrs B J Cannell MHK Hon. S C Rodan SHK Mr D A Callister MLC
Clerk: Mr J King
Business Transacted Page
Procedural...... 3
Evidence of Hon. D M Anderson MHK, Minister for Health and Mr D Killip, Chief Executive Officer, Department of Health ...... 3
The Committee adjourned at 4.22 p.m.
______2 SAPRC-H STANDING COMMITTEE, MONDAY, 9th JULY 2012
Standing Committee of Tynwald on Social Affairs Policy Review
Department of Health
The Committee sat in public at 2.30 p.m. in the Legislative Council Chamber, Legislative Buildings, Douglas
[MRS CANNELL in the Chair]
Procedural
The Chairman (Mrs B J Cannell MHK): Welcome to this public meeting of the Social Affairs Policy Review Committee, a Standing Committee of Tynwald. For the benefit of Hansard, I am Mrs Brenda Cannell MHK and I chair this Committee. To my left is the Hon. Steve Rodan, Speaker of the House of Keys; and Mr David Callister, Member of the Legislative Council. To my 5 right is our Clerk, Mr Jonathan King. Can I ask everybody in the room to please ensure that your mobile phone is switched off and not just on silent, please, as it interferes with the recording of Hansard. Also for the purposes of Hansard, I will be ensuring that we do not have two people speaking at once. The Social Affairs Policy Review Committee is one of three new Standing Committees of 10 Tynwald Court established in October 2011 with a wide scrutiny remit. We have four Departments to cover, namely the Department of Education and Children, Department of Health, Department of Home Affairs and the Department of Social Care. Today’s session is the second of our routine scrutiny sessions with those Departments. We started with the Department of Education and Children in May. Today, we move to the 15 Department of Health. The two witnesses are sitting as a panel, but I must explain that we intend to direct some of the questions to particular individuals and not just leave it open for whoever feels able to respond.
20 EVIDENCE OF HON. D M ANDERSON MHK AND MR D KILLIP
Q1. The Chairman: So, first of all, if I could welcome our witnesses, and if I could ask each of you, for the record please, to state your name, your job title and when you were appointed to 25 this role.
The Minister for Health (Hon. D M Anderson MHK): Good afternoon. My name is David Anderson. I am Minister for Health. I was first appointed as Minister for Health on 1st April 2010 and was reappointed after the General Election. 30 The Chairman: Thank you.
Mr Killip: Good afternoon, Madam Chair and Members. I am David Killip. I am the Chief Executive Officer of the Department of Health and I was appointed to that post on 1st April 2010, 35 which was the date upon which the Department was established.
Q2. The Chairman: And your responsibilities within your role, Mr Killip… what are you responsible for?
40 Mr Killip: I am responsible to the Minister for the management of the Department and for the delivery of the services that the Department is required to provide to the community of the Island.
Q3. The Chairman: Do you have any other role within the Department, as its Financial Officer or anything like that? 45 ______3 SAPRC-H STANDING COMMITTEE, MONDAY, 9th JULY 2012
45 Mr Killip: Under the Audit Act and under Government Financial Regulations, I am what is termed the Department’s Accounting Officer. That does not mean that I am a qualified accountant – which, in fact, I am not – but I am responsible for the administration of the budget that Tynwald allocates to the Department. However, the Department does have a qualified accountant among its senior leadership team, 50 because the Director of Finance is so qualified.
Q4. The Chairman: Thank you. Regarding your Service Delivery Plan and your priorities setting, we have a copy of your Service Delivery Plan for 2011-12. When was that issued? 55 The Minister: This was issued on 20th April 2010 and placed on the Department’s website at that time.
Q5. The Chairman: Can I ask what progress has been made with the next Service Delivery 60 Plan?
Mr Killip: Would you like me to deal with this?
The Minister: Yes. I will pass over to… 65 Mr Killip: It is perhaps worth prefacing my answer, Madam Chair, by saying that the Service Delivery Plan concept is something that was produced, or that has been conceived by the centre of Government and there are Service Delivery Plans for all Government Departments, Boards and Offices. So the form and the content of a Service Delivery Plan is, in some measure, determined 70 by the wishes of the centre. The reasons for this are easy to understand. There is a keenness that there is continuity among the presentation of Service Delivery Plans, so that a person with an interest can find the same information in the same way, depending on what part of Government their interest may be in. The specifics with the Service Delivery Plans, of course, vary according to what the responsibilities of 75 the Department or Board may be. So the production of a new Service Delivery Plan is… The Department is, to some degree, in the hands of particularly the Chief Secretary’s Office as a vehicle for giving effect to the wishes of the centre, because although I am aware that it is a matter that is very much alive, they are yet to determine the format of new Service Delivery Plans in a pan-governmental way. 80 That said, the Department has been looking quite closely at the way in which we produce, capture and monitor the kind of information that one finds in the Service Delivery Plan, and we are fairly far down the road in producing that in a contemporaneous way, rather than the former Service Delivery Plan that you have just referred to, and in fact we have had an opportunity to share the work we have done in that area with the officer from the Chief Secretary’s Office who is 85 leading on the development of the corporate nature of Service Delivery Plans, so they are aware of what we are doing. I have a copy of the kind of front page of that document here, and I can let you have it, if you wish. It is what we call a corporate strategy map, and I can either leave it with you for scrutiny or talk you through it, as you wish. 90 Q6. The Chairman: The purpose of the question, really, is that the Service Delivery Plan that we presently have is, of course, somewhat dated (Mr Killip: Yes.) and there is not anything or there does not appear to be anything coming in terms of the next one. This is the purpose of the question. So it is a case of where is it? Are we going to have it? 95 What you have explained, or what I am getting from you is that it is the centre that dictates when, if and how the Service Delivery Plans are executed, i.e. the Chief Secretary’s Office, and you are suggesting that the format and how you predict the indicators – KPIs, as I like to call them – or the targets, how they are translated in the next Service Delivery Plan. So are you saying then that the whole thing is being reviewed with the view of bringing forward something that is going 100 to be more easily understood by members of the public.
Mr Killip: Essentially, yes. You have interpreted my remarks correctly. The Service Delivery Plans’ form, content and presentation is something that to date, anyway, has been done on a pan- Government basis and the documents have a corporate style and content and template to them. So
______4 SAPRC-H STANDING COMMITTEE, MONDAY, 9th JULY 2012
105 until the Department of Health or indeed any Department knows what the future form and style of a Service Delivery Plan will be, then we will not be producing one. What I wanted to do was reassure you that the disciplines that go into the creation of a Service Delivery Plan have not come to a shuddering halt simply because we await a steer on the form and content of the new ones. This is, as I say, an illustration with rather more detail behind it, but this 110 is an illustration of what we are doing to evolve the service delivery planning process. But the corporate nature of pan-Government Service Delivery Plans which you have just alluded to, I am aware from communication from the Chief Secretary’s Office that it is, as you say, ‘under review’, and is likely to have a revised form and content; but as we have this conversation today, I do not know what that revised form is. 115 Q7. The Chairman: Do you have any idea when we can expect the revised form coming forward?
Mr Killip: I do not. I would have to ask you to refer that question to the Chief Secretary’s 120 Office, although it is likely that once that is known, certainly chief officers will be advised of that, because I imagine the centre will want us to produce a Service Delivery Plan in the new form as speedily as we can; but I do not have any details on timescale I am afraid.
Q8. The Chairman: So currently, then, each Department does not have a target date by which 125 to get their Service Delivery Plan ready?
Mr Killip: No, they do not. I anticipate that the centre will impose a target date, but presently that has not been done.
130 The Chairman: Mr Speaker, do you have any questions on this topic?
Q9. The Speaker: Yes. In the context of the Service Delivery Plan and priorities setting within the Department, I notice, from the corporate strategy map that you distributed, specific objective number 3, ‘to improve health outcomes through prevention, early detection and intervention’. Part 135 of that process in the initiatives section is implementing disease-specific plans – cancer, renal, coronary heart disease, stroke, diabetes etc. Do all those depend on successfully agreeing business cases as part of your budget setting with Treasury for those things to happen?
Mr Killip: I would not say that they do rely on that. Within each of those specific areas that 140 you have mentioned… That list that you see there was determined as being areas where there was a particular clinical priority, under the umbrella of the Strategy for the Future of Health Services. You allude, Mr Speaker, to objective number 3 on this document. You will see that all four of the objectives set out there in the green-shaded boxes are all drawn from the objectives of the Strategy for the Future of Health Services, which was endorsed by the Council of Ministers at the very end 145 of 2010. So I would not say that they are specifically dependent on agreeing business cases with the Treasury, because there may well be aspects of the creation of plans for those conditions that can be advanced and that implementation can go forward by redeploying existing resources or by restructuring services in a particular way, and by, for example, examining the interaction between 150 primary and acute care. Having said that, in order to advance anything in a particularly substantial way, then, who knows, there may be a requirement for resources that presently we do not have, and that could generate a bid through the annual budget round, which, as you know, is subject to political and officer discussion with Treasury. 155 Q10. The Speaker: If I just give you an example – if I may, Chair – of a business case that I am aware is before the Department, and that is to do with age-related wet macular degeneration, which statistically is the leading cause of blindness, and there are issues, are there not, with timely diagnosis and early treatment? Has any progress been made with having on-Island treatment for 160 those particular groups who have been subject in the past to unfortunate delays of timely early treatment and the risk of going blind? What progress has been made with that?
Mr Killip: The Department is looking, as you say, at providing more on-Island treatment for that condition. It is an interesting one to use as an illustration, because of course it is one of a 165 range of conditions that, without in any way wishing to sound patronising – it is a statement of ______5 SAPRC-H STANDING COMMITTEE, MONDAY, 9th JULY 2012
fact… It is one of a number of conditions that tends to be a feature of the older person, (The Speaker: Yes.) and, of course, one matter of prime strategic concern – not simply to the Department of Health, I might add – is the demographic of the Island’s population and the percentage within the population that one might describe as the older person. 170 So the Department is acutely aware that this is a need and is a service delivery area that is only likely to increase in terms of those who need to access that service, rather than to remain static or decrease. We are all equally aware of the current financial constraints that Government finds itself working under, and I think it would be naive for any Department to anticipate that there will be an automatic and guaranteed access to additional funding. 175 So the Department’s plans to advance this, or any other highly pressing service, I would venture is likely to have to recognise the need perhaps to redeploy resources, rather than to rely on the advent of new funds.
Q11. The Speaker: In other words, there is no new money for any new additional services. It 180 will have to be resourced from redeploying, reprioritising existing services.
Mr Killip: I believe, essentially, yes. In planning for the advancement of the Department’s services, I personally… and nor am I encouraging colleagues to anticipate that there will be significant new money available, because the message that has been coming from the Treasury or 185 other sources within Government is that we cannot operate in that way or anticipate that.
Q12. The Speaker: Maybe if I ask the Minister: is this actively being pursued – this particular issue, which is one example – by reprioritising existing services?
190 The Minister: We have, Mr Speaker, many business cases with equal validity as the one that you raise, but we have been left under no illusion from the Treasury that we have to live within a budget and that we must prioritise within our Department and make savings in other areas if we are going to fund new areas of activity.
195 Q13. The Speaker: So what are the priorities that you would like to see for new services financed in that particular way?
The Minister: I think we have been quite successful in recent times, and we will come on later to the development of breast care services which, quite clearly, is where there is a business case set 200 out, and if we have had to deliver those services we would have to make economies in other areas of the Health Service. The Chief Executive mentioned a few minutes ago that we have to identify those areas if we are going to have money to spend in new areas. Nobody holds their hand up and says, ‘Don’t fund our area. Fund this new area.’ So we have to look at it with the clinicians to see where we get a best return for the money invested in the Health Service. 205 The Chairman: Mr Callister.
Q14. Mr Callister: Yes, thank you, Chairman. Good afternoon, gentlemen. With the Service Delivery Plan, the one we have in front of us 210 here, the 2011-12… I think it is 2011-12 – anyway, you know the one we are talking about – it has got an organisation chart on page 4, headed by the Minister and the Member and thereafter 13 positions below that in management roles. When the new document is produced, is there likely to be any reductions in the numbers of those higher officers on that page?
215 The Minister: Could I just start by saying that we have had a review into the higher management structure of the Department of Health from an outside agency that gave very clear direction to me that what we had in place was appropriate, not over the top and fit for the challenge that we have going ahead. I cannot see there being any drastic changes – there might be some tweaking certain areas. 220 I don’t know if you want to answer that, David?
Mr Killip: Can I just say – not that I in any way object to it – the structure chart that you refer to is one illustration of a component in the Service Delivery Plan that was required by the centre in terms of the presentation of the Service Delivery Plan, and so it is in there from a common 225 perspective.
______6 SAPRC-H STANDING COMMITTEE, MONDAY, 9th JULY 2012
As the Minister says, following the creation of the Department, and once the dust had settled, because I think we all found the restructuring of Government was something that hurtled in at high speed without much in the way of advance notice really, the Department commissioned an independent management assessment which included a healthcare professional from another 230 jurisdiction. The people who provided the review for us were a local management consultancy on a number of the Department’s senior posts, specifically my own post, that of the Department’s Deputy Chief Executive, the Finance Director, the Director of Healthcare Delivery, the Hospital Manager and the Manager of Primary Care. It was quite an exhaustive review and it concluded that the 235 Department’s range and extent and demands upon it required that those posts needed to be retained. From recollection, Mr Callister, I cannot recall all the posts on the structure chart that you are referring to, but I can speak about any specific post, if you want me to do so.
240 Q15. Mr Callister: Two specific posts, please. What is the case for having a Director of Public Health and a Director of Health Strategy and Performance?
Mr Killip: The Director of Health Strategy and Performance post per se does not exist any more. The role of the post that was so described is now the lead post that draws together the 245 delivery of healthcare services, both in the acute and primary area. So the post is a managerial leadership post. The Director of Public Health is a statutory post that is filled by a clinician and is the Department’s principal source of clinical advice and guidance to the Minister, or indeed to the Council of Ministers, and is a post that is very much approaching public health from a medical 250 perspective, from a clinical perspective. So the two posts are not the same, and as I say, the DPH post is a statutory appointment.
The Minister: Maybe just to build on that, you are well aware as well that mental health will be coming over to the Department of Health and this management structure actually will assist in 255 that. If we had slimmed it down in any way, shape or form, I think we would have struggled to fit it in as it is.
Q16. The Chairman: Thank you, Minister, for that. That was going to be my next question actually, that Mental Health Services are coming back to you – 260 Mr Killip: Subject to Tynwald approving the Order this week.
The Chairman: Sure, but they are coming back to you, and I do believe, Mr Killip, you argued, all the way through the restructuring of Government Departments, that in fact Health 265 Services should have remained with the Department of Health. I recall some evidence that we gathered (The Minister: Mental Health.) on that occasion with a previous (The Minister: Mental Health.) Scrutiny Committee. So are you suggesting then, Minister, that all the staff from Social Care will come and that you will have to accommodate them, or that your staff are still in situ within the Department of Health? 270 The Minister: No. The staff will come over to us and they will be managed from within the existing management structure of the Department of Health.
Q17. The Chairman: Thank you. So your wages bill is bound to go up then, isn’t it? 275 The Minister: It will be vired over from Social Care, I would imagine.
Mr Killip: Yes, the Mental Health staff will transfer to the headcount of the Department of Health – that is correct – and the relevant budget lines to pay for the Mental Health Service will 280 similarly move into the Department of Health from the Department of Social Care. You mentioned accommodation. Many of those delivering mental health –
The Chairman: I am sorry, Mr Killip, I did not mention accommodation.
285 Mr Killip: Sorry, I thought you mentioned accommodating them.
______7 SAPRC-H STANDING COMMITTEE, MONDAY, 9th JULY 2012
The Chairman: No, I did not. No.
Mr Killip: Forgive me. 290 The Chairman: Accommodate in terms of being able to transfer – not the buildings.
Mr Killip: I am sorry. I thought you meant physically accommodate.
295 Q18. The Chairman: Can I move further forward now, but still sticking with the dated Service Delivery Plan. On page 19, it states… This is to do with the KPIs and it is to do with the development of the Cancer Services Strategy, and your target was that that would be done by 31st March 2012. Of course, we have bypassed that date. Has it been done? What is the outcome?
300 The Minister: It has been done. We now have in place our National Cancer Plan, which was completed by the Cancer Strategy Group in February 2012. It was approved by the Department on 16th March. Subsequently, it has been presented to Tynwald Members on 24th April. The key points of that were made known to Tynwald Members at that presentation, namely that cancer is important because of the morbidity and the mortality, with 350 to 400 cases of cancer per year on 305 the Island.
Q19. The Chairman: I am sorry, Minister, can you recap those numbers?
The Minister: Three hundred and fifty to 400 cases of cancer per year on the Island, as far as 310 morbidity and mortality are concerned. The Cancer Plan is unique, in that the patients and cancer charities were fully involved in the development of the Plan. The Plan comprises eight chapters and all aspects of cancer, such as prevention, screening, early detection, treatment, palliative care and living with and beyond cancer are covered within the Plan. 315 Q20. The Chairman: So, in effect, the Strategy now has been adopted, so it is… You have met your target, then?
The Minister: We have. (The Chairman: Yes.) There has been a full presentation to Tynwald 320 Members on it as well.
Q21. The Chairman: Yes, well, the presentation was 24th April, so at what point did it actually become your official Strategy? On what date?
325 Mr Killip: I believe you could say on 16th March, which was the date that it was approved by the Department. In order to avoid confusion in the use of the term ‘Strategy’, that word is confined to meaning the Department’s Strategy for the Future of Health Services, which is why the cancer document is now known as the National Cancer Plan. That was approved by the Department on 16th March. 330 Q22. The Chairman: Thank you. The 350 to 400 cancers per year on the Island – have you got those broken down into headers, into what area of cancer we are talking about?
The Minister: We have not got those figures with us today, but we can easily supply those to 335 your Committee if you request them.
Q23. The Chairman: That would be very useful if you could. The reason I am asking is that I am just wondering… I understand that skin cancer is quite high on the Isle of Man.
340 The Minister: It’s all the sunshine we get!
Mr Killip: I can proffer some information, Madam Chair, about skin cancer and cancer incidence a little more broadly, but I want to hold off from giving you unconfirmed figures and I also want to hold off from straying into clinical areas, as I am not a doctor; but the incidence of 345 skin cancer that you specifically refer to is rising in the United Kingdom more broadly – it is believed, I understand, as a consequence particularly of tanning treatments and sunbed use, and I think is particularly a feature of younger females. ______8 SAPRC-H STANDING COMMITTEE, MONDAY, 9th JULY 2012
I allude to incidents in the UK because about two to three years ago, the Director of Public Health commissioned a piece of work with an organisation called the North West Public Health 350 Observatory with statistical rigour to look at the incidence of cancer in the Isle of Man as compared with that of the neighbouring jurisdiction. That process resulted in a public presentation of the outcomes which took place in Keyll Darree facility at Noble’s, and the outcome of that was to show that there is an extremely close correlation between the incidence of morbidity and mortality in the Isle of Man as compared with 355 the UK. So, for example, the incidence of lung cancer in the Isle of Man was very similar to the equivalent incidence in the UK, as were, for example, the incidence of brain tumours and leukaemia. So, without being able to give you specifics of how many cases of leukaemia there might be per annum, for example, I can tell you that the distribution of cancers among the population of the 360 Isle of Man reflects that which you see in the UK as a whole and there was also some benchmarking done against the North West of the UK and again was very similar, though from recollection, in some cases of particular cancers our incidence was actually slightly less than that of the North West.
365 Q24. The Chairman: However, we have moved since 1991, because I recall Liverpool University also did a study called ‘Cancer in Man’ and I still have the reports they produced, Of course, at that time we were not documenting cancer at all, we were not feeding into the national databank either, but as I understand we are now (Mr Killip: Yes, we –) for all different types of cancer. 370 The purpose of asking you about skin cancer is following on from a presentation that was given by Mr Upsdell, a public presentation, earlier this year, when he highlighted the fact that skin cancer is very high in the Isle of Man, but he did not elaborate, he did not go any further than that, but it is a concern. So any additional information that you can supply to the Committee in respect of that would be most appreciated. 375 Mr Killip: We are happy to do that and we will give you the latest figures we can of the breakdown of individual cancers.
The Chairman: Mr Callister. 380 Q25. Mr Callister: Yes, thank you, Madam Chairman. This word ‘morbidity’ has been used a bit here, we are talking about – the figures you are quoting – about one person per day. I take it these are referrals to hospital and presumably they do not all end in the demise of a patient, but rather some of them go forward cured? Can I take it that 385 way? Or is this a case of the people who lose their lives because of cancer in the Isle of Man?
Mr Killip: These are the total number of confirmed cases of cancer – sorry, Minister?
The Minister: Within that year? 390 Mr Killip: Yes, within a year, so at any one time, you will have more cancer sufferers than this, because of course, there will be people whose cancers were detected in the year before and the year before that and so on. But you are right, cancers can be dealt with, can be cured and they are not invariably fatal. 395 Q26. The Chairman: Just to clarify that point, Mr Killip, what you are saying then, is the 350 to 400 are newly diagnosed cancers per year, but that does not take into account those who are currently living with cancer?
400 Mr Killip: Correct. Those currently living with cancer, of course, will still, very probably be under treatment, so they will be of great concern to the Department, but these are the number of confirmed cases on an annual basis.
Q27. The Chairman: But once somebody is diagnosed with cancer and they undergo 405 treatment, they are then on the books, are they not, for a period of five years?
The Minister: It varies.
______9 SAPRC-H STANDING COMMITTEE, MONDAY, 9th JULY 2012
Mr Killip: Yes, I think the Minister is absolutely right, it varies. Individuals whose cancer is in 410 remission, or who have been cured, receive periodic checkups and I think the frequency and the longevity of how long that person will require to be checked up on will vary according to the nature of the cancer from which they were suffering.
The Chairman: Thank you. Mr Speaker, do you want – 415 Q28. The Speaker: Yes, a couple of other aspects of the Service Delivery Plan. It mentions financial targets to ensure that budgets in relation to salaries and wages do not exceed those budgeted from the previous year. Were those targets met? Were they achieved?
420 Mr Killip: They were. Let me clarify that. The Department remained within its overall financial allocation for that financial year. Within the great scheme of things some budgets were overspent, as it were, accounted for greater amounts of money than we had initially anticipated, whereas other budgets were not. I know we came under pressure in particular clinical budgets, specifically medical budgets, as distinct from nursing budgets, but there was no substantial 425 overspend and no requirement for supplementary budgets.
Q29. The Speaker: But salaries and wages, do locum hospital staff costs come within the overall target?
430 Mr Killip: They do.
Q30. The Speaker: Can you inform us of the up-to-date position on locum costs in the hospital?
435 Mr Killip: Locum costs remain a challenge, but as reported to the Department meeting last month, and indeed the Department meeting for July will take place on Friday… but as reported to the Department meeting last month, all our budget lines are currently within the expenditure limits.
440 Q31. The Speaker: How much have you spent on the locums currently in the hospital?
Mr Killip: I am afraid I have not got that to hand, but we can let you know.
The Minister: Mr Speaker, we will have to get back to you, and maybe if we could do it in a 445 corresponding period just to give you the general flow of which way things are going.
Q32. The Speaker: Yes, I am just asking because there was a Keys Written Question, not too long ago, and I think the figure was about £3 million, and so I wondered if it was still a similar figure? 450 Mr Killip: That sounds plausible.
Q33. The Speaker: But if there is significant pressure on having to fund staff costs through the use of locums, is there not? 455 The Minister: Locums are an expensive way, but unfortunately sometimes it is the only way we can staff those areas.
Q34. The Speaker: That is fine. 460 If I could move to the other aspect, there is reference to an indicator developer comprehensive IT hardware and software replacement programme and the target of July 2011 for that full suite of information to be available. Has that been successfully implemented and could you tell us the cost of that?
465 Mr Killip: The Department rolled out a significant IT infrastructure programme, referred to as the CSST. I would have thought earlier than July of last year the last components were put in place. Far and away the greatest single element of that IT programme was the replacement of the Patient Administration System, or ‘PAS’ as it is called, at Noble’s Hospital, and the new system is referred to as ‘Medway’, which is the manufacturers term for that suite of programmes, and that ______10 SAPRC-H STANDING COMMITTEE, MONDAY, 9th JULY 2012
470 links up all or clinical activity at Noble’s Hospital and includes components for the pharmacy, for radiology, for all sorts of things. Indeed, at that time there was quite a major change and improvement in our IT links within GP surgeries and links between GP surgeries in the Department. So that programme is largely complete. IT is not exactly an open-ended cost, but it is something which is more or less perpetually in 475 evolution, because even now the Medway system that I just referred to at Noble’s Hospital, the manufacturer of that system has a new updated version of it. There is no pressure upon the Department to upgrade to that version just yet, but I would imagine that in the fullness of time we will face with our current PAS the very reason that emerged for the replacement of the previous one, which was the fact that it was very old and long in the tooth and the provider no longer 480 supported.
Q35. The Speaker: So what is the estimated life of the recently introduced system for patient management in the hospital?
485 Mr Killip: A number of years. Because it was the largest and most significant component of a suite of activities, it was actually the one that was done first, and I think, from recollection, it went live very late in the year in 2008, so it has already been with us for a while. It will still serve us well for a number of years yet, but we do have to anticipate preparing the ground to update and evolve it. 490 Q36. The Speaker: But we do not have integrated acute and primary care in totality as yet, do we?
Mr Killip: Not to the extent that I think myself and a number of colleagues would wish, but 495 certainly better than there has been before.
Q37. The Speaker: Yes, so the overall cost of that programme, appreciating it has run over a number of years?
500 Mr Killip: From recollection, it was just over £7 million, and again from recollection, I think it was dealt with as a capital scheme.
Q38. The Speaker: Yes, okay, and one very last question on this document: UK referrals, patient travel £11.6 million – an upward trend, presumably, as greater demand requires more off- 505 Island referrals?
The Minister: Yes, that is correct. The demand does grow, but there are certain areas now that we are able to treat because we have a greater number of specialists delivering certain aspects of care that have not been done on the Island before. So there is a small balancing act as far as that is 510 concerned, but it is a challenge and will continue to be a challenge for the Department in the next few years in the way that we do not just fund patients travelling off Island, but support for those patients as well.
Q39. The Speaker: Yes. Is the Department giving consideration to other providers outside the 515 North West – Scotland or Ireland, Belfast?
The Minister: Yes, both the Chief Executive and myself have actually had talks with other people from other jurisdictions to see if there is any synergy between us and them, in them providing services. At this stage, there does not seem to be an alternative that looks to be on a par 520 with what we have got, but we are continuing to look and our door is always open, because if there are savings to be made, we want to know where they are and we want to talk to them.
The Speaker: Thank you.
525 Q40. The Chairman: Just before we finish that particular subject, we do spend an awful lot of money, don’t we, sending people away for cardiac treatment in respect of heart disease and also radiotherapy in respect of cancer. I know that we could not ever hope to emulate a centre of excellence to do with cardiac heart disease on the Isle of Man, but what about the receiving of radiotherapy? Bearing in mind that cancer does appear to be quite high in the Isle of Man, that is 530 going to be a growing thing in terms of the services and having to send patients off Island to ______11 SAPRC-H STANDING COMMITTEE, MONDAY, 9th JULY 2012
receive that kind of treatment, which sometimes can be anything from one to three weeks’ stay in the UK, which we have to find the finances for. Is there any hope in the future of being able to provide radiotherapy on Island?
535 The Minister: I think there would be a significant capital cost, as well as the medical costs associated with that, and I do not know… David, do you have any idea of the cost of…?
Mr Killip: The hospital management… and within that term, I include clinicians – for example, the Medical Director, whom you had occasion to mention earlier. That is Mr Upsdell. He is the 540 Medical Director. They are, I would say, switched on to the opportunities or the scope to bring back into Noble’s services which perhaps previously were provided elsewhere. Radiotherapy is a big issue, because as the Minister says, if we were to gear up to provide radiotherapy at Noble’s, we would have to provide adequate physical space for it, we would have to acquire the correct range of hardware – for which I imagine the initial outlay would be costly, 545 though that is not to say one would rule it out on finance grounds, far from it – but there is also the fact that applies in many clinical areas, that we would have to be absolutely certain that it was safe to do it, because of course not all cancers are the same, not all radiotherapy treatment regimes are the same, and we would have to ensure that our personnel had sufficient ability, sufficient clinical expertise in treating a range of cancers. 550 Of course one of the primary reasons why we send patients to the UK, not necessarily for cancer but for any particular condition, is the fact that there are a number of cases, or a number of illnesses, where it occurs infrequently in the Isle of Man, relatively speaking, and it is not feasible for there to be medical or clinical facilities who perform that procedure or address that illness frequently enough to remain adequately skilled. If Royal College advice or Department of Health 555 UK advice is that a particular clinical procedure… that a medic doing that requires to do it 30 times a month to remain skilled, and yet in the Isle of Man there are only 30 cases a year, it would not of course be at all wise, from a clinical governance point of view –
The Chairman: I can accept – 560 Mr Killip: – to try and do it here, and the same clinical governance considerations would of course apply in the case of radiotherapy in the Isle of Man.
Q41. The Chairman: Mr Killip, the purpose of my question was the fact that we spend an 565 awful lot of money on having to send people away for radiotherapy; whereas chemotherapy, we can provide that on Island. It is whether or not it is in the thoughts of the clinicians that there might be a possibility in the future to provide a degree of the service on Island. Obviously, a business case would need to be put together, but clearly it is costing a lot now to send patients away for this treatment. If it was good for the patient and it was cost-effective to 570 provide it on Island at some point in the future, then I would have thought that they may well consider it. The purpose of the question was to fish, to see had they considered it or would they consider it?
The Minister: Madam Chairman, if I can just add to that. I think Mr Killip makes a very good 575 point in that to have the clinical experience they have to have so much throughput per year and in certain areas it would be unlikely that they would be able to keep up their professional standards because of the lack of throughput on specialities. But you mention cardiology, and people travelling across. One of the improvements we hope to make very shortly is to do with pacemaker implants and the ability for the team on the Island to 580 actually fit those on the Island, because that is not just a saving through that operation, but all the follow-ups because you have to go back to the same consultant. So we are hopeful that will be introduced in the very near future.
Q42. The Chairman: That is good, but that would have to come out of your existing budgets 585 and something else would need to be –
The Minister: We have budgeted for that and obviously there is a saving to be made there as well, because we are not using the centre in the UK.
590 Q43. The Chairman: Sticking with, not the Service Delivery Plan but the subject of cancer, as you know the question of the provision of breastcare was referred to this Committee back in June ______12 SAPRC-H STANDING COMMITTEE, MONDAY, 9th JULY 2012
2011 by the previous House before we had even been appointed – this particular Committee. You have sent us a lot of information on this subject, for which we are very grateful, including the paper of 29th February 2012. I would just like to go through that paper with you. I do not know 595 whether you have brought copies with you.
The Minister: We have details of the response that was sent to you.
The Chairman: The first section deals about the waiting lists issue and the amount of patients 600 actually waiting. There does seem to be a significant wait still, just looking at this and reading it.
The Minister: Madam Chairman, could I give you, maybe, an update?
The Chairman: Yes, please, if you wouldn’t mind. 605 The Minister: Following that request for the information, following that, as at 30th June 2012, there were 74 patients on the out-patient waiting list who had been waiting an average of 36 days for their appointment. There were 36 patients on the in-patient waiting list with an average of 134 days for admission. Although there is a rise in the number of in-patients waiting at the end of May 610 2012, this is because there is an increase in the services we offer. So basically, we are doing more services as far as breastcare is concerned now and that is why, however, despite that, the waiting time is reducing. So we are very pleased with that. We are very fortunate to have the team in place. We have delivered, as you are well aware, the three elements of breastcare improvement that 615 we hope to do within three years. We have done it in substantially under that period and I am delighted that this element of care in the hospital is being very well received in the community.
Q44. The Chairman: Thank you for that. Just before we move off the issue of waiting times, is it not the case when an urgent referral 620 has been made through a GP, for example, that the standard rule has always been that they have to see the consultant within 21 days? Is that still the same, that they have to see them within three weeks maximum? Is that being maintained?
Mr Killip: I believe it is 21 days. There is certainly a procedure where cases that the GP flags 625 as urgent are advanced speedily to the consultant or to a surgeon, yes.
The Minister: I think we are meeting that target.
Q45. The Chairman: Okay. It is hoped that you are, but of course, as of 30th June this year, 630 74 patients are waiting 36 days. I take it –
The Minister: It depends on the –
The Chairman: – the 74 patients were not regarded as urgent? 635 The Minister: It depends how the medics determine, or classify them.
Q46. The Chairman: Okay. We are aware that breast reconstruction is now taking place on Island and absolutely delighted that it is, because quite clearly it is much better for the patient and 640 her family, but also, of course, it saves us a huge cost in those women that did have a deferred breast reconstruction and were sent to the United Kingdom in the past. Minister, you said all three intentions, or all three elements of developing the breastcare service are now in place. Can I ask for an update on the sentinel node biopsy? This is the sentinel node biopsy machine and a different way of actually doing the biopsies, a much quicker and more 645 simplistic way was being proposed in that second strand of the three-phase strategy. Is that in place now? Looking at this, the paper just says: ‘be introduced in the next few months following completion of staff training.’ As I understand it, staff did their training for this during Miss Hamo’s tenure?
650 The Minister: You take that?
______13 SAPRC-H STANDING COMMITTEE, MONDAY, 9th JULY 2012
Mr Killip: Okay. The answer is yes, it is happening and the answer to your comment about the training, you are correct that staff received a significant degree of training beforehand. However, we wanted the new surgeon, who is called Mrs Bello, to be in place, so that it could be understood 655 exactly how she wished to undertake this sentinel node biopsy, because a surgeon has a degree of control over their own internal processes among the team that they lead and we wanted to make sure that our staff would be up to speed in delivering, if I could describe it as such, the internal service to the surgeon that the surgeon particularly wanted to have. Those staff who were trained in the past, there was a need for a degree of refresher training, so 660 that they were bang up to speed with the process. Now that we have Miss Bello in post and we understand how she operates – forgive the pun – the additional training has been undertaken and is complete. I would also make the point that this is – and I make this observation as a non-clinician – a complex, clinical procedure, requiring high levels of skill on the part of the surgeon and 665 supporting personnel and that consequently, training and refresher training and training to bring people up to speed with new procedures, will, I suspect, always be a feature.
Q47. The Chairman: Okay then, if I might, just trying to get down to the ultimate question. The training has all been completed and accepting what has been said, has this equipment now 670 been installed? Is it up and operational and being used?
The Minister: It is.
Mr Killip: I am not aware of any difficulty in doing this procedure. 675 The Minister: Madam Chairman, I think we can be truly proud of the breastcare service the Island now has. For the size of the Isle of Man, what we are delivering is exceptional service for the population base of our Island. We are delighted with our new consultant and the way that she is delivering the service and we are getting some very positive feedback as a result. 680 Q48. The Chairman: It is very warming to hear this news. With regard to the sentinel node biopsy, we did in fact have a situation, did we not, where the patient would go into theatre, the biopsy would be taken using the blue dye, the results of which would be… Someone would be charged with the sample, had to race down the corridor to the 685 clinician to have it tested before the surgeon could be clear on what needed to go and what could stay. So, in fact, it is a very good, positive step forward, but it is also obviously going to save a lot of time in the delivery of breastcare service and also 100% greater efficiency than what we had previously. So that has been a very positive investment.
690 Mr Killip: It has, and as you say, it is a major step forward. I would not want anybody to think that previous practices were in some way deficient or unusual. They were practices that you would have seen replicated in NHS hospitals elsewhere. It is just that now we are providing up-to-the- minute biopsy procedures.
695 Q49. The Chairman: Well, it does afford your new surgeon to be able to do more operations because it is using that theatre time more efficiently. Sticking with this particular subject, in terms of the general surgery on call, we understand that Mr Stock, one of the four general surgeons, has gone, so you are back now to three, if we include the breast surgeon as a third one. What is the latest situation with that? Are you looking to recruit a 700 fourth surgeon? Because you are now back to where you were pre taking on Miss Bello.
The Minister: No, we are not, because we have four surgeons on call. It is just that one of those surgeons is currently a locum surgeon, until Mr Stock’s surgeon replacement is put in place, so they are doing one in four now. 705 Q50. The Chairman: Right, so it is the intention of the Department to try to recruit another general surgeon?
The Minister: Yes it is. 710 Q51. The Chairman: With any particular speciality in mind?
______14 SAPRC-H STANDING COMMITTEE, MONDAY, 9th JULY 2012
The Minister: The same speciality as Mr Stock.
715 Q52. The Chairman: As Mr Stock. Okay. Has that been advertised yet?
The Minister: I am not sure where we are with the time frame on that.
Mr Killip: Nor am I. I think that the Royal College has approved the job description and I think 720 the advertisement has been placed. We can let you know where it is in the system.
Q53. The Chairman: Yes please, if you would not mind. Can we ask how many times the new breast surgeon, Miss Bello, has been called to do the on- call general surgeon surgery rota? How many times she has actually been called to actually 725 perform surgery, or to give guidance during surgery?
The Minister: That is not something we have in our heads, but it is something we can find out. I –
730 The Chairman: It would be greatly –
The Minister: – know she is very happy to take part in this element of general surgery, to keep her professional level up and she was very keen when she came here, that would be an element of her job. 735 Q54. The Chairman: You will recall, Minister, in June last year, when we had the debate in respect of the breastcare services, there was great concern of the impact that, being on a general surgery, on-call rota would have on the delivery of breastcare, so it would be –
740 The Minister: That certainly has not materialised, has it?
The Chairman: Not since 1st February, we understand, but it would be very useful to know –
The Minister: I think I would be first to know if that had happened. And I am delighted it 745 hasn’t.
Q55. The Chairman: Ah, but would you be the first to let the Committee know also, is the other question? We have been given this remit to investigate and ensure the delivery of a really good breastcare service – 750 The Minister: We have.
The Chairman: – and we want to reach the point, Minister, where we can make that report back to Tynwald and say that we are very happy and satisfied. 755 The Minister: Well, I hope you will very soon.
The Chairman: Yes, but, as I say, there are still questions outstanding, and –
760 The Minister: I think the questions you say are outstanding are just elements where you need to have the facts and figures up to date. Everything is on track, (The Chairman: Quite.) as we predicted it would be.
Q56. The Chairman: Yes, well, if you could provide us with the facts and figures, so that we 765 can be satisfied.
The Minister: We will do that.
Mr Killip: I can recall being told of one occasion when Miss Bello was brought in when she 770 was on call, though of course there may be other instances, so we will give you definitive data on that.
______15 SAPRC-H STANDING COMMITTEE, MONDAY, 9th JULY 2012
Q57. The Chairman: I think, Mr Killip, that one occasion might be the one that this Committee flagged up to you by way of enquiry. 775 Mr Killip: It was flagged to me by the Hospital Manager, I recall, but it may be one and the same event.
Q58. The Chairman: But we have written to you with regard to another matter. (Mr Killip: 780 Right.) I think that it is important for Hansard that it is not just merely a case of receiving visits from the various Departments every so often and about probing and questioning and scrutinising. We do a lot of work behind the scenes by way of writing to chase up particular things, and sometimes, if we do not get a sufficient quality answer, then we will ask, in terms of oral evidence. 785 The Clerk: Mrs Cannell, can I just come in? You mentioned Hansard: there was a question there where the Chairman said, ‘Has it happened?’ and the Minister said, ‘It hasn’t happened,’ but I do not know exactly what you were asking. What are we asking here?
790 Q59. The Chairman: The question was that the time just to… I think it is probably the politics – the politicos now talking – and perhaps the Clerk has lost the thread of what we have just been discussing. During the debate in June 2011, the emphasis of public concern – and it was raised in debate this year in Hansard, and I have got Hansard in front of me – was this concern that by engaging a 795 general surgeon with an interest in breast, we had the quibble about the job title. We got over the job title. The second concern was that if a breast surgeon has to be on call once every four days for a 24- hour period, and once every four weeks for a whole weekend period from a Friday night to a Monday, that might impact negatively upon the delivery of the breastcare service. The Minister 800 has suggested that has not happened. My question is, really, on how many occasions has our new breastcare surgeon been called upon to perform surgery, or to advise while surgery is taking place, in terms of the on-call general surgery aspect? That is simply the question: how many times has it occurred, since her appointment on 1st February 2012? (The Minister: It was – ) 805 Does that satisfy you, Mr King?
The Minister: If I might add, it was the Royal College’s recommendation that we should move to a one in four. We were on one in three, so this lessens the obligation on the other three general surgeons to cover that on-call rota. 810 The Clerk: Thanks very much, Mrs Cannell. I think it was just in the interest of the scrutiny process to make sure we had asked a precise enough question for the Department to answer.
Q60. The Chairman: Yes, thank you. 815 Yes, it is in Hansard and the Minister did say about the Royal College of Surgeons direction that we increase on-call general surgical cover from one in three – considered by the College to be onerous, too onerous – to one in four. Currently we have a locum stepping up to provide the fourth position to replace Mr Stock as a temporary measure; but what we are asking is, has it had an impact on the delivery of breast surgery? 820 Also, when do you expect to find a replacement, because obviously, the longer that goes on the greater the potential for having a negative impact on the delivery of breast surgery?
The Minister: Certainly, I will just re-emphasise the point that it has not had a negative aspect to the delivery of breastcare. We have already had the job description approved by the Royal 825 College, as far as we know, and we will let you know the exact date it is going out to be advertised, that post.
Q61. The Chairman: That would be very useful, thank you. There was also indicated in Hansard last year the level of operations that were being 830 undertaken by the previous breastcare surgeon, who was a locum, and I am just wondering where we are with that now. How many breast operations are being conducted on a weekly basis now?
______16 SAPRC-H STANDING COMMITTEE, MONDAY, 9th JULY 2012
The Minister: Certainly we can get that information for you, but the theatre time has been increased significantly, so I would imagine the number of operations is also going up in the same 835 form. We will get that information for you.
Q62. The Chairman: Thank you, Minister, because previously, last year, you said in Hansard:
840 ‘The present locum undertakes two to three operations per week…’
– and that only two were undertaken between 1st January and 13th March, two per week for that period of time. So it would be useful for the Committee to know how many are being undertaken now, (The Minister: Yes.) accepting that breast reconstruction can take up to a four-hour stint in 845 the theatre.
The Minister: That is the point I was coming to, that we are doing more procedures on Island now, therefore we need more theatre time and that has been worked into the planning for this consultant. 850 Q63. The Chairman: Okay. It would be very useful also, when we get that information from you, if we could have an idea of how many breast reconstruction procedures have been taken on Island, since Miss Bello joined us on 1st February. Mr Speaker, do you have any questions on this? 855 The Speaker: Not on this subject, no.
The Chairman: Mr Callister?
860 Mr Callister: No thank you, Chair.
Q64. The Chairman: Right, we look forward, then, to the further and better information in respect of the delivery of breast service. If we can… sentinel node biopsy machine, you say everything is imposed and that is working well. 865 We can move on to the service delivery contracts. The Department is responsible for a number of service delivery contracts and one of those, for example, is the Prison, the Prison health service. Can I ask you what arrangements are in place to make sure people actually deliver the services they are supposed to deliver under such contracts? Mr Killip, can I ask you?
870 Mr Killip: You give a good illustration when you cite the Prison contract. It might be helpful if I mention one or two others, because, of course, primary health care services with GPs, dentists, pharmacists, optometrists are services that are delivered under contract. They are not employees of the Department of Health, so the primary care landscape is a landscape very much of a contractual complexion. 875 We have a contract with Flybe to transport patients, who require treatment in the UK; we have a contract with the air ambulance company; UK taxi contracts. Locally, we have a contract with the Red Cross for non-urgent patient transfer, patient transport. We have a contract for the supply of orthotics and many maintenance contracts, for example with Philips in respect of radiology equipment and, akin to a contract, we have a service level agreement with Hospice in respect of 880 the resources that we provide to them. So how a contract or a service is measured will vary according to what the contract is and what performance standards might be set, because there are performance standards within the GP contract and indeed GP remuneration is linked to those performance standards. So the GPs are monitored by an annual performance review by a range of what you might call intermediate 885 measures, like prescribing statistics, patient surveys, report on access time and stuff like that. Transport contracts are monitored by things like measurements of activity, promptness, whether there is a service failure, complaints, for example. The Department… I will speak in a moment about more formal contract monitoring, but of course, one element of contract monitoring is patient and public feedback, which we get quite a lot 890 of. So we pay great heed to what we hear from patients about whether a service was particularly good or whether it did not meet their expectations. So I would not set aside public feedback from the context of performance monitoring.
______17 SAPRC-H STANDING COMMITTEE, MONDAY, 9th JULY 2012
Q65. The Chairman: If I could just ask you to pause there. (Mr Killip: Sure.) What you are 895 saying is that of course you rely on the public to let you know how a service is being received, how it is being experienced. Do you seek that information from the public, or are you in a receptive situation where you rely on people to get in touch with you?
Mr Killip: We do have recurring patient surveys, particularly at Noble’s Hospital, and that is a 900 kind of formal process with a form to fill in. That takes place biennially, from recollection. But there are quite frequent direct samplings of patients’ experiences – not only in-patients but out-patients – because every week there is what is called a patient safety walk, where the Hospital Medical Director and the Director of Nursing will descend upon a part of the hospital unannounced to establish how that particular service is being run that day. It may be the blood 905 clinic, it may be a ward, it may be radiology, it might be the audiology out-clinic. The service being inspected does not know. Part of those patient safety walks is very deliberately a series of conversations with service users who may be present on that day. Of course, an individual who does not wish to talk about their treatment is not pestered to do so, but many patients are very willing to talk about their 910 treatment. The most recent patient safety walk that I personally went on was in the renal department, and I spent quite a long time talking to people who were having renal treatment and they were very willing to talk about the experiences that they were having. We also do get quite a lot of unsolicited patient feedback through the access available on our 915 website and through other sources, and I am pleased to say that it is not always complaint. The Department had some very positive feedback from a visitor who had to be admitted to Noble’s during TT week – amazingly, for a non-motorcycle-related ailment – and that feedback was very good. More formal contract monitoring, of course, is very often through both the Internal – 920 particularly Internal – Audit, but also could be through the Government external auditors. Because the Department is large and provides a huge array of services, it is not uncommon for Internal Audit to be looking at something within the Department of Health pretty well consequently. I think over the last three years we have had probably around a dozen, and possibly more, Internal Audit assessments of something in each of those years. So we are talking about one once a month, 925 and they quite often focus on contractually related issues. So there is assessment of contract performance that is out of the hands of the Department as well.
Q66. The Chairman: If we can just leave the contracts issue for a moment and come back to that, dealing with the patient and the public in terms of the delivery of the service, whether it is 930 provided directly from the Department or through a contractual arrangement, can I ask you, Mr Killip, perhaps to take your mind back to 2006 when in Tynwald Court there was a Select Committee on the Petition for Redress of Grievance of Andrew Cooil and Thomas Arthur Cooil that reported with a series of recommendations. The recommendations were in terms of improving the health complaints procedure. That was back in 2006. 935 All the recommendations were unanimously approved by Tynwald Court, and yet, in the latest Tynwald Policy Decisions Report, which came out in October last year, which gives us an update on progress on these matters of policy, it is reported as ongoing and it stated that:
‘A review of the Complaints Procedure (including role of Independent Review Body) is underway including 940 consultation with interested parties. Any necessary changes to law will be incorporated in forthcoming amendment to, or replacement of, the NHS Act 2001 and, if necessary, reflect the creation of the post of Tynwald Commissioner for Administration.’
That was six years ago those recommendations were made. It is reported, as of October last 945 year, as still ongoing. Do you have an update for us in respect of this?
Mr Killip: You are right that it was reported as ongoing, and there are two components to that, both of which I am happy to talk about, but one of which you have touched upon yourself.
950 The Minister: But all the others have been completed.
Mr Killip: But all the others… a number of the recommendations have been given effect. The review that you referred to by the Department and the consultation with interested parties, that is all concluded and a draft report summarising that process and any potential outcomes does 955 exist. As I said, the report is draft; however, I am aware and have been assured that a final report ______18 SAPRC-H STANDING COMMITTEE, MONDAY, 9th JULY 2012
will be submitted to the Department/Minister within four weeks from now. So that particular process is nearing completion. The other ongoing element, which explains why it has been going for a long time, is that, as you have correctly highlighted, a number of those recommendations were linked with the 960 anticipated creation of the parliamentary commissioner, or the parliamentary ombudsman, and there is a degree of… there are matters to be determined within this overall process as to what role that figure would have to play in terms of the recommendations that the Select Committee came up with. Of course, the creation of the parliamentary ombudsman has not yet come to fruition, so those matters linking this series of recommendations, both in general and between the Department 965 and the parliamentary commissioner, cannot really be put to bed until the parliamentary commissioner element is a little more mature than it is at present.
The Chairman: So by way of explanation then, you are saying that because there is a holdup or a hitch in terms of… or a question mark attached to whether or not we are eventually going to 970 have a Tynwald Commissioner for administration, that the recommendations cannot be proceeded with. Is that what you are suggesting?
Mr Killip: Some of them cannot be proceeded with in full because some of the recommendations anticipated activity by the parliamentary Commissioner. 975 Q67. The Chairman: Okay. So you are in possession of a draft report following the Department’s consultation in respect of the recommendations, but that was only in respect of recommendation 5, wasn’t it? Recommendation 5 said:
980 ‘The National Health Service Independent Review Body Regulations 2004 and the National Health Service Complaints Regulations 2004 should be redrafted to reflect the above recommendations.’
So that is what you have been reviewing as to whether or not you can in fact do that.
985 Mr Killip: It is what is being reviewed, although I think the report is likely to comment a little more broadly than just that. I have not seen the draft report yet. It is in existence, but it is not finalised to the extent that it could be submitted to the Minister and I will probably see it at that time. I could actively go out and seek the draft now, but it is imminently coming to the Minister, as I have said. 990 The Minister: It has not been to the Department –
Mr Killip: It has not been to the Department.
995 The Minister: It is what you were saying and it is unlikely to be at our next Department meeting, which is this week. So it is unlikely that we will see it before the end of August now.
Q68. The Chairman: Why do you think it takes so long, once a policy decision has been made by the parliament, for a Department to bring it into effect? In this case, it is six years old. 1000 The Minister: Well, quite clearly there are elements that the Select Committee thought would be in place that are not in place for that to take effect. There is no ombudsman in place. Quite clearly, it expected there would be within that timeframe, I would imagine.
1005 Mr Killip: I would just add that some of the recommendations have been effected. For example, there was a recommendation concerning what was termed the ‘local resolution process’, i.e. the complaints process within Noble’s Hospital itself. Changes of that nature have been made as a consequence of the recommendation. The Report also suggested changes to the processes that were undertaken by the Independent 1010 Review Body (IRB), which is the entity to which a person who has a complaint can turn, if they are dissatisfied with the way the Department has concluded their complaint. The Department has to be cautious in being seen to lean on the Independent Review Body because it is specifically an entity that is deliberately separate from the Department and is there as an auditor of the Department’s performance.
______19 SAPRC-H STANDING COMMITTEE, MONDAY, 9th JULY 2012
1015 Having said that, the recommendations that were made by the Committee to change the processes of the IRB have also been implemented. As the Minister says, the uncertainty particularly surrounds this issue of the role of the parliamentary Commissioner.
The Chairman: Mr Killip, I think I sat on that Select Committee back in 2006 and I remember 1020 the issues very well.
Mr Killip: I think you chaired it, didn’t you?
The Chairman: Well, yes. Nevertheless – 1025 The Speaker: Could I just ask a question about this, please?
Q69. The Chairman: Yes. Nevertheless, there were problems with the health complaints procedure and we as a 1030 parliamentary assembly, and indeed this Committee, have not had an update, other than what appears in the Tynwald Policy Decisions Report. So as soon as you can, will you give us an update on what the Department is proposing, what it has done up to date, and what it is proposing to do in terms of meeting the requirements of these recommendations, please.
1035 Mr Killip: We will willingly give you such an update. I would suggest that the update will probably have greater value to you, if we do so once the Minister has received the Report that is in progress, and what the Department’s view about that Report is.
The Chairman: It will be needed to be reported upon anyway for the next Tynwald Policy 1040 Decisions Report, which is published in October every year. As we are the Standing Committee on Scrutiny in these areas, it would be very, very useful if we could have it as soon as the Minister has had a chance to look at it. Mr Speaker.
1045 Q70. The Speaker: Thank you. Can you advise us whether the review into the independent complaints procedure involves a change of status of the recommendations by the Independent Review Body which deals with appeals? Is it not the case that at the moment they are recommendations, but are not mandatory?
1050 Mr Killip: That is the status of IRB recommendations. They are not mandatory, nor are they binding in law. There is probably a debate to be had about whether they should be, although I am not aware of any occasion when the Department has declined to give effect to an IRB recommendation or to respond to an IRB question. My mind is open on whether the status of IRB recommendations should be changed in the way 1055 that you describe. Were they to be so, and the recommendation is to become binding, it may of course have a knock-on effect in the procedure as well and you may find that individuals… I would not say are less willing to give evidence, but there may be a requirement for a more formalised approach to the process if there was going to be a more formalised aspect of the outcome of the process. 1060 Q71. The Speaker: The Department of Health then is not aware of any case where recommendations have not been carried out in full?
Mr Killip: I have received copy correspondence from the IRB, which was sent to a third party, 1065 in which they expressed disappointment at the outcome of one particular matter, which as I understand it, relates to responses received from another Government Department.
Q72. The Speaker: Not the Department of Health. In the case of the Department of Health, recommendations have been carried out in full. 1070 Mr Killip: That is my belief.
Q73. The Speaker: But as you alluded to, there exists a case where that did not happen on the part of another Government Department. Would you agree that there can be little purpose in
______20 SAPRC-H STANDING COMMITTEE, MONDAY, 9th JULY 2012
1075 having an Independent Review Body convened at considerable expense and time for the parties involved, if recommendations are ignored or are regarded as purely advisory?
Mr Killip: Yes, I would reiterate what I said before. The Department of Health has never to my knowledge declined to implement a recommendation. I would hope that it would be recognised 1080 that recommendations coming from the IRB should be given effect, in terms of internal processes. Were they to become mandatory, I think one would need some kind of safety net inasmuch as whilst it is probably very unlikely, I suppose it is possible, technically possible, that the IRB could make a recommendation that –
1085 The Minister: That could have financial implications –
Mr Killip: Yes, exactly so.
The Minister: – outside the scope of the Department that would affect our budget in some 1090 way.
Mr Killip: Or which were –
The Minister: It is a very delicate balancing act, I would suggest. 1095 Mr Killip: Ultra vires, or whatever.
Q74. The Speaker: Which Departments of Government did the IRB provide a service to, to your knowledge? 1100 Mr Killip: The IRB provides a service in respect of complaint, or unresolved complaint in respect of the delivery of healthcare services. Now, at present, until the events about which we spoke a little earlier, at present healthcare is delivered by two Government Departments: the Department of Health, but also the Department of Social Care inasmuch as, as we have this 1105 conversation, Mental Health Services are the responsibility of that Department, although we have spoken on this earlier this afternoon and from 1st August that may not be the case.
The Speaker: Thank you.
1110 The Chairman: Mr Callister?
Mr Callister: No, thank you.
Q75. The Chairman: We have no further questions on that. 1115 Quite clearly you are facing some harsh economic times and you have already said, on more than one occasion, that you are going to have to live within your budget, and so clearly you will be looking at certain services, reviewing certain services with regard to whether or not you can continue with them, or if you do, whether you do so by modifying them or becoming more efficient in terms of the delivery of that service. And, of course, you will also, will you not, be 1120 looking at things like services to the public for which they pay in part, namely, prescription charges, for instance? Are you any further forward in reviewing that at this current time?
The Minister: No. The papers in respect of that and other such issues are still being worked at within the Department before it comes to Council of Ministers. I am not in a position to make a 1125 comment on those at this stage.
Q76. The Chairman: So it will automatically go to the Council of Ministers. Why is that Minister?
1130 The Minister: If we were going to make substantial changes to the services we provide, we need to make sure that Council is comfortable taking that uncomfortable position if you like, which will be… undoubtedly, there will be uncomfortable decisions to make. The Department of Health is not immune to the financial scrutiny that is going on and because we are such a high spending Department, we must be shown to be acting in a responsible way to
______21 SAPRC-H STANDING COMMITTEE, MONDAY, 9th JULY 2012
1135 make sure that we are delivering the services, the essential services; but if there is any way of delivering a similar service in a different more effective way, we must look at that as well. I am afraid it is a case of watch this space. We have not made any decisions in those areas yet, but we have to deliver our services in the most cost efficient ways that we can and it might be a point that we have to deliver services through different means in different areas that we have not 1140 looked at before.
Q77. The Chairman: If it comes to that, then that will automatically be a policy change, will it not?
1145 The Minister: There will be policy changes, but it is early days.
Q78. The Chairman: As such though, a policy change ought to come before Tynwald, should it not?
1150 The Minister: It will.
Q79. The Chairman: So the Council of Ministers will be asked to make the first judgement on what might be an unpopular decision, is what you are suggesting.
1155 The Minister: Well, I do not think any of these difficult decisions are going to be popular.
The Speaker: If I might –
The Chairman: Yes, Mr Speaker. 1160 Q80. The Speaker: The process of considering what areas of charging to the public for Health Services involves consultation with relevant professional bodies. Is that correct?
The Minister: It is. Indeed it is. 1165 Q81. The Speaker: Inevitably during that consultation, it will become more widely known that areas such as whether it be charging for eye tests, dental care, prescriptions or anything else, these are areas under consideration. Would it not be, from the Department’s point of view, useful to engage with the public itself who readily understand the financial pressures Government is 1170 under, rather than waiting until a decision has been made and that then a rearguard action often gets fought to oppose those cuts? Is it not better to sign the public up to what is coming by talking to them first?
The Minister: Yes, I think you do make a valid point, but I think it is important that we need to 1175 see what the alternatives are through the professionals who deliver these services as well and I think that is an important first stage. There might be certain areas that we have overlooked, certain possibilities that we have overlooked and if we talk to the professionals who deliver these services first, we might be able to narrow down the options before going to the public. 1180 Q82. The Speaker: Because would you agree that, with the demand for Health Services increasing exponentially, you have to devise a corresponding speed for getting new sources of income in. So in other words, are you proposing within this current financial year any changes that will involve new income streams? 1185 The Minister: We are looking at all options, Mr Speaker, at the moment. Obviously, what our budget for next year is is a bit of a movable feast at the moment. We are waiting to hear back to see what will be allocated from Treasury for the next financial year, but we have to move independently of that and make sure that we move forward for the next financial year to show that 1190 we are actually making progress in doing what we should be doing as a Government Department to make sure that the services we deliver are our best and efficient as possible and delivering as best we can within the resources we have.
Q83. The Speaker: It is just that – this is my final point – a comment really is that the public 1195 do understand the vast gulf that has opened up with the income shortfall and so on, but is there a ______22 SAPRC-H STANDING COMMITTEE, MONDAY, 9th JULY 2012
real sense of urgency within Government Departments to be bridging that gap by getting new sources of income identified and the public signed up to them quickly?
The Minister: Are you specifically, Mr Speaker, asking about the Department of Health’s new 1200 income streams?
The Speaker: Well, as a Member of the Council of Ministers you will have broader perspective, but yes, primarily from the point of view of the Department of Health.
1205 The Minister: We are looking at different aspects that I cannot go into obviously here this afternoon. At the moment those are not seeming to deliver millions of pounds to the Department of Health, but that does not stop us looking at these areas for investigating. I think a little earlier you alluded to looking at getting into contractual relationships with other jurisdictions and delivering services, for example. Even though we might come back with a blank, 1210 we have to look down those avenues and explore what we might do to make savings; but actually generating income is more difficult in this Department than many Departments.
Mr Killip: Mr Speaker, just on that theme of direct consultation with the public, late in 2009 the Department did publish a consultation document on which we invited direct responses from 1215 the public and it was called, ‘Your chance to Influence Future Policy’. It posed a number of questions, both about the nature of service delivery, but also the financing of services and the charging for services. Ironically, quite a substantial chunk of that document related to state benefits and social care type topics, which within a very short space of time had become the responsibility of another Government Department because of the restructuring of Government. 1220 However, I passed those responses on to the Chief Executive of DSC. The document was helpful in informing a view of public opinion, although if I am frank, the number of responses, which was fewer than 100, was a little disappointing, although some of them came from representative bodies rather than single individuals; but I would not rule it out as something that the Department may choose to do again. 1225 Q84. The Speaker: So is that evidence from the public been used to inform the Department’s decision-making currently as to what found favour in areas that might be charged for?
Mr Killip: Yes, it has been used to inform the Department’s political leadership of ideas that 1230 were mooted previously and which may or may not represent scope for evolving in the future.
Q85. The Speaker: But there might be a repeat of that exercise. It was when Minister Teare, I think, had a series of meetings –
1235 Mr Killip: It was in the time of Minister Teare, and you are right, he followed up the document with a series of geographic public meetings. There are no plans for the Departments specifically to publish a new version or a new public consultation –
The Speaker: That was going to be my next question. 1240 Mr Killip: – but I would not rule out that the principle might be given effect again.
The Minister: Can I just build on that by saying that the comments that we received on the Roamin’ CoMin meetings are all being noted and taken account of in individual Departments, so it 1245 is a new form of feedback that we are receiving from the general public as well.
The Speaker: Thank you.
Q86. The Chairman: Just following on, just to close that particular issue down. The 1250 consultation that the Department undertook in 2009, has the Department issued a findings report following that consultation exercise?
Mr Killip: No, we haven’t. I would have to check. I think we published a press release saying that the public responses were varied and had proved useful, but we did not publish any 1255 subsequent findings in respect of each of the questions that were asked in the document.
______23 SAPRC-H STANDING COMMITTEE, MONDAY, 9th JULY 2012
Q87. The Chairman: It is a desirable measure to undertake under the Chief Secretary’s Code on Public Consultation. So I flag it up. Following on from what Mr Speaker said, I think we would all agree around this table at this 1260 Committee that, in fact, any options that you do finally come up with, following your experts having highlighted them for example, prior to it going to Council of Ministers for a final decision, it may well be very useful to let the public know what those options might be so, that you can canvass a degree of ownership before the unpalatable decision, one way or the other, is taken by the Council of Ministers. It is very worthwhile, but I think rather than just give them a blank open 1265 cheque book and say, ‘You can influence policy’, it is better I think for the public that they are given one, possibly, of three options to see which one they favour, to see if you can get a common consensus view out there. Just one final question I think, and this is in respect of a paper that you sent us in February this year outlining your legislative programme, for which we thank you, and when we were reading it, 1270 we noted that the Nurses and Midwives Act came under the Department of Social Care. Is that correct?
Mr Killip: It is correct. You will be aware that the Nurses and Midwives Act goes back to 1947. Speaking as a non-legislative expert, the Act in 1947 essentially had two functions. Firstly, 1275 it defined who could call themselves a nurse or a midwife, essentially only an individual so qualified, because having not been around in 1947, I am told that even then there were still individuals who promoted themselves as midwives to assist in births, but who in fact were not, or at least not qualified. And the second thing that the Act did was to regulate the acquisition or the provision of nursery personnel from agencies who would provide such a service. 1280 Time moved on, and 10 years ago by order of Tynwald, not in primary legislation, there was the latest evolution of the first bit of the 1947 Act, which was those who could call themselves nurses and midwives are defined in an Order dating from 2002. So that component of the 1947 Act effectively evaporated into history. That is why, when the Departments were split in… or rather, when the DHSS ceased to be in 1285 2010 and the Department of Health and Department of Social Care were created, the only extant element of the 1947 Act was the bit about regulating the providing of nurses through agencies and that regulatory element was seen to be akin to the regulation of care homes, the regulation of pre- school nurseries etc, which function existed in the Department of Social Care. So the Transfer of Functions Order that parcelled out all the numerous functions of Government Departments to the 1290 new post 1st April 2010 structure, and Departments, allocated the Nursing and Midwifery Act to the DSE because the 1947 Act, the only element that remained was that regulatory aspect and the regulatory function was in the DSC. At the same time, the DSC were working up their Regulation of Care Bill within which this kind of thing is addressed. So that is why you see the replacement of the 1947 Act under the 1295 heading of the Department of Social Care. The ‘are you a midwife and can you prove it?’ bit of the 1947 Act is still the Department of Health, but under a 2002 Order of Tynwald. That is the best I can do on that one, Madam Chair. The AG’s Chambers are aware of all of what I have just told you, both as a consequence of the 2010 Transfer of Functions Order and as a result of their involvement with the DSC over the Regulation of Care Bill. 1300 Q88. The Chairman: I take it then, Mr Killip, you are having input into the drafting of the Regulation of Care Bill? (Mr Killip: Yes.) Can you give us an update on progress?
Mr Killip: The Bill goes forward. In terms of its approval by CoMin and introduction to the 1305 branches, I am afraid you would have to ask DSC – it is their Bill. I understand that it remains a high priority for them and that it is proceeding towards the branches and elements of the Bill of direct interest to the Department of Health, the DSC have fully afforded us opportunity to comment.
1310 The Minister: We are comfortable with what they are doing in relation to that.
Q89. The Chairman: So is the Bill still in draft form or is it in final form?
The Minister: You would have to ask DSC where it is. We have made our contribution on the 1315 elements to do with the Department of Health.
______24 SAPRC-H STANDING COMMITTEE, MONDAY, 9th JULY 2012
Q90. The Chairman: And that is it? Yes. So you have made your contribution, but will you not have a last say, once it is all finalised and in a draft Bill?
1320 The Minister: I understand from the officers who dealing with it from the Department that they were happy having made representation to the Department of Social Care with the drafters, so we will just have to wait and see what comes back in the draft Bill.
The Chairman: Right. Okay. 1325 Mr Speaker, do you have any further questions?
The Speaker: No, we will have to leave it there. Thank you.
The Chairman: Mr Callister? 1330 Mr Callister: No, thank you.
The Chairman: Mr King?
1335 Q91. The Clerk: I am conscious that we want to wrap up, Mrs Cannell, but could I just ask you a question that occurred to me as the discussion went on. Is the Isle of Man Health Service a centre of excellence for motorcycle related conditions?
The Minister: I think we will both respond on this. David is a motorcyclist, I am not. 1340 However, my understanding from the people who have to be patched up in Noble’s Hospital during motorcycling events is if they are going to have a motorcycling accident anywhere in the world, then the best place to have it, unfortunately, is on the Isle of Man because the service level and the service we provide in that time are of such high standards and the clinicians have such a wealth of experience in those areas. The service is first class in that area. 1345 We do not encourage them to come to Noble’s Hospital, but unfortunately some of them do end up in Noble’s Hospital, but the clinicians themselves say, ‘If you are going to have a motorcycling accident, the Isle of Man can do the best to patch you up than anywhere,’ I believe.
The Chairman: Does that satisfy you, Mr King? Do you have any more questions? 1350 The Minister: Mr Killip might be able to –
Mr Killip: No, Mr Killip has consciously endeavoured not to fall off his motorcycle (Laughter) although sometimes, of course, that is in the hands of others and if it ever comes to pass, I am 1355 relaxed about passing into the hands of my orthopaedic colleagues.
Q92. The Speaker: Through the Chair, the cost of recovering the cost of such treatment from visitors is something that the Hospital pursues with vigour?
1360 Mr Killip: Yes, we are coming forward with the necessary legislation to approach insurance companies for reimbursement of costs. Where the costs of patching somebody up relate to a foreign national who is not covered by the Reciprocal Health Agreement, they are pursued for costs.
1365 Q93. The Speaker: And a foreign national is somebody outside the UK and EU?
Mr Killip: Correct.
The Chairman: Thank you very much Minister and Mr Killip. I trust that we will receive the 1370 further written confirmation of questions raised?
The Minister: The actual figures that you require (The Chairman: Yes, please.) we will let you have as soon as we possibly can.
1375 The Chairman: Alright. Thank you very much for your time.
Mr Killip: I have noted that and we will get it to you as soon as we can. ______25 SAPRC-H STANDING COMMITTEE, MONDAY, 9th JULY 2012
The Chairman: Lovely. We look forward to receiving you early next year, if not before.
1380 The Minister: If we are still here, who knows.
The Chairman: Thank you very much.
The Committee adjourned at 4.22 p.m.
______26 SAPRC-H