Transcript

So you're going to say it's a live, are you? We're going to do that now, are you? We're good to go. Okay, welcome to this formal public meeting of the Health and Well-being Board. Board members attending remotely will not be able to vote on the recommendations and will be marked as apologies attending remotely. Those attending remotely please turn off your camera and microphone when you're not speaking. This meeting is live for public viewing via the live stream on the Council's website. I welcome those watching via the webcast. It is obviously then open to the press and the minutes will be published on the Board's website. There is no fire drill plan so if the alarm sounds please use the exit. Actually can we use the exit because it's, yeah, so it's not the normal door that you know about because that is not functional at the moment. You have to go out through the reception where you probably came. Can I please ask Board members and anyone presenting to speak clearly and directly into their microphones? Mobile phones are to be switched off and turned to silent which is what I should do because the last time mine was the phone that went off. Okay, so I would formally like to welcome to the Board's membership Michael Coughlin who actually has sent his apologies but he is the interim head of paid service for Surrey County Council. So this is a message for this time because we are in the pre-election period. So as you're aware we are now in the pre-election period for the general election taking place on Thursday the 4th of July. Guidance has been issued to members and officers and I would like to remind members when presenting reports or asking questions to please refrain from endorsing or referencing any candidates or political parties standing in the elections and any controversial political campaigns or policies related to the election. Okay so we move on to apologies. So we've got apologies from Karen Brimacombe who because she's attending remotely and Sue Murphy is also attending remotely. Fiona Edwards is being substituted by Nicola Airy who's director of place and communities at Frimley. Dr. Sue Trestman is being substituted by Kim Jacobs who's over there as Surrey Joint Carers Program Manager. Professor Helen Rostel is being substituted by Kate Barker who is in attendance as P2 co-sponsor. Oh my goodness. Tim DeMeer is being substituted by Tamara Cooper managing public relations Surrey Police. Lisa Townsend substituted by Laura McAllister partnership community safety lead. Rachel Waddell substituted by Kate Barker woman of many hats this time. Liz Williams, Kevin Deenis, Joe Cogswell, Michael Coughlin, Sinead Mooney, Claire Curran, Carl Hall and I think Siobhan Kennedy is attending remotely. Anyone else? Thanks chair. So we've also got Anne-Marie Barker has sent her apologies and Steve Flanagan is attending remotely. Okay so going on to the minutes of the previous meeting held on 20th of March. Are we satisfied that's a fair representation? Yes, right. Number three, declarations of interest. Does anybody feel the need to declare an interest, a declaration of interest? Nope. Number four, questions of petitions. There's no members questions, no public questions. We passed the deadlines for submitting petitions so there's no petition. So we move on to the first substantive item which is the health and well-being strategy highlight report. I'll hand over to Karen Brimacombe who will, if you'd like to introduce the presenters as you go on this item. So Karen's over. Thank you. Thank you chair. I'm sorry that I've joined remotely today but in a minute I'm going to hand over to one of my public health colleagues and she's going to talk to you a little bit in a little bit more detail about Surrey's efforts around tobacco control but before I did that I just wanted to highlight a number of things. So the first thing I wanted to talk about was work around encouraging young people to maintain a healthy weight and some of the work that we did revealed that there was a gap in support for kids between the ages of five and seventeen. So active Surrey has been awarded a Be Your Best programme contract and that's to deliver a programme of works to this age group. The second thing I wanted to outline for you was that two outreach workers from the Surrey Bridge the Gap programme had a great opportunity to speak to a number of representatives from across various government departments and so that was really helpful in promoting how we in Surrey are delivering cost-effective system outcomes. Some more good news in that Changing Futures had an opportunity to present some of their work alongside the Alliance for Better Care and that was at a national conference and I'm really pleased to say that they actually were given an award and that recognizes that they are one of 24 services across the UK which is taking significant strides in supporting individuals with lived experience to get back into meaningful employment. So a number of agencies have been working together in key neighbourhoods and addressing current lower levels of referrals and uptake of NHS health checks and that's in in doing that work they've been working with a number of community and faith organizations with the Surrey Minority Ethnic Forum and with active Surrey to name but a few organisations. We've also got a Macmillan researcher who's based at Surrey County Council who's begun some work on looking at cancer inequalities and a really interesting programme going on around hoarding. I'm sure most of us in our professional lives have come across people who have hoarding tendencies there's been some training to raise awareness and we've also got a SharePoint site for professionals so that they can log on and get some information and help as to what to do. Falls we know is a real issue and we've been doing there's a training package being developed and also a checklist which helps people and patients to prevent themselves falling, risk of falling. And finally we've got a new carers partnership group operational and some of you in the room will know a lot more about that than I do but the great thing about that is that 75% of that group are actual carers non-paid carers so really encouraging. But without further ado I'll now hand over to Emma Jones. Emma's the Public Health Lead at Surrey County Council for Cardiovascular Disease Prevention. So Emma if you would like to take over. Thank you Karen. Hopefully everyone can hear me okay in the room. So thank you very much for having me. I'm going to kick off the conversations around smoking and tobacco control in Surrey. So a little bit further. Perfect thank you. So smoking continues to be the leading cause of ill health early death and a significant contributor to health inequalities. Action on smoking and health estimates that smoking costs us in Surrey nine hundred and fifty million pounds per year. We still have just under 12% of our population who still smoke with the highest prevalence in populations such as routine and manual workers and people in treatment for substance misuse. Back in September the Surrey tobacco control strategy was refreshed and came to this board for comments and was then launched in October. Later that month the government announced their plans to create a smoke-free generation by introducing legislative change through a tobacco and vapes bill which has cross-party support. This would increase the legal age to purchase tobacco products by a year every year, strengthen our enforcement and crack down on youth vaping. However the bill did not pass through Parliament before the election but despite this our work in Surrey continues to address smoking and the associated health inequalities. This is through the additional grant allocation we've received as part of the wider smoke-free generation program. We've been awarded an additional grant of just over 1.1 million pounds for the next five years. This will help us support an additional 15,000 smokers to set a quick date to tackle their nicotine dependence for good. We've got a detailed action plan to help us achieve these ambitious but realistic targets working with a range of stakeholders from across our system. We will firstly increase the capacity of our current stop smoking service which was recently commissioned and will expand upon the 13,000 smokers that we will already be supporting over the next five years through the core contract arrangements. We will also focus and target our support on populations where smoking prevalence is greatest. As I previously mentioned our routine and manual workers, people in treatment for substance misuse but also other inclusion health groups such as the gypsy home traveler communities and those who face homelessness. The evidence tells us that only around five to six percent of smokers will go through local stop smoking services so we want to drive demand to these services by generating local mass media campaigns particularly highlighting the message of hope and the benefits to individuals who will get support to help them quit smoking. And we'll do this by applying local insight and behavior change approaches so that our communication resources are seen by all and have maximum impact on our residents. We will also continue to build on the strengthening partnerships with our NHS colleagues particularly through the long-term plan tobacco program in our acute trust and across our maternity services. This will ensure that all smokers are given an opportunity to access support at every possible interaction. We'll also support this by increasing our training provision for all of our frontline staff which is also outlined in the strategy the tobacco control strategy so that they're up-skilled and confident to be able to have conversations about support available and this will be through very brief advice and specialist smoking cessation making every contact count modules. We've got a really strong and robust governance route through the combatting drugs partnership the sub group for which is to reduce alcohol and tobacco related harm and this is where we're going to track our progress and monitor our performance. I would just like to end by saying the smoke-free generation announcement was a momentous moment for the public health community. We really have to seize this moment to support our residents to have the best possible health outcomes and ensure that no one is left behind because of the damaging impacts that smoking can have. Thank you. Anybody have any questions for Emma or Karen on that? Otherwise would you like to move on with the other items? Okay so thank you very much for that and this funding is for how long? The additional funding you've got is for how long? It's free it's an annual grant but it has been committed for five years. We move on to Kate Barker for priority two. Thank you chair. The team have asked me just to bring some items to your attention following ongoing work with the main themes in the highlight report. For priority two outcomes we're pleased to announce that after significant national government changes to the national suicide prevention strategy and you'll be aware that there were delays in the publication earlier this year there is now consultation on the revision of the Surrey suicide prevention strategy. The public health team is engaging with all relevant board chairs and groups across all ages to gain their input by July the 22nd and then we propose that our refreshed countywide strategy can be published. There's also good progress on creating a universal well-being plan for children and young people. This is in readiness for Surrey's Feeling Good Week activity that's during the 7th to the 11th of October and there will be more information on the campaign to follow. There's also more development to support on the first steps to support work. Firstly there are pilot areas now extended to the boroughs of Waverley and Woking and to care homes and secondly the launch of the chat box pilot means that access to the first steps program is now across Surrey and there is more supportive information in the main report. And in regards to the mental health investment fund and workplace well-being the myth team is at the final stages of agreeing an evaluation framework which will support the impact analysis of the currently funded myth programs and the roll out of this will be across the funded projects and it will commence at an early autumn workshop. COMs across the County Council and Surrey Heartlands are now to be released monthly to highlight the impact of the myth funded programs and to showcase the return on investment this money is having. Several releases are ready but they will go out post-election. There was a roundtable workshop on the 12th of June which involved representatives from across adult and children's from the VCSE sector and place commissioners and use of voice and work is advancing in allocating the remaining funds. So I'd now like to introduce Jack Smith who is going to provide an update on our green health and well-being program the dose of nature. Thank you. Thank you very much Kate. Hello everyone thank you very much for having me today. I'm just going to share some slides with you. I've just got a handful of them to take you through some of our updates. Hopefully they'll show okay on the screen there. So yes once again thank you everyone for having me. I just want to share a quick overview of dose of nature as well as some of the outcomes of their first year as well as some of the challenges that both they and other green health projects are facing at the moment. So what is dose of nature? You might have read a little bit about it already within the health and well-being report. They're a charity, they're established to promote mental health benefits of engaging with the natural world. They already have a pre-existing and well-established hub in Richmond that's commissioned through their local ICB and we also then commissioned dose of nature a hundred grand to set up a second hub in Guildford and they have two main offers. The first of them being nature prescriptions where a GP will refer to dose of nature. They'll receive an assessment by a psychologist before moving into an eight to ten week nature based intervention program led by a volunteer nature guide. They then move on to a second psychologist review before then being referred on to in-house group therapies. Some of those include things like creative writing, art, knitting, mindfulness, all of which are both in and inspired by nature itself. Dose of nature in Surrey, like I said we commissioned dose of nature as part of our green social prescribing program in 2022 to set up a hub in Guildford and Guildford specifically due to two of the top five priority neighborhoods being in that area as per the health and wellbeing strategy. The aims of that commission are for them to establish a hub in Guildford and offer services to patients in the North Guildford PCN, to promote mental health and wellbeing throughout the population of North Guildford, offer targeted support to adults experiencing a wide range of mental health issues and also to reduce demand on health and social care services in the North Guildford PCN. The outcomes of that first year were that they received 80 referrals, 83% of those engaged at initial assessment and 97% engaged after assessment in that 8 to 10 week program. As a point of reference, not a point of comparison so I know that they're different cohorts but just a point of reference, 36% of our referrals accessed in completed treatment in the year 21 to 22. Those 80 referrals, the dose of nature received, they saw an average reduction of seven points in both the PHQ-9, a measure of depression and the GAD-7, a measure of anxiety, with six or more indicating a reliable improvement. They also had referrers, GPs and GPIMs reporting relief on demand to their services, particularly for those patients that might be referred to as revolving door patients and also those that might struggle to access traditional services. In addition to that, they also saw a number of qualitative improvements in people's connection with nature, one of those I've shared on screen with you which I'll read out in case it's too small there. Thank you so much for reminding me of something I've always loved and enjoyed. I don't know when I forgot but now I remember I have a refuge in nature when things get overwhelming. So what does the future of dose of nature in Surrey look like now? Well they have found a permanent home at Wharf Cottage within the National Trust Dapton Wharf site in Guildford, some of you might be familiar with that, and they're very well embedded within the primary care and VCSE in the area. They've got partnerships with charities like Zero Carbon Guildford, YMCA, Surrey Hill Society, they've also done some fantastic collaborative work with the Department for Work and Pensions, and they've also got very strong links to both local GPs and GPIMs. There is in fact a study that was done at their Dose of Nature hub in Richmond, Kew, that showed that there were 40% fewer GP contacts post nature intervention at a six-month follow-up. Dose of Nature, they are likely to receive some limited funding from DEFRA in phase two of the National Green Social Prescribing Programme, but that will only be for a year and doesn't necessarily cover their full operational costs, and so they do continue looking for other sources of funding to support their sustainability. And that brings me on to some of the challenges that both Dose of Nature and other green health provisions across the county are facing at the moment. So for just a little bit of context, Dose of Nature was just one project funded through our phase one DEFRA funding of Green Social Prescribing, part of our whole green health and wellbeing work at Surrey County Council, and the aim of that work being for us to embed that well-researched health value of nature into our healthcare system. And what we know are that projects like Dose of Nature, they are a good news story for health and wellbeing in Surrey. They make a really clear and obvious contribution to the health and wellbeing strategy, and they demonstrate really robust and positive quantitative outcomes. However, that being said, they do still struggle to attract funding from the local system, so funds like the Mental Health Investment Fund and the Better Care Fund, both of which they did apply to but without success. And what we see is that when these types of provisions or projects do attract funding, it is rarely for more than a year, and what that tends to do is just foster a reliance on that kind of yearly grant funding cycle rather than supporting any long-term sustainability and growth of these preventative kind of interventions. When that funding does come through, that sort of patchy funding, it does little for having a coordinated system-wide approach to how we can embed nature into healthcare, particularly in a way that might align with health strategy. Other projects that are within our work, like Nature in Virtual Reality for people with dementia, or where we're creating therapy gardens for children and young people, they similarly are praised and publicized, which is fantastic for the role that they play in prevention, but that similarly rarely translates into any sustainable funding or support for them. However, we're in a position now, with our green health and well-being work, where we have a number of these successful green health projects. We've got this large evidence base that we've developed, both locally but also the evidence that exists on an international scale. We've got a huge network of local stakeholders interested in this work, and that puts us in this position where we could coordinate this systemic approach to how we can embed nature into healthcare, but that's not particularly doable without any sustainable funding that takes us or any of these delivery partners beyond just a year of operation. So, what we're acquiring now is that strategic support to identify financial resource for how we embed and align green health with our health system priorities. What we'd be able to do with that, we could support the sustainability of these voluntary sector organisations offering green health provisions through things like business planning mechanisms for sharing learning and resources, developing their own funding streams. We could facilitate funding through corporate social responsibility, strengthen their connections with our Environment College, our Environment Directorate, to align with their priorities, things like green skills and local nature recovery, and of course also support their alignment with health strategy and what we know to be the health priorities, rather than at the moment what can be quite disparate and overlapping provision that doesn't necessarily align with our priority populations, for example. So, with that in mind, I just wanted to leave you with both mine and my manager's contact details, Rebecca Brooker, and I'm more than happy if there's a moment for any questions now to take any, but if not, if you want to follow up with myself or my manager, please do drop me an email, and thank you again for your time. Thank you. Does anybody want to ask any questions? Graham, do you want to introduce yourself? Yeah, hi, Graham, Chief Execs are on board of the Mental Health Trust, so fantastic presentation, Jack, thank you very much. I had one question and one reflection. So, the question was, is this service, we know there's a lot of correlation with mental health and anxiety with neurodiversity and alcohol and substance dependency, so one, is this service open for people with those presentations, and the second, I guess, was a reflection observation, which is, I think, across the County Council and the National Health Service, we are now looking at building a much more integrated charity and health sector offer. So, hopefully, Jack, you're plugged in to the voluntary and VCSE alliance, and so we'll be building in, I think, a much more substantive integration and, therefore, funding and permanency around relationships with National Health Service. So, hopefully, that's good news in the future, and I can, if you want to contact me afterwards, I can put you in contact with how we're going to do that, if that's of help. Absolutely, yeah, thank you, Graham. Yes, to answer your first question, yes, I'm fairly sure that Dose of Nature will take referrals for people with drug and alcohol concerns, for example. I know that in their psychology assessment, there may be various reasons why they might reject a referral, but as a blanket rule, it's not as if they would reject anyone with those kind of concerns. And on your reflections, yes, that sounds fantastic. That's certainly the kind of thing that we're interested in, and we are in contact with the VCSE alliance, but it may be helpful if I could drop you an email at some point, just to perhaps spit your brains a little on that as well. Thank you, Graham. Thanks for the presentation. I mean, 100,000 pounds, 150 people, so about £600 per person per program, which I think is probably comparable to current, I don't know what IAPT kind of contracts now per person would be, but maybe between £600 to £1,000, depending on the acuity of the individual. I suppose my question is, so there's a number of providers of IAPT services in the county, and if the program of work is reducing anxiety, depression, for instance, whilst it might not be a traditional psychological therapy, whether within the kind of rolling funding envelope that sits around IAPT services, whether there was a different way of approaching the funding for a more sustainable model as opposed to purely relying upon green funding, so meeting two different priorities at the same time. So it's just about thinking a bit more broadly about where the funding sits and how the county and the health and well-being board might want to look at that provision. I mean, it means bidding for contracts, et cetera, in the same way that other providers do across the county, but there's a number of smaller providers that do that. So it was just a thought for future funding for the program. I completely agree, actually, because I think the proof is that a lot of these sorts of practical, enjoyable, if you like, interventions have a much larger and longer impact and also can be sometimes repeated by people after they leave your system. It becomes part of their way of life and a much longer-term impact than repeat sessions on CBT that cost a fortune or whatever it is. And also I think it's something that these are the sort of things I think the BCF should be funding. And we'll get to this, but I notice that maybe all mental health, social prescription and autistic services on the BCF funding have reduced their expense remarkably. And this is exactly the sort of thing. I personally believe that we should be looking towards for long-term impact for our residents. Who wants to say something? Oh, Helen. >> Thank you. So for those of you who don't know me, I'm Helen Coonsie, Executive Director for Adults Wellbeing and Health Partnerships. It's really great. It's a great presentation. It was really great to hear the support for prevention early intervention, because that's exactly what we're talking about. I think Ruth and her team are doing an awful lot of work to make sure that we're aligning this into all of our strategic conversations at every level in terms of whether we're working with the provider collaborative, whether we're working with the community collaborative, whether we're talking about our commissioning, these sorts of conversations are starting to pick up strategically. We only have so much amount of money. Where do we want to invest that money collectively together? And how do we create the best integrated prevention early intervention model? I think that's the point that we need to get to rather than looking at lots of individual projects. And I know Ruth and her team are overseeing that, because that's in line with health and well-being strategy. And it's the priority for the ICP as well. So I didn't want us to walk away thinking we weren't having the right conversations. >> I think my problem is with this, Helen, is that for probably six years now, well, certainly since I started sharing the other -- you know, the adults and health, lots of these initiatives have come through, albeit in the past not necessarily with the best data collection methodologies, which I think we're improving on. But I still go back to what you hear me say at every meeting, that when we're looking at impact, it has to be cross agency impact. And these -- often these things are pilot studies for a year, which I don't even think is a true reflection. Why are we entering into pilot studies anyway if we know we can't fund them at the end? So there's got to be some serious idea about these pilot studies. You know, they should be, you know, running for a couple of years. But also, are we tracking a sample representative of people who go through these systems so that we actually, you know, know the impact? Because the feeling on the ground, you know, when you're talking to residents who do -- you go down the social prescription route, they actually -- they are seen in a very different place from what I -- you know, I call the business as usual, often far more expensive methodology. So I just don't know how -- somehow it seems so obvious that this piecemeal approach to these kinds of -- I mean, it's important to have these individual projects. And I really love this. But we shouldn't be looking at them, I think, the way we're looking at them. And that's that -- as piecemeal. They might be the replacement system. But for six years now, we've been talking about this. Nobody has the guts to cut something that's business as usual. For some of something, it seems a little more left of field, it would seem. Anyway, Ruth.

Just to give you the assurance of what Helen's already said. So it's really important. And as Russell quite rightly challenged, that all these initiatives are looked in the round. And we've got that robust impact on our population health, but also that return on financial investment. And so that's really key. And then it's key that we don't look at them separately, as you said, but in the round. And that's happening as part of our transformation program, also happening as part of our mental health one system plan. And they'll be fed into those key decisions. So it is happening on an ongoing basis. Thank you. I don't want to -- perhaps we should discuss this afterwards. But at what stage are we going to -- well, certainly for the last six years, I feel, you know, we've invested in certain things. And at the end of every single one is where's the investment -- oh, no, that's all that acquired knowledge gone. You know, that's, you know, somebody's been helped but we're not doing this. When are we going to start -- you can't have -- we can't keep having things that are coming up to the knife edge and have no idea whether they've got a future. We either don't spend it ever or we start committing to some of these things. And looking at the BCF thing, I'm actually shocked at what's in there, to be honest, with regard to services in this respect. I am really, really quite angry about it, actually. And this is just another one. Not that I disagree with you, but I think a lot of these projects, if you like, the funding dictates the projects. So we apply for a lot of different funding streams to get these projects. So it's not that they're being done for no benefit. I mean, obviously, there is the benefit here, and Jack's very clearly described the benefit of the projects that's going on there. But the funding came from DEFRA in this instance, and that tends to dictate then that pilot project taking off. So you could argue we just don't apply for the funding and we don't do the pilots. So it's a bit of a chicken and egg. We get the funding, we do the pilot, we look at the overall project, and that's what we're now trying to do is take the overall picture and strategy forward to say we've done lots of these, we know where the benefits are, how can we then bring all that together. [inaudible] [inaudible] [inaudible] [inaudible] With this, they're bright and fluffy and just keep operating on this level. They only needed two sessions of this. There's a very, very big difference in outcome, but the first thing we need to measure is where would they might have been across agency, maybe with increased health, not just mental health because it's not been addressed properly. It's that kind of thing where do we really know that a person might have had multi-intervention over several years or this might be a real solution, not just they've done this and it worked out quite well for them and 83% of people came out of this better than they went into it. How do we know where they might have ended up? Well, and I think that's the work we're doing now is to create that strategy is to do those business cases through all this modeling to say if we didn't intervene there, we didn't prevent there, what would be that ongoing cost? Well, it's interesting because I've tried to ask -- I've asked for all the patterns that be -- Well, maybe that's why it's happening, Chair, because you've been pestering us for so many years. But so far I've been told that's exactly not what's happening by the powers that be, that they actually are doing that. No, well, we have to do that work because we have to know where we can best spend our money and for the best return but also the best benefit for our residents. So if I may come in, so I think the study certainly, a lot of the projects that we've supported it through the myth now have very robust outcome measures. They're going to be followed up over a longitudinal prospective study. Across agency. But across agency because they're supporting. So -- but we don't have -- we haven't had for six years the maturity as a system to do what you're asking for. It doesn't exist. It is developing. I think if you look at the outcomes from this particular program, you've got a six-month follow-up, I think, Jason, is that right? You've reviewed six-month -- a six-month set of data. So we know that the patient or the person who enters that program feels supported -- Do you think six months is long enough? No, definitely not. Definitely not. Because I don't think that you can say that somebody is cured of condition one with six months of follow-up. But I understand that when you've got a year's program, Jason's not got a lot of choice, has he? My point. So I think that's why our myth-supported programs are longer than a year. That's why we have committed to two to three-year-plus sets of funding, picking up on your point that actually a year's pilot is really not sufficient. The other thing is that you can't do a random controlled blind trial on two sets of interventions to ever be able to say that intervention A is better than intervention B. That was a bit oversimplistic. Yes. So unfortunately, for different people, intervention A may be superior to intervention B and last longer. But it will be very -- oh, thank you. Sue, I'll stop rabbiting and give you your expert voice on this. No, not at all. The conversation has slightly gone on a bit forward. From the presentation, Jack, some of the activities by dose of nature are the activities that people can get from Community Connections. And I wonder whether that may be some of the challenge, that it's duplicating another service. And there's probably a conversation that I can pick up as it's North Guildford if you give me the contact details. And I think that nicely segues into what Helen, Ruth, and Graeme was talking around about the work that is going to happen to look at the other activities that are happening. So we don't see that duplication. It's much more cohesive and the community collaborative where there are much more people around the table to bring some of these things together much more. So I think some of this is around duplication of activity. And of course we have that lack of funding that, you know, which will address that if we can all come together much more. Yeah, yeah, absolutely right. So yeah, I think there is duplication happening across the county, sometimes in the same patch happening at the moment as well. And that is certainly one of the issues that we're facing. And particularly when it comes to needing to have that kind of coordinated approach to how we do this. Like that's why there seems to be sort of that overlap in similar provisions happening in similar places because there isn't necessarily that work happening just yet, although I hear it is kind of waiting in the wings to happen. But there isn't that work to coordinate of saying, well, this provision will target this population, this provision will target this population, for example. And that's the position that we feel that we're in at the moment to be able to do. Thank you very much. I think I'd like to -- Sorry, hi, Jason Gaskell. Jason Gaskell is sort of VCSE alliance, amongst many other things. Also someone who was involved in the very early trials of green social prescribing in 2004. So it's not really a new thing. There are a couple of points I would like to make. Actually let's take advantage of that duplication. There are a lot of organizations that deliver and are desperate for volunteers to do green activities and be a range of intellectual and physical stuff. So rather than criticize the duplication, let's look to see what we can do to get people like Jack involved with that wider range of voluntary sector organizations doing a similar thing. In terms of clinical evidence, I'm no clinician, but I have spent a bit of time working with, you probably know Dr. William Bird, who has done a lot of work on this for the best part of 30 years. So rather than reinvent the wheel, is there anything we can do to get people like that to come in and talk about the values of those interventions, the cost efficiency of those interventions and the longer term outlook for the people involved? Let's take that up. Anybody else? Oh, go ahead. Just one supplementary thing. I presume that these programs or projects are accessible to people with physical disabilities? Absolutely, yes. Of course, not all of them. But yes, there are certainly a number of them that are accessible to people with disabilities. I mentioned one for therapy gardens for children and young people and we just recently had a wheelchair accessible path installed there, for example. Thank you. So now we'll move on to Mary Roberts-Wood, managing director for the priority three. Thank you, chair. And in the spotlight today, I'll shortly be handing over to a colleague from public health to talk about the Surrey sexual health program. Before I do that, I'd like to just update on a couple of things in relation to priority three. So in terms of the emphasis on people's basic needs are being met, Surrey county council's warm welcome scheme launched back in November of '23. It's obviously closed for '23, '24, but had over 40,000 residents attending the sessions across winter as around against 16,000 visitors the year before. It distributed over 1100 fuel vouchers and also 9,000 winter essentials to residents. Energy advice was given, depth support was provided to nearly 5,000 attendees and the feedback county have received has been overwhelmingly positive. Obviously, we'd rather not be in the situation where we're having to do it. However, you can see in the second year, the -- I think the word has gone out and obviously we're able to help and support a lot more people. I think the ability of wrapping some of those additional services around those warm hubs is really, really important, particularly when we're talking about the prevention agenda. There's a real opportunity there to engage with residents and help intervene that's an early opportunity. We will be reviewing the feedback and findings from this winter and although I appreciate it's June, winter will be upon us, won't it? So we'll be looking to improve the program even further for '24/'25. In addition, Surrey community action has been successful in their funding bid submission around fuel poverty program and will continue to provide energy support to residents in Surrey for another 12 months. This year, they plan to do more work engaging with key demographics who are in particular risk of experiencing fuel poverty, including targeted projects to assist older people, the GRT community and those living in our more rural areas and residents with disabilities. In terms of children, young people and adults being empowered in their communities, there is a program in our own words, so it's for young people, it's a peer research project is now in the implementation phase and research training is being delivered to a group of recruited neurodiverse young people who will have research questions developed and reviewed by the supporters by the end of June. So in terms of training and employment opportunities, the Surrey Community Council WorkWise program, which is a free employment service available to any person with a mental or physical health condition, disability or neurodivergence who wants to work, the program is now fully live and accepting referrals. For more information, please have a look at the link in the highlight report. And finally, before I hand over, in relation to our focus on people being safe and feeling safe in our communities, the sanctuary scheme offers households the choice of remaining in their homes where suitable, appropriate and where the domestic abuse perpetrator is no longer resident in the property. As at March this year, the sanctuary scheme has fitted nearly 300 security measures in the homes of survivors across Surrey. And as we all know, not only are the lives of individuals who are experiencing domestic violence horrendous, the fact that they have to leave their homes, leave their communities is further trauma for them. So the ability to keep those people in their homes and for them to feel safe in being there is absolutely something that we can give to these people. So I'm very pleased to see the progress has been made there. So if it's okay with your chair, I'm going to move to my colleague, Julia Groom, who's a consultant in public health. And this is in relation to the sexual health programme that Surrey has been developing. So over to you, Julia, thank you for joining us. Thank you very much. Just wanted to check that everybody can hear me okay. You're fine. Lovely. Thank you. So first of all, I want to say good afternoon and thank you for the opportunity to have a spotlight on sexual health. We're delighted that sexual health has been brought into the scope of the health and wellbeing strategy and with a particular focus on priority three, reflecting the kind of broad factors that impact on people's sexual health and wellbeing. So our vision for sexual health in Surrey is positive sexual wellbeing for all, and that includes providing access to high quality sexual health services when needed, but particularly reducing sexual health inequalities so that nobody is left behind. Surrey sexual health provides a range of services across the county and details of those are all set out on the Healthy Surrey website. I wanted to focus this afternoon, in addition to the information that was put in the pack for you, on three areas that sort of demonstrate a wide approach to addressing sexual health and wellbeing. So the first area I just wanted to highlight was chlamydia. This is the most common bacterial sexually transmitted infection in England, and the focus and priority is on testing young women because they are most at risk of reproductive harm through untreated infection. We've just received our data for 2023, which measures our chlamydia detection rate for this group of women aged between 15 and 24, and this measures our control activity. So it's how well we are targeting our testing to reach the right population. It's not so much measuring the level of morbidity, and we're pleased to say that our detection rate has actually increased and is the highest it's ever been since 2012. So we're very pleased that we're heading in the right direction, but we know like the rest of the southeast of England and wider parts of the country, we still need to do more to reach our national targets. So the data is showing that we're increasingly testing the right people, but we need to make sure we continue to do that and reach more people. So an example of some of the work we're doing in this area includes targeting our 21 key neighbourhoods, so ensuring we are promoting pharmacy access and working with organisations that work with young people, in particular colleges and universities, to make sure that we have got really effective communication and also using a really targeted approach to social media to engage young women and promote greater testing. Moving on, I also wanted to touch on teenage pregnancy. So there are many factors that influence a young person's journey to either becoming a teenage parent and having a teenage conception, and there's really an important need to work in a whole systems way to address the very varied range of reasons that influence those outcomes. So teenage pregnancy aligns very much with priority three of the health and wellbeing strategy because it is very much influenced by the broader determinants of health, particularly around education, wellbeing, a young person's early life experiences. So over the past year we focused on developing a teenage pregnancy prevention action plan, and this is really important at the moment. So after a long period of decline in the rates of teenage pregnancy nationally, there has been an increase in rates of teenage pregnancy. In Surrey, although our rates are lower than England, over the past three years our rates have now plateaued, so we are really keen to kick start a continued decline in those numbers and also kind of prevent the risk of our numbers also beginning to increase. So we've been engaging partners across the system. Our plan focuses on leadership support, on understanding our data, targeted communications, expanding contraception support in nonclinical settings, targeting some of our prevention work, and making sure there's a really good focus on relationship and sex education in schools. So just to give an example of some of our recent work, we've been working with teams who work with care experienced young people, including those working in residential homes and children's social workers, and we have delivered two sets of training and there are more sets of training to come, which is really making sure people feel confident to have conversations about healthy relationships, about sexual wellbeing and contraception and access to services, and that is just one of the routes in which we're really hoping to address the challenges of reducing teenage conceptions. And the final area I just wanted to highlight this afternoon was around HIV. So we have an HIV action plan in Surrey which reflects the government's national action plan and focuses on four areas. Those are prevent, test, treat, and live well and reduce stigma around HIV. So a recent example of some of the work we've been doing in Surrey is to undertake a pilot of point of care testing. So that is HIV testing that provides instant results and we're trying to roll this out much more widely in the community to increase access. So organisations such as substance misuse organisations like Guildford Action and iAccess, homeless organisations, sex worker charities such as Streetlight UK, and also the Women's Support Centre have been trained so that they can offer HIV testing to their clients when the time is right for them. And the test can be administered by the client, but the staff in the organisation are there to provide support, whatever the result. So far it's been received very positively and as I said the aim is to actually increase that access to testing and to reach those who may not normally access services and address some of the stigma associated with HIV testing. So we know in Surrey that our prevalence rate of HIV is lower than for England, but the challenge we have is that nearly 60% of HIV diagnosis are late diagnosis and this is against the national ambition that that figure should only be 25%. So it's really important that we are promoting testing as much as possible in the wider community to make sure it's accessible. So I will stop there. I hope you found this update on sexual health interesting. I'd be very happy to take any questions and very pleased that it's now a kind of part of the health and wellbeing strategy. Thank you. Thank you. That's very interesting. Any questions? Thank you, Kate Scrivens, Chief Executive of Lumines, which runs the Health Watch service within Surrey. I wonder if you could just say a few words, please, about the way you've involved either people with lived experience or people from the target cohorts that you are hoping to access with your particularly communications and I'm thinking of use of social media. How are you ensuring that the people who that is aimed at are actually involved in helping you design those messages so that you've got the confidence that they really are going to work with those target audiences? So is there a little bit of co-design in this work? Thank you. Thank you. Yes, so I suppose there are a number of areas where we have worked with people to co-design services. So, for example, we have a joint sexual health outreach plan with our sexual health service provider, Central Northwest London NHS Trust, and that involves people and gets feedback from service users about different aspects of the service and how those can be included. And we particularly want to make sure that we're including groups that are more, find it more difficult to access services and how we can make that services more of an outreach approach. I think one area where I would actually have to check with my commissioning manager, we have done some really targeted work recently around chlamydia screening, sorry, chlamydia testing, and that is using kind of targeted social media messages to girls aged 15 to 24. And I know there was a lot of discussion around the message, the images, how that is presented, but I'm very happy to go away to my team and check exactly who was involved in that process and come back to you on that. Mark. Thanks, Julia, for the presentation. I was just going to say I visited Guildford's sexual health clinic, which is quite amazing. And I was really surprised and impressed with how many youngsters were there, not because they had issues, but because they were very concerned and being very sensible about their own health. So the messaging is getting through, certainly to that sort of university cohort in Guildford and around that area. Obviously the more people that we encourage to use the facilities and the services, the cost will go up in the initial and then hopefully plateau out as we start to receive the reduction of some of these infections going forward. But it is encouraging when you talk to the youngsters. They get it. And I think Sarah just put in the chat here, a lot of the work we're doing has been designed with the help from the Surrey School of Acting to make sure that it's focused on that younger cohort, that it's relevant to them, that they get it and they move forward. But I think it's probably all of our responsibility to make sure that these types of subjects aren't or don't come with a taboo, that we openly discuss them with anyone and everyone. And it's not just youngsters. There's a lot of people in our society now who get divorced in middle age and then go out into the new social world. Of course, they think they're never going to catch anything like this and maybe aren't as aware as you are when you're growing up into university scenario. So again, it's not necessarily just the young. It possibly could be everybody that we need to get the messaging out to. I think one of the, I'll just make a comment. One of the comments I've had from residents in some parts is obviously house prices are very high here. So you have quite a lot of young people who might have been living independently still living at home. And one of the issues they've said is that there are quite a few parts of Surrey where you are not, you can't access a physical sexual health clinic very easily. It's a very long way away. And they don't really want the testing kits coming to their home where their parents are. So they're actually not getting tested. And I do wonder how big a problem that home testing is for this increasing number of people, many still in their mid 30s who are still living at home and don't want those test kits coming through the door. Well, it does, I mean, so the test kits are brown enveloped. So if their parents are still opening their mail, then maybe it's still a problem. But assuming their parents aren't opening their mail, they're very discreet in terms of the packaging. It's not identifiable on the outside. And we should maybe make that a bit clearer. My question really was also around that geo geographical data, because I guess it doesn't surprise me that our pregnancy rates have plateaued when they should be going down. Because I know locally in my practice area that our access to sexual health services has stopped. We lost a sexual health clinic at Ashford Hospital that was -- well, actually St. Peter's Hospital that was very well attended. And so I just wonder if we're looking at where our chlamydia rates are and where our pregnancy rates are and making sure that we're cross-referencing gaps in access, gaps in transport access, gaps in actual access of services. Are we being, you know, intelligent about our targeting and our data? Can I just add to this? Interestingly enough, one of the things that we -- I had levelled when I was going to a particular conference, and I wasn't expecting to be talking about this, and the point came up that an awful lot of people on zero hours contracts, so if you have to travel an hour and a half to get on a bus to go to a sexual health clinic and an hour and a half back, that is three hours, well, plus the time at the clinic, that's half a day of work gone, and then awful lot of people in Surrey, you know, this lack of access is an issue for quite a wide cohort, quite a wide cohort of people. Should I come back and just respond to a few of those points, Chair? Can you hear me okay? I'm sorry, yes, please, I'm not. >> Oh, sorry, I'm sorry, I didn't see you. So I suppose just on the point around young people, sort of young adults living at home, I would reinforce that these are very discreet packaging, but also there is access to some testing from pharmacies, so that's another route that people could take, but I think there's also something about, you know, trying to, as you said, reduce some of the stigma about talking about sex and relationships as well, so that I think is a longer term perhaps aimed through relationship and sex education that we're keen to support our schools with. I think there was another question about targeting and about how we are targeting services, and I think in terms of teenage pregnancy, we did look very closely at the latest data, and whereas previously we have definitely seen, I suppose, geographical hotspots of teenage conceptions, we are not actually seeing that as much anymore, so quite a bit of the focus of our work is looking at our priority neighbours, the 21 priority neighbours, but also looking at groups that we know are at higher risk, so particularly young people who are excluded or missing from school, care experienced young people, and we think that is probably the most effective way of reaching people, young people who we think may be more at risk. And I think there was another question about access to services for young people, and as I said, one of the things we've seen through, you know, since COVID is this real step change in accessing online services, and we are keen to continue to promote that widely, but we do also monitor it, so we do check, you know, where access is easy or difficult and what we can do around that. We have also seen that the service expand its access for young people, so now they've introduced a Teen Tuesday so that all the three main clinics are offering teenagers drop-in every Tuesday, so hopefully that will become a clear message for people, a simple to understand as they know where they could go if they do need face-to-face support. Thank you. Thank you. I think we'll, oh, just what, that's last, last statement on this one, because I'm already overrunning. Sorry, apologies Chair, I know that I'm adding to the burden. Just actually to support the work and highlight the work, I know that Ruth's team and your team, Julie, are doing great work. I think Rachel reached out to us in primary care a while ago, ran a webinar for World AIDS Day with a sexual health consultant and somebody with lived experience highlighting the late presentations for HIV, particularly in Surrey, some of that population. It's from a South Asian and some of our black communities in the county, so men who don't identify as being gay or bisexual, for example, and reached out to primary care to really destigmatize HIV testing and to think about lots of other conditions that might look like they're a different illness but actually have the root cause being HIV and AIDS. I know, Kate, that they've also been working with, to go back to your question, Kate, about reaching the right communities, working with SMEF to see how they can support those communities to think about HIV testing more broadly. Just to applaud the work that, Ruth, your team, Julie, are doing around this. Thank you. Thanks very much. I really appreciate the support you gave during HIV testing week, which was focusing on stigma this year. That's very appreciated. Okay. Actually, the risk of going a bit late. On the priority three, the WorkWise program, which is available to people with mental and physical health, we know the statistics for employment for this group is staggeringly low and the impact for many of them is dreadful because they're eminently employable and with no hope of work. No wonder many people in neurodiversity have mental health issues. I went on to the link but I wasn't clear how many people had taken up this service and how much bandwidth you had to really communicate this across the piece because I think it's a very important service. And are employers aware of your attempts? Are we badgering the employers as much as we're trying to get young people to come to you to get advice? Thank you, Chair. I'm not sure of the figures off the top of my head but happy to get those for the board in terms of take-up. So it's obviously a pre-service and any person can be referred into it. So often those referrals come from other partners. So whether that be voluntary community sector partners, districts and boroughs, in terms of business, via the economic prosperity teams within the districts and boroughs, this scheme has been advertised as well. So I think there's always more we can do in terms of communication and reach, particularly for cohorts who wouldn't necessarily be looking at those sorts of channels. So maybe it is about looking at our neighborhoods that are more difficult to reach and how we do that. No problem, Chair. Thanks. So I'll just go on to the recommendations. Amelia, if you would. Yeah. So the board is asked to use the highlight reports and engagement slides to increase awareness of delivery against the health and wellbeing strategy and recently published an upcoming JSNA chapters through the organizations to note the opportunities and challenges which include the following, the sharing and use of the updated HWB strategy index, the increased focus being seen on health inequalities through key neighborhoods and priority populations, the doubling of funding for local stop smoking services for the next five years, expressions of interest being requested for organizations to benefit from workplace wellbeing program, workshops to inform topics for the health determinants research collaboration program that will boost research capacity and capability within Surrey and the beneficiaries being supported by Bridge the Gap are at significant risk without securing sustained funding from April 2025. And sorry, lastly, the funding for serious violence program finishes on the 31st of March, 2025, and there is currently no indication of a future funding settlement. Okay. Everybody happy with that? Yes. I take that as a yes. We'll move on. Thank you very much for the presenters and sponsors, et cetera, of that section. And we'll dash on to item six, which is health and wellbeing strategy index school board. Now, a specific work has been progressed and add over 20 new indicators to the index. The scored card presents an opportunity to baseline progress against priorities and outcomes and start assessing impact in these areas. Any gaps that remain are due to be picked up in the longer term as they are largely due to the more extensive work that is needed to collect new data or ensure rigor and relevance of existing data. So this is presented by Ruth Hutchins, director of public health, Surrey County Council, and rich carpenter, senior analyst and analytics inside. Thank you, chair. I'll introduce this item, then hand over to rich. So as board members will remember, last year, rich and rich's colleague Uma came to present the health and wellbeing index and what it can do in essence, which is another tool that we have as a board to measure our progress. What the health and wellbeing index does is measure those high level outcomes of what we're aiming to achieve. Because as per our previous discussions, a lot of our programmes go towards meeting a number of outcomes. So it's not one programme leads to one outcome. That's why it's really important we have the index. The index is online. I know a lot of board members and other colleagues across the system are using that. So that's really great and it provides some transparency to our residents as well as how we're doing as a board. So we encourage board members to continue to use the index. Now rich is showing screenshots. Last time we had a live demo of the index on the left hand side of this slide that you can see at the moment. When we came last time, we were saying that it was some of the indicators weren't covered, but after lots of hard work and engagement with partners, we can now say that every part of the strategy, we have a related index that's now available. And if you look at appendix two in your paper, we list all the indicators in detail. So that's for your reference, but you can see it online in the index. And just a reminder, where available and where meaningful, the index allows us to look at different geographical areas, in particular district and borough, ward and primary care level, PCN network level. If it's not available, obviously we can't publish it there. And at the county level, there's a section of the index which provides data on our priority populations where available and our overarching indicators, which are life expectancy, healthy life expectancy, but in particular those inequalities, which of course are overall strategic ambitions. The only part of our strategy where we haven't got data in the index is those with multiple disadvantage. See next agenda item. We're really pleased that we've managed to meet that to a certain extent of our JSMA chapter. That will go into some detail about the challenge of collecting that intelligence. So that's the index. What's new to this board is something that we're determining the scorecard because the index is something that you need to go in. It's interactive. You can toggle between the various indicators and the geographical areas. The scorecard is a snapshot. It's a static piece of work that pulls out actually at a high level. What is the index showing us at any one point in time? And we aim to produce this scorecard on an annual basis to really give that overarching picture. And this is based on feedback we've had from board members and other colleagues across the system. And so what the paper does and what Rich is going to do is outline what the scorecard is telling us at the moment, where we're doing well, where as a system we've got some challenges and we need to focus. It gives the overarching indicators, priority populations, and then the sub indicators by the geography. And so this is the tool we now have at our disposal. I think it's really important to say that on an ongoing basis we'll use our quarterly highlight reports that shows our delivery. We will weave in those outcomes as presented in the scorecard and the index into our quarterly highlight reports so we can map that delivery against our outcomes. So especially where we've got challenges, then we'll really emphasize that so it's systematic and ingrained into our ways of working as a board. Rich is going to highlight some of some high-level examples briefly. Thank you, Rich. Thank you, Ruth. Yes, the scorecard and index, they're both quite large products. I think the scorecard is around 30-odd slides. It will move to a live kind of Tableau dashboard, but at the moment it's presented as a PowerPoint pack. So yes, it is quite sort of extensive, so I can't go through everything in detail. So as Ruth said, I'm just going to kind of put out a few kind of examples where there's significant changes in performance or kind of progress. And so the one you're looking at now is inequality in life expectancy at birth. And so this has been highlighted because this is kind of, you know, one of the kind of key things of the Ambitions Strategy for reducing health inequalities and making sure that no one's left behind. So our life expectancy inside the inequality is essentially the difference in the highest deprivation areas and the lowest deprivation areas in years of life expectancy. And actually we're performing better than the regional and national average, but there has been a slight increase in kind of the recent period. And that's the same as national and regional. They've all seen increases and it's likely that this is due to COVID, perhaps, which has kind of, you know, played its part in people living in more deprived backgrounds. So that's kind of one of the key overarching ones, which is a challenge for us. So the next one is an opportunity, which is the employment gap for adults with learning disability. So highlighting this as a wider determinant of health example of a priority population where we're seeing some improvement. And so I do have the kind of the more detailed numbers if people are interested, but this is essentially the gap in employment rate for people with learning disabilities compared to people in the wider population. So that gap has come down recently. I think the employment rate for people with learning disabilities is still quite low. It's about 11 or 12 percent compared to 70 odd percent for the wider population. But the gap is reducing, which is, I think, a positive thing. And we recognize that there are some programs that have come online since the latest data period there, which will kind of have an effect to improve that, such as the WorkWise program. Just a quick note on some of those data points. We are using publicly available data because this is a public document. So some of the kind of the data that's published might be one year behind what kind of be obtained internally. So just to kind of to raise that for you. The next one is a challenge around the employment gap for adults in contact with secondary mental health services. So the indicator definition for this has changed recently. So the trend you're seeing whilst sort of relevant isn't going to be the most reliable because the figures are actually quite different for the latest period. And so this is the employment gap, as with learning disabilities, is employment gap between the general population and people known to secondary mental health services. There was a JSON-A chapter which highlights this. And there's a recommendation there around the kind of employment and the need to address stigma, which I can kind of share with people. But that's an important one to raise for you. So the next one, these are within the kind of the indicator level kind of recommendations. So it's a quick summary of ones where we're seeing some challenges. Sorry, I got that wrong. These are the opportunities. So these are the ones where we've seen some improvement. The one that's highlighted in bold hasn't been referenced in the paper. So I wanted to kind of make you aware of that one. But all the others are referenced in the paper. And interestingly, from Julia's comments earlier, we do have committed detection rates in there. And those are very, very good. And there are others, unemployment benefits, antisocial behavior, and physical activity. So the next one is challenges. So these are the indicators where we are not doing quite as well as we could be doing. And so there'll be various reasons for these that need some exploration in appropriate forums. And there'll be further details kind of through highlight reports in the future. We do also have an FAQ document we've put together to address some of the kind of explanations for these, which I'm not sure if it's gone out with the papers, but we can make that available. So that's the kind of the quick run through. And as Ruth said, the key messages that we'll be focusing on these areas in highlight reports and kind of going through the existing programs and governance arrangements to kind of look at those in a bit more detail. Anybody got any questions? Great. Thanks, Richard. Really interesting presentation. I just wondered on the mental health, you didn't talk about stable housing, where it looked like it was quite a significant gap. And I just wondered on what you were saying on employment, whether you had any reflections about whether we should be thinking therefore if the data kind of was lined up with apples and apples, whether that would mean actually Surrey was doing relatively better than England, or whether you think actually it would still be saying we've got a relative challenge to the England and whether finally there's any correlation between the lack of stable housing and the employment gap for people open to secondary mental health services. So we do have data in the index for those who are in stable appropriate accommodation, both for learning disabilities and secondary mental health. I don't have the figures in front of me, but they are on the scorecard and in the index. So I don't know, Ruth, whether you have. So I think this is a really good example of where we've got all those challenges they need to that highlights where we're not doing as well as we'd hope as a system that needs to be read in conjunction with the JSNA, which triangulates that data and then that relevant part of the system. So for us as a health and wellbeing board, I've our priority one, two or three, and the various governance that this is where now we can, we are already taking back those areas. And you've given us one example to say, okay, what does this mean for us? Is that what we're already working on? And it's often the case because when we looked at those challenges, there were already programs in development to sense check that actually we're putting enough energy as a board into those areas. Charlotte. So I think one of your questions at the end is, you know, what as a health and wellbeing board should our reaction be to some of this? So I'm going to declare my interest. I'm a GP in Spelforn. Spelforn does not come out very well in this report. So what is our ask of Spelforn around this health and wellbeing board to come to this health and wellbeing board and share with us what its action plan is to improve against some of those indicators. And that, you know, that's the health, the local authority, the voluntary sector, you know, the whole, all of them, including my practice, you know, what is our, what's our action? Because I know there's lots going on, but it would, I think from a health and wellbeing board perspective, we ought to be asking them to come and share their plans so that we can support them and allow them to, you know, ask for support where they feel their support is needed to make things better in the particular areas that are struggling. And that picks up your point about the mental health questions and employment. So again, in the mental health system committee, we ought to be receiving this information and then asking, what are we doing about employment? I know, because I'm the executive lead for adult mental health with Helen, that there are a lot of programs in play around employment support for people with a mental health diagnosis. However, what we've learned from looking at that data is that there's a lack of knowledge about those services from professionals. So there's a lack of referral into those services. So the services exist, they have capacity, but we're not referring into them. So again, we should be able to triangulate this a little bit so that health and wellbeing boards have a little more richness to the tableau. But the tableau is brilliant. It helps us point us in where we need to go. But also there's a kind of triangulation, and I don't really want to sort of go into it necessarily because we've all got the tables in front of us here. But if you take the spelt on example and you see some of the areas where they're classed as the worst of the boroughs and you sort of triangulate them, one feeds into each other. And yes, I think it would be really interesting. Actually, there are patterns across certain boroughs actually, apart from spelt on. I really would like to have almost a workshop on understanding myself what, if you take a Mull Valley or a Tandridge or what have you, these figures relate to each other. And how do we as councillors or health professionals, whatever else we do here, understand the impact of those within these areas? Because we do tend to work on them separately. I don't say you are, but we, when we have these meetings for adults and health, we work on these things separately. I would absolutely agree, and I think that's a really good point you make. The idea of the index is to start raising those questions and kind of allow us to see those patterns, and then we kind of take those away and kind of, we can generate some hypotheses and we can probably work together to incorporate that into some sort of the deeper dives in a workshop style session or something similar. I'll be Nick. I always hated Mark. Two things. One, a lot of it's based around percentages, which always fazes me because it doesn't tell me the story. We can be down 20%, but that could be one person or one, you know, so maybe building some relevance to some of the figures so that I can see where there is a real problem, because there might be a reduction of 60%, but that might be half a person or, you know, so there's that relevance to it. But the other thing is, what it doesn't give me is it gives me the real-time figures, but maybe as a board or as an institution, we need to also have a line in there, which is our aspirational line, because you've got the England, the South and Surrey all running along. I could argue, oh, great, we're running lower than the England average, but if the England average is really high and is bad anyway, then it doesn't really tell me that the figures are actually helping me. So maybe we should set, or if there is a national setting, you know, where we want to be, and then that would give me a real idea of where we're going towards the target. And so those are both very good points. So I think an example of the sort of percentages, real numbers, I think the youth unemployment, there's been a drop in youth unemployment of less than a percent, but that actually represents about a thousand young people. So it's a really, really big change and meaningful impact. Yeah, absolutely. And so those real values are in the index. So on the dashboard for each indicator, we have the score, the rank and the actual value for that index, for that indicator. And we can also see historical data where it's available. The aspiration is baked into the index as well from the kind of the ground up. So the scores for each indicator and outcome prior to an overall from zero to 100, and we get that from zero being what we think the worst outcome looks like, and 100 is the best, and the 100 is an aspirational target. So we either base that on what we think is the most achievable, or sometimes it's a stretch based on kind of the best in the area. So those scores should give you an idea of what we think we can do. So for example, if we picked sort of outcome one in priority one and an area is scoring 30, that's because we think it could be doing a lot better rather than what it is compared to kind of the region of the nation. So there is a lot of detail in there. It's quite hard to kind of convey in a meeting, but that stuff is kind of in there. So hopefully that kind of helps. Just to wrap up, as well as that target aspiration, we've got now trend level data. You'll see that in the index, and that's absolutely key so we can see what the direction of travel, and we make it clear whether it's good to go up or down. Sometimes it's the opposite. Exactly, and that's really important to look out for that. Sometimes it's not what you think. But also just to clarify the action, so as a board we've had that high level overview and we've seen where we've got those particular challenges, and as well as taking those to the program subboards, and as per the examples that I've just given as a team, we'll take that high level overview of the index of those challenges to the relevant boards in the system, for example, the Mental Health Committee. Thank you. Thank you, Chair. I think this is a great piece of work. I just wanted to check what the interrelationship is, and I think you've just referred to this, Ruth, between the various boards in the system that developed their own strategies and these high level indicators. The reason I ask that is because, just as an example, there's a piece of work going on within the Carers Partnership Group around the carers strategy developing an outcomes framework in coproduction with carers about what matters most to Sari's unpaid carers. Now, the only metric in here that I can see around carers is whether people report they have enough social contact. Not quite sure where that comes from. That would be useful to unpick a bit more, but as a real life example, if during the course of the work through the Carers Partnership Group, we come up with some different metrics that are based on what Sari's unpaid carers have told us are the most important things to them, would that then feed through into a discussion about whether these high level metrics need to change over time? So what's the relationship between the work going on in strategies within all our boards across the system and these high level metrics? Thanks. Yeah, so we are restricted a little bit in terms of the index, in terms of how the data is published, in terms of the geographic levels and the timeliness. But where possible, we've worked with subgroups to identify that overlap with kind of subject specific strategies. But really, it's come down to data availability and geographic levels to be able to build it into the index. So we are kind of held a little bit by that. But if there is an indicator that you think we could use, I'm very happy to kind of have that conversation and see how we can include it. But we have tried to kind of align with the sort of other strategies as much as possible. We've had quite a lot of, yeah, sort of workshops and meetings kind of with subgroups to kind of ensure that alignment as much as possible. And we need to recognise this, the index and scorecard is one tool in our armoury. So it's about shining that high level overview, acknowledging the feedback and some of the indicators and we can, well, we have evolved it quite dramatically over the last 12 months, but it needs to be seen in conjunction with JSNA chapters and other sorts of intelligence, of course, it's that snapshot. Thank you. Thank you very much. Thank you very much for what you're doing on that. I'm sure it will come increasingly interesting as time goes on. So the board is asked to review and provide feedback to health and wellbeing at surreycc.gov.uk on the annual health and wellbeing strategy index and scorecard and the progress slash needs it highlights to promote the health and wellbeing strategy index and scorecards to inform organisational and partnership plans where relevant and to raise awareness of the health and wellbeing strategy index and scorecard at related boards and networks. Number seven, joint strategic needs assessment, JSNA, otherwise known and multiple disadvantage. This paper outlines headline draft recommendations that are currently being finalised with the view to publishing the chapter later in the summer following final engagement with key stakeholders. As part of the presentation, a member of the lived experience group that have co-produced chapter will describe his experience of the process. Some of the members of the group involved in co- producing the chapter will likely be in the public gallery also. I don't know if they are. Yes, yes, yes. Terrific, terrific. Lovely to see you. Thank you. Presenter Ruth Hutchinson, Lisa Byrne, he's changing futures programme delivery manager, Ella Turner, research officer, Surrey County Council and Steve Saunders, expert by experience, lived experience recovery organisation. Are you at the table, Steven? Okay, right, lovely to see you. So over to you. Thank you, Chair. I'm really proud to be framing and introducing this item. Of course, I don't need to remind our board of our key overarching priority of this health and wellbeing strategy which is to reduce health inequalities so no one is left behind. This is why this work over the past year has been absolutely fundamental and aligned to our key strategy priority. So it's great to be here today to share with you the key findings and our draft recommendations for our JSNA chapter on those with multiple disadvantage. My colleagues are going to go into the detail but it really represents a phenomenal effort and hard work to understand the breadth and depth of the challenges faced by those with multiple disadvantage. I just want to flag one point and then I've got two questions for the board to consider as we go through the presentation. Lisa's going to describe how multiple disadvantages is complex so therefore I just really want to highlight that this chapter and these recommendations really need to be read in conjunction with other chapters and we do this throughout the JSNA. We sign, post and triangulate but for this area in particular the mental health chapter, the substance misuse chapter and the housing chapter. They're key alignments to this work and also factors that as board members we can consider as we hear the presentation is actually what is our collective action and how can we consider those findings and recommendations in our everyday work in our strategic considerations as part of our review of services and most fundamentally working alongside those with lived experiences. We've already touched upon that today has been a fundamental part of this process. How as a board can we consider to hear about learning from this process and we can continue to implement that in our work. Thank you chair. You've already introduced Lisa, Ella and Steve so I'll hand over to our colleagues. Thank you. Thank you Ruth. Thank you chair. The experience of multiple disadvantage is where people face concurrent and compounding challenges such as mental health needs, substance use, homelessness, domestic abuse and often contact with the criminal justice system. In 2015 it was estimated that there was approximately 336,000 adults in England experiencing multiple disadvantage. The findings laid out in this chapter identify that we have at least 3,000 residents experiencing multiple disadvantage in Surrey. This project has been conducted with consistent and uncompromising adherence to strong ethical and professional principles and values. The findings come as a result of extensive stakeholder engagement, data analysis and collaboration across sectors. By bringing together insights from health, social care, housing, criminal justice, the voluntary community sector and residents experiencing multiple disadvantage, we aim to provide a detailed picture of the needs and the gaps in suitable service provision so that we can do better to meet the needs of this vulnerable population. It is important for me to highlight that this chapter has been co-produced in partnership with a group of experts by experience who are members of Surrey's changing futures lived experience and recovery organisation or the LIRO as we call them. The LIRO was set up in early 2023 and have been involved in the co-production of this chapter from the very beginning and have been committed through each stage of the chapter writing process from setting out the scope and the content, designing the surveys, supporting and conducting the stakeholder engagement, supporting the thematic analysis and shaping the key findings in the draft recommendations. Steve Saunders who is one of our experts by experience, a member of the Surrey LIRO and other strategic LIROs including the national meme and NECG has joined us today to share his reflections and experience of being involved in the co-production of this chapter. Over to you. >> Thank you, Lisa. Thank you, chair and everyone else. I have been part of the LIRO for just over a year now. Myself and my colleagues behind me are very passionate about what we are trying to achieve and the main aim is really the co-production of all the work that we are doing. I myself have come from a background of disadvantage because of my misuse of substances. So I would say I am at the sharp end of what decisions are made on my behalf. And what we are trying to do with our sort of involvement is to try and get our word across to say the boards or the committees and maybe get one of us to sit on there to sort of give people the actual stories of what we go through. I also run smart recovery meetings. I am a facilitator. And I come across people in my meetings both online and face-to-face who have both got mental health issues. They have got housing issues. They have got issues with substances, obviously. And I personally would like to represent all those people because this is my goal now. Because of what I have been through, I feel I am in a fantastic position now to put that word across for the people that haven't got the strength or the ability to speak up for themselves. So I would like to sort of suggest that we could go ahead and go forward with co-production. I am also part of the NECG as was mentioned. And that is -- we have been working with Deloitte together with sort of government representations to try and get a more balanced view by having co-production on all the boards, as many boards as possible. And we know for a fact that certain areas in this country are doing very, very well and other areas lagging behind a bit. For example, people like Essex are doing very well, Middlesbrough area, Sheffield have got a lot of people, got a lot of lived experience people actually on board with the committees and they are putting their word forward. And the main thing is action has actually been taken on what they are saying. At the end of all this, I just hope that -- because we have put a lot of work into this. I mean, we meet very regularly. I would like to see our hard work actually acted on. You know, we can talk a good talk. But to see action is our plan. And I don't want to see -- I mean, it's been said many times in our meetings, we don't want to see all our hard work left sitting on the shelf gathering dust. Not after putting all this hard work in, we would like to see some sort of action coming from it and we will sort -- we will definitely be sort of 100% behind it to get what we can get for the people who are less able than us to actually speak up for them. Thank you very much, chair. Thank you. Thank you, Steve. This multiple disadvantage JSNA research project adopted a mixed methods approach. And it includes cross-cutting representation from a range of stakeholders across the system. As a result of our large scale system engagement, this JSNA chapter identifies a range of key findings which have informed a set of 11 draft recommendations. The JSNA chapter is awaiting final sign-off from the JSNA oversight group. But the full document will eventually be made available on Surrey Eye in the coming weeks. We will also be creating a summary version and inviting you to join us at some dissemination and discussion events this autumn. I will now hand over to Ella who has been the lead author and research officer and has worked in co-production with the LIRO. She's going to share the findings and the draft recommendations with you in more detail. Thanks, Lisa. So I'll start by sharing some of the key findings. So our first theme is ways of working. So the research has identified a key theme of fragmented care which could represent some siloed working across the system. This theme also considers how statutory services are often geared up to assess and treat only what they consider to be considered an individual's primary need. Our next theme is feeling abandoned. Here we identify gaps in unmet needs and service provision. Our first example is the impact of limited access to mental health services and how this often intensifies mental health challenges for people experiencing multiple disadvantage. We also explore how the housing and accommodation support system could be better designed for people affected by multiple disadvantage. And then finally in this section we look at early intervention and prevention. Theme number three is misheard and misunderstood. People affected by multiple disadvantage commonly experience stigma and judgement and often this is due to the lack of understanding around multiple disadvantage from both society and the system. We use this section to think about a shift in culture change and understandings around trauma and psychologically informed approaches. Our next theme is one size doesn't fit all. Not all services are designed for people experiencing multiple disadvantage and the JSNA identifies a need for bespoke support that recognizes the interconnected nature of multiple disadvantage. This support should focus on relational rather than medical models of support, build trusted relationships with individuals and deliver assertive outreach that works at the pace and the way the individual decides. It should also be outcomes led and not outputs driven so thinking about longer term more sustainable impacts. The next theme is overcoming hurdles. There are numerous barriers that prevent people from accessing services. Firstly we look at service thresholds and eligibility criteria which often risk excluding people from accessing support and people also face logistical barriers such as travel and transport service support services, language and literacy and factors relating to the physical environment. And the final theme is under pressure. Strategic challenges can create disruption and discord. In particular current commissioning structures do not always foster flexibility, choice and innovation. This theme considers how funding could be redistributed or restructured to create serviceability and support longer term strategic planning. So I'll move on to the recommendations now. So the following set of draft recommendations have been developed in partnership with the Lived Experience Recovery Organization and using the research findings identified in this JSNA. These recommendations set out priority actions and identify steps towards culture change and system change in Surrey and just to mention that we do understand that these challenges will not take place immediately but they'll require time and collective action going forward. So recommendation one is to strengthen governance structures by establishing a multiple disadvantage partnership board. So working in partnership is essential for you to effectively deliver the recommendations outlined in this JSNA and as a priority there is a need for a refresh of current governance arrangements for multiple disadvantage and that will help to develop a clearly defined and robust partnership structure. The partnership board will have consistent and genuine representation from all local partners and will work alongside people with lived experience in co-producing joint solutions. The board will also be responsible for agreeing a system wide definition of multiple disadvantage and we're also proposing that the partnership board reports to and is supported by this health and wellbeing board but we do welcome your thoughts on where you think this board could sit in order to put the recommendations into action. So in line with that then recommendation two is to develop a five-year strategy for multiple disadvantage. So these recommendations will form the basis of the five-year strategy and this strategy will be used to achieve sustained change at system service and individual levels and that will help to continually improve the life outcomes for its population. The strategy will also be flexible, innovative and iterative. Recommendation three is to improve system wide data collection and sharing protocols. So there's a notable scarcity of data and intelligence available regarding multiple disadvantage which we heard about earlier and that data could be used to inform future commissioning and decision-making processes. So to help address these gaps it's recommended that a population health management approach is adopted that brings together health and social determinants data to identify people who are at risk for priority action and prevention planning. Current IT systems and infrastructure could also be reviewed to ensure they enable routine data collection and practitioners could be supported to collect sufficient cultural and demographic data to provide a fuller social context. This would enhance the system's visibility of people with characteristics that might require reasonable adjustments and encourage the adaptation of approaches towards more person-centered and trauma-informed care. Recommendation four is to ensure people experiencing multiple disadvantage are placed at the center of decision-making processes and involved in the design, delivery, co-production and evaluation of services. So the voices and also the full involvement of people who have experience of multiple disadvantage or who have been impacted by it are integral to decision-making. So it's crucial that we start to see a shift in power so that the system becomes or is transformed into a service user- led system whereby people with lived and living experience are valued as equal partners in decision-making around the design, commissioning, delivery and evaluation of services. Recommendation five is invest in early intervention and prevention solutions to reduce the prevalence, duration and impact of multiple disadvantage. So improving intervention and prevention approaches at all stages of the life course is crucial to reducing the incidence and impact of multiple disadvantage and the prevention of multiple disadvantage and sorry must be a whole system responsibility with an expectation for all areas of the system to take accountability for improving the life outcomes of this population. Recommendation six is to prioritise embedding across cutting trauma-informed approach at individual service and system levels. So embedding a trauma-informed approach cannot be done piecemeal. It's a system-wide cultural change that requires the system to work collectively and take small steps towards embodying trauma-informed principles in a meaningful way. So not everybody needs to become a trauma-informed specialist but everybody should have a foundational understanding of the basic models of implementing the strengths-based practice. Recommendation seven is to ensure that key health and care services are commissioned in a way that promotes partnership and integration through the adoption of commissioning best practices for people experiencing multiple disadvantage. So commissioning models really are vital to tackling multiple disadvantage as they determine the type and the way that services are delivered and sorry could start to look more outwardly and work at pace and learning from other areas to progress and embed innovative best practice commissioning if we want to see significant and meaningful improvements to the way that services are delivered and work at pace and learning from other areas to progress. So commissioning models really are vital to controlling the type and the way that services are delivered and work at pace and learning from other areas to progress. So commissioning models really are vital to controlling the type and the way that services are delivered and work at pace and learning from other areas to progress. Recommendation eight is to ensure that key health and care services are commissioned in a way that promotes partnership and integration through the adoption of commissioning models through the adoption of commissioning models through the adoption of consultation. And then the third one is to ensure that the best practices are delivered in a way that supports people's health and well-being and the way that services are delivered and work at pace and learning from other areas to progress. So commissioning models really are vital to controlling the type and the way that services are delivered and work at pace and learning from other areas to progress. So commissioning models really are vital to controlling the type and the way that services are delivered and work at pace and learning from other areas to progress. So the final three recommendations then we've got recommendation nine. Ensure people affected by multiple disadvantage have access to high quality effective person-centered alcohol drug and recovery services by conducting a comprehensive review of commission substance use services in Surrey. So carrying out a comprehensive review of substance use services can help ensure the transparency of funding availability and identify ways to redistribute and restructure relevant funding streams to maximize outcomes for people experiencing multiple disadvantage. And the planned review of these services in 2025-26 could provide a good opportunity for this. However, a comprehensive review is required as a priority and it must involve people with lived experience of multiple disadvantage. And as in other areas, substance use services could also consider developing suitable outcome measures and broadening the focus beyond standard KPIs associated with drug and alcohol treatment outcomes, focusing instead on what good outcomes mean for those that are being supported. Recommendation 10 is to ensure that people experiencing multiple disadvantage offered a diverse range of mental health services with improved ease of access, flexibility and better outcomes. So mental health plays a key role in overall well-being and quality of life. However, the limited availability, accessibility and flexibility of mental health support in Surrey often intensifies mental health challenges for an individual experiencing multiple disadvantage. So ensuring that people are offered a diverse range of mental health services would help to reduce barriers to access and ultimately lead to better outcomes. And then our final recommendation is recommendation 11, improve ease of access to housing and accommodation support and ensure sufficient housing options for people experiencing multiple disadvantage. So the current lack of housing, both nationally and locally, means many individuals experiencing multiple disadvantage are homeless or living in inappropriate and unsuitable accommodation. However, housing should be considered as a priority and primary need for people experiencing multiple disadvantage. So this means ensuring access to suitable and specialist housing options, improve planning for winter provision and investment in rough sleeping solutions and initiatives. So that's all of our recommendations and our key findings. And just as a final point, we'd really like to thank our experts by Experience who have put heart and soul into co-producing this assessment and shaping the draft recommendations. And we also extend our gratitude to all of the partners and stakeholders and individuals that have been involved in the primary research. So thank you very much. Thank you very much team and it's definitely a team approach there. And I just start by commending you for actually your co-design approach. I think this should be a blueprint for every other JSNA chapter that we undertake or that is undertook, if my grammar is correct, because actually the real experts in your research are the people who with lived experience. And I know that in my day job, I rely very much on the people's own experience to help me with that decision making. So thank you. I had the pleasure of having an early presentation of this myself, little private viewing. So I have had an advantage, I guess. And what I would say is all of your recommendations have great value. But I think that we could spend probably a full day trying to discuss that as a health and wellbeing board and to give it the credibility that it actually needs. So I am going to suggest that this needs to be taken out of this room. I think that we need to work across and Ruth, maybe you've already got some ideas about where you'd like to take this next so that as a health and wellbeing board, we can support, you know, progress against a number of those recommendations. Thank you Charlotte and echoing the thanks and thank you to the presentations. This is so fundamental and it's so large. And as Ella you were saying in the recommendations, of course we appreciate they're significant and we need to take time to embed them properly and really hear you Steve and what you were saying. We want to make this work. So for me, a key part of the next stage is those engagement events that Lisa highlighted. So we will make sure they're communicated out to the board early so that board members would really, really encourage board members and representatives, other representatives from your various organisations to engage with those events because that's going to be a key part of the next steps. And in particular that for me, that governance piece has recommendations one and two so that there's that really board to really pick up on those learnings, but acknowledging this is about system wide work. So it will fit in various parts of the system. Hence my point at the beginning about the housing, mental health and substance misuse to give some examples so that we can really drive this forward in a number of ways. But if we, as a board, take those as a very, very initial step, take those engagement events as our next step, we will send Amelia a link to the chapter as soon as it's published. It will be heavily advertised, but also that how we can all get further involved. So I encourage the board to take part in that. Thank you. Do you have a co-production and insight group or anything like that where you get a cross section of people working just generally speaking together from the various aspects and various stakeholders present? I think there are pockets of co-production happening across the council, but it's specific to multiple disadvantage. We have the lived experience recovery organisation. In the mental health, we have the CPIG group, which is very, very, all the different areas, for instance, carers or people with disabilities or whatever group they represent. There's quite a large number of people on this group, and people keep adding as different groups are represented, because obviously people come at situations from different routes, so an answer doesn't always fit more than half the group. So if you have something like that, maybe we could talk, I'd very much like to be part of something like that, but yeah, we'll leave it with you. Graham, then Russell. Yeah, well, first of all, thanks Lisa, Ella and Steve. It's a fantastic chapter. I'm so pleased we've got it, and I just wanted to build on your point, Bernie, about the co-production and insight group, because I was really struck by what you said, Steve, about co-production being so important and not wanting to see this as a review that sits on a shelf. I think there's a really important opportunity to use the experience of people who know the most about this, which is yourselves, to help those of us responsible for designing and delivering services to really hear about, well, how we need to change. So I wonder if we can take this methodology, this co-production methodology, and actually make this the way we do the recommendations. So agreeing with Charlotte, if you like, there's a lot of commissioning language in the recommendations at the moment, as opposed to co-production language of actually getting people responsible for delivering services, working alongside people who those services support, to come up with a new vision. I absolutely think it's so right that access is really difficult with forms and access criteria, all of which are exclusionary. So I'd really welcome what you're saying, Bernie, about using the co-production and insights group and what Charlotte was saying and Steve's saying about really making these recommendations, co-produced recommendations with the people who are going to be delivering services as well. Thanks, Chair. And again, Steve and your colleagues as well, thanks for coming today. I think you can hear that it's landed well and it's also a really important piece of work. I think, you know, looking back at recommendations 7 and 8, this would be evidence of real partnership working across the system for a part of our population that needs that help and support. And I think looking through a five-year strategy, actually the finances and actually how you carve out finances from our shared pools about how we do this properly, as opposed to creating a strategy that looks good but doesn't have a resource attached to it, I think would be really important. And actually we were having a similar conversation in place today about the role of place in supporting this population and other populations, such as our homeless population, for instance. My ask would be, and I look through the list of your partners within the work so far, is actually veterans. I think most -- all but one of our PCNs in Surrey Heartlands have signed up to be veterans accredited practices through the RCGP. And I think roughly about 5% of the homeless population would come from veteran backgrounds, so I think it's really important that within that work we consider that population as well. And you may have already done that, but just looking through the list. Kate, did you want to get relevant to that conversation? No. >> Well, firstly, thank you, and I was privileged enough to be interviewed as one of the council -- and really enjoyed it, actually. I was really nervous about being interviewed, but you were excellent at doing it and made me feel very welcome and calm. So thank you for that. There's a lot of detail in here in the recommendations, and a lot of cross-partner, cross-stakeholder work that will be required to bring some of this to fruition. And as Chair and Charlotte have said, you know, that's what we can take forward outside of this board, but certainly own it from this board. The one thing that really hits with me is number five, which is about prevention and intervention, because I'm passionate about stopping this happening in the first place, then we don't have the problems going forward. And I would really be interested to hear more of your stories of how circumstances were such that multiple disadvantage was something that came along, because I think as much as we look to put prevention and intervention into place, I don't think we can do that without asking you, your experiences, what would have helped at the right time, when, how, we're growing and concerned about access. Where are those points? Where was that turning point where if we had have intervened, if we had have got in, that it would have helped you more conclusively than what we're having to do now. It's always disappointing when we find out that services that we offer aren't maybe doing what they need to do, aren't enough, are convoluted, complex, difficult to get into. And I will say, some of the wording here is quite complex and quite counsel. And I'd love to get away from some of that and actually simplifying down some of this. But fundamentally, I'd really love to hear more about your stories and more about your avenue into this and where we could have stopped and where we could have intervened. Because if we don't get that right going forward, we're just going to be on this eternal circle, which we can't afford to do. Absolutely. Thank you. And just to quickly come in now, this JSNA chapter really is focusing on adults, but we're following up with a children, young people and families phase, which will have a focus on early intervention and prevention. And in particular, that transition period between 18 and

1. And then hopefully our events later in the summer, we can showcase kind of a bit of some more of the stories and case studies. So thank you. Hi, I'm Nicola area from the friendly system. I guess one of the things I'm reflecting as I listen to it, as well as what a great piece of work is how, as someone who's worked in a statue organization forever, what we tend to do is overlay new ideas and ways of working on the old, particularly in terms of the way we structure ourselves and have meetings. So I guess my plea is if we're going to try and take a different lens on things, let's stop doing some of the things that we're replacing so that we don't just end up with building an ever more complicated networks or of how we try and deliver change. Mari then Kate. Thank you very much. Mary Roberts was on the managing directive rug and massive borough council, obviously, as a district and borough with responsibility for homelessness services, which firstly say thank you, Steve. And thank you all. It's really, really important that we push this work on. Mine's more of a tactical point around your last recommendation around accommodation, not to suck the joy out of the room in any way. So apologies if it comes across as that, but I think you all know how complex the accommodation or rather lack of for everyone is at the moment, not just people with multiple disadvantages where it is absolutely. What I would ask is early engagement with Surrey chief housing officers group. Quite frankly, those services are on their knees and quite frankly, you know, under, you know, significant pressure. I would ask for early engagement via that group, via that chief housing officers group, because you'll get more of a constructive response to that as opposed to, oh, look, we've come up with another strategy and can you implement this or, you know, and I, I'm being facetious, but the point is, you know, there are lots of ideas of lots of people working in that sector trying to do the right thing, go about it in the right way and you'll get a better response because as I said, the pressure and quite frankly, the end of that tunnel is not coming anytime soon. So I'd just ask for thinking about how you do that. Thank you. Yeah, absolutely. And just to say the group, we did engage with the group throughout some of the primary research and it's planned as well moving forward and also just picking up on Ruth's point about aligning with the other JSNH chapters and working together. But yeah, absolutely. We'll be taking that on board. Thank you. Thank you very much for all the work that's gone into that. And it's, it's a lot of food for thought. And I think a lot of areas we recognize happening in other areas that we're looking in. So there is a sort of synergy with work that I think we're doing in some other areas, but we've got to do the perspective and take into account the circumstances that you've all highlighted. And I think your recommendations are pretty thorough and I'm sure that we will be able to come back. But I'd very much like to be invited to the whatever sessions that you're planning. Is it in the autumn, I think you said, or by the autumn. And so, and I'm sure quite a few other people here would be something close to my heart. So I'll be very keen to go along. So the board is asked to consider how the headline draft recommendations are relevant to their own organizations and what actions can be taken to support progress to be made. Once the final chapter is published support dissemination of the chapter's findings and recommendations within their own organizations and networks. Okay. So thank you very much for attending. Move on to better care fund. Okay. Right. Move on to better care fund. And we are a little bit late on this. Rather a lot late, actually, but sorry about that. It was quite a few meaty issues today, I think. We can hold it over, if you like, or we can run it, but I've got time pressure, John, for this to be signed off. Recommendations are in three parts. So it's really to confirm sign off of the submission that's already been made. We have had discussions with the chair, Bernie, and it's been circulated to other decision makers. So it's more a formality for noting the two-year plan, the year-end submission, and the updated plan. So I think it's reasonably straightforward. I think it is. I just want to register how very, very disappointed I am that the areas -- on the tabular areas where it indicates there's been a reduction in funds seems to align pretty well with mental health, social prescription, and autism services, page by page. If you find a line that has the word mental, social, or autism in it, there seems to have been a reduction. And I just -- I'm aware, for instance, that funds may have come from elsewhere in some cases, but when you actually dig down, there seems to have been a fairly -- well, a very disappointing attitude towards quite a few things going forward on the better care fund particularly. And when you bear in mind that where funds are put in elsewhere, we don't always know where the follow-up funds are coming from. It might look good on a yearly basis, but it isn't if you look any further than that. But if you go table by table on this, I can click out any page, wherever those words supply, you've run it across to the -- over there, and there's been a reduction. And almost every one of those reductions is to do with mental health, social prescription, and neurodiversity. So I am very, very disappointed in that. I'll just register that vote. I don't know if anybody's got a comment on that. I can pick that up separately. I'll go back through the detail, and I can provide a written note on that if that would be helpful. I would like -- I would -- I'd like a detailed explanation of why that is the case. And what that means going forward. What is the impact of that? So perhaps if we took an action for a private consultation with you from the BCF team, one to run through the process of how these decisions are made, because as I understand it, John, it does go down to places and local areas who know their areas well and what their needs are. I thought we'd had those discussions, that I'm saying, and then this comes out, and it's kind of the reverse of what I understood the discussions to be. What you were expecting. So I think perhaps we should take that action then to have that meeting. Which is quite infuriating, to say the least, as you can imagine. I understand. So should we take that action? Yeah. Well, I'm happy to pick that up. So we can move, you know -- I think, therefore, anybody else got any comments on this? Otherwise, we -- Nicola. Nicola. It's more about looking forward than this particular plan, which we've already signed off. It would be really useful, I think, to do our planning for the next Better Care Fund, because this is year two of a two-year plan, sort of between now and September, end of September, so that we can have proper conversations and time to really think about what we want to do probably in the next two years. Yeah. Absolutely. I would 100% agree with that. We've got additional team member work in Better Care Fund starting in a few weeks' time, so we'll have the resources to kind of pick that up. It will build on the workshop we had back in February, where there's some good conversations around strategic themes that we'll want to focus on for next year. So yeah, 100% agree. And I also take into account some of the conversations that did take place as we went under tables, and that also adds to my fury about what's happened there. So, you know, either those discussions are meaningful or they're not, you know, and if it's just window dressing to sit at a meeting and have those priorities put forward and then they're sort of reversed without discussion is -- I don't find very thrilling. So I think we've got opportunity to look at how we move towards the next iteration of BCF spend, and I think we've heard today a number of programs of work that would benefit from a long-term funding solution from the BCF. Our present company, for example, along with statutory funding that exists. So I think that we've heard that, we've got an action of how we would move this forward, but as you say, this current fund is the second year of an already committed -- It's a slightly bulldozed field from one side feeling I have about this regarding mental health. I think we've been bulldozed a bit. Right. So whizzing -- if we could just whizz quickly. Has everybody read the -- well, the recommendations? We've got those. You understand the recommendations? We're noting this basically. Yeah, so we'll say yes to that. We're noting. Fine. And then the integrated care system update. Has everybody read that and got any comments? No. So I think we are left with the date of next meeting, basically. And we're only 10 minutes late. So that is on the 18th of September, 25 -- although this might change because there's changes afoot, which we haven't necessarily sorted out yet. So potentially 18th of September, potentially not. Thank you, Chair. Okay. Thank you.