Transcript

Will Community Health Foundation Trust forecast variation from their plan of about a million pound benefit and worth the teaching hospital, 5.2 million pounds of drift of their plans. So it seems what's driven that we know that certainly through the place predominantly packages occur, increased in packages occur and responsibilities around sorts of respondents of the pressures that we've seen. Prescribing costs have also been a key feature of the pressures that we've seen. For worth, main issue is being industrial action in the cost of industrial action. So again, I think you put probably that 5 million pounds out to all of that. So, in terms of the month 11 financial performance, predicting as a healthcare system for the full year, we were planning a 25.6 million pounds deficit. The prediction at month 11 was 46.8 million and the next report I'll confirm the final figures that have gone in as part of the final accounts. I think just moving on to the poor funds and the better care funds. Again, I think those figures will be broadly similar. I think when we see the final accounts, the one changes to report just that just the sort of heads up for the next report would be the better care funds actually has overspent this year by about 150k. To answer pressures in the world, the world depends on the service as well. So, the partners are enacting the risk share and that will be shared around 50/50 between the ICB and the local authority and the finance teams are just working through the transaction on nature of that and what that means. So, that's the report. Happy to take any questions anyone has. Thanks Martin, any questions? Hey, Karen. We'll just put your mic on please, Karen. Thanks. Well, of course, the community wealth building, how are we involving community groups and community organizations in that? Community wealth building. How are we involving community organizations in that? So, one of the things that we've been in around sorts of trends where we put our investments in the best place has been to run a full plan and session and we've had representatives in the voluntary community social enterprise sector as part of that to understand how we actually reach in and get maximised the community assets that we have, particularly around the people that we've got, to make sure that we can join that to NHS local services as well. So, we've been doing it through that plan and session. I think, Carol, you've been part of that as well if you wanted to. Okay, thank you. Yeah, there's been a number of us who have attended those sessions and also Lauren Quigley's been leading the piece of work looking at quality impact assessments and how we can do that better as well and involve different members of the community, voluntary faith and social enterprise sector. So, it's a bit of a testing at the moment, how that works. I hope at some point we can report back to the board, how that's going and that will influence on some of the papers, what is said in relation to equality and community wealth building as well. Greg, you have a question? Yeah. Put your mic on, please, Greg. So, yes, Martin, so the numbers are obviously huge in the deficit beyond plan on top of the actual out turn. I mean, it is significant and I understand that that's pretty much the pattern across the whole patch, Cheshire Mersey. So, then one would expect at some point and I think that Graham's written to chief executives at local authorities across the patches to say that there will be work to reduce the size of the deficit. I don't know in terms of the process for that, how it will be decided where savings will be made and how savings will be made. I guess you can't say a lot about that but I just wondered whether you wanted to say something about how the budget could be brought back into line or how the process might work. Thank you. So, the ICB will effectively enter into recovery mode, financial recovery mode and that will include highlighting what we believe our key priority areas are. So, if we were to go back to pre-COVID and have a look at how the financial position was in the service position at that stage, we were still under pressure, we still had an underlying deficit at that point. However, we were sort of managing on a year-to-year basis what's noticeable to think since COVID has been the increase in the workforce and that hasn't been sort of brought together with a subsequent increase in productivity and there's multiple reasons around that because again I think we've seen an acuity in patients that have come through. I think some of the workforce changes some of the actual sorts of practices have had to change because of COVID and things like that. So, but the challenge back from the centre of the NHS is all around how is the workforce grown, how is productivity changed and the big focus for us on that is around age and care. So, everything that's happening sort of from front door admission even before that if you think about it again sort of including primary care as age and care services or the way through to how we discharge people effectively, how people are then cared for the independence that they can manage with. I think after the hospital stay, the level of support that they need, all of that is sort of part of like the key focus. So, there are other streams coming off. So, for example, admission avoidance will be a key feature, how we do discharge through our hospitals and also I think ensuring that what we get ensuring the packages occur that people receive post-hospital support are the appropriate ones as well because again I think there's a sense that you know we've taught in the past in the committee about a potential overprescription of care at various points, it's about how we sort of manage all of those issues together. Thanks Martin Simon. Yes, so if we turn that sort of the financial challenge into a more of a quality ambition, the ambition should be to eradicate corridor care and corridor care in terms of people at Auro park hospital being cared for in the corridors there at times of escalation because that is poor quality care for the people in those beds and for the hospital staff themselves and it prevents the flow through the hospital. And then in terms of if we apply that to mental health services, it's people waiting in their homes for mental health inpatient beds because that's kind of the mental health service corridor care. It's also then about getting on top of our discharge processes so we've made some significant inroads in terms of non-criteria to reside in rural at the hospital. I think we're at 84 this morning, 81 this morning which is significant less than when we started 18 months ago, at daily 240. There's this equal challenge to be achieved in terms of people who are clinically ready for discharge in mental health beds as well again in terms of that flow. So the ambition is to improve how we deliver care in the energy and unchedule care space which then in itself means that we reduce waste which is in the standard definition work that doesn't meet need and actually we expend money on additional agency staff, positional beds etc. So that's where we believe the biggest benefit to be be gained in terms of our financial recovery for the next year. Thanks Simon. Are we okay to move to recommendations? Yeah, so the recommendations, it's recommended that the Rural Place Base Partnership Board, note the report and the specific recommendations in relation to the pool budget listed below. Note the Rural Place System Forecast Reporter position at month 11, 2023, 24 and note that the forecast reported position for the pool and the discharge funds as at month 11, 24, 25 and note that the shared risk arrangements are limited to the better care fund only which is reporting a forecast break even position. Are we okay to approve that? Yes. Yeah, I'll be less. Okay, reporting, moving on to Agenza Rice and Six Quality and Performance Report. So this is pages 21 to 40 of your pack and Simon is going to present this report on behalf of Lawner. Yeah, so Lawner has just called away literally minutes before the meeting started. So I'll just touch upon the metrics for un-chedule care. Actually, in the un-chedule care program delivery will be included in Gen John that. In terms of planned care, we're all continues to perform well across all of the aspects of planned care in terms of elective recovery and particularly in terms of some of the areas around cancer targets and diagnostic testing. I've touched upon mental health. We are consistently holding multi-agency discharge events with Cheshire World Park ships and the super made event actually brings together places across Cheshire and we're all to look at unblocking delays and addressing the challenges around that. We do have people waiting long lengths of time for delays and we timed those events focus on the people waiting for the longest periods of time and in the report there was somebody who'd been waiting seven and thirty days but that was due to their choice but by being in the inpatient bed, they're actually stopping somebody else coming into it. Equally, when we have people who are clinically ready for discharge and they need to move on, some of that is actually beyond their control and it is about having appropriate and timely assessments of need and moving them on to their appropriate accommodation as quickly as possible. In terms of healthcare acquired infections, it's still a priority for all place and we are being included within our priority areas. Moving on to a couple of the programs just for updates, special educational needs, disabilities, continues to be a priority for us as a system. We still have an existing written statement of action. The governance around this has recently been refreshed and the new board established under Paul's chairmanship. That will be meeting regularly and will be putting more emphasis upon some of the the the dials we need to shift in terms of improving SCND provision so ensuring the graduated approach is rolled out but from a health perspective actually really focusing on some of the service provision for children, young people of neurodevelopmental needs and the implementation of a new care model that aligns to the graduated response and we're doing that. We have a new designated clinical officer starting imminently who will help us tackle that. At the time of writing, in terms of measles, looking to Dave, we had one, so at the time of writing, no confirmed case and subsequent to that, we did have one confirmed case of measles within our system. I'm happy to take any questions on the report as best I can so that's all there is on that chair. Thanks, Simon. Question or comments? Kieran and then Elizabeth? Yeah, off the eight people detained on the mental health act alluded to in this week, people have armed in, you know, even some of the how many of them are being under the sole form of care program. They would all be under a care program approach by the virtue of the fact they've been admitted as an inpatient so everybody admitted through that route would have been subject to care program approach. That's correct, Fauzi. Fauzi, do you want to respond back to that? Yeah, we no longer use the term care program approach. It's just because NHS England changed the policy, but we essentially do them as if they were under CPA. Thanks. Thank you, Elizabeth. Thank you, Simon. Thank you for highlighting that this ends improvement work. As Simon mentioned, we've got new governance boards in place, which we'll be meeting on a monthly basis with DFE and NHS England. Just a reminder that we've got an induction session for that later this week, but we really are moving to with pace and grip to get the improvements we need. Simon also welcome the new DCO starting the designated clinical officer and the Fudge Conversations with Lorna about an induction for them and making space available with the council team as well to improve that joint work in. Thank you. Thanks, Elizabeth. Any other comments or questions? Are we okay to move to the recommendation? Okay, so the recommendations are that the Rural Place-based Partnership Board is asked to note the work underway across the system to monitor quality and performance, identifying areas of improvement. Note and endorse the further work underway to strengthen the governance around quality and safety across health and social care, and receive assurance around the robust improvement plans in place to manage specific areas of improvement. So just wanting to get a sense of approval for that in the board. Fabulous, thank you. Okay, moving on to agenda item 7, the planning 24/25 updates on pages 41 to 56 of your pack. Over to Simon again. Thank you, Chair. So the NHS, England planning and priorities and operational planning guidance this year wasn't released for Christmas, it was released for Easter. So some three months after we would normally expect to receive it, the final priorities and operational planning guidance came out. That was on the 27th of March. The full guidance is on the NHS England website, but we have attached some thinking appendix one and extract from that guidance which sets out the national objectives. Alongside this NHS, Cheshire, Mozart are working with system partners to develop an update of our joint forward plan, and there's also an update of the health and care partnership plan. In terms of ourselves and we're all, Martin is running the final planning workshop on the 20th of May, which was referred to earlier, so we've had a series of workshops since December with system partners to construct the World Health and Care Plan, the metrics and outcomes we're going to measure against that and how that is going to be delivered. In your pack, you'll note that I have written out to each of the senior responsible officers for our agreed programs of work asking for a narrative update, so we can update our World Health and Care Plan. The deadline for that was Friday, we've had a majority of them in. I did a chase here on Friday and I'm assured that the remaining narratives will be with me by the time I return from leave on the 20th of May. That will enable us to present the final World Health and Care Plan here at the June meeting for approval. As previously indicated, this is an update at an extension on what we have agreed to do in 23, 24, so it will be the same programs of work that we are familiar with on schedule care being at the heart of that. In terms of reporting here, the rest will be reporting through Strathming and Transformation Group into here. So happy to take any questions from members on the planning round and next steps. Thanks Simon. Karen? A couple of questions and comments actually. Specialists, when the Health and Care Plan is updated, why is it that people with disabilities and long term health conditions do not have to be involved in this process? Okay, so we are involving voluntary community faith sector groups as representatives as those sectors. Our expectation is that in our normal work anyway, we involve people in care planning and this is a response to national guidance as well as local activities. Any change that we therefore put in place would be needed to be supported by the appropriate quality impact assessments or quality impact assessments, which we then need to demonstrate how that engagement happens. So we would not routinely involve individuals in planning round. It is more of a technical matter that takes account of the needs of those people and therefore the best we can do is to seek representation through health watch being at those workshops and representatives from the VCFSC at that workshop. We are also going through, as part of that, each program will have those EQIs in place as well, which demonstrates how that impacts upon service users and carers. I just had a couple of questions. The second one is, when it comes to the engagement process, who are the partners? If you are not actually engaging with individuals, what specific groups are you actually engaging with? So as per the degree process, we ask the voluntary community faith and social enterprise sector through the CVS to identify groups of people who wish to attend our planning events. So in the past, we have had WIRED, we have had AGUK, we have had CAB, we have had Involved North West, we have had Koala North West, I cannot think of else who has been in the room. Who is that, Martin? We are all mind have been there as well. So a variety of groups have been involved in that and therefore are part of that planning process. As I said previously, we try to seek them as the voice of the people, as far as it is possible, as it would not be practical to have everybody in the room or 30,000 people. And presumably if those community groups choose to involve the people that they support, they are free to do so, don't they? It is our expectation that those groups do that actually. The arrangement with the voluntary sector has been that their representatives come as representatives of the whole sector and the people who serve the sector not necessarily of their individual organisations. Thanks, Karen. Just up to that, on behalf of the sector, we do challenge as well and we do offer that individual perspective and say in relation to things like how does this impact on carers, how does this impact on people who have got disabilities and lots of disabilities. There is a whole range of different perspectives and experiences ourselves as well, both in the sector and also a large number of those individuals who are residents who use the health system themselves and have relatives who use the health system as well. So it does feel as though we are involved and able to contribute to that planning. Any other questions or comments, Dave? Thanks. It was just a quick question, just in terms of the national objectives, it is really, really good to see them laid out. And the bit that is missing on this appendix is actually the importance of tackling antimicrobial resistance. It is mentioned in the guidance but it is just a plea to keep that on the agenda because it is so crucial that we address that and show leadership and key actions to address it. So antimicrobial resistance will feature in a medicines optimisation work programme. So it is already in for 2324. We will continue for 2425. So yes, you are right, Dave. Thank you. Any other comments or questions for Simon? No? Okay, Fab. We will move to the recommendations then. So it is recommended that the Board notes the update provided by this paper, supports the approach being taken to update the We're All Health and Care plan for the planning year 2425 and receives the We're All Health and Care plan 2425 for approval at the June meeting. Are we happy to approve this? Yeah, fabulous. Thank you. Okay, we are moving on to the programme delivery report. So I will hand it over to James Barfley for the first paper, Agenda Ice and Eight, the We're All Health and Care plan of programme delivery dashboard, pages 57 to 68 and James is presented on behalf of Julian Ayer. Thank you, Chair. So you have the paper in the packet that you've all received and that's with the aim to provide the Board with information and assurance of the programme's associated with the We're All Health and Care plan. The overall delivery rating for the Health and Care plan delivery in March, April, was green with one programme in the portfolio reporting red, three reporting amber and the rest reporting green and that's summarising the table on page 58 at 1.1.3. I'd just provide now, I'll go through an overview of the programmes, obviously not able to go directly here but more than happy to take any questions on individual items. So starting with the guiding programmes, within the neighbourhood programme, core group panels are now underway, both Bergen had A and Wallace C. A template has been developed by neighbours to enable people or organisations within their neighbourhoods to apply for available funding. A population health programme, a workshop is held on the 11th of March to bring the system together to focus on how we can tackle fuel poverty as a collective in We're All. And that's with a follow-up event plan for summer 2024 that will take the action plan forward. Within the use of resources programme, the rag rating of red, that relates to the overall financial deficit position. I won't go any more into that, as Martin's already provided an update on the agenda today. That takes us into the delivery programmes, starting with the Children and Young People's programme. I was going to elaborate a bit on that but I know Simon and Elizabeth have covered the key items on that today, again happy to take any further questions on that. Within the All Age Disabilities programme which has commenced to determine how the All Age Disabilities Strategy is agreed and March can be delivered for rural residents. The Mental Health programme board for April was stood down and that's for the second times in three months due to choracy. In support of the Integrated Housing Workstream proposal has been received from agenda to living for an independent living planet and that's for five properties. The Primary and Community Care programme has identified the initial focus's frailty, supporting people to age well. The programme will support reducing attendances at ED and GP practices through a number of solutions including anticipatory care planning and the May programme board will include a facilitated discussion to support further development of the programme. Going into the enabling programmes, within the digital maturity programme the top priority remains the migration of the population health management system for work for the rural care record to cipher. Work is underway to address the programme governance function for effective monitoring and evaluating objectives and progress. The estate sustainability programme has developed an overall group approach to managing the deliverables. This has resulted in the finalisation of key delivery pillars and set of documented outcomes and leads have been identified for three of the programme pillars. The medicines optimisation programme that is overseen by the Rural Place medicines optimisation group. However, there have been some constraints with the capacity of that metres to drive the work forward. So there's been an agreement for a view to be completed for the end of May to fully define the priorities for that programme and the structure in the governance and how it all progresses forward. So that will go by our STJ. Within the workforce programme, the baseline workforce data project group and compiling the data at organisation level, exploring hosting for the place level dashboard and overlaying the population health and social value data. There isn't an update in this much report for the place supported delivery programmes at scale as you understand there are some changes in leadership of the work. However, reporting will be back in place in time for the next floor. So I'll pause at that point. I'm happy to take any questions. Thanks James and Brian and Simon. Thank you. I guess when we started on the workforce programme, the primary focus was having sufficient people to undertake the work and we were seeing particular shortages in areas, nursing, care, staff, a whole range of other areas. It's quite interesting when we were talking about the financial situation earlier on that what Martin was indicating was that the workforce has grown significantly, but that the performance of the workforce in terms of productivity is not as high as it should be. So I guess I would expect maybe the workforce strategy to also now be considering productivity as a key part of its approach going forward and that would be linked up with the work around the budget across the patch and that would be clear about what that actually means in terms of workforce and implications. Thank you. Thanks, Brian. James, are you going to take that back to Julie? Yes. Yes, so just a few things. Obviously this is retrospective as a programme delivery dashboard, but as a few things I want to pick out in terms of how we play this forward in the planning round. So there are clear interdependencies between the mental health programme, the uncheduled care programme and primary community care which needs collectively to focus on that admission avoidance piece and what services that we have in place to maintain people in their own homes for longer. The uncheduled care programme has done a fantastic job in terms of improving flow at the back end of the hospital, discharging people. It's about now, I suppose, for next year applying similar vehicle to maintaining people in their homes because it's not just about the mission avoidance, actually it's attendance avoidance, it's stopping people getting to the front door of DD in the first place. So I know that's been worked on at the moment about how the programme then evolves into the next stage. The second thing for me really is we work as a collaborative as a partnership and therefore the activity we undertake to depend upon everybody playing their part in that and it's really disappointing to see that the mental health programme board had to not meet for a couple of meetings because of non-attendents. So we do urge people to attend that. There's some significant work in that group going on around improving community services, improving the crisis response, looking at housing options, all of which contribute to keeping people out of mental health in patient units, stopping them crash landing at Arrow Park in terms of crisis and moving them back to their homes as well. So there's significant work happening in that work stream. It is for us as well as an NHS Cheshire Emergency Centre key priority. It's one of our priority schemes programmes for this year in terms of improving quality and achieving financial recovery. So I urge people to be – and if necessary, I'm quite happy to support Suzanne in writing to the organisations who aren't sending people regularly. It's really important we do that. And then I just acknowledge that there has been a bit of a change in the elect – the programmes at scale but we have had a really strong narrative from them for next year's planning round, again, building on a successful year in terms of the hospital trusts and response to on elective care, cancer diagnostics and maternity. So I'm hoping that that work will continue into 24/25. Thanks, Simon. Any other questions or comments, Elizabeth? Thank you. Thank you. I just wanted to note that the Children and Young People's programme, which is currently a rag-rated grade, that reflects the activity from the programme that's been completed over time but some recent reflection in the self-assessment that's referred to is shown that the impact of that activity isn't where we want it to be. So I would expect when that comes back to future reports that the rag-rating will have changed and will be refreshing our action plan alongside that. Thanks, Elizabeth. Karen. What plans are there to involve people with disabilities and long-term health conditions in the core group plan? It's a similar situation again to the planning round here and that we have representatives in the volunteer community, faith, social enterprise sector. We have health watch and that all activities that are presented that require changes of business cases have to demonstrate that they're engaged with people who use the services through their equality impact assessments. Thanks, but any other comments or questions? Okay, we'll move to the recommendations then. So it's recommended that we're all place-based partnership board. Note this report, which provides assurance on the delivery and oversight of the health and care plan programmes. Are we happy to approve? Yeah, fabulous. Okay, back to James again. We've got two reports back to back. So this is the unstructural care improvements programme update, pages 69 to 90 of the parks. Hand over to James to present. Thank you, Segan. Chair, again, had the report in the park, similar aims provide the board with information and assurance of the work of the unstructural care programme in this case. I won't recap and I will sometimes recap on that on the programme today, but again, more than happy to take any questions on the scope and work of the programme. Maybe just to say that we are, as Simon touched on before, in the process of a refresh in line with the planning so that the scope for the programme will change and not to be managed through the unscheduled care board. Going into the report, I'm pleased to say that this follows on for the positive update presented at last month's meeting. And that's analysis of the data since the previous report shows a decrease in the number of number or possible on patients with no criteria to reside. The number has decreased from 1.35 in February to 1.32 on the 1st of March. Following the national picture of increased winter pressures, a recovery plan has been in place with the aim of returning the no criteria to reside in almost a pre-Christmas levels of 100. Interim data shows this has been consistently achieved with the no criteria to reside in the number, which is in 9/8 February, 97 in April. And Simon mentioned before at 8/8 on this morning, which is really positive. Where will has continued to perform strongly compared to other places within Cheshire Mercy integrated care system, where all has consistently been a first or second position out of seven areas over the winter period. This did deviate slightly in March, however, we were back to position one weekend in the 14th of April. A successful week-long super-made agency discharge event known as MADE took place in Whirrall in March, which is part of Cheshire Mercy ICS wide event. This brought together a health system and local authority partners to support improved patient flow across the system, recognise unblock delays, challenge and improve the discharge process. This was deemed a successful with partners working effectively over a seven-day event, and significant key learnings were captured throughout the event that have been worked up by system partners into a report and being taken for the first point to the un-scheduled care program board later this month. The capacity among work system partners have continued to develop the Whirrall capacity and demand work and are scheduled to bring this back to then this next board in June, as I understand, and that will go in the meantime via the un-scheduled care program board following the governance arrangements. And just to highlight as well, two significant visits to the transfer of care held by national representatives have taken place during March. On the 21st of March, Amanda Doyle, the NHSE National Director for Primary Care and Community Services visited, and this was followed by a visit by the Department of Health and Social Care System oversight team on the 20th of March. Both visits were deemed a successful with positive feedback received and a note on Amanda Doyle, also up the home first team as part of the community integrated response team joint care visit. Included in the report is an update on each of the component work streams under section 1.2.4. Again, I don't intend to run through these in detail today, but I'm happy to take questions and questions. I'll pause that. Thank you. Thanks, James. I've got a grave on that side as well. No, just a grave. It's probably more of a comment than a question, really, but it's just that, clearly, there are some positive stats in there, but again, it depends when you look at positive stats, which angle you're looking at them from. So, we do see some really high levels of care package implementation, 3,906 against a target, 3,224. Of course, there is a significant cost to that, and one of the issues as we improve performance through the hospital is that we do see a significant cost through the local authority in terms of package of care in the community, both domiciliary care, but also residential and nursing care. We have seen with the increased performance, we have seen the uptake of residential and nursing places increase significantly. So, there is a challenge for us as a system as we go forward in terms of ensuring that we use our home-first model, our able-me model to support people outside of residential settings and not kind of rush people into care sooner than they would have ordinarily gone in. I think that's a real risk of chasing the numbers around and CTR and has been for some time now. Now, the point is that's a financial risk, but it's actually much more than that. It's an independence risk as well in terms of the people. Their outcomes are not as good if they go into care rather than go home. So, we do need to keep close eye on that. It would be good to see the stats together so that we're seeing what's happening around those types of settings as well as what's happening from a hospital from a dorm back door perspective. I think the good news though is that we are as a system looking to shift into early intervention and prevention of admissions from hospital and I think that puts us into a better position in terms of monitoring what's happening across the whole community. But I think not for me as it is the next stage of moving forward on this. At the moment, it's like a single focus, which was right for its time, but we need to move on now. Just to say, I agree with what Graham said there. I'm looking at the figures. Day 35 of the 81 are on Pathway 1, which is a significant proportion of the people not meeting the criteria to reside. I know people actually can go home with a very low level support. They don't need to go into risk, risk and care. So, I think there has to be that focus on Pathway 1 and I think sometimes I think the longer people spend, or we know, the longer people spending a hospital setting, the more they decondition, therefore, we'll move to Pathways 2 and 3. So, there is a bit of a different focus now, isn't there, Graham, for 24-25, which is stopping people getting and improving the flow and processing of people back home rather than into residential nursing care. Simon David. Thank you for the report. I'm just wondering whether there's going to be a switch this year or fairly soon from the Unshared Your Care Improvement Program to looking at the front door and the long waits in A&E. I understand starting your work, we're getting the flow through the hospital because that is critical to where patients go from A&E, but we're still seeing those long waits in A&E and I would like to see some work within this improvement program around the waits in A&E, and I think we've discussed that before at this sport. Yeah. So, as part of the planning rounds at the moment, emission avoidance is proposed to feature us as a workstream on that, and there's a lot of planning work started, it will be formalised through the Unshared Your Care Program Board, and we'll be able to be brought back here, I'm sure, but I can assure that that does feature on the planning so far as we switch into the phase through the program. Thanks, Dave, and thanks, James. Any other comments or questions? No? OK, we move on to the recommendation then, so it's recommended that the Board note this update, and we're happy to approve that. Yeah, fabulous, thank you. So, we're moving on to items for discussion and decision, items for information support in the group chairs report. So, a gender item at 10 is the primary care group report, it's on pages 91 to 96 of you pack. I think Lauren was meant to be covering this for Ian, so I presume you're taking it, Simon? Yes, no, I thought I wasn't at that meeting, so if we just take this, if anything we want to pull out of it, I'm happy to answer any questions. Cameron? Could you make this like so many things? You, your way of working with people with disabilities, a lot of different conditions, is to work with community groups that you've outlined earlier. Can you say to me about the process of how you decide which way to which groups you have to work with, please? As referenced earlier, we don't decide which groups we work with. In terms of the people on these supporting groups, they've been elected by the voluntary community faith social enterprise sector, they represent the sector, and on this, on the primary care group, it's Chris Webb and Lee Pennington, who represent the sector. But then in terms of how, as I said, how we earlier, how we then engage with people, we would expect that to happen through the services themselves, and for them to reference that in any work that they do. I'll just add to that, Karen, so there's a representation model that the sector's got and that every organisation has a vote when there's ever any masons that put on to community voluntary faith and social enterprise to represent that, and then each of us who represents feedback to rural CVS after each meeting about anything that's been specific, it's been discussed, and relevant that's then fed back out. I'm happy to meet you outside the meeting, and if that would be helpful to go through that a bit more with probably Gareth from rural CVS, that would be helpful. Any other questions and comments? We'll move on to the recommendations then, so it's recommended that the rural place-based partnership board notes the work of the primary care group and continues to receive updates as a stand-in agenda item, and we're happy to approve that recommendation. Okay, so we'll genderise some 11, the Quality and Performance Group Report, this is pages 97 to 102 with your packs, hand over to Simon. Yes, again, significant focus in here on special educational needs, disabilities work, a deep dive into the work of the talk and therapy service, but again, going back to our consistent theme about children presenting with neurodiversity, a focus on children's new development of pathways, but also the demands we have in the ADHD for adults, where we have a primary care service through the LEAP model, which makes a slightly different to the parts of Cheshire and Merseyside. In terms of some of the recovery programs, we mentioned earlier, we mentioned urgent emergency care being one mental health service being another or mental health system flow. There is another work stream around neurodiversity, a Cheshire and Merseyside level, and focusing in some of the adults who have neurodiversity on ADHD specifically. But again, I'm not a meeting I attended here. I don't know if you were at this meeting, Paula. Unfortunately, I wasn't at this meeting, Simon, but I am a regular attender. I'm happy to take any questions on behalf of Lorna. Thanks, Simon. Thanks, Paula. Any questions or comments? Simon? Thank you. ADHD. We're double the Cheshire and Merseyside percentage rates. Is there why are we over-identifying or are we just different? I'm happy to attempt to answer that because it has been a discussion and debate within the group on several occasions. There's two things that we're exploring. The first is a potential for over-identification, and the second obviously is are we an outlier in terms of that presentation, but all of that is still under consideration at the moment. But it's a situation that is well identified within that group and is a discussion point regularly. I don't think we have an answer, Fizer, do we? It is very difficult to say we can give a specific answer. I think in general, over the last maybe 15 years, on the world we've actually provided better care for people with ADHD compared to in other areas. At least we have a service. In lots of other areas, they simply don't have it, so therefore it's hard to even compare because they don't identify because there is no service. At least we are identifying, I think there is an argument in terms of are we over-identifying, and therefore obviously the question will be significantly different. It's a clinical dilemma, which we obviously have to answer at some point. Thanks for that clarification. Any other comments or questions, Ian? Just to say that one of the challenges with the identification is that the almost complete unavailability of medicines to treat ADHD at the moment. So in areas where we haven't identified it, there isn't the clamor for medicines. In our part of the world, the whole of world, there's such an acute shortage that we have anxious parents, traipsing from pharmacy to pharmacy, looking for medicines, which physically are just not available. And the service does need to think about the continued prescribing of prolonged sustained release medicines rather than the three times a day medicines, because that is the major challenge. So all the prolonged ones, which we cannot get hold of. That was my concern really, that if we are over-prescribed, or whatever the reason may be, from the percentage figures, we may have a number of individuals taking medication that perhaps don't need, or not taking medicines that it should be available. That's my problem, really. I think people who are taking the medicines, they need it because we monitor them. I don't have a problem there. I think I agree we've had, since November last year, we've had significant shortages of medications. We are managing this kind of approach. We did have an improved picture in January, February, but we've been told, again, there's a problem in the last few weeks. It's a national problem, so it's not just like the world. And hopefully, at some point, we will get to a better position. But, like I said, it's a national question. Thank you, David. From a general practice point of view, the situation is getting worse because of the lack of availability for an NHS diagnosis or to refute the diagnosis. We are seeing more and more patients going privately who inevitably give them the diagnosis, and then the request for the prescription from the GP, and the system is completely broken at the moment because I'm not convinced all these patients do need the medication, and it's only adding to the strain on the availability of that medication in the system. So, I think that we have to come up with a fix that prevents people going off for a diagnosis, have to self-identify. I'm not sure what that fix is, but we do need to focus on a fix locally for this. For me, there's two aspects of this. There's adults with neurodiverse conditions who often find out later in life the impact that has had upon them in terms of a whole range of things, the family life, their employment, etc. In terms of children, young people, it's really important we get it right for them, and that's why we're doing the work on the neurodevelopmental pathways, and that has to be a long graduated approach as well, because as you said, not everybody will need a medical, so pharmaceutical intervention, they may need other support. So, there is some national guidance around autism. There is also stuff there around ADHD, which are equally applicable in terms of what happens pre-diagnosis in terms of supporting people. What happens once a diagnosis has been made, and then the post-diagnotic support, which may or may not be medication. And we are working there for, as I said, it's one of the key programs for Chester and Merseyside, but then we're translating it into being a key program for ourselves within Whirl, because there is a possibility that we are over-diagnosing. There is also a possibility of a very good at diagnosing, and therefore putting in, but certainly the demand at the moment is outstripping the supply of some of the intervention options, but some of that demand the NHS doesn't have control of, because it's being generated by schools, etc., and by parents themselves, and therefore it's about providing better support in those frameworks, rather than necessarily coming into a GP or other medical-led service. I think in terms of the diagnosis, people who end up in secondary services, we are confident about the diagnosis, because you don't get a diagnosis in five minutes. It's actually a process which takes a very long period of time. The issues which I think in John's mention is that people can just go to any private person, and then you can't verify the actual quality of these assessments, and therefore it's really hard, and then you get a referral, you prescribe the following. So I think it's a system thing which we need to actually look at, but yes, it could be over-diagnosing when people self-identify and say, these are my symptoms, and then you get a diagnosis. Certainly some of our concern has been about the quality of the provision provided by some of those private providers who indeed now are closing their doors to new business, as it were, because they're being swamped with people coming and wanting a diagnosis. Nationally, it's about a year ago now, there was a neuro-diversity complex, but we mustn't confuse ADHD with autism. So a year ago, there was a new all-age autism strategy and operational planning guidance which had no new money attached to it. That was issued about a year ago, so we're in the process of responding to that, and again, it's a similar principle, how you're chunk of the pathway, but I think ADHD is now such an issue for us in terms of health and care, and politically, a new national task force has been established by NHS England to look at ADHD and its provision, because it doesn't fall anywhere. So you can go onto the NHS website now, type in ADHD, or tell you what should happen, but it doesn't sit in the transforming care programme for learned disabilities in autism, and it doesn't sit in the mental health programme. It's just, it's almost orphaned, and therefore there isn't, and my personal view is we shouldn't, because neuro-diversity isn't a spectrum, for me it's more of a kaleidoscope of conditions and traits and so on. I think we actually need to focus on neuro-diversity per se as health and care rather than try and junk it up into little bits, and certainly the numbers of people we're seeing. So one of the things we do in terms of the transform care programme has been trying to get the numbers of people in long stay inpatient beds down from about, we were at about 140 years, Chesh and Mozart seven years ago, and we need to get them down to around about 60 people, about 90 at the moment. What's hampering that is the number of people now ending up in a mental health bed, and then getting the secondary diagnosis of autism, so they go on to that. So for the first time we're seeing in those beds more people with a primary diagnosis of autism rather than learning his ability, or learners with end autism. So we're seeing growth in, in neuro-diverse conditions, impacting all parts of our services. Thanks Simon. So just to clarify the quality and performance group picking up all of that what's been discussed today about the system wide impact. They will be picking up through the neural development, children's neural development to work. So the quality and performance group monitors what's happening in terms of quality and performance. The work stream that is dealing with this is the children young people's work stream, and then the Chesh and Mozart level, those in ADHD work stream for adults. Thanks for that. So it will come back through those reports that the progress they made based on those comments. Fantastic. Thank you. Any other quick hearing? The letter report alluded to on page 98. There are only plans to take that to the two either the sub-formal care operations board or the strategic board. Yes. They will be taken to both those boards. Okay. Both. Okay. Thank you. Thanks. Any other comments or questions? Okay. We'll move to the recommendations then. So the we're all place at the base partnership board is asked to note the work underway across the system to monitor quality and performance, identifying areas for improvement, receive assurance around the robust plans in place to manage specific areas for improvement, and note the effective use of data to understand population health need and improve equality and access to services. And we're happy to approve those recommendations. Okay. Moving on to agenda item 12, a strategy and transformation group highlight report, which is pages 103 to 180 of your PAC assignment. Again, I'm sure I'm happy to take any questions on this. It's there for information and further investigation. Any questions, comments? No. Okay. We'll move to the recommendation then. It's recommended that the we're all place-based partnership board notes the work of the strategy and transformation group. We have to approve. Okay. Agenda item 13, finance and investment groups, group highlight report, which is pages 109 to 112 of your PAC, Martin. Yes. Just to note at this stage of the year, we are doing a lot of sort of collective work to understand each other's plans, making sure there's no one in terms of consequences of those plans for other partners so that we can really sort of tease out what the issues are that are facing the we're all and then come up with some of the appropriate mitigation options. Thanks, Martin. Got any questions or comments about the report? No. Okay. I'll move to the recommendation then. It's recommended that the we're all place-based partnership board notes the work of the finance and investment group and continues to receive updates as a standing agenda item. We have it to approve. Okay. So moving on to the closing business. Agenda item 14, I don't think we have any public questions, statements and petitions do we know. So a agenda item 15, we're all place-based partnership work program pages 113 to 120. I'm going to have to you, Vicki. Thank you. This is a standing report which comes to each meeting of the board to enable members of the board to comment on or contribute to the board's annual work program. You'll see there are a number of items already listed on the work program for the coming meeting on the 20th of June. If there are any additional things that members would like to comment on or add to the work program, this is the opportunity for you to do so. Simon? Thank you. I'm just going to ask for an update on the sends for children, young people to be added to the work plan, please. Simon? And then that send will become a standing item for each board thereafter. Is the plan, I think. Can I add, please, we're all review. We wrote to you back in February, I think, with our intentions around commissioning of a review of the collaboration, integration, opportunities for health and care across rural. The review is principally on the opportunities for greater collaboration between the community trust and the hospital trust but has objectives around developing a strategy for greater collaboration, integration across acute community and primary care services, identifying those opportunities and creating way forward. We have appointed a external partner to support us in doing that and then we intend to bring regular reports to the place based partnership board on progress. Some people around the table today are being interviewed as part of that review process as well and are participating in it. So we'll add that to the junior agenda, please. Okay, thanks, Simon, Cameron. Yeah, not necessarily for junior agenda but for some points later on in the year. Could we have of course on what's happening with the Transforming Care Program, please? That'll be Pauline McGraw. We'll invite for that, Vicki, and I can sort that outside the meeting with you. Thanks, Cameron. Anything else? Any other suggestions for the work program? I'm happy with everything, Vicki. Okay, so just note the reports, subject those changes. So is there any other business anyone has? Okay, well, I will close the meeting. The next meeting is on the 20th of June, so stay well and look forward to

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[BLANKAUDIO] [BLANKAUDIO] [BLANKAUDIO] [BLANKAUDIO] Hello everyone and welcome. Is that my quirk in?

Yeah, so my name's Carol Johnson there, I'm the chief executive citizens of Vice Whirlpool and I'm the chair of the meeting. The chair has changed. So for this next year's community voluntary faith and social enterprise sector. The world chair and so I've got the honors and it's my first meeting. So be kind to me and I'm full of cold. So if you need me to repeat and it's in, please do that. And so to read this out first for those people who are watching on the webcam. This meeting will be webcast and a record retained on the council website for up to two years. By participating in this meeting, you're consenting for your name. The content of what you say and your image to be broadcast and stored to the council website. If any member, officer or member of the public addressing the committee has concerns with this, please contact the committee services officer immediately. For those at home viewing the webcast, I would like to inform you that if you look above the video, you will see a resource tab. Select this and a link to the agenda will appear on the right hand side. This will allow you to open the agenda in a PDF form and follow the discussion and debate. Okay, fab. So we've got a couple of apologies. We've got apologies from Janelle Holmes from the university teaching hospital. Karen Pryor from HealthWatch and Lorna Quickly from Simon's team. And Paula Simpson's up here on behalf of Karen Howell. Have we got any other further apologies or anyone else who has replaced anyone else? Okay, thank you. Thanks. Yeah, fab. I just remind people to put the mic on and switch it off, please, when they're speaking. So that it gets picked up from the webcast, James. Sorry, yeah, I'm here for Julianna. James. [BLANKAUDIO] [BLANKAUDIO] [BLANKAUDIO] [BLANKAUDIO] Oh, sorry, I'm not doing what I told everyone else to do, aren't I? So yeah, it's just that anyone got any decorations of interest. No, okay, fab, thank you. So moving on to the minutes of the previous meeting, this is pages 1 to 12 of the pack. I want to just check if there's any inaccuracies in the minutes. Simon? Just notice that Simon White is missing any in terms of people who are present. Sorry for the ultimate pattern, Draper. [BLANKAUDIO] Thanks, Simon, and is there any outstanding actions from minutes? No, okay, we're happy with them. Yeah, so if we are happy to approve the accuracy of the minutes held on the 27th of March 2024, yes, fabulous. Thank you, and there are no items in the action log. So moving on to the board assurance reports, agenda item five, which is pages 13 to 20 in your pack. Martin, I'm going to present this report. Okay, thank you, Chair. So this is actually the month 11 report, so this goes to the end of February. And since then, time has moved on a little bit, hasn't it? So we've closed the final accounts subjectible to approval for, I think, certainly the NHS organizations. And I would imagine that the local authorities going through the same process as well. So at month 11, a continuation earlier, the themes that we'd seen throughout the year. We're all place based part of the ACB, just in the table on page 14. Sorry, we're all place based part of the ACB forecast over spending around $16 million. We're all community health, foundation, trust, forecast variation from their plan of about a million pound benefit and worth the teaching hospital. 5.2 million pounds address their plans, so in terms of what's driven that, we know that certainly through the place, predominantly packages occur, increased in packages, occurred in responsibilities around sort of responding to the pressures that we've seen there. Prescribing costs have also been a key feature of the pressures that we've seen. For worth, main issue is being industrial action in the cost of industrial action. So again, I think you put probably that five million pounds answer to all of that. So in terms of the month 11 financial performance, predicting as a healthcare system for the full year, we were planning a £25.6 million deficit. The prediction at month 11 was $46.8 million and the next report I'll confirm the final figures that have gone in as part of the final accounts. I think just moving on to the pool funds and the better care funds. Again, I think those figures will be broadly similar. I think when we see the final accounts, the one changes to report, just the sort of heads up for the next report would be the better care funds actually has all the spent this year by about $150K to answer pressures in the world, the world independence service as well. So the partners are enacting the risk share and that will be shared around $50.50 between the ICB and the local authority and the finance teams are just working through the transaction on nature of that and what that means. So that's the report, happy to take any questions that anyone has. Thanks Martin. Any questions? Hey, Kevin. We'll just put your mic on please, Kevin. Thanks. Well, come to the community wealth building session. How are we involving community groups and community organizations in that? So one of the things that we've been doing around sorts of trends, where we put our investments in the best place, has been to run a full planning session and we've had representatives from the community, social enterprise sector as part of that to understand how we actually reach in and get maximised the community assets that we have, particularly around the people that we've got, so I wanted to make sure that we can join that to NHS local services as well. So we've been doing it through that planning session. I think Carol, you've been part of that as well if you want to do it. OK, thank you. Yeah, there's been a number of us who have attended those sessions and also, Lauren, quickly, has been leading the piece of work, looking at equality impact assessments and how we can do that better as well and involved different members of the community, voluntary faith and social enterprise sector. So it's a bit of a bit of a testing at the moment, how that works. I hope at some point we can report back to the board, how that's going and that will influence on some of the papers, what is said in relation to equality and community wealth building as well. Graham, you have a question? You may come, please, Graham. So, yes, Martin, so the numbers are obviously huge in there, you know, the deficit beyond plan on top of the actual out turn. I mean, it is significant and I understand that that's pretty much the pattern across the whole patch, Cheshire Mersey. So then one would expect at some point, and I think that Graham's written to chief executives at local authorities across the parties to say that there will be work to reduce the size of the deficit. I don't know in terms of the process for that, how it will be decided where savings will be made and how savings will be made. And I guess you can't say a lot about that, but I just wondered whether you wanted to say something about how the budget could be brought back into line or how the process might work. Thank you. So, the ICB will effectively enter into recovery mode, financial recovery mode, and that will include highlighting what we believe our key priority areas are. So, if we were to go back to pre-COVID and have a look at how the financial position was in the service position at that stage, we were still under pressure, we still had an underlying deficit at that point. However, we were sort of managing on a year-to-year basis. What's noticeable to think since COVID has been the increase in the workforce? That hasn't been sort of brought together with a subsequent increase in productivity, and there's multiple reasons around that, because again, I think we've seen an acuity in patients that have come through. I think some of the workforce changes some of the actual sorts of practices have had to change because of COVID and things like that. So, but the challenge back from the center, the NHS, is all around how's the workforce grown, how's productivity changed, and the big focus for us on that is around age and care. So, everything that's happening sort of from front door admission, even before that, if you think about it again, sort of including primary care as age and care services, which is upon services, all the way through to how we discharge people effectively, how people are then cared for the independence that they can manage with. I think after hospital stay, the level of support that they need, all of that is sort of part of like the key focus. So, there are other streams coming off. So, for example, admission avoidance will be a key feature, how we do discharge through our hospitals, and also I think ensuring that what we get, ensuring the packages occur that we, that people receive post hospital support are the appropriate ones as well, because again, I think there's a sense that, you know, you've taught in the past in the committee about a potential over prescription of care at various points, it's about how we sort to manage all of those issues together. Thanks Martin Simon. Yes, so if we turn that sort of the financial challenge into a more of a quality ambition, the ambition should be to eradicate corridor care, and corridor care in terms of people at Arrog Park hospital being cared for in the corridors there at times of excavation, because that is poor quality care for the people in those beds, for the hospital staff themselves, and it prevents the flow through the hospital. And then in terms of if we apply that to mental health services, it's people waiting in their homes for mental health inpatient beds, because that's kind of the mental health service equivalent of corridor care. It's also then about getting on top of our discharge processes, so we've made some significant inroads in terms of non-criteria to reside in the hospital. I think we're at 84 this morning, 81 this morning, which is significant last time when we started 18 months ago, at daily 240. There's this equal challenge to be achieved in terms of people are clinically ready for discharge in mental health beds as well, again, in terms of that flow. So the ambition is to improve how we deliver care in an unchedule care space, which then in itself means that we reduce waste, which is in the standard definition work that doesn't meet need, and actually we expend money on additional agency staff, positional beds, etc. So that's where we believe the biggest benefit to be regained in terms of our financial recovery for the next year. Thanks, Simon. Are we okay to move to recommendations? Yeah, so the recommendations, it's recommended that the Whirl Place Base Partnership Board, note the report and the specific recommendations in relation to the pool budget listed below. Note the Whirl Place System Forecast Reporter Position at month 11, 2023-24, and note that the forecast reported position for the pool and the discharge funds as at month 11-24-25, and note that the shared risk arrangements are limited to the better care fund only, which is reporting the forecast break even position. Are we okay to approve that? Yeah, I'll be less. Okay, reporting, moving on to agenda item six, quality and performance report. So this is pages 21-40 of your pack, and Simon is going to present this report on behalf of Lawler. Yeah, so Lawler's just called away literally minutes before the meeting started. So I would just touch upon the metrics for unscheduled care. Actually, in the unscheduled care program delivery will be included in the agenda on that. In terms of planned care, we're all continues to perform well across all of the aspects of planned care in terms of elective recovery, and particularly in terms of some of the areas around cancer targets and diagnostic testing. I've touched upon mental health. We are consistently holding multi-agency discharge events with Cheshire world partnerships, and the super-made event actually brings together places across Cheshire, and we're all to look at unblocking delays and addressing the challenges around that. We do have people waiting long lengths of time for delays, and we time those events focus on the people waiting for the longest periods of time, and in the report there was somebody who'd been waiting 730 days, but that was due to their choice, but by being in the inpatient bed, they're actually stopping somebody else coming into it. Equally, when we have people who are clinically ready for discharge, and they need to move on, some of that is actually beyond their control, and it is about having appropriate and timely assessments of need, and moving them on to their appropriate accommodation as quickly as possible. In terms of health care acquired infections, it's still a priority for all place, and we are being included within our priority areas. Moving on to a couple of the programs just for updates, special educational needs, disabilities continues to be a priority for us to assist them. We still have an existing written statement of action. The governance around this has come recently been refreshed, and the new board established under Paul's chairmanship. That will be meeting regularly and will be putting more emphasis upon some of the the the dials we need to shift in terms of improving SCND provision, so ensuring the graduated approach is rolled out, but from a health perspective actually really focusing on some of the service provision for children, young people, and neurodevelopmental needs, and the implementation of a new camel door that aligns the graduated response, and we're doing that. We have a new designated clinical officer starting imminently who will also help us tackle that. At the time of writing in terms of measles, we're looking to Dave, we had one, so at the time of writing, no confirmed case in subsequent to that, we did have one confirmed case of measles within our system. Have you taken any questions on the report as best I can? So that's all there is on that chair. Thanks, Simon. Question or comments? Kieran, and then Elizabeth? Yeah, of the eight people detained of the mental health act alluded to in this week, people's and in New Year even, some of the harmonism are being under some form of care program. They would all be under a care program approach, but the virtue of the fact they've been admitted as an inpatient, so everybody admitted through that route would have been subject to care program approach. That's correct, Fauzi. Fauzi, do you want to respond back to that? Yeah, we no longer use the term care program approach, it's just because NHS England changed the policy, but we essentially did them as if they were under CPA. Thanks. Thank you, Elizabeth. Thank you, Simon. Thank you for highlighting this end improvement work. As Simon mentioned, we've got new governance boards in place, which we'll be meeting on a monthly basis with DFE and NHS England. Just a reminder that we've got an induction session for that later this week, but we really are moving with pace and grip to get the improvements we need. Simon also welcome the new DCL, starting the designated clinical officer and to fudge conversations with Lorna about an induction for them and making space available with the council team as well to improve that joint work in. Thank you. Thanks, Elizabeth. Any other comments or questions? Are we OK to move to the recommendations? OK, so the recommendations are that the World Place-based Partnership Board is asked to note the work underway across the system to monitor quality and performance, identifying areas of improvement for improvement, note and endorse the further work underway to strengthen the governance around quality and safety across health and social care and receive assurance around the robust improvement plans in place to manage specific areas of improvement. So just wanting to get a sense for approval for that in the board. Fabulous, thank you. OK, moving on to agenda item 7, the planning 24/25 updates on pages 41 to 56 of your pack. Over to Simon again. Thank you, Chair. So the NHS England planning priorities and operation planning guidance this year wasn't released for Christmas, it was released for Easter. So some three months after we would normally expect to receive it, the final priorities and operational planning guidance came out. That was on the 27th of March. The full guidance is on the NHS England website but we have attached some, I think, in Appendix 1, an extract from that guidance which sets out the national objectives. Alongside this, NHS Chesham Mayes had a working with system partners to develop an update of our joint forward plan and there's also an update of the health and care partnership plan. In terms of ourselves and we're all, Martin is running the final planning workshop on the 20th of May which was referred to earlier. So we've had a series of workshops since December with system partners to construct the World Health and Care plan, the metrics and outcomes we're going to measure against that and how that is going to be delivered. In your pack, you will note that I have written out to each of the senior responsible officers for our agreed programs of work asking for a narrative update so we can update our World Health and Care plan. The deadline for that was Friday. We've had a majority of them in. I did a chase here on Friday and I'm assured that the remaining narratives will be with me by the time I return from leave on the 20th of May. That will enable us to present the final World Health and Care plan here at the June meeting for approval. As previously indicated, this is an update and an extension on what we have agreed to do in 23-24. So it will be the same programs of work that we are familiar with with on schedule care, being at the heart of that in terms of reporting here. The rest will be reporting through strategy and transformation group into here. So happy to take any questions from members on the planning round and next steps. A couple of questions and comments actually. Specialists, when the health health and care plan is updated, why is it that people with disabilities and long-term health conditions do not have to involve in this process? Okay, so we are involving voluntary community faith sector groups as representatives of those sectors. Our expectation is that in our normal work anyway, we involve people in care planning and this is a response to national guidance as well as local local activities. Any change that we therefore put in place would be needed to be supported by the appropriate quality impact assessments or quality impact assessments, which we then need to demonstrate how that engagement happens. So we would not routinely involve individuals in planning rounds. It is more of a technical matter that takes in, that takes account of the needs of those people and therefore the best we can do is to seek representation through health watch being at those workshops and representatives from the VCFSC at that workshop. We are also going through, as part of that, each program will have those EQIAs in place as well, which demonstrates how that impacts upon service users and carers. I'll just add a couple of questions. The second one is when it comes to the engagement process. Who are the partners? If you're not actually engaging with individuals, what specific groups are you after engaging with? So as per the degree process, we ask the voluntary community faith and social enterprise sector through the CVS to identify groups of people who wish to attend our planning events. So in the past, we've had Wired, we've had ASUK, we've had CAB, we've had Involved Northwest, we've had Koala Northwest. I can't think of else who's been in the room, we're all minded being there as well. So a variety of groups have been involved in that and therefore are part of that planning process. As I said previously, we try to seek them as the voice of the people as far as it's possible as it would not be practical to have everybody in the room or 30,000 people. And presumably if those community groups choose to involve the people that they support, they're free to do so, don't they? It's our expectation that those groups do that actually. So the arrangement with the voluntary sector has been that their representatives come as representatives. The whole sector and the people who serve the sector not serve their individual organisations. Thanks, Karen. Just up to that, on behalf of the sector, we do challenge as well and we do offer that individual perspective and say in relation to things like how does this impact on carers, how does this impact on people who have got disabilities and lots of disabilities and there's a whole range of us who have got a range of different perspectives and experiences ourselves as well, both in the sector and also a large number of those individuals who are residents who use the health system themselves and have relatives who use the health system as well. So it does feel as though we are involved and able to contribute to that planning. Any other questions or comments, Dave? Thanks. It was just a quick question just in terms of the national objectives. It's really, really good to see them laid out and the bit that's missing on this appendix is actually the importance of tackling antimicrobial resistance. It's mentioned in the guidance but it's just a plea to keep that on the agenda because it's so crucial that we address that and show leadership and key actions to address it. So antimicrobial resistance will feature in the medicines optimization work program. So it's already in for 23-24. We will continue for 24-25. So yes, you're right, Dave. Thank you. Any other comments or questions for Simon? No? Okay, Fab. We'll move to the recommendations then. So it's recommended that the board notes the update provided by this paper supports the approach being taken to update the Whirl Health and Care Plan for the planning year 24-25 and receives the Whirl Health and Care Plan 24-25 for approval at the June meeting. We're happy to approve this. Yeah, fabulous. Thank you. Okay, we're moving on to the program delivery report. So I'll hand over to James Bathley for the first paper agenda item eight, the Whirl Health and Care Plan Program Delivery Dashboard, pages 57 to 68 and James is presented on behalf of Julian Ehr. Thank you, Chair. So you've had the paper in the packet that you've all received and that's with the aim to provide the board with information and assurance of the programs associated with the Whirl Health and Care Plan. The overall delivery rating for the Health and Care Plan delivery in March, April, was green with one program in the portfolio reporting red, three reporting amber and the rest reporting green and not summarizing the table on page 58 at 1.1.3. I'd just provide now, I'll go through an overview with the programs. Obviously, you're not able to go directly here, but more than happy to take any questions on individual items. So starting with the guiding programs. Within the neighbourhood program, core group panels are now underway in both Birkenhead A and Wallace C. A template has been developed by neighbours to enable people or organisations within their neighbourhoods to apply for available funding. A population health programme, a workshop is held on the 11th of March to bring the system together to focus on how we can tackle fuel poverty as a collective in Whirl and that's with a follow-up event plan for summer 2024 that will take the action plan forward. Within the use of resources programme, the rag rating of red, that relates to the overall financial deficit position. I won't go any more into that as Martin has already provided an update on the agenda today. That takes us into the delivery programs, starting with the children and young people's programme. I was going to elaborate a bit on that, but I know Simon and Elizabeth have covered the key items on that today. Again, happy to take any further questions on that. Within the all age disabilities programme which has commenced to determine how the all age disability strategies agreed in March can be delivered for Whirl residents. The mental health programme board for April was stood down and that's for the second times in three multitudes of core receipt. In support of the integrated housing work stream proposal has been received from agenda to living for an independent living pilot and that's for five properties. The primary and community care programme has identified the initial focus is frailty, supporting people to age well. The programme will support reducing attendances at ED and GP practices through a number of solutions including anticipatory care planning and the May programme board will include a facilitated discussion to support further development of the programme. Going into the enabling programmes, within the digital maturity programme, the top priority remains the migration of the population health management system for work from the Whirl care record to cipher. Work is underway to address the programme governance function for effective monitoring and evaluating objectives and progress. The estate sustainability programme has developed an overall group approach to managing the deliverables. This has resulted in the finalisation of key delivery pillars and set of documented outcomes and leads have been identified for three of the programme pillars. The medicines optimisation programme that is overseen by the Whirl place medicines optimisation group, however there have been some constraints with the capacity of that meeting to drive some of the work forward. So there's been an agreement for a view to be completed at the for the end of May to fully define the priorities for that programme and the structure in the governance and how it all progresses forward. So that will go by STJ. Within the workforce programme, the baseline workforce data project group compiling the data at organisation level, exploring hosting for the place level dashboard and overlaying the population health and social value data. There isn't an update in this report for the place supported delivery programmes at scale as you understand there will be some changes in the leadership of the work, however reporting will be back in place in time for the next board. So I'll pause at that point. I'm happy to take any questions. Thanks James and Brian and Simon. Thank you. I guess when we started on the workforce programme, the primary focus was having sufficient people to undertake the work and we were seeing particular shortages in areas, nursing, care, staff, a whole range of other areas. It's quite interesting when we were talking about the financial situation earlier on that what Martin was indicating was that the workforce has grown significantly but that the performance of the workforce in terms of productivity is not as high as it should be. So I guess I would expect maybe the workforce strategy to also now be considering productivity as a key part of its approach going forward and that would be linked up with the work around the budget across the patch and that would be clear about what that actually means in terms of workforce and implications. Thank you. Thanks, Brian. James, are you going to take that back to Julia? Yeah. Happy next time, Simon. Yes, so just a few things. Obviously this is retrospective as a programme delivery dashboard but as to the few things I want to pick out in terms of how we play this forward in the planning round. So there are clear interdependencies between the mental health programme, the unchudged care programme and primary community care which needs collectively to focus on that admission avoidance piece and what services that we have in place to maintain people in their own homes for longer. The unchudged care programme has done fantastic job in terms of improving flow at the back end of the hospital, discharging people. It's about now, I suppose, for next year applying similar vehicle to maintaining people in their homes because it's not just about the mission of avoidance, actually it's attendance avoidance, it's stopping people getting to the front door of DD in the first place. So I know that's been worked on at the moment about how the programme then evolves into the next stage. The second thing for me really is we work as a collaborative as a partnership and therefore the activities we undertake depend upon everybody playing their part in that and it's really disappointing to see that the mental health programme board had to not meet for a couple of meetings because of non-attendance. So we do urge people to attend that there's some significant work in that group going on around improving community services, improving the crisis response, looking at housing options, all of which contribute to keeping people out of mental health inpatient units, stopping them crash landing at Arrow Park in terms of crisis and moving them back to their homes as well. So there's significant work happening in that work stream. It is for us as well as an NHS, Cheshire and Moses had a key priority. It's one of our priority schemes programmes for this year in terms of improving quality and achieving financial recovery. So I urge people to be and if necessary I'm quite happy to support Suzanne in writing to the organisations who aren't sending people regularly. It's really important we do that. And then I just acknowledge there has been a bit of a change in the the elect, the programmes at scale but we have had a really strong narrative from them for next year's planning round again building on a successful year in terms of the hospital trust response to on elective care cancer diagnostics and maternity. So I'm hoping that that work will continue into 24/25. Thanks Simon. Any other questions or comments Elizabeth at Nankairi? Thank you. I just wanted to note that the Children in Young People's programme which is currently migrated green, that reflects the activity from the programme that's been completed over time but some recent reflection in the self-assessment that's referred to is shown that the impact of that activity isn't where we want it to be. So I would expect when that comes back to future reports that the RAG rating will have changed and will be refreshing our action plan alongside that. Thanks Elizabeth. Karen. What plans are there to involve people with disabilities and long-term health conditions in the core group plan, core group plans? It's a similar situation again to the planning round here in that we have representatives in the volunteer community faith social enterprise sector. We have health watch and the all activities that are presented that require changes of business cases have to demonstrate that they've engaged with people who use the services through their equality impact assessments. Thanks. Any other comments or questions? Okay, we'll move to the recommendations then. So it's recommended that we're all place-based partnership board. Note this report which provides assurance on the delivery and oversight of the health and care plan programs. Are we happy to approve? Okay, back to James again. We've got two reports back to back. So this is the unstructural care improvement program update pages 69 to 90 of the parks and hand over to James to present. Thank you. Sure. Again, had the report in the park similar aims provide the board with information and assurance of the work of the unstructural care program in this case. I won't recap and I will sometimes recap on that on the program today but again more than happy to take any questions on the scope and work of the program. Maybe just to say that we are, as Simon touched on before, in the process of a refresh in line with the planning so that the scope for the program will change and that's been managed through the unscheduled care board. Going into the report, I'm pleased to say that this follows on for the positive update presented at last month's meeting and that's analysis of the data since the previous report shows a decrease in the number of number or possible on patients with no criteria to reside. The number has decreased from 1.35 in February to 1.32 on the 1st of March. Following the national picture of increased winter pressures, a recovery plan has been in place with the aim of returning the no criteria to reside numbers to pre-Christmas levels of 100. Interim data shows this has been consistently achieved with the no criteria to reside number which in 9.8 in February, 97 in April and again Simon mentioned before it was 80 on this morning which is really positive. Where will has continued to perform strongly compared to other places within Cheshire and Mercy integrated care system. Where will has consistently been a first or second position out of seven areas over the winter period. This did deviate slightly in March however we were back to position one weekend in the 14th of April. A successful week-long super made agency discharge event that was made took place in Wirrall in March which was part of Cheshire, Mercy ICS wide event. This brought together a health system and local authority partners to support improved patient flow across the system, recognise unblocked delays, challenge and improve the discharge process. This was deemed a successful with partners working effectively over the 70th event and significant key learnings were captured throughout the event that have been worked up by system partners into report and being taken for the first point to the un-scheduled care program board later this month. The capacity of the among work system partners have continued to develop the Wirrall capacity and demand work and are scheduled to bring this back to then this next board in June as I understand and that will go in the meantime via the un-scheduled care program board following the governance arrangements. Just to highlight as well two significant visits to the transfer of care held by national representatives have taken place during March. On the 21st of March Amanda Doyle, the NHSE national director for primary care and community services visited and this was followed by a visit by the Department of Health and Social Care system oversight team on the 27th of March. Both visits were deemed successful with positive feedback received and a note Amanda Doyle also up with the home first team as part of the community integrated response team joining her visit. Included in the report is an update on each of the component work streams under section 1.2.4. Again, I don't intend to run through these in detail today but I'm happy to take questions and questions. I'll pause that. Thank you. Thanks James. I've got a grave in that sign as well. No, just a grave. It's probably more of a comment than a question really but it's just that clearly there are some positive stats in there but again it depends when you look at positive stats which angle you're looking at them from. So we do see some really high levels of care package implementation 3,906 against target 3,224. Of course there is a significant cost to that and one of the issues as we improve performance through the hospital is that we do see a significant cost through the local authority in terms of package of care in the community. Both domiciliary care but also residential and nursing and we have seen with the increased performance we have seen the uptake of residential and nursing places increase significantly. So there is a challenge for us as systems we go forwards in terms of ensuring that we use our home first model our able me model to support people outside of residential settings and not kind of rush people into care sooner than they would have ordinarily gone in. I think that's a real risk of chasing the numbers around and CTR and has been for some time now. Now the point is that it's a financial risk but it's actually much more than that. It's an independence risk as well in terms of the people their outcomes are not as good if they go into care rather than go home. So we do need to keep close eye on that. It would be good to see the stats together so that we're seeing what's happening around those types of settings as well as what's happening from a hospital front door perspective. I think the good news though is that we are as a system looking to shift into early intervention and prevention of admissions from hospital and I think that puts us into a better position in terms of monitoring what's happening across the whole community. But I think not for me as it is the next stage of moving forward on this at the moment it's like a single focus which was right for its time but we need to move on now. Just so I agree what Graham said there I mean looking at the figures the day 35 of the 81 are on pathway 1 which is a significant proportion of the people not meeting the criteria of desire and their people actually can go home with a very low level support they don't need to go into red damage nurse and care. So I think there has to be that focus on pathway 1 and I think sometimes I think the longer people spend in our or we know longer people spending a hospital setting the more they decondition and therefore we'll move the pathways two and three. So there is a bit of a different focus now isn't there Graham for 24-25 which is stopping people getting them improving the flow and processing of people back home rather than to residential nursing care. Thanks Simon David. Thank you for the report. I'm just wondering whether there's going to be a switch this year off very soon from the unshared your care improvement program to looking at the front door and the long waits in A&E. I understand starting your work we're getting the flow through the hospital because that is critical to where patients go from A&E but we're still seeing those long waits in A&E and I would like to see some work within this improvement program around the waits in A&E and I think we've discussed that before at this sport. So as part of the planning rounds at the moment emission avoidance is proposed to feature us as a workstream on that and there's a lot of you know well planning work started it'll be formalised through the unshared work here program board and we'll be able to be brought back here I'm sure but I can assure that that does feature on the planning so far as we switch into the face through the program. Thanks David. Thanks James. Any other comments or questions? No okay we move on to the recommendation then so it's recommended that the board notes this update and we have to approve that. Yep fabulous thank you and so we're moving on to items for discussion and decision items for information support in the group church reports. So a gender item at 10 is the primary care group report it's on pages 91 to 96 of you pack. I think Lauren was meant to be covering this for Ian so I presume you're taking it Simon? Yes no I thought I wasn't at that meeting so if we just take this if any of you want to pull out of it I'm happy to answer any questions. Cameron? Could you make this this like like so many many things you you you're way of working with people with long with disability and law development condition. It's a work with community groups that you've outlined earlier. Can you say something about the process of how you decide which groups you have to work with please. As referenced earlier we don't decide which groups we work with in terms of the people on these supporting groups they've been elected by the voluntary community faith social enterprise sector they represent the sector and on this on the primary care group it's Chris Webb and Lee Pennington who represent the sector but then in terms of how as I said how we earlier how we then engage with people we would expect that to happen through the services themselves and for them to reference that in any work that they do. I'll just add to that Karen so there's a representation model that the sector's got and that every organization has a vote when there's ever any meetings that there wants a community of entry faith and social enterprise to represent that and then each of us who represents feedback to rural CVS after each meeting about anything that's been specific it's been discussed and relevant that's then fed back out I'm happy to meet you outside the meeting here and if that would be helpful to to go through that a bit more with probably Gareth from the rural CVS that'll be helpful okay so any other questions and comments okay and we'll move on to the recommendations then so it's recommended that the we're all place-based partnership board notes the work of the primary care group and continue to receive updates as I stand in a gender item and we're happy to approve that recommendation. Okay so we're gender item 11 the quality and performance group report this is pages 97 to 102 with your packs and hand over to Simon. Yes again significant focus in here on special educational needs disabilities work a deep dive into the work of the talk and therapy service but again going back to our consistent theme about children with neuro presenting with neuro diversity a focus on children's neurodevelopment pathways but also the demands we have in the ADHD for adults where we have a primary care service through the LEAP model which makes a slightly different to the parts of Cheshire and Merseyside. In terms of some of the recovery programs we mentioned earlier mentioned urgent emergency care being one mental health service being another or mental health system flow and there is another work stream around neuro diversity at Cheshire and Merseyside level and focusing in some of some adults who have neuro diversity on ADHD specifically and but again I'm not a meeting I attended here I don't know if you were at this meeting Paula. Unfortunately I wasn't at this meeting Simon but I am a regular attender happy to take any questions on behalf of Lorna. Thanks Simon thanks Paula. Any questions and comments? Simon? Thank you ADHD we're double the Cheshire and Merseyside percentage rates is there why are we over identifying or over or are we just different? I'm happy to attempt to answer that because it has been a discussion and debate within the group on several occasions. There's two things that we're exploring the first is a potential for over identification and the second obviously is are we an outlier in terms of that presentation but all of that is still under kind of consideration at the moment but it's a situation that is well identified within that group and is a discussion point regularly. I don't think we have an answer for Pfizer. It is very difficult to say you know we can give a specific answer I think in general you know over the last maybe 15 years on the world we've actually provided better care for people with ADHD compared to in other areas at least we have a service in lots of other areas they simply don't have it so therefore it's hard to even compare because they don't identify because there is no service. We're here at least you know we are identifying I think there is an argument in terms of are we over identifying and therefore obviously the question will be significantly different. It's a clinical dilemma which we obviously have to answer at some point. Thanks for that clarification any other comments or questions Ian? Just to say that one of the challenges with the identification is that the almost complete unavailability of medicines to treat ADHD at the moment. So in areas where we haven't identified it there isn't the clamor for medicines in our part of the world the whole world there's such an acute shortage that we have we have anxious parents tracing, traipsing from pharmacy to pharmacy looking for medicines which physically are just not available and the service does need to think about the continued prescribing prolonged sustained release medicines rather than three times a day medicines because that is the major challenge so all the prolonged ones which we cannot get hold of. That was my concern really that if we are overprescribed or whatever the reason may be from the percentage figures we may have a number of individuals taking medication that perhaps don't need or not taking medicines that it should be available and that's my problem really. I think people who are taking the medicines they need it because we monitor them and you know I don't have a problem there I think I agree with had since November last year we've had significant shortages of medications so we are you know managing this on a based you know kind of approach and we did have an improved picture in January February but we've been told again there's a problem in the last few weeks so it's again it's a it's a it's a national problem so it's not just like the world and hopefully at some point you know we will get to better position but like I said it's a national question. Thank you David. From a general practice point of view the situation is getting worse because of the lack of availability for an NHS diagnosis or to refute the diagnosis we are seeing more and more patients going privately who inevitably give them the diagnosis and then the request for the prescription from the GP and the system is completely broken at the moment because I'm not convinced all these patients do need the medication and it's only adding to the strain on the availability of that medication in the system so I think that we have to come up with a with a fix that prevents people going off for a diagnosis have to self-identifying I'm not sure what that fix is but we do need to focus on the a fix locally for this. So it's best for me there's two aspects of this there's adults with neurodiverse conditions who often find out later in life the impact that has had upon them in terms of a whole range of them that things you know the family life their employment etc. In terms of children young people it's really important we get it right for them and that's why we're doing the work on the neurodevelopmental pathways and that has to be a line graduated approach as well because as you said not everybody will need a medical so pharmaceutical intervention they may need other support so there is some national guidance around autism there is also stuff there around ADHD which are equally applicable in terms of what happens pre-diagnosis in terms of supporting people what happens once a diagnosis has been made and then the post-diagnotic support which may or may not be be medication and we are working there for as I said it's one of the key programs for Chester and Merseyside but then we're translating it into being a key program for ourselves within whirl because there is a possibility that we are over diagnosing there's also a possibility of very very good at diagnosing and therefore putting in but certainly the demand at the moment is outstripping the supply of some of the intervention options but some of that demand the NHS doesn't have control of because it's being generated by schools etc and by parents themselves and therefore it's about providing better support in those frameworks rather than necessarily coming into a GP or other medical lad service. I think in terms of the diagnosis people who end up in secondary services we are confident about the diagnosis because we have you know you don't get a diagnosis in five minutes it's actually a process which takes you know a very long period of time the issues which I think you know Dr. Jones mentioned is that people can just go to any private person and then you can't tell you can't verify the actual quality of these assessments and therefore it's really hard and then you get a referral you prescribe the following so I think it's a system thing which we need to actually kind of look at but yes it could be over diagnosing when people self identify and say these are my symptoms and then you get a diagnosis. And certainly some of our concern has been about the quality of the provision provided by some of those private providers who indeed now are closing their doors to new new business as it were because they're being swamped with people coming and wanting a diagnosis. Nationally about what it's about a year ago now there was and you know we must neurodiversity is complex but we mustn't confuse ADHD with autism so a year ago there's a new all-age autism strategy and operational planning guidance which had no new money attached to it that was issued about a year ago so we're in the process of responding to that and again it's a similar principle say you're chunk of the pathway but I think ADHD is now such an issue for us in terms of health and care and politically a new national task force has been established by NHS England to look at ADHD and its provision because it doesn't fall anywhere so you can go on to the NHS website now typing ADHD or tell you what should happen but it doesn't sit in the transforming care program for learned disabilities in autism and it doesn't sit in the mental health program it's just it's almost orphaned and therefore there isn't and my personal view is we shouldn't and because neurodiversity isn't a spectrum it's more of a for me it's more of a kaleidoscope of conditions and traits and so on and I think we actually need to focus on neurodiversity per say as health and care rather than try and junk it up into bits and certainly the numbers of people we're seeing so one of the things we we do in terms of the transform care program has been trying to get the numbers of people in long stay inpatient beds down from about we were at about 140 years Cheshire most had seven years ago and we need to get them down to around about 60 people at about 90 at the moment what's hampering that is the number of people now ending up in a mental health bed and then getting a secondary diagnosis of autism so they go on to that so for the first time we're seeing in those beds more people with a primary diagnosis of autism rather than learning disability or learners but they end autism so we're seeing growth in in neurodiverse conditions impacting all parts of our services thanks simon so just to clarify the quality and performance group picking up all of that what's been discussed today about the system wide impact they will be picking up through the neurodevelopment children's neurodevelopmental work so the quality performance group monitors what's happening in terms of quality and performance the work stream that is dealing with this is the children's young people's work stream and then a Cheshire motorcycle level there is an ADHD work stream for adults thanks for that so we'll come back through those reports that the progress they made based on those comments fantastic thank you any other quick hearing the letter report alluded to on page 98 as only plans to take that to the to either the sub-formal care operations board or the strategic board yes they will be taken to both those boards okay both okay thank you thanks any other comments or questions okay we'll move to the recommendations then so the we're all place at the base partnership board is asked to note the work underway across the system to monitor quality and performance identifying areas for improvement receive assurance around the robust plans in place to manage specific areas for improvement and note the effective use of data to understand population health need and improve equality and access to services and we're happy to approve those recommendations okay moving on to agenda item 12 a strategy and transformation group highlight report which is pages 103 to 108 of your pack assignment again chair happy to take any questions on this it's there for information and further investigation any questions comments no okay we'll move to recommendation then it's recommended that the we're all place-based partnership board notes the work of the strategy and transformation group we have to approve okay agenda item 13 finance and investment groups group highlight report which is pages 109 to 112 of your pack Martin yes just to note at this stage of the year we are doing a lot sort of collective work to understand each other's plans making sure there's no one intends a consequences of those plans for other partners so that we can we can really sort of tease out what the issues are they're facing the we're all and then come up with some of the appropriate mitigation options thanks Martin not any questions or comments about the report no okay i'll move to the recommendation then and it's recommended that the we're all place base partnership board notes the work of the finance and investment group and continues to receive updates as a standing agenda item we have to approve okay um so moving on to the closing business agenda item 14 don't think we have any public questions maintenance and petitions do we know um so a gender item 15 we're all place-based partnership work program pages 113 to 120 and over to you Vicki thank you this is a standing report which comes to each meeting of the board to enable members of the board to comment on or contribute to the board's annual work program you'll see there are a number of items already listed on the work program for the coming meeting on the 20th of June if there are any additional things that members would like to comment on or add to the work program this is the opportunity for you to do so Simon thank you i'm just going to ask out for an update on the sense for children young people to be added to the work plan please Simon and then that sandal will come a standing item for each board thereafter is the plan i think um can i add please we're all review um we wrote to you back in february i think with our intentions um around uh a commissioning of a review of the um collaboration integration opportunities for health and care across we're all um the reviews principally on the opportunities for greater collaboration between the community trust and the hospital trust um but has objectives around developing a strategy for greater collaboration integration across acute community primary care services identifying those opportunities and creating way forward um we have appointed a external partner to support us in doing that and we intend to bring regular reports to the place-based partnership board on progress um some people around the table today are being interviewed as part of that review process as well and are participating in it so we'll add that to the junior gender please okay thanks simon karen yeah um not necessarily for junior gender but for some some points later on in the year could we have uh of course on what's happening with the transform and care program please that will be pulling the graph we'll invite for that bicki and um i can sort that outside the meeting with you thanks karen anything else any other suggestions for the work program happy with having a bicki yeah just okay so just note the reports subject those changes um so um is there any other business anyone has okay well i will close the meeting the next meeting is on the 20th of June so um uh stay well i look forward to seeing you then thank you 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