Transcript

in the meeting late, but it was due to technical difficulties and we'll leave it at that. Okay, so just to introduce myself, David Ross, the new cabinet member for Public Health and Wellbeing at the County Council and Chairman of this Board and thank you all very much for coming this afternoon. We'll turn to the agenda, do we have any apologies and substitutes? Yes, we have apologies from Vic Allison that we have Jen Taylor with us, we've had a apologies from Robert Mackey, but Sue Harris is with us and we've also had apologies from Tina Russell and Gary Woodman. Thank you. Thank you very much Kate, thank you. We move then to item two declarations of interest, do we have any declarations of interest? There have been on, thank you very much. Any public participation? No, good, well that's on, so moving to this at a pace. Item four, confirmation of the minutes. Have you all had chance to read the minutes and are you happy that there are a true record bearing in mind I was near last time of the meeting that took place on that date? Thank you. In that case I'll be to sign those, thank you. Thank you. Before we move on to the next item, I just want to thank the outgoing Chair of the Health and Wellbeing Board, Councillor Karen May, who was an excellent Chair, a strong advocate for public health and a strong voice for all the residents of Worcestershire. Thank you very much indeed for all the work she has done. I just want to say that some of the significant achievements during her tenure were the Stay Connected Pledge, launching of the joint local health and well-being strategy with its tenure priority around good mental health and well-being and the wider determinant of health work and I'll start again if you don't mind. You can see I'm a bit nervous today, so please bear with me colleagues. So thanks to the outgoing Chair, Karen, for launching the joint local health and well-being strategy with its tenure priority around good mental health and well-being and the wider determinants of health work alongside system partners to bring together the Integrated Care Partnership and its Assembly. So thank you very much indeed Karen. Great job. Also I want to welcome some new members, Robert Mackay, on behalf of the Health and Care NHS Trust, Gareth Morgan for West Mercier Police, Councillor Richard Morris, of course, and my colleague from Cabinet as the CMR for Adult Social Care, welcome. And a change for one is can I welcome Councillor Ellen around who is here for Worcester City. Thank you. OK, having done all that then now we move on to Agenda Item 5, the Public Health Review 2324 and the Board sponsor for that is Lisa Macklin. Thank you Lisa. Thank you Chair and take the opportunity also to put on record my thanks to Karen as her director, I really enjoyed working with her and I'm going to carry on working with her but I echo your thanks for her work as Chair of this Board. So I wasn't able to do this last time because we ran out of time didn't we? But not to be outdone and back and we've put this as a public health review. It's a look back over the last year but of course one thing I always tell people about public health is we don't do anything on our own. Literally nothing on our own. Everything is with partnership with NHS colleagues, voluntary sector colleagues and of course our residents and literally just come here from a meeting with some residents and it always reminds me how they're part of our public health team as well. So this is a bit of a look back. As you know it coincides with the publication of the Directors of Public Health Annual Report, copies of which are on sale there at the desk to the right, to the left of David. Also with leaflets about the with all fun run which is happening on the 23rd of June and as members of this Board obviously you're all entered for the 5K or 10K automatically so see you there but do pick up a leaflet for that as well. So public health review, firstly just want to talk a little bit about what sort of team we are. From the start I was asking my team that question from the moment I walked in. What type of public health team are you? And the answer came back a very resounding definition which I think we've gone on to further develop over the last 12 months and for me I couldn't have wished for a better attitude from a department full of public health professionals who just know what type of public health professional they all are and I can see some of them hiding at the back there. They're absolutely outstanding group of professionals to work with and we talk a lot about asset-based approaches and deficit-based approaches. And it's always interesting when you hear someone talk about asset-based approaches. It's sometimes seen as almost in conflict with a more traditional treatment type of approach. So just to define those two, deficit-based approaches which I think is quite a pejorative term actually but it really refers to professional services where you have a professional doing something for a person. The obvious example is a doctor treating a patient and but also traditionally public health has been run in that way. If you look back and actually if you go to some areas you'll still see a public health approach where tell you what we love to do, we love to get in front of our data and our bar charts. We find out what's wrong with which haven and then we go and fix it. We commission someone to come in and we fix the area and we cure them of all their ills and you can see the way that's still a legacy. We do need assessments where we identify this population of smoking too much or obesity is too high or and then we commission something to fix it. Now asset-based approaches. So in a sense those approaches start with what's wrong. They look for issues to solve and they solve them. Asset-based approaches start with what's strong. So rather than assessing what problems exist in which haven, they will go and find out what local people, the voluntary sector, residents trying to get started in which haven, what is it about which haven that's strong and can we help enhance that? Now I actually think there's a room for both approaches because sometimes when you hear this debate often people who favor an asset-based approach can actually be quite scathing of the more traditional treatment approach but actually I don't buy that because there's times in my life when I want a professional to use his or her expertise to give me a treatment, to help me reach a solution to that issue and our residents feel the same. So what we try to do in our public health work as much as possible is get the best out of both worlds. So if you ask us what type of team we are, that's us. We try to combine both approaches and you'll hopefully see this in the work that I described coming through and in particular some of the work that's coming forward as well. We will deliver professionally led services but in combination with asset-based approaches which allow our residents to be active partners in that and actually to define the solutions and to not just co-design but co-produce and co-deliver the solutions. Literally just come from a meeting, as I said, where I was asking a group of ladies from the W.I. in claims to help us design and deliver a particular program and they were well up for it and it will be better because of their involvement and their leadership. So just a review of some of the outcomes then, that's what type of team we are, what have we achieved, not just as a team but as all of you guys in relation to public health over the last 12 months or so. I'm going to rattle through and I could do a presentation on every single line in this presentation but obviously I won't because our new chair will turn my microphone off and I'll have to get going. So our health visiting service, that's you, that is. So the health and care trust and many others of course contribute to that. Our health visiting service currently scored well above the national averages on all performance metrics and I don't need to tell you guys how important for example doing new birth visits in a timely way is both for the health and development of the child and the family but also for safeguarding reasons as well. Our work with maternity services has significantly reduced the smoking and pregnancy rate. I can see my colleague Claire at the back there, has been glaring at me in case I show all of her slides that's coming up later in this presentation. I've taken them out, don't worry. Low birth weight rates have dropped to below national average and of course these things are linked. Smoking is one of the key drivers of low birth weight and unhealthy birth so those two are linked. Recently we've been working with NHS colleagues and vaccination UK on MMR pop-up clinics. Even though our MMR rates are traditionally very good in Worcestershire, we still had pockets of vulnerability, we literally got the map out and looked at where MMR was actually going off like, sorry, measles was going off like a bottle of pop particularly in Birmingham and the black country. We've got areas that absolutely border that area and natural neighbourhoods so we needed, we knew we needed to shore up vaccination rates to as high a percentage as possible in those areas as well as to one or two other areas where we knew rates were lower and we're measles free at the moment and have been for some time so and MMR rates are through the roof and I cannot wait to get the data for the next year's iteration because we're going to be very, very high indeed. I think we're already top but we're going to be even more top, if that makes sense. Just a case study about our work with young people. I've been talking about whichever, let's talk about Worcester, the city of Worcester, so in part we knew, a few years ago, not very long ago in fact, the level of physical activity among kids in the city of Worcester was significantly worse than the national average and that is something cities are prone to. You will often see that if you go to where I'm from in Liverpool and other areas, you still will see urban areas where physical activity among kids, it can be quite low. Obviously there's a correlation with socioeconomic deprivation there so a lot of work and this is a good example of where public health has just been one player in this. We worked with the city council to and a local running club, the black pair joggers, give them a shout out, we established a new junior park run at Diggless Fields and if you're in Diggless at 9 o'clock on a Sunday morning, you will see hordes of kids flying around. Some of them at really quite high speed, running the park run, it's really gone off so well and is getting big groups, not just of kids, but of parents as well. Junior park run is a good way to get kids running. Equally we've worked with our local schools, we established the health and wellbeing grants for schools and youth clubs and Sam drew me up a list of all the grants we've given. It's a spreadsheet in itself, but just in Worcester we've provided local schools and youth clubs are grants for kickboxing sessions, be careful. Next time you argue with a child in Worcester, bellboating projects, equipment for daily mile schemes, actually little digital watches that can help them track their mileage and their times and their points, new cross-fit rooms, weightlifting rooms, skateboarding, coaching and forest schools as well. So you can see there the asset-based approach in action. We didn't go to, I didn't know what bellboating was, I had to look it up, but that was actually the pupil referral unit that were really keen to take the kids bellboating. All of these ideas were ideas from the school themselves when we said to them, If you come up with a crazy idea to get kids active, we'll give you the money for it. And the variety of ideas has been enormous. And we are at the position now where Worcester City now has the most active kids in the region, and that's a district level. So that's out of dozens and dozens and dozens of districts around the West Midlands region, one of the highest in the country. Moving on to adults, again community development programs have led to Worcester having one of the lowest rates of loneliness in the country. And you mentioned chair the stay-connected pledge which kicked all that off. And again, you're going to have a presentation, don't worry Lucy, I've not got any of your slides either, on loneliness and isolation. If there's one key outcome alongside mental health for us, it's that, it's reducing social isolation. Any GP will tell you, any clinician will tell you how much of a driver of physical health issues, and of course demand on health services, social isolation is. So the more we can do about that the better. Our work with primary care colleagues and others have led to yet another this year, significant increase in bowel screening. I'll still remember one of my first interviews here on Harvard and Worcester was on the breakfast show talking about poo, which went down really well with the audience, but did the trick, and the work that's going into screening across secondary care, primary care, and the public health colleagues promoting it is extraordinary. And both of those achievements were featured on BBC TV and radio news. A case study again, strength and balance, resistance bands. The evidence around resistance bands is amazing. A piece of plastic, but the things these things can do in terms of increasing strength and conditioning is really quite well evidenced now in the literature. So we've been giving resistance bands an advice on how to use them across all of our libraries and other venues. I think the latest figure of resistance bands out there now through the Living Well for Longer Project is about 40,000. We also worked with University of Worcester to do a systematic evaluation of that work. And they did reveal significant improvements in key conditioning metrics and false related admissions in the county have fallen again this year, pardon the point of reduced this year, to where we're significantly below the national average right across the county. And again, I don't need to tell anyone in this room the importance of reducing falls, and how we have to, we can't wait for someone to fall if we're going to make an impact on falls. We need to engage in widespread primary prevention. And finally, one thing a lot of people don't know that we do in public health is we're also the leads for community safety and crime prevention. So I have Andy Booth reporting to me who leads a whole unit of people working on everything from both reducing neighbourhood crime right through to work, to projects that are mentioned there. So firstly, our local Prevent Program and a name check to the awesome Jim Bayless and his colleagues on the Prevent Program, we were the only area in the West Midlands to be rated as strong on all of those, all of those areas. Prevent, of course, prevents radicalisation and pathways into terrorism, incredibly important work that often goes unseen under the radar but keeps us all safe. And of course, we take a public health approach to that. A lot of the methods we use to encourage kids to become active are the same methods we use to help kids steer away from difficult influences, both on the web and also in their social groups. Our work on illicit vape sales, again, has been featured on breakfast television recently, along with our social norms, work in schools. We are trading standards team regularly join the police on busts to uncover vast amounts of illegal vapes as well as illegal tobacco, and we've just funded some extra work in collaboration with district councils to increase capacity within the legal teams to focus particularly on closing retailers down if they're doing this. So we're going to move past fines, we're going to move past temporary reprimands. If you are selling illegal tobacco and vapes in Worcestershire, we are going to close you down from now on because it's not good enough. Everyone knows the rules around this now and it's incredibly damaging to still be trying to profit from that. And we're working with our PCC Police Crime Commissioner on all of this, including a new project called Operation Freya, which is all about preventing serious violence and homicide. And it's been really interesting to work with the police and their evidence gurus. They have as much of a strong evidence approaches health. Not a lot of people know that, but the College of Police, I'm talking, I'll see someone over there. Steve, Councillor MACKAY, who knows this, the evidence based on policing is incredibly robust and it's been really interesting as a public health team to immerse ourselves in that and work with them. So, just to focus on substance misuse, I've told you this before, but we were on the naughty step 12 months ago with O-Hid. I had a particularly robust running with, when I first arrived, with some of the senior civil servants at DHSC about this, but I can say 12 months later, we've seen massive improvements in the numbers in treatment. In fact, we've already hit this year's targets for numbers in treatment, so everything now is soaring above that. One thing I think is particularly important is our improvements in continuity of care rates. When someone comes out of prison, we really, really need to engage them and work with prisons and all of our colleagues around the criminal justice system. And of course, the community safety partnerships in the district councils are absolutely crucial to this run by district councils, but partnerships of all of us. In fact, I think we've got one of our chair, Jen there, who runs the South Worcester CSP, absolutely important in this work. We've increased continuity of care rates significantly over the last year to one of the highest in the country. And so that led in a recent review when O-Hid came back at the behest of ministers to review how areas are using the extra money we got in substance misuse. Worcester has just been identified as one of the top performing five areas in the country, so we're going to have a visit from the Department of Health to come and see what Worcestershire are doing now to inform, work in other areas. So well done, all of you involved in that. We've won a few awards, and I won't go on about them, but we do love awards. And awards are not just for our ego, although they help, but they're also about building trust in our services. They're an objective measure for our residents to say, actually, that is a service, that is a program that we can trust. And so moving on the year ahead, we're going to continue to try and hit that combination. Yes, we're going to have professionally run services. We always will, but we'll always make sure we're at least equal parts asset-based approaches, finding out what's strong and working with that in our community. We'll continue to work towards this board's priorities with mental health as art. That should be overriding aim. Overrisings, not bad either, are overriding aim. And we'll continue to build with you on Worcestershire's already national reputation for preventative public health and upstream work. So a massive thank you to every single one of you who's been working with our team over the last 12 months, and who knows what we're going to be able to achieve going forward. And that's it, I think, Chair. Thank you, Lisa. Thank you very much. And thank you for that comprehensive review of 2324, and all the highlights in there. For ignoring us like me, what is bell-boating? Of all the questions. So I had a look at a photo. If anyone can help me out here, now is the time to raise your hand. They looked like a bit of a catamaran with thing in the middle on the rivers. I'll email you. But they're doing it, and they love it, and it's great, and it's physically active. But yeah, they look like little catamaran to me. But yeah. Well, thanks for that. And as I said, there's many highlights there, and lots of positive actions being taken by the team. So thank you, Lisa. So before we move on, questions from anybody? Councillor HARDIMAN. Thank you, Chairman. Yes, very interesting. So I do refer back on something you mentioned with the Police and Crime Commissioner involvement. Several years ago I was on the Police and Crime panel, and I remember we were concerned about reoffending, and there seemed to be a gap in what happens with the person who served their term, and they come out, and they're in the wilderness. Are you able to expand on what we're doing to alleviate that, please? Yes, Councillor, I think probably probation and other services would be better placed than me. But what we do know is probation have stepped up their work and are now part of the Crime Reduction Board and another of the agencies focused on exactly that. So there are a number of reoffender programs in place. The area I know most about is anyone who's been convicted of drug-related offences or alcohol-related offences, and as you've seen, we work very carefully with them, and actually move into a model where we might want to keep people, some people, in treatment for longer. Sometimes we move people out of programs too quickly, rather than holding them in that supportive environment. But I can get you some more... Why don't I take an action to get you some more data on reoffending levels in the county as a whole, and also a summary, which I can distribute to the board on the various youth programs and know about, and also the programs for adults. Sorry, sir. I can't see your name for it. Sorry, yeah. Chris Day. Apologies, Councillor Chris Day. Oh, all right, Chris, thank you. Yes, look, Lisa, thank you very much for really compelling presentation, and I think it would be great if we could share the slides. I'd be particularly keen to follow up on what Worcester City are doing in their schools and see if we can support the ones in which haven. I think that all sounded great. I guess I had a couple of thoughts. I mean, one was one of the things that you think we do need to work on going forward, that way, and you don't feel that Worcester City, for whatever reason, is still quite where it was. I thought I'd read in the past that we had a higher level of infant mortality than other areas compared with nationally, and it surprised me when I saw it, and when I looked at the smoking figures as well, we're doing better. I mean, the one that we're going to be presented to shortly, but we're still mid-table, really, I suppose. There are places that have got a lower percentage. I just wondered, what's your next target as it were? It's going well in lots of areas, but what do you think are the ones that we need to work on next? It's fundamental, I think. The latest report on infant mortality shows that it has improved, but it's nowhere near where it needs to be. In many cases, they are not so much health solutions, but social solutions. It won't surprise you to know that there's a real linear relationship between deprivation and infant mortality. Smoking is another one we hope that when, as we continue to work with and have more pregnant smokers quit in a timely way, we'll see a reduction there. I think there's probably more that NHS colleagues could talk about in terms of maternity services and NHS services, so that's the public health side, I think, working with almost deprived communities. For example, the Westlands Project, I think, and projects like that, place-based projects are going to be quite fundamental, where we do community development in the areas where we're seeing pockets of high rates of deprivation, but also, I think, individual behaviours like smoking cessation, children's social care, and I don't know whether NHS colleagues want to come in to some of the system-wide factors there. I wasn't going to comment on that one particularly, but I was going to go back to the falls you talked about as one of the opportunities. So, we were just talking about infant mortality, and I was saying, does any NHS colleagues want to comment on infant mortality? Well, I mean, I agree. It's come down. It was worse than national average. It's now the third lowest, in the latest data, of the third lowest in the West Midlands, lowered only by hair refrigerator and Dudley. Not surprised by hair refrigerator being lower, but probably a little bit surprised by Dudley being lower. So, more work to do on that, but very closely related to what we're going to talk about in the next meeting, which is maternal smoking. Very close correlation there. Okay, so I comment on the fourth one as well, because you mentioned falls coming down, we still do have a bit of a problem with hip fractures, so yes, fewer people are falling, but when they fall, more people than the average fracture in the hip, which obviously is quite a significant cause of mortality that we would want to address. So, more work to do in that particular area. And to add to what David said, what we're trying to produce now is, or to bolster, because it's already there, but to bolster is a really seamless pathway, so the people can get the right intervention at the right time. So, we'll look after the very preventative primary prevention side of falls, and I know NHS colleagues are already got strategies together looking at the slightly more treatment-y side of that as well, because as David said, when a fall is serious and somebody breaks the hip, the mortality rate is something like 30% within 12 months, and even if it doesn't lead to that, you're looking at a massive impact both on the individual, their family, and of course, health service demand. Thank you. Any more questions? Well, thank you. Thank you, Lisa, and thank you all those contributed. We can move on to the next agenda item, which is the end item six, which is a partnership approach to reducing smoking in pregnancy, and this is going to be presented by Claire Mitchell and Hailey Darnell. Thank you. Thank you for having us today. The work we're bringing to the board is, excuse me, the partnership approach that we've been taking over the last few years to reduce smoking in pregnancy. So, I'm Claire Mitchell. I'm a senior public health practitioner in the public health team, working in the Children and Young People's Portfolio. Hello, I'm Hailey Darnell. I'm the program director of the local maternity and neonatal system at Herrford Children's Studio ICB. So, we know there was a really clear need for action around smoking in pregnancy. It's been one of our top priorities for a few years. We know that smoking in pregnancy is the single biggest modifiable risk factor for poor birth outcomes. We've listed a few of them there, but we know that smoking in pregnancy is linked to poor outcomes for both the mother and the baby. And we know that if we can support women to reduce smoking in pregnancy and to quit smoking, it's the best thing they can do to provide a best start in life for the baby. We also know that we had quite a problem to solve in Worcestershire. I was just noticing that actually, yeah. This is the data from the public health outcomes framework. So, this is the percentage of women that were smoking at the point of delivery in Worcestershire. So, as you can see from the red line on the graph, we had an increasing trend between 2015 and 2019. So, we were higher than the regional and the national average, peaking at 13.1% of women smoking at point of delivery in 2019. So, we had an increasing trend and something that we really needed to focus on locally. Just to give a bit of context behind the services around about that time and the pathways, we did have a smoking and pregnancy service that we commissioned, but it sat quite separately to our maternity services, which is obviously where our referrals are coming from in pregnancy. The outcomes were poor with the service and we had kind of weaker referral pathways between maternity services and the service provision. We also had low confidence amongst midwives, have professionals to have conversations around pregnancy. It's quite a tricky topic and an awkward one to approach sometimes. So, we had issues around confidence to start the conversations and make those strong referrals. We needed to increase our calmer and upside screening at various points within the pregnancy and we also didn't have a postnatal smoking offer. So, when people were having their babies and giving birth, there wasn't an offer to support them to prevent that relapse, which is something we wanted to focus on. As well as the health impacts, we know that there's huge financial implication linked to smoking and pregnancy. If a woman is smoking during her pregnancy and prenatal care, it costs over three times more to deliver care to that mother. So, that's linked to the additional scans and complications that are linked with pregnancies and the care that are associated with those. So, as well as the health impacts, we know that there's huge financial impacts across the system as well. So, definitely a problem we wanted to solve in Worcestershire. So, we just wanted to give you a bit of a background about the local maternity neonatal system because this really has been a facilitator in some of the system working that's really helped to see some of the improvement in outcomes locally. So, the LMS, as it's known, you can see on that slide all of the partners that sit around the table and that includes public health from Worcestershire local authority, county council, and maternity neonatal voices partnerships as well who are there to represent the voices of our local families to make sure that they are influencing how our local care is provided. So, the vision of our system is to collaborate to provide consistent high quality and safe personalised care that's delivered equitably according to need. We'll just go on to the next slide, thank you. And this is our LMS strategy on a page which is co-produced with those partners sat around the table and it feeds into the local priorities across the system of the best start in life. And you can see there that one of our shared priorities is reducing health inequalities which is really where this work with reducing smoking and pregnancy stems from. We know particularly in Worcestershire we know we see a gradient with those who smoke, during pregnancy and smoke at time of delivery, those who are most deprived and more likely to continue smoking throughout pregnancy and therefore likely to experience the poorer outcomes that are associated with it. And we also know locally we have high rates of preterm birth and preterm birth is associated with smoking and pregnancy. So, as a system we're working together to drive this reduction in smoking and pregnancy and you can see at the bottom there we're trying to do that through effective communication, working collaboratively and reducing inequity across the system. So, all of the work that we have been doing over the last few years is based on local and national evidence. So, from the engagement that we do with our service users and professionals and the local service data that we look at to shape our services. Also national evidence-based tools are used when we're looking at self-assessing our system. I'll touch on that in a bit more on the next slide. Our pathways and our service offers and models are based on nice guidance and best practice and also we are also constantly reviewing the literature and evidence to ensure that our key focus areas are in line with best practice and evidence. So, for example postnatal relapse is a really key focus for us. We know that 85% of women that do quit smoking and pregnancy will relapse within the first eight weeks postbirth. So, we know that there's a real focus to support people to not relapse and go back to smoking and then going into next pregnancies as a smoker as well. So, all the hard work will be undone. So, we wanted to close that loop and also really focus on a whole family approach to smoking and pregnancy. We've got a real focus on partners and household members because we know the evidence is really strong and that if you are quitting smoking with a partner, 67% more people are likely to quit than doing it alone. Over the last few years when we have been kind of focusing on this area there's been lots of work because it's banned over quite a few years. So, I'm just going to pick up some of the key pieces of work we've been doing as a system and the main themes throughout all of the work we do is that we look at a whole system, a whole pathway and also do the work that we do in partnership with wider partners. A lot of areas and a lot of pieces of work that are often focused on would look at a need and a commission service. So, we didn't just want to look at smoking and pregnancy and think what is our commissioned offer doing. We wanted to take a whole system approach to look at what are we doing, kind of preconception, what are we doing throughout that whole journey of the maternity pathway, which is where all that really close working with the trust comes in around the maternity care, what are we doing with our international services, our postnatal offer but also the system wide deep dive that we did with that national tool helped us look at our community offer, how are we shaping other services to incorporate positive messages around pregnancy and what are we doing around messaging. So, much wider than just that commissioned offer. The deep dive that we did back in 2018 and then re-completed in 2021 really helped us look as a whole system where our gaps, where our strengths and how can we shape evidence-based actions to improve our local system. So, we developed a partnership action plan following that and multi-agency task group was formed in 2021 to have a look at how we can really drive the action plan forward. We also created a smoking and pregnancy specific dashboard which had over 30 indicators of various smoking related data across the system. Again, not just looking at our commissioned service data but looking at the data across the antenatal pathway, data within both our antenatal and postnatal service offers, how many people are smoking in the neonatal unit, how many people are smoking across the system at different points in their pregnancy. So, we can really have a view of that whole journey and how we can support people's journey through their antenatal and pregnancy offer, antenatal and postnatal smoking route. The CO screening audits were a really big part of the pathway that we were able to increase. So, the mothers that enter their antenatal journey have carbon monoxide screening at both at booking and at birth. So, it's a really key point to enter conversations and enter the referral pathways and open up those conversations about people that are smoking but if we're not able to do that CO screening then we're not able to identify smokers to open that door. I'll touch on the commissioning of the smoking office in the next slide but we have an integrated antenatal and postnatal smoking offer for those that are smoking. We also identified needs around professionals' confidence to have conversations so we developed and commissioned a challenging conversations training offer for midwives to help them have tricky conversations around issues such as smoking and pregnancy and maternal obesity to help those kind of journeys through their pregnancy. We have two public health midwives that we funded that have been really key to driving the operational and kind of functional actions within the pathways and within the antenatal provision. The picture in the top right are our two public health midwives that have been really key to the work and to have that strategic capacity within maternity to work on the ground with midwives has been really helpful with the work. All of the work we have been doing is driven by a whole partnership approach like we've said so all of it feeds into the LMS board and we're working really closely with our partners around the board to work as a system with all these actions and changes. I'll just touch briefly on the smoking offers that we have. We have a maternity based smoking service that we commissioned in 2019. This is one-to-one support embedded within our maternity team so from the engagement we did a few years ago we knew that midwives and we know from the evidence base that smoking care directly linking with midwives is the best approach to integrate the support and how far ongoing communication between the support service and the ongoing maternity care. So we have three smoking advisors across Worcestershire that are embedded within the district-based midwifery teams. They deliver face-to-face support in various settings and directly supply NRT to service users. We more recently commissioned a smoke-free home service which is looking at the postnatal support for anyone with a child under three in the household that are smoking. That is about to extend to anyone over 18 to align with the family and a 19 sorry to align with the family hub model. We also wanted to be able to put support in place for women that have quit smoking in pregnancy to support them to prevent relapse so rather than them looking to needing to look for support when they have already relapsed postnatal. The service will make contact with them before they've given birth to introduce themselves so they're really joining up that pathway at that key point that we know relapse is most likely to occur. We've worked really hard between the two services to also make sure there's a really integrated pathway in terms of the referrals so we don't have two separate service offers. They work really closely within the two organisations to join up that pathway of care for families. There have been various barriers over the years with the work that we've done. COVID has probably been the key one so we had a particular focus on smoking your pregnancy around 2018 and 19 where this work really started and we achieved a lot of things with pathways and with services that we've set up but then COVID completely derailed that the work that we've done to embed pathways and increased conversations was completely halted because the services couldn't deliver, the CO screening couldn't happen, the pathways were interrupted and we had to work really hard when we came back to really focus on this as a partnership in the last couple of years to bring all that back on track. We've also had various barriers linked to NRT supply, data collection and the consistency between Harry from Worcestershire across our LMS with our service offers and pathways. This is just to bring you back to the picture before the the focus work that we were doing in Worcestershire so as you can see there was the increasing trends with that red line and we were pleased to see that since 2019 we've been able to reverse that trend and over the last few years we've had a decreasing percentage year one year with our biggest decrease in the last year on the chart between 22 and 23. So we're now at 9% on the National Public Health Outcomes Framework data but we do know that unpublished data for 23, 24 we have seen a further decrease for the last 12 months as well so we're now under 9% for women that are smoking at the point of delivery in Worcestershire. Also within this time there's been a real focus on saving babies lives and the maternity work so the decrease I think is a really good combination of the service model, the enhanced partnership work that we've been doing, the system-wide approach but also the drive within the LMS and maternity systems regarding saving babies lives. Just wanted to touch on a few of the outcomes and outputs from the pathways that would have contributed to the population impact we've seen with the FOTH data. So our CO screening has increased at booking and also at 36 weeks in Worcestershire to 88% and 82% so we know that's quite a jump from our rates in 21 and also pre-COVID and our pregnancy service data we've seen increasing referrals over the last few years and our highest river had 838 referrals into our pregnancy service and our four week quit rates have really increased in the last 12 months as well nearing 50% and over the last few years we've never really been able to get over 40% it's really hard not to crack smoking and pregnancy so to see those rates come up has been really great. We know the impacts are long term for smoking and pregnancy the health benefits for a child that's born to a non-smoking mum we know are lifelong and the impact for the parents as well is lifelong if we can successfully support them to focus on reducing relapse. We know the population level impacts as we can see from the data has also been sustained over a number of years and we hope that will continue as well. I just wanted to bring in some service user voices into the presentation as well to really highlight the individual level impact this is having for families in Worcestershire. So these are two service users that were supported by our smoking advisor Heidi and Kitty Minster. I'll just read out a couple of the highlights from the feedback we've received. I was supposed to meet Heidi back in 2022 to start my stop smoking journey during my pregnancy but sadly lost my daughter due to medical complications we know this lady delivered extremely early. I felt pregnant again just after just three months after my loss Heidi was super supportive from the very start fast forward I've gone seven months smoke free I didn't think I would ever manage to give up smoking and the second lady has said I was very anxious about stopping smoking this made me feel like such a letdown. My midwife referred me to the service and this is when I was introduced to Heidi. She's been there any time I've needed her for advice and reassurance now my baby will have the best starts of being healthy the best chance of being healthy along with me too and I'm certain I will never touch a single cigarette again I can now proudly say I'm a non-smoker. So what's been really lovely to see with these two ladies that the service has been supported as well as the health outcomes that they've would obviously be gaining from quitting smoking obviously and also the healthy birth of their baby the the impact it's had on their well-being as well and their confidence because of the change they've been able to make in pregnancy and the confidence it's given them to go into motherhood has been really lovely to see. So where do we go from here? I think us as quite rightly already been pointing out there still is work to do. We are sort of middle of the table in terms of comparative areas for smoking in pregnancy at time and delivery although it is going down it's definitely going the right way. We will continue to work as a system because as you can see that graph clearly highlights that this works. In terms of the LMS and working with the choice and working with public health we are continuing to implement the saving babies lives care bundle which is a national care bundle that all maternity units are being asked to implement which is working towards the national ambition of half in the United deaths still birth, the United brain injury and maternal deaths and smoking in pregnancy is a big part of that care bundle. We have regular reviews with the trust to look at their implementation of that care bundle as a partnership approach and we'll continue to disseminate the learning and learn from others working as a system, having a heritage and relationship together gives us the opportunity to do that on a local scale and I think Claire and the team have been approached by various different areas to learn from themselves and have presented nationally as well so we really are commended for some of this work that's been going on and really it's just to say that it will continue to be a priority for our system and will continue to target our interventions to reduce those inequalities and that's all thank you to her if there's any questions. Thank you, thank you Claire, thank you Haley. Some significant achievements in a very difficult area, intervention in smoking is not easy and I speak as somebody that's packed up 20 years ago, have his smoke for the best part of 40 years previously so I know how difficult it is to and how resistant I was so congratulations on handling that, questions everybody. Yes, Jonathan. Thanks very much. Jonathan Wells, I'm a GPN Raditch and one of the clinical directors for the primary care networks. Great piece of work, thank you for the presentation, such an important subject. Well done for getting down to 9% it would be really useful to see the percentages in each of the areas, obviously I work in a deprived area such as Raditch, it would be very interesting to see what percentages you got down to there compared to some alike bombs go for Droitrich and can you confirm that the amount of resource that you are putting into the deprived areas is significantly higher than the amount of resource that you're putting into the easier areas to achieve the figures. And then second, I just want to obviously when the midwife first sees the pregnant lady they are already 7, 8, 9, 10 weeks pregnant what about preconception advice and ability for GPs to refer in at a much earlier stage for these sort of services. Thank you, that's a really valid question. We have unfortunately lost some of the visibility at a national level with the data in terms of that granularity but we do know that YFIRIS and Raditch are the areas where we've traditionally seen higher rates of smoking and pregnancy. In terms of the resource the offer is for everybody that smokes during pregnancy but the evidence base is around reducing barriers for all women who smoke in pregnancy because we know any barrier to access a service particularly for a pregnant woman is a barrier too far so that in itself address providing the service according to the evidence base will support that reduction in inequalities. And in terms of preconception, absolutely preconception is a priority for our elements. We're working together with stakeholders around the table to look at our preconception offer locally because I agree there is more that we can do and thinking about how we get women who are ready to think about having a baby into these services at an earlier point is really key for us and it's not just limited to smoking, it's about being in the best physical and mental state for pregnancy and what comes beyond really. Well please, I've got the data if you wanted by district, sorry I just got excited and started up. You carry on and I'll come in at the end Jonathan with the data. I was just going to add to that that as Haley said the services for anyone that is smoking in pregnancy so it's a universal offer and it's an opt-out pathway that anyone that is smoking at their booking appointment is referred into the service. But in terms of the inequalities that might be in the service access and uptake we did do an audit not too long ago looking at our access to to break it down into those that are referred which populations and communities and districts are most likely to access the service of those that access who are more likely to quit whether it's reaching a manual workers or office based or we're able to split it into occupation type, ethnicity, age. So it was really interesting to see some of the areas that might have differences in outcomes with the service and we've been looking at how we can try and target those areas that may not be accessing as much as others and how we can reduce some of those inequalities in access and outcomes but in terms of the access and referral into the service that would definitely be fairly all-pagnet manual. Castle Wild. Thank you Chair and thank you for your presentation. I'm a bit baffled by this because as a mum who had first child in the more 1980 it was no smoking then so we knew this so we've still got this problem so I find that quite concerning that we're still talking about this. So just to broaden it out a bit how are we actually working from maybe childhood to the non-smoking culture? I know the Prime Minister has got a goal but it's still a big problem and I'm very concerned to hear that because I actually thought this was all sorted out and you just didn't smoke when you were pregnant. So how are you working maybe at a younger age just to have that culture of not smoking? Thank you. I think it's definitely about taking a preventative approach so we know that definitely younger women are smoking a pregnancy so how can we prevent adults from taking up smoking in the first place and as you said children the childhood is a perfect place to start and we are looking at expanding our services soon to the smoke-free home service that previously supported parents of children aged 0-3 that will be expanding to parents of age 0-19 so we're hoping if we can reduce from parents smoking that have children in the household that will hopefully reduce kind of learned behaviours and children from taking up smoking initially and then hopefully years on that will reduce the numbers of people going into pregnancy as smokers as they grow older. We are also expanding our service offer to start to support it within the next month or two anyone over the age of 12 that is smoking will be offering one-to-one support. It's a service that we're starting soon and we're just in the process of looking exactly how that will look but hopefully from the summer onwards we'll be supporting any children over the age of 12 with one-to-one support to help them stop smoking. Council odd I think you raised something really crucial that is when you said like many people we thought we'd solve this and you won't see it and when was the last time you saw a woman obviously pregnant with a fag at the bus stop you won't see it but it's going on the stigma is enormous and also I know growing up in a very economically deprived area with often smoking rates are very high to start with so you're right if we stop people starting that's always the best way to address smoking but also there's cold there's other influences and voices on women so for example I've heard many pregnant women told actually the stress of quitting will be worse for your baby than than smoking itself and if you speak to anyone who runs stop smoking service or GPs they will have heard that many times so we should never underestimate a how much this is happening behind closed doors and also how there's other wisdom out there in people's ears and that's why specialist services like this that can work very gently and supportive way with no finger wagging it are really important so it's why we have a specialist service for this rather than just saying to pregnant women join any stop smoking group because they wouldn't join because they know about the stigma that's there thank you chairman again yeah very interesting progress thank you very good two things i think i've got in my mind one is secondary smoking how do you deal with that when you're saying to a lady who's pregnant your husband's a serious smoker what are you doing at home do ask that question and the other question that i've got is really how you or do you deal with i know you said you have a concern about when the mother returns home with her child and what's going on in the home there my question is is there any advice about postnatal prevention of i mean if that the lady has resorted back to smoking or her husband's smoking as well is there any advice given to make sure that they know their newborn child is going to be affected thank you thank you the um both of the smoking service offers that we have have a really strong focus on the whole household so it's not just the pregnant woman or the postnatal woman that would receive receive the support anyone living in that household whether it's a partner a friend a grandparent anyone that's around that pregnant woman will be able to access support one-to-one support and the free and arty as well so we're hoping we can kind of be as inclusive as possible with that service and we're also ensuring that all professionals that are coming into contact with pregnant women through the training that's received through the maternity systems to ensure that that conversation is had as well we're not just looking at the pregnant woman that's within that booking appointment but having the conversations around it is anyone in your household smoking so we can have we will also accept referrals for household members where the woman that woman herself isn't necessarily a smoker if she lives with a smoker then we can support that household member as well and in terms of postnatally so we that was the key reason why we wanted to commission the postnatal service because we know there's a huge rate nationally of relapse and we wanted to make sure that we were preventing the relapse as well not just having a service in place for when women relapse but we've got the communication between the postnatal advisors working really closely with the antenatal advisor so if there's a lady that's quit smoking the reddish maternity advisor is in contact with the postnatal advisor in reddish to say I've got a lady coming up to give them birth she's done really well with her smoking journey may have a bit of a wobble she's got a few concerns so the lady the postnatal service will make contact with that lady per shot before she's given birth so that link has been made they know who to call they've already had that conversation and started that relationship so if they're starting to have a bit of a wobble postnatally that relationship's built they're not having to start that conversation again with a new advisor and starting that support so we're really keen to look at that preference of approach around around relapse Thanks and yeah some really good good things to hear there just just some of the questions have triggered me just to think a little bit about how much of this is in isolation and is there any work or similar work proposed around alcohol use in pregnancy again another sometimes more socially acceptable but still sort of a real a real stigma and and my second point was around women who don't want to engage who say that they smoke but don't want to be referred are we sort of looking at it kind of more of a holistic either trauma-informed approach or or what are the other barriers that may be in the way that you don't want to actually stop smoking in terms of the the other work that might be going on in in other kind of areas of maternity this now feeds into why the best start-in-life partnership which is a new strategic group that was set up in the autumn last year which feeds into the children's young people strategic partnership and that's looking at kind of various priorities across health while being for an order five so antenatal and maternity care and preconception anything during the perinatal period is a really key focus there's a set task group that feeds into the partnership which just focus on perinatal health and well-being so smoking and pregnancy is one of those key focuses along with maternal obesity infant feeding there's separate pieces of work with similar themes of partnership work and kind of whole systems approach work with those work areas alcohol is one of the key themes within the work area that we're aware of we need to focus on slightly different approaches with that with pathways and services more work with things like the safeguarding midwives but there's it's definitely a key priority within that wider best start-in-life partnership and thanks Claire and just just to add to that we as part of the aluminous we have our perinatal health and lobbying group and that looks at care for families that have more complex issues because we know from our information from our data that where we see poor outcomes are in those those families that have lots of things going on that are so sure as well as well as clinical risk factors so that's something that we're doing we're mapping out all those pathways to understand that work more and there's nationally some work around alcohol and pregnancy that looks at alcohol consumption prior to pregnancy which is a more holistic view because obviously people do tend to see pregnancy as a way of changing their behaviour so yeah just want to have that in terms of women that may not want to engage in pregnancy obviously we do get that thought they are all referred as an opt-out pathway but there are women that don't engage as I'm sure you can imagine so I think that's why one it's a huge benefit that the smoking service is embedded within the maternity teams because previously when we had a standalone service separately the referral was made and that was the last the kind of communication was had the midwives didn't often know how that how that referral went and whether they were engaging but because the smoking devices are sitting in offices with the midwives they're able to say all this lady didn't turn up to the appointment have you got an appointment coming up that you can maybe nudge her or let me know how she's getting on and it's that ongoing communication with the embedded services that is really helping that disengagement Steve yeah thank you chair obviously from the from the data and the service users the the results are quite fantastic going down one of the issues that we've had of late and quite a few discussions about has been vaping and I see part of the preventative program is the provision of vapes so I'm just wondering how confident are we that we're not causing harm to an unborn child by giving or handing out the the vapes but I suppose really it is an ethical question about the about the issue about bringing down the overall problem thank you for your question so we know that if a woman stops smoking in pregnancy it is the best thing she can possibly do for her baby in terms of the long and short term outcomes for that child and herself and we also know that there's really strong evidence that vaping is a superior alternative and will provide better outcomes for that pregnancy than than smoking during that pregnancy so ultimately we need to be doing what is the right thing for our families and our our children locally and there's lots of strong evidence around vaping as an alternative to smoking in pregnancy to improve outcomes just to add also as you mentioned we've got vapes as part of our service offer and that came in just under 12 months ago and we've been really surprised how it's impacted the outcome so our service referrals have really shot up since july when the vapes came in and also the outcomes it jumped up nearly 10% in referral in quit rates at four weeks and we knew from the evidence that there was a strong evidence in terms of the outcomes and we were hoping they would be an increase but we've been really surprised in terms of how many people have come into the service more than before and also quit I think going back to what Lisa said that it's really key to have that specialist support in pregnancy we had people that were wanting to give up smoking because they wanted to choose to use vapes and if we previously weren't offering that then they did it alone and didn't access the service but now we are offering vapes as an option we are finding that women that would have previously quit by themselves without service support how that gold standard evidence base and one-to-one support so it's opened a few more doors to people that may not previously access the service so we've been really impressed with the difference that vapes have made and it's been done in a supportive safe environment as well it might just be worth us clarifying our position on vapes because Council Mackay's question is incredibly important it's something we think about a lot it's something we've considered in depth not just in smoking in pregnancy but in our smoking cessation work in total so the NHS position at the moment and the advice we get is that vaping should be on offer in smoking and pregnancy services we take the view on vaping that as my colleagues have said it's much much safer than smoking but we we don't see it as we see it in the same way as on any other nicotine replacement so we don't encourage women or any smoker to come off vaping as well we always advise and support people the vaping is to help you through that initial period of not smoking it's not something for life and so on that view I think the the cost benefit ratio in terms of the risk it is a no-brainer if it means someone's going to stop smoking combustible tobacco but we never present vaping as a completely risk-free option and we advise people to also not see that as a long-term option as well and we're always checking the evidence and always updating our position on that so I think it's an important question we always need to revisit yes it's nice a day thank you I just wanted to ask one question if you had from your perspective a limitless budget and you could spend whatever you wanted and I know that's not something that's going to happen but if you could what would you do and what difference do you think it could make I mean in other words what's the untapped potential out there that's not happening because you've got some constraints and then the broader thing I suppose that prompted me to ask it was I guess I can't be the only person who was shocked I supposed to read the all parliamentary report on natal services apparently traumatic births are costing the country billions is what it says you know we've got we spend across the whole of the country the entire budget for maternity and neonatal services is only 3 billion and we're spending 1.1 billion on clinical negligence claims so it was in reflecting on on those two things no I'd be interested to know whether we are going to look at that report within Worcestershire obviously to reflect on how you know we are responding to those findings but in the light of that and that I suppose wasted money potentially that's having to go on on negligence you know how does that compare with your own budget and and what you could spend on on avoidance thank you cancer day I'll take your last question first if that's okay and yeah so it it was in the the birth trauma report that was released last week lots of the themes that were in there I think we have seen before in maternity we know that we need to provide well staff services and personalized care and to be essentially putting women and families and birthing people at the heart of our care to inform that care to make sure that we are making the right decisions and that decisions are being taken together with with women not not for women so I'm really pleased to say that locally across Hurfordshire and Worcestershire we have our maternal mental health service which is Beacon and it's provided by the Health and Care Trust and it's a service which is for women who've experienced previous birth trauma and also women who have severe fear of childbirth at jusochophobia and this is a service that uses psychological intervention to support those women throughout their pregnancy and beyond make sure that they're limiting the impact of that trauma because it does obviously as in the report have a really severe impact on their life going forward so and yeah so I'm happy to report that that's where we are with that in Worcestershire but obviously we will be doing a response as a system to some of the recommendations in the report and in terms of the limitless money I'll let care onto that one. So we have been able to kind of enhance the reach of our maternity service recently thankfully due to some national funding so in terms of our smoking advisors we were able to kind of meet the need but the expansion that we'll be looking at doing in the next few months we'll be able to hopefully expand the service to align more with clinics align more with clinics with women that we know at high risk of smoking or that are smoking and being able to really target people and be on the ground where they're receiving their maternity care and more visible to be able to encourage people into the service that might not be accessing. In terms of the maternity service other than expanding the capacity slightly there wouldn't be a huge amount we'd probably want to do with limitless money because there's only so many women that come through the maternity pathway are smoking and we feel that with the recent expansion we've probably managed it and hopefully we'll be meeting that that need comfortably. The post-natal smoking service is probably well we've got more reach to expand and kind of access families in different ways which will need more capacity but being able to target areas we're hoping that the advisors will continue to be visible and they will be visible in family hubs but if we had more capacity we could maybe have some advisors in if we had a limited as money. Smoking advisors in every family hub smoking advisors linked with kind of health instinct clinics and being kind of more visible locally but we do hope that the capacity that we're looking to start within our post-natal service and expand with the National Fundy will be able to meet that need. It'll be interesting to see how that services kind of access and take a note because it's not an area that we've particularly focused on in this way and was to show in terms of family so we really hope that we will be able to engage with as many families as possible but I think there'll be a lot of work to do with local services then social workers and libraries and kind of clinical care that's supporting families and children to be able to raise the awareness of that service so if they're coming across families we know that the asthma clinics for example are kind of keen to look at children that attend netlinics and having that as a pathway into supporting a route for their parents to hopefully reduce the impact of the child's condition so being able to network out into all those referral pathways would obviously need capacity so if we had that endless pot that's probably where we'd really look at spreading that and focus on that access. Thank you very much Claire and Haley for a comprehensive and interesting important thank you for answering all those quite difficult questions thank you very much. Thank you. Colleagues next thing we're going to now is agenda item seven which is tackling loneliness and isolation in Worcestershire, the draft action plan and that's going to be presented by Lucy Chek. Thank you Lucy. Afternoon everybody it's a pleasure to be here to introduce this item. My name is Tanya Richardson I'm a public health consultant at the County Council and I'm also the clinical lead for social change at the ICB. I'll get Lucy and Lucy to introduce themselves and then do an intro. Good afternoon everyone I'm Lucy Chek. I'm one of the senior public health practitioners at the County Council and I'm Lucy Bird and I'm a community builder based in Troybridge. So this item is a key part of our strategy I've taken the opportunity to bring my copy here to wave it today to remind you I'm still so proud of this this is a fantastic strategy for this board to be pushing forward and as Lisa said earlier that focus on good mental health and well-being that key priority for us across Worcestershire. So this plan that we're bringing to you today we're asking you as a board to review and comment on the plan but critically to support to continue to tackle it. This plan has been developed through the tackling loneliness and isolation partnership which Lucy chairs and it's the strength of the partnership working in that group is fantastic. Every organisation on this board is represented there and I think it's such a celebration of the work that goes on the strength of the partnership working in Worcestershire. The strength of the people in Worcestershire again as Lisa alluded to earlier the assets that the people of Worcestershire and the communities in Worcestershire present in this area and the place of Worcestershire. So there's a lot to celebrate here about the work that that's been going on and we hope we can bring it to life to you also by we're so delighted Lucy's come today to talk about her volunteering work as well. We've got a little video to show you at the end of that but I hand over to Lucy first to talk us through the plan. Thank you. Thank you Tanya and thank you for having us today to talk to you about this it's such an important issue. As you can see from the papers that we've presented to you today we know that sometimes we only can be a normal part of life but often it can be severe and can last quite a long time and can have a significant health impact on those that it affects and actually the stigma of loneliness can make people feel worried about being judged and will coming forward or feeling like a burden for people that are around them. Evidence shows us that loneliness leads to greater pressure on public services to increase visits, longer hospital stays and increased likelihood of entering residential care and both loneliness and that social isolation are serious health concerns and not addressing these issues could lead to poor several poor health outcomes. As Dr Richard as Tanya said tackling loneliness is one of those key ambitions of our 10 year strategy and this is a bit of an action plan for us so this focuses our work on to loneliness and isolation but it certainly forms part of our wider plan and as Tanya said we've developed this with the loneliness partnership which has got lots of different organisations that support us in doing that whether it's our voluntary and community sector representatives whether it's colleagues from the NHS and the ICB but also our districts and our district collaboratives as we know several collaboratives have identified loneliness as an issue in their local populations as well and certainly we're working with them and alongside them to look at ways to address tackling loneliness as part of this. So the action plan focuses on three different kind of key areas for us to look at one of those is working in partnership one of those is looking at connecting people and one of those is working with our communities and we know that connection is really what we're talking about here and we saw this in the community stories event for those of you that were able to join us last week and several of those videos that talked about some of those activities that are happening in communities all focused on connections and I was like and people talking to us how they've been able to meet new people get involved in new things whether they've been bereaved which is what Lucy's going to talk to us about today whether they are live alone and may feel isolated or whether they live in a family but feel lonely as part of their every day. So we've looked at a number of different ways and this has all been based on several pieces of evidence and looking at national strategies that enabled us to use this focus and we know that loneliness is really an individual experience but we know by coming together and making those connections that can help people feel like part of a community. So we've seen that loneliness numbers in Worcestershire tend to show that we're quite low in one of the best areas but that doesn't mean that that's really a true and accurate representation of what we know a lot of people may not identify their own loneliness or may not admit to their own loneliness as such and it can often go unreported so we know that we are not resting on those figures and we want to continue to pursue and look at those opportunities to do more. So we've had a number of different things happening across Worcestershire already and to date because we've had loneliness action plans previously this is an update for us and that puts it as part of our wider 10 year strategy. As has already mentioned today we have our stay connected pledge which is working with organisations to ensure that they are open and accessible to people who may feel lonely and may want to come in and use those those facilities or engage with those organisations. We've had our strength basis approaches and work that we've been doing and that's continuing in our healthy Worcestershire programme that will also focus and work with those communities. We have our orange button community scheme that also looks at those that may be having real strength of loneliness I've got mine on as well. Real feelings of loneliness that may be leading to more suicide ideation and activity that we obviously look to aim to prevent as much as possible. We've also got our work well live better workplace health programme because again number of people colleagues that we may work with may speak to us every day on teens but may not have anyone to speak to outside of working time and actually it's really important to create opportunities for all of our staff and our colleagues to make connections that are not just in teens meetings or on calls. And one of those key areas that we've really got Lucy and I want to help us talk about today is our new our new stay connected community grant programme. So we've had a grant programme that we launched at the end of last year and it's the first time we've done something this and we thought we'll give it a go and it's been fantastic and we've had a real great number of organisations that have applied to these grants. So they are for community based organisations across Worcestershire to apply for funding of a minimum of £250 up to £2,500 and the reason it's a minimum of £250 is because we also have a micro grants programme that we've had in place which is up to £250 so that can be for any activities to help facilitate an opportunity. So I know that we've worked with a small couple of men's groups have bought some gains and puzzles to use when they're bringing men into the organisation so they can get chatting and get doing something. But these grants are slightly larger and it's looking to create or to expand projects that specifically look at loneliness and isolation and we've received such a wide range from all over the county and one of those projects is Lucy's project. And this ranges from nature based, physical activity based, cafes, support groups, art projects, so many different things and I'm pleased to say that this work is going to continue into this financial year. And I'm looking at Chris because Chris is a fantastic member of our panel so we have a small panel that helps us sign off these grants and Chris has really been fantastically supporting us in doing that as a member of the voluntary sector VCSE but also obviously as a board member but we have representatives from the ICB, WCC on that panel that helps us sign those off and we've got a couple of examples in the paper that I've shamed to you today but what I will do is just get Lucy to briefly introduce her project and one of those projects that has been fantastically supporting as well as her role as a community builder locally and we will show you if I can get it to work a small video that will be shared at later days so the link won't have been sent round so for those that haven't seen that we will be sharing it later but this was part of our community stories project that again as I referenced we've had an event about that last week for those that are watching online which I try to forget about when you're presenting but for those that are watching online and I've got to put the microphone to the laptop and hopefully you'll be able to hear it if you can't hear it we will send it outside of the meeting so I do apologise in advance if that's the case but Lucy do you want to just introduce a little bit about your project? Okay so I'm a community builder and I'm based at the local CVS in Droitwich and the idea of my role is that I'm based completely embedded within the community so I can talk to people that's when I got the job they said I said what do you want me to do with it just talk to people listen to people and then help them and enable people to do things for themselves so going around Droitwich initially to meet people get going to groups one of the biggest factors that I was coming across was bereavement but because my role isn't to set things up for people I kind of needed a linchpin to get that going and again part of those conversations during some of the work I was doing with Ukrainians was to meet a wonderful wonderful volunteer in the community called Geena who you will meet on the film shortly she is a volunteer and president of the local Saint Vincent de Paul society which is a Catholic charity who support anyone in the community doing some fantastic one-to-one work with people and she'd come across the same thing bereavement being a huge issue within the community and access to support right in the community we all know there's some fantastic organisations such as Saint Richard's Hospice who deliver counselling but their waiting list is pretty long and when we approached them about this project they were really keen to support it which was fantastic so I'll initially let you watch the film and then I'll just tell you a little bit about the practicalities of how my role helped get it going so hang on excuse me a moment the bereavement project started because we had bereaved people asking us what we could do to help them they were struggling so we started the bereavement cafe and from there we've started the bereavement journey with Android which there seems to be very little support for bereaved people the bereavement cafe is a safe place where people can come once a month and sit and talk with other people who are bereaved there's no pressure they can just come and sit and have a cup of tea if that's all they want to do but they are finding it useful just to be able to talk to other people who are all so bereaved so I work for joint which obviously and the rural's well-being team and my role in the community is a social prescriber I knew that SVP did a lot for the community and I heard that they were looking at running the bereavement journey so from there I started to have conversations and pretty much approached them to see how I could help so for the bereavement cafe the aim was for people who have all of a sudden found themselves in a situation where a key person in their life is now no longer here it's a safe space for them to go meet others who may be going through similar and what we do know with grief is that people can actually hide away and that's where that can tip the balance of it being grief into mental health I think I found that I got as much from it as I've given to it the people we met on the journey came on the first week looking very anxious but by the seventh week of the journey the ten folk had really got to know one another they bonded well and they went out with smiles on their faces if people are not going out or suffering with stress it puts extra stress on local GPs and on other services in the town and therefore I think it's quite vital so I think it's been a beautiful example of how well the community can work together there is a lot of stigma in the news that services are overstretched but what's not overstretched is people's willing to give I just think to see the difference to individuals and knowing that they may have just that little bit better of a day because of what the community is able to give them that's enough for me. So my role in this was to work with Geena because she'd done the research she knew exactly what she wanted to do she had in her head she wanted to deliver a cafe and then a more I suppose supportive setting where it's a seven week program that people work through different stages of their grief and she just did not have the confidence or some of those connections that I had to get it going so we set up a program where we recruited volunteers which was fun we had a fantastic response it's one of those things where you give people a menu of where is your skill what can you offer and whether it's making a cup of tea or whether it's actually delivering this the supports program itself it's a very different role volunteering role but those people came forward and Vicky who you saw spoke on there the local PCN wanted to support this project because again social prescribers GPs were coming across lots of bereaved people and so Vicky was given volunteer hours to support this project which was wonderful we looked for local funding to support the project so that was the local town council have given some money the local rotary club lots of smaller organizations like the local funeral home they gave us that it's still a year a year later they're still giving us teas and coffees and buying all the refreshments paying for flowers for each of the sessions so it's those small things but contributing to one fantastic project and the volunteers are now it's self-sustaining with those volunteers they created their own WhatsApp group they're running it for themselves it's fantastic and the people that are coming through the program now we're on our third program and I felt so passionate that I'm now volunteering for the project so we're delivering the the bereavement the third bereavement journey at the moment and I can't even tell you the impact it's having on those individuals I sat next to a man and on the first week he had been married for 63 years and he said to me I lost my mom I lost my dad I've lost a sibling and he said and I I worked through that and I was okay but this time losing my wife the loneliness is killing me and it's taken in 15 months to step forward and take up this program and after the first week his words were I can't put my finger on it but I went home last week feeling better and he said because you've provided a space for me to talk to other people who understand what I'm going through and so this project has been so wonderful seeing that impact on individuals supporting each other and that's what we've said to them this program isn't going to make you better you are going to have to do this work and they are all doing that grief work for themselves it's just so rewarding to see them doing it and because of its success we're now working on moving it to Evesham and developing it so wonderful Geener and I put together a how to guide how to set one up in your area and thanks to the as Lucy mentioned the new stay connected community grant they've received some money to get that set up in Evesham and they've already got a team of volunteers that have stepped forward to deliver it somebody's coming to see how we've run run the breathing journey next week and so hopefully that will be up and running soon so this is a project where those assets the people in a community are supporting one another to feel better feel less isolated and move on with the sport of each other and at the end of the program we've got lots of sign posting lots of groups to say droid which is full of amazing groups lots of different organizations and being able to sign post them onto that so that they can keep seeing other people keep connected and it's just yeah it's it's been an amazing project to be part of thank you Lucy and thank you for joining us today because I think it really brings to life what we're talking about and what we're focusing on and I think alongside this work where we can really see how putting some of that funding out into our community spaces can have such a ripple effect into into so many other spaces and bring so many people together alongside that really what our plan does is help us also focus on those that are least likely to come forward that perhaps suffering with more inequality where we can particularly put our focus as our such a strategic system as all of our partners sort of working together and we've got a number of different ways that we look to do that within that plan and we'll be looking to take that plan forward after being here with you today one of those things is how we can use sort of how we can measure our loneliness better how we can understand what that picture is and working with our primary care colleagues also promoting the use of things like the ask-off measure the adult social care outcomes framework measure to record loneliness as the shorthand tool or the UCLA loneliness measure score and having a number of different conversations about how we make that happen with our adult social care colleagues and linking to the prevention strategy from the adult social care colleagues as well but we also need to make use of some of our spaces our libraries our digital champions our libraries unlock projects our spaces that people are going to use because we need awareness of projects like Lucy's and activities like Lucy's and using things like the community services directory to help us help us get there so what our plan aims to do is really put that structure around what we're doing but we have some absolutely brilliant partners through the loneliness partnership that are helping us deliver that and we encourage anybody who's not part of that who wants to be part of that to please come and be part of those discussions and so we can find continue to find ways to take this forward so I'd welcome and invite any additional questions that anybody may have and hope that we have shared with you how we will take this plan forward and how we can put this into action and when this is signed off I can thank you Lucy and thank you Lucy thank you Sony I can see there are some hands already up but before I do if I may with your indulgence just have a comment myself the first event I attended as the portfolio holder for for this was the community stories event at the cricket ground last week loneliness is is no one wants to admit to being lonely there's a stigma attached to it somehow it's my fault that I'm lonely I must be doing something wrong and the effect it has both on physical and mental well-being is significant so I was delighted to see the numerous stories that I saw last week of various community groups where one person who who just had the courage to take the first step and they've been helped with the grants and the support from our team to develop a community group and the golden thread that ran through all the stories was I've joined up I wasn't quite sure what it was all about but now I feel so much better I feel myself confidence returned my mental health is getting better so it was a fantastic event thank you very much and this is a really great program now the first question is from Chris and then from council about thank you um a cheat it's not a question but you can understand I love this program so much I couldn't not say something um I'm very lucky I run the citizens of iSpura and Brahms go from ready I love my job I love what I get to do but we're deeply frustrated often by the limits on on what we can do but even in my diary which I generally enjoy when I know I've got these meetings coming up it's one of those high points you look forward to and it's just because of the way the group works you know yes I I run a moderate to reasonably sized charity but I have a deep deep passion and so does everybody else on the panel indeed everybody I've met in public health for the other side of the voluntary sector and we need both we need the big players but we need those small bodies those small organizations and every time we meet we go through it's not a harsh yes or no I feel particularly sorry for Jess here actually because every meeting we very rarely say no we'll send it back with a or Jess could you ask them if they could do that or can we refer them to another grant or something like that so it's a really constructive process it's not even just a fill in a form and you're going to get a yes are you going to get a no but yeah I mean we get to see some of the amazing stuff just the tip of the iceberg and I really would if you know anyone who's doing something and they're at that cusp where a little bit of money might just move them to that next level please encourage them to apply it's a very friendly process and we love it we leave the meetings grinning like Cheshire cats it's just wonderful wonderful project you part of thank you chair and thank you for your presentation um I was moved to tears um I always am at these meetings I think you're all you're all getting to know this um I've been lonely and it's it was when I was a carer and I've still a carer but it's not as intense um and I think I went to my doctor many times as a result of what was happening to me but I wasn't the patient so all the focus should go on the patient but the carer was kind of screaming inside and um I think I I was um had heart trouble had dizziness I had all sorts of things so I was costing the NHS a huge amount and the one thing I felt was trapped in that situation because you don't want to leave the person that you're caring for um I have a question but I wanted you to know that I know about this feeling and I'm very concerned about the people that we can't reach the people who don't want to admit it I don't think I ever admitted it because I didn't know what was actually happening to me and in a rural district's ward that I represent I I know that there are people behind doors so it's going to be very hard to reach them um but my question is and I think there are some members here that have heard me ask this before I'm very concerned because I think sometimes when you felt like I did you're actually going to be approaching your GP and presenting with various things and they're standard it's not that long ago I've been experiencing this and they're standard responses to antidepressants and then you sent away and what concerns me now which has been concerning me about GP access is that it's really difficult to get a doctor's appointment now and but before at least you could phone the doctor and get an appointment and then go and see the doctor and the doctor possibly would spot something else while you were there well nowadays a lot of people will phone up and so perhaps it does either be given something for her to go or something like that and being a bit simplistic here but um you've not seen the doctor you've just spoke to the doctor and what's worrying me with this patient access that has changed so significantly since covid is that people aren't seeing someone where they're most likely to tell this story or be spotted on their way out and you know is there anything else and then you might break down in tears you know because there is something else and so that's what I'm worried about here of how to the people that we're not finding and whether we can improve our patient access thank you thank you for your question and thank you for sharing your story with us as well um and I think it's a really important issue that you raised and I think it is worth just me noting as well that carers is one of those groups in particular that we are we are um absolutely wanting to target and wanting to focus on as part of our work and it's one of the groups that we've identified as part of the strategy or action plan um but it's certainly something that we need to come at this from a number of different angles there's sort of no one way of tackling loneliness and isolation and such and you're right a lot of people may go to their GP and and what we have now is social prescribers and other additional roles in the GP practices that can look and work with people on perhaps more socially determinant aspects of their health that they can look to identify and send off to different solutions because we've worked with a lot of our social prescribers and again Lucy and I've worked together so long that I've actually was part of the project when Lucy was hired as a social prescriber um quite a few years ago now um but we worked really closely with those roles and other community roles because we know so many of our organizations as Chris talked about earlier some of our larger organizations have lots of people working out in those communities so we've got to help them identify but what we've also got to do through projects um like Lucy's and like the other ones that we funded is to get him before they even re before they even ring the GP before they even recognize their own loneliness and try to alleviate that as early as possible by working through village halls and parish councils and we've got some town and parish council's projects that we're doing as part of wider WCC work so how do we go in at these multiple different spaces and really what the plan is trying to do is say we as a system need to work together and look for those opportunities and how we can break those down but we've also got to recognize that there's such strength in our communities being able to do that for themselves but absolutely there will always be additional people that we can work with and it's it's an intention of this to continue to strive to reach those that are probably least likely to access or those suffering certainly with the most sort of levels of depurational or inequality that mean we need to go and support them with additional additional work. So thank you and I was just reflecting what a really powerful account you've given us about the importance of having our 10 year strategy of mental health and well-being so as reflecting when I started in my career we never talked about mental health and over the last five years we're talking about it pretty much all of the time but what we've heard today is all of the reasons we need to have different conversations and not medicalize it we talked about grief, housing, work and I think that's the important that we need to hold as a board I just wanted to reflect that back because we did say at the time wanted to do 10 years wanted to do it in this space and I just think even now where we know the demand for mental health is coming through we can do different things we can put community solutions inside to hear that really playing out in practice was really helpful I think we need to keep that in our minds of how do we really scale that up and do more. Thanks so if I can just come back in because absolutely there will also be life events and triggers that we need to be conscious about we've just heard a presentation on giving birth and having a child that's a hugely disrupting time of life and actually so what we've been able to look at as part of the funding is that we've supported a dad's grief actually to bring some dads together to talk about having a child and how that might have affected them but we've also got programs around women who've just given birth and perhaps at home and not used to being at home all the time or not used to kind of being in different conversations but we'll certainly see that it will go up and down throughout life and sometimes you can manage it and sometimes you can't so if we can have those number of different solutions at different levels this is an all-age piece of work as well so we're certainly looking at this throughout the life course we can't always assume that loneliness is is older people and I think sometimes we do when actually it can be through all those ages and certainly we're working really closely with my colleague Claire and others about how we can support women and families from young ages and I think we've certainly seen that in some of the work that we've done but also particular groups whether it be people that are caring or those that have children with a disability and bringing those groups together as well. Was it were you Steve? Do you want to get Steve and then let's cancel on this. Thank you Chair. Lucy you just touched on this thank you very much indeed the fact that since we are asked to comment on the plan I think it's important to raise the issue that this doesn't just concern the elderly while the elderly are particularly vulnerable group this can be at any age and as you pointed out in the in the video bereavement can affect anybody at any age but I would just like to bring a mention to one particular group which is young people who are in or have been in care and transitioning so you're talking about sort of 16 to 18 year olds who may be why they will have a PA themselves the the group can find themselves in yeah particular loneliness moving to a bed set flat whatever at that given time in their lives and it's the time of life where they can make the wrong friends and make them particularly vulnerable to criminal activity in such like purely through being lonely they're introduced to the wrong people and that sort of touches also on a group of people that Councillor Harriman mentioned a little while ago those coming out of prison all of a sudden lonely making the wrong friendships it's just a point that I'd like to make in relation to all age thank you I think you've got your thank you very much for highlighting those and absolutely it's something that we would like to why we've sort of got a long list of groups that we'd like to work with and people in in those sort of transition periods of life as we've sort of identified this is one of the pages from the strategy those life events and triggers become really important and I think it's worth reflecting as well certainly in my wider role I look after work around suicide prevention and mental health as well and it's certainly something we're concerned about from loneliness as suicide prevention conversation so absolutely we will work alongside our probation colleagues and our other fantastic colleagues in public health who work around the prevent area of work and I think we've got some work in how we deliver healthy Worcestershire the career program that we've got coming and the use of grants to help develop that too so yes we've got the stay connected ones but if there's some wider pieces of work for us to do that absolutely we're open to doing those and I think that's an absolute fair reflection on make sure that's reflected a bit more strongly in the strategy moving forward thank you good to see everybody thank you very much for a powerful presentation I want to pay respects to Lucy actually in the work that she does in Droitwich which I think is superb and it really goes back to the I guess the establishment of the community builders and that role and how it can liberate and support the community and we've got somebody who carries that out to an excellent standard I also support the action plan I read through it and I think I'd like to share what I wrote at the end of it because there are some points whilst it is excellent that I do have some concerns with and that echoes councilor wild and it's the hard to reach people again with the Westlands project I see that sometimes we touch the same people over and over and yet we know there's people out there that we just don't get to that we cannot reach and that's the the pride sometimes that they have and they don't want to access services so you know if we would call them they wouldn't answer the calls because they'd be worried about scams we live in an age where people take advantage and and they would worry about that so how do we get to those core people that really need that help that we know are probably suffering in some ways because they won't make that handout to get support we know that transports an issue potentially as well perhaps mainly for the rural areas I would imagine but it is within the towns as well and how can we overcome that that difficulty of getting through to those doors that we can't open thank you I think that's probably some of the most difficult aspects of this work that we're trying to certainly and break down those barriers and look at those opportunities and thank you for talking about the western's project as well because I think that is a really great example of how we've gone in and worked with the community again in a quite a different way than we have done previously I think we have been able to engage people through those routes who may have not come to a service somewhere else and actually by putting those solutions in that community level then it's more likely that people will interact and will come forward and will sort of reach out into those spaces but it's meeting people like Lucy and the people that Lucy works with that we find those connections so we start to understand well actually that's so-and-so that lives down the road who very rarely comes out we don't really see her too much and that's actually a bit of knocking on the door a bit of talking we can try to engage within different within different opportunities really can't we and actually that we are just about to do that so in Westlands particularly we're focusing on some of the older people we know are not coming out so I'm working with platform housing and potentially doing a little bit of door knocking to try and see if we can we're basically going to sit in front of people's houses with scones try and draw them out but it is really important the work I do that we work with people like social prescribes that's why we have our droid which network meeting to enable us to find those people because there might be one conversation that somebody has that can then you know it can then roll out and we can support them by just a small connection and it's getting that one person so that's why the network with in droid which and other areas have their own networks is really valuable and the loneliness partnership again it's just those people that are embedded with it roles like social prescribers they're really important because as a social prescriber in a previous role I can't you're the first person that said right I've got you've got an hour tell me everything and they do and then you realize they don't know how to connect with other things so it's it's going and telling them how they connect with other things so those roles are really really important for people like me but we are going to try some door knocking and see how that goes but it is we're trying things for different there's no age like you say for the bereavement there's no age limit on any of these things that we're offering that's why we're trying with the next bereavement journey we're actually running in Westlands itself to so it's on their doorstep as you say transport is an issue I work in lots of rural communities Hampton love it for example is a very small community and we've set up two groups in the last six months so it is about getting out there and that's the importance of roles like mine that I can do that yeah I was really struck in that video I wrote down I can't remember he said it whether it was a social subscriber but she said what's not overstretched is people's ability to give and I'm really struck that each of us in the room here we are members of communities we are members of communities of place of communities of interest of communities of practice where members of professional communities were members of organizations but within those communities we know people who are lonely or isolated we may have been ourselves we know and we have family members who struggle we can we can also be that link we can also reach out and I think the power of bringing this here today to help more being board and the organizations represented here is that request to you as well as board members to take this back to whatever organizations to meetings to make sure that we're making all the connections we can at the strategic level in order to support all those connections at the community level yeah just a very very quick point slightly more focused on my last contribution in bronze go from ready to with the household support fund we tried a very slightly different communication method which is built very much on what you said because I pointed out at the meeting that often what we're trying to do is communicate directly with that very isolated person and we live in a very private society a very siloed society it horrifies when you hear the people don't talk to the neighbors and things like that but what we try to do is give permission we talked wider and said do you know someone who this applies to please pass it on and we have seen huge numbers of applications so whether i'm sure it wasn't just that but I think that's something we can order because that doesn't cost any money to turn around and say actually we're all in this together and you can do something to help that neighbor next door because yes they're probably not on the internet but you can just say are you aware this fund exists have you heard of that club down the road and I'm surprised you haven't pushed it yourself Lisa but I think healthy was to share is very much aimed at doing exactly this reestablishing communities because 50-60 years ago people would have gone to church or they'd have gone to the pub and that's where they would have had lots of these conversations and now so few people do that go home to their their little houses come out they sit in their hemetically sealed communities they don't even use public transport but I think I was saying to someone this morning everybody should do that who works in this sector every so often go on to public transport and sit with people who ain't like you because you learn an awful lot but I think there is something about saying to people it's okay for you to talk to other people about this so yeah I mean you all know how central this is to health to well-being to quality of life you'd expect me to say something challenging because I often do and I know I don't know as wind friends with it but do we really mean it as a system because I think social isolation and loneliness is one of those things that if we invested as much time and resource into it as much as we talked about it then we'd start to solve it so I think there's brilliant work going across the system but I've never met anyone in my life who I think could achieve a good standard of health and well-being if they're socially isolated we've heard that it drives mental ill health physical ill health it drives service demand it drives crime we know how drug gangs we talked about earlier the first thing they offer people is friendship oh we are system that means it when we talk about social isolation and loneliness because throughout my career I've been talking about it as a psychologist and as a public health professional it always still feels like a bit of a side salad to the main course of proper health care proper proper work and I suppose you know there's no answer to my question but if we could all introspect a little bit as a system and my challenge is national as well as Worcestershire do we really mean it when we sit around and talk about the importance of social isolation and how is that being manifested in our own organizations and in our own work in our investments of time and resource because if we don't deal with this if we don't constantly put this at the top of our priorities there's a lot of our other priorities that we won't achieve so I guess mine is a challenge to us to the whole system is let's do this as much as we talk about it I suppose so yeah and just wonder thing not at the table I'd big shout out to Jess she is our she hates it when calls our loneliness guru but but no her expertise and enthusiasm alongside other colleagues is boundless so big shout out to you Jess for all this work on isolation and loneliness as well and I'll just say the grants are open if you know anyone that might want one please do come and talk to us because as Chris says we try our best to say no to say yes we'll try our best not to say no so we will always welcome a discussion and always welcome a conversation about it and as we say it's part of our developing our Healthy Worcestershire program as well so there will be additional opportunities available and we would welcome anybody to come forward even if it's just an idea because we're more than happy to work with you on it and as we said Jess has been done a fantastic job looking after them and making sure people do apply to it and we will say yes to them thank you very much indeed Tanya Lucy and Lucy great presentation lots of questions and answers and I think a very really good discussion on that matter thank you very much indeed thank you thank you colleagues the next item the penultimate one is the an update on the better care fund and is that going to be presented by Simon thank you March just looking across the room at me and saying who but hopefully the report chair is quite self-explanatory it's an update and we've got to in particularly asking for the board's permission to delegate the sign off of some forms that we have to submit to an HS England in a few weeks time outside of the board process so we're asking for permission for those templates to be completed they're in line with our plans that we had anyway for this year and next year that the board has previously agreed and we would retrospectively bring the detail of that back to the next meeting of the board so that's the main item if that's okay with everybody thank you Simon yes it's colleagues it's printed on page 35 of your report and I'll just read it for the sake of being formal the health and well-being board is asked to agree to provide the integrated commissioning executive officers group delegate responsibility to sign off the 23-24 better care fund end of your template and the 24-25 better care fund plan update this is to ensure that all templates are submitted within national time scales provided by NHS England this agreement is with the caveat that the documents we've formally signed off at the following health and well-being board so colleagues are we so agreed thank you no this is the last one we're not doing any more we are we're not really finishing we are doing some more we'll get them to you I promise okay oh it's just the year the trunk apparently Sarah Sarah say yeah right okay well it's just the year that the next meeting is on the 26th of September 2024 council what can I ask a retrospective question please on the minutes yes Christine you've been very patient so it's a radical regarding the we spoke about earlier yes of course yeah so I'm not expecting everybody to look at the minutes again but at the very end of the last meeting on autism it was suggested by the former chair that we all had training and I was just wondering about the progress on this yep on the case councillor world so all of them are going training which we heard about the last meeting which really enjoyed the presentation so it's been arranged for the July development meeting on the 16th of July one hour starting at 2pm via teams so we'll get that out to everyone and we'll keep pushing that training out as much as we can starting with the members and colleagues here thank you Lisa well then colleagues thank you very much thank you I hope it wasn't too traumatic for you my first meeting it did start late but I'm not going to take the blame for that one but however it was thank you very much and I'll see you all again in September have a good summer everybody thank you and July the 23rd with all 5k 10k I expect to see you all there unfortunately I won't be there you you you you [ Silence ] [ Silence ] [ Silence ] [ Silence ] [ Silence ]