Transcript

Transcript

[INAUDIBLE] . >> [INAUDIBLE] And I'm Jeff Whittle, I'm the Assistant City Mayor for Environment and Transport. You're right, Jeff, I'll forgive you. Good morning, I'm Councillor Elaine Pantling, and I'm Assistant City Mayor for Education. [INAUDIBLE] To remind you to press the microphones when you speak. [INAUDIBLE] I've just forgotten to do it myself as well. First of all, have we got any apologies today? Yeah, we've had apologies received by Caroline, [INAUDIBLE] Thank you so much. So the first item on the agenda is the terms of reference, the refreshed terms of reference for the health and well-being boards. I guess these are not for discussion, but just for acceptance. [INAUDIBLE] Okay, I've made another error already. So the next part is has anyone got any declarations of interest, just for the members of the board? No, [INAUDIBLE] And to confirm the membership of the board as listed in the papers as well. Is there anyone with any objections or comments on membership? No, we agree. It's all been agreed, and it's been signed off by full council. Okay, so the next thing is the terms of reference. This is really just for acceptance, but if anyone has any issues they want to raise about that, please feel free to do so now. Otherwise, we can say those terms of reference have been accepted for the record. Thank you very much. So the next is the minutes of the previous meeting. Has anyone got any corrections that they would like to make for those sets of minutes? No corrections noted. We don't do actions or matcherizing, so we can move on to the first of all the questions from members and from the public. No questions have been received, Chair. So we can now move on to the first substantive item, which is the health needs assessment for sexual health, which was presented by Laura French. Thank you. I'm going to attempt to share my screen. Strange that it feels being simultaneously in a meeting remotely under the room. Okay, brilliant. Thank you, everyone, for inviting me to come and talk to you all this morning. I'm going to talk about the health needs assessment that we did in preparation for recommissioning our sexual health service in the city. So I'll very briefly run over what our sexual health commission, because it's a huge thing and we only do certain bits of it, I'll talk about how we put the needs assessment together and then what the findings were. Some of the findings have little stars against them, and I put those in to denote where we just had some new data released literally within the last month. So I've updated this presentation, but the existing needs assessment online has not yet been updated. So that explains the discrepancy if anyone is very eagle-eyed and spots it. I'll run through a little bit about what we made in terms of recommendations and talk about some of the challenges. So in background, so under the terms of our public health grant, I'm sorry, this is quite small. The local authority public health team were required to commission an open access sexual health service. So that means that anybody can come to it regardless of where they live. They can come to our services investor and anyone in the city, regardless of where in the city they live. They can come and access those services. And that has to provide AI testing and treatment to provide all range of contraceptive services through thing. Very simple through to the complex stuff. We have a psychosexual counseling service. We oversee sexual health and reproductive education in educational settings. We do quite a lot of outreach, there's a big outreach function with various key communities that I'll mention later. And most recently into our kind of bucket of responsibilities, we've had HIV pre-exposure prophylaxis added. So that's where people can take a tablet to prevent them contracting HIV. It gets abbreviated to PrEP and that's now in our commissioning responsibilities as well and we do that through our sexual health service. But overall sexual health commissioning is really complicated. I've not put this up for everyone to read in detail. It's really just to demonstrate there's a lot going on. And whilst we have quite a lot of it, there's other things that go across. This is an old slide that says clinical commissioning groups that now should read ICS or ICB. But basically, although we all work together, we kind of all commission slightly differently, which can make it a little bit complicated when it comes to designing services. So what are the health needs assessment? I'm sure lots of people in the room know, but for those who haven't come across this before, what this means is we do a systematic approach to reviewing a specific health need of a population. So that can be a condition specific, so if we're thinking about we want to know about diabetes in the population, for example. Or it can be population specific, so we want to know about the specific needs of a specific group of people, like older people, people who are leaving care, etc. Or it can be like this one, so service based, so we want to look at all of the things that a particular area of our service does. And the textbooks will tell you there's lots of different ways of doing it, so you can look purely at data, you can talk to stakeholders, or you can compare yourself against either a peer or a gold standard. But generally speaking, we do a mixture of all three, and that's what we did on this occasion. So why are we doing it now? Well, our last big one was 2016. We update the data kind of every year or regularly as it comes out, but in terms of a big piece of work like this, the last one was pre-pandemic, certainly. And also when we were kind of looking at the service last time. So we've had loads of changes to what we do since then, and we've had a pandemic which brought about lots and lots of change in the way that people like to access health services. And it was also time to recommission our new service, so that was starting April 2024, so the time was right to do it. We took our previous one, we looked at all of the information in there and the recommendations, and we spent some time working out what had changed from there, what was still the same. We updated our data from lots of different sources, so there were quite a few national sexual health data databases, but we also got things from the Office of National Statistics, our public health data, we got local data from our sexual health service providers, UHL colleagues and various other partners. And we spoke a lot to providers and local experts for information on what we have, what they thought we needed, what the local need was. Simultaneously, we ran a public consultation exercise which gave us loads of really useful information, and I'll talk about that in the next presentation. So in terms of a summary of what we found and what the picture was in Leicester, so Leicester is kind of about in the middle of the pack when it comes to local authorities in terms of new STI diagnoses. Our rate is slightly lower than the England average, when you look at it, so we're 58th highest out of 154 upper tier local authorities. And that kind of doesn't change, we tend to sit about there when we look at the data. What is different in Leicester is that 61% of all of our new STI diagnoses in Leicester are in young people, so the group 15 to 24, which is significantly higher than the national average, and although that group is the group that tends to use these services the most, that proportion of STI diagnoses is higher than normal. So that gives us something to think about in terms of when we're defining our services. Chlamydia still is the most commonly diagnosed STI, and that's true, always has been true, it's true nationally, we're not unusual in that regard. But what has been unusual recently are the rates of increase in gonorrhea, and that's a national problem and we're looking at it. So what we saw in Leicester is where during 2020/21, all of our rates of STI fell quite abruptly, the gonorrhea rate didn't fall quite so rapidly, which was indicating that there was something going on. This is a comparator of us with some of our, what we call statistical neighbours, these are both authority areas that look a bit like us in terms of numbers of population and population breakdown. So we do better than our comparators in terms of new STI diagnoses. These are new STI diagnoses excluding chlamydia because that gets counted separately, but we're kind of similar in the rankings on both things. HIV in Leicester, we are considered to be a high prevalence area for HIV, which is important, our rate is 2.8 per thousand, which doesn't sound very high and it isn't, but when you compare it to the England average of 1.7, we are significantly higher, and we're the highest in our little group of comparator cities. We're the fifth highest prevalence area outside of London, so nationally we're considered to be a high prevalence area. Generally speaking, our HIV coverage is really good, our testing coverage indicators are excellent, which reflects a lot of the work that our community partners do with work in the community. However, we do have comparatively higher numbers of late diagnoses than average, so that's people who for whom their first diagnosis of HIV is being made where later on in their disease process, their blood counts are lower, their viral loads might be higher. And that's a bad thing because that means they have a worse prognosis in terms of how well they do. We also have slightly lower rates of repeat testing in some of our particular groups where we advise repeat testing and that's something that we need to work on. Moving on quickly to contraception. So long-acting reversible contraceptive methods are what are recommended by NICE and by the NHS, so these are methods where you don't have to take a pill every day. They're either a coil or an implant or an injection, something that you do once and then last the period of time. And our rates of uptake in Leicester are significantly lower than the national average, although we do see quite a lot of variations between communities, and there's lots of reasons for this, but the main thing for us to look at as a service is making this more accessible for people who want it. Interestingly, there's been a shift in where people go for their contraception, so in terms of general practice versus online versus into our sexual health services, we've seen a year-one year decrease in contraception provision in general practice, and that predates the pandemic. That's not just a pandemic effect. It kind of reflects the changing ways in which people like to get their contraception. One of the things we also clocked in our needs assessment was that postnatal provision of contraception, so contraception for people who've just had a baby needs looking at in terms of how we make that easier for people who, frankly, have a lot on their plate. Having just had a baby, we need to make it easier for them to get their contraception sorted. Termination of pregnancy, although we don't commission it, clearly a very important part of sexual health services, and it helps us know whether we've got unmet contraceptive need in our population. Actually, the provision's changed quite a lot since we last did a needs assessment because we've now got a BPAS in the city. BPAS is the British Pregnancy Advisory Service. They are an organization that specializes in kind of contraceptive family planning termination of pregnancy care, and the NHS conditions through them. They're a great expert organization. We've also got a service at UNH, which is brilliant and is now also open to self-referral as well as clinician referrals, so people can phone up and refer themselves to that service, and they also provide a real range of post-termination contraceptive options. Our TOP rate is higher than the national average in Leicester, and it's increasing, and this trend has been noted nationally, and it's an area of focus. So it's something that, as a system, we've been asked to look at in more detail, and that work is ongoing. We have a section in our needs assessment on teenage pregnancy, so our under-18 contraception rate has reduced significantly in recent times, so if you look at the last 20 years, it's fallen a massive amount, like 80% from where we were, and that is also mirrored nationally. That's been the trend. However, we still see quite a lot of variation within the city, and so our more deprived wards in the south and west of the city have significantly higher rates than the national average. Though overall, our rate is similar, so that reflects that variation. Some places are very low. Some places are much higher. Leicester has some particular demographic challenges when you're planning a sexual health service. We've got a younger than average population, and that's the group that uses services the most, so we need to make sure that we've got capacity for that within our service. We know that deprivation is correlated with poorer sexual health outcomes, so we need to make sure that we have services in the right places in the city that are available to people that need them. And we've also got a very diverse city, which means we have people from different backgrounds, different cultures, different ethnicities, and they have different needs in terms of what they need from the service and how they like to access it, and I'll talk a little bit more about that in our next presentation. In our specification of the service, there are particular groups that need to be taken into account as well, so young people, as I've spoken to, but particularly those with special educational needs, gay, bisexual, men who have sex with men. We have a good service that looks after our sex workers, so goes on street and premises workers, and we work with partners in the community to do that. Again, partnership in the community, we have an outreach service that looks after people who are newly arrived to the city, which includes refugees and asylum seekers, and our university students. So there's a big table of recommendations in the final document, there's about 30 or so detailed recommendations, and they're assigned to different commissioners, and I've pulled about 12 out in the executive summary that are the kind of main ones, so I haven't put them all on here, but I've put a link at the end if you want to go and have a read. But in terms of theme, basically what we saw were the following things, so access is a big theme, people want options and a range of access methods between online, face-to-face, telephone, sit and wait, pre-booked, etc., and ideally a simplification, a clarification of where they go if they want a long-acting reversible contraception. And again, I'll talk a little bit more about that in the next presentation. There was definitely a theme about people wanting services, alleged services, so things that work specifically for them and different ways in which the different communities like to access these services, so they were keen to be involved in co-designing what we did, and also better integration. I showed you that table at the beginning about how all the commissioning responsibility fits kind of across the system, so there's this basically a need for us all to work together in a kind of more seamless way, and there's lots of different bits of work going on to help that happen. Challenges, so obviously financial challenges, the sexual health services in general have had that for years, and that also translates to staffing challenges as well, so we kind of have not quite as many consultants who are skilled in sexual reproductive health because we've got older cohorts retiring and we're still training people, so that's also been a challenge. Changes are the ways of working, but also I considered this to be an opportunity, so we had a pandemic which meant we had this kind of forced change where suddenly we had to do everything differently, but that actually meant that our ways of doing remote telemeds and things for like contraceptive prescribing, termination, were forced to kind of keep up with the times and actually that was an opportunity. As I say we've seen these rising rates of gonorrhea and syphilis which is something that we need to be looking at, and nationally we've seen termination rates increasing, particularly in the over 25s. And we've got some targets to meet in the HIV action plan from nationally which are challenging, but we're working on it. Would you like me to pause the questions now, or carry on? Okay, perfect. Okay, thank you very much. I'll read the question out, but first of all before she scrubbed this out she did say it was an excellent summary. It's a great question. Oh, you put it on there, so thank you. Really fantastic presentation, but also comprehensive papers and work behind that and we don't want to just show you the amount of work that's gone into that, huge, and we'll come on to the consultation shortly. I'm going to let Councillor Russell ask the first question, which is so are low STI diagnosis rates could be seen as a good thing, but could potentially be an indication of a need that people are coming forward, so what do we know about that and what's your feeling around that. Great question, and that's partly why they exclude chlamydia from that initial outcome because chlamydia is the one that we find more difficult to diagnose because it's classically no symptoms exactly, people don't know they have it, so there's a separate outcome for that, which looks at your screening rates. So we actually do pretty well in terms of chlamydia screening rates, so again, slightly better than average. I think it's a mixture, so I think that's a fairly good summary of where we are, where we fit in the pack in terms of our STI diagnosis. We see we've got a range of ways that people can access STI testing, including going to the services to the spoke clinics, but also online and we've seen a real uptake of our online services, which I think is an indicator that people find that accessible. And we've also got vending machines and various other ways around the city to access it, so I think we could always do better. I think it's probably improvements we made, but I am fairly confident that what we see is a reasonable indicator of the genuine picture. Thanks, Laura. So we'll open this out to further questions. I've got one question for Councillor Pantale. Thank you. Thank you, chair. Thank you for bringing this. It is really informative. But one of the things that I wanted to ask you was, and it's regarding HIV, what plans are being put in place to encourage the repeat testing? Yeah, it's actually testing, HIV testing quite an exciting time in Leicester, so we've had a couple of things happen. There's been a national HIV action plan released, which we're implementing locally, and the drive behind that is to have no new HIV transitions in the UK by 2030. I don't think we'll quite get there, but I think it's a good place to aim for. Locally, one of the things we've been looking at is improving our kind of opportunistic ways in which we test for HIV. So we just had some funding nationally to start an opt-out testing campaign in A&E and UHL, so that means anyone who comes into A&E with anything, if they have blood done, unless they tell people, you know, say we don't want it, they'll test that blood for HIV. And the idea there is that that will help us with some potential missed opportunities in terms of late diagnoses. One of my registrars has also been doing an audit of case notes from the past year and a half of people who we've either seen coming with a late diagnosis as well, or where they've probably potentially missed testing opportunities where they should have been repeat testing. So she's, when she's finished analysing that, she's going to bring us the learning for the HIV action plan group, and we're going to see what we can do. But I'm really interested to see what the outcome of the UHL, the A&E testing is. In terms of kind of repeat testing in our communities, we're working with various third sector organisations, trade particularly. One of the things we're trying to do is to, but it's easier than it used to be to get HIV tested because now they have point of care testing in some of our voluntary sector organisations, but also we're doing some work around sort of de-stigmatising and demystifying the process of HIV testing. So even amongst health professionals I think sometimes they think that still you can only test for HIV if you've been trained to do the counselling, it's a really complex thing, but actually in reality it's not. All you have to do is do the test and then some of the experts will pick that up and look after it. So a range of things, in answer to your question apologies I've probably spoken too much there, but I will hopefully at some point when we've done audit HIV action plan work I can bring that back to the meeting if that's of interest or I can circulate it, feel free to pick it up with me. Okay I've got another question from Sarah, a comment from Sarah which is around how one route for loc would be very positive, women discuss loc and as different GP practices offer different services it can sometimes inadvertently confuse people with various options available. Yeah I think sometimes lots of options, too many options, and one of the things we've been looking at and that comes out in this next presentation is simplifying people's route into getting these things. So trying to have one phone number, one website, one email address, whatever that you can go to if you think I want a coil, I want an implant. At the moment our single point of access such as is our sexual health service website which has a click through of this is what I want, these are the places that you can go, but the ambition is to have a literal one stop kind of phone number. Because I agree I think that's a major problem and one of the reasons why people don't have loc as much as they might want to because they don't know where or they don't know how. Okay any further questions before we move on to the consultation? No one online? Okay. I will move on, so some of this will be a little bit of repetition I apologise I'll try and move through quite quickly. So what I've done in this presentation is a summary of what else we were doing around the procurements other than the HNA stuff and a more detailed summary of our public consultation and stakeholder engagement. So what we asked them about, who we asked, what we found out and how we've used it or how we're planning to use it. So as I'm sorry this is also a repeat but we're commissioning sexual health service and that table that I showed you in the last presentation there are some changes afoot or ongoing so this is the updated version. PREP responsibility as I mentioned is now asked about HIV pre exposure for Alexis but now it goes in the top box. HIV commissioning is transferring from NHS England into the ICB and as I put there CCGs were replaced by ICBs. So this is a slightly updated version of the previous one but some of these changes are still ongoing so it's worth noting that at the beginning of this because some things that I say now may not necessarily be the case in a year's time. And it just reinforces what we're dealing with in terms of the continually changing picture of sexual health commissioning. So timeline our contract for sexual health but now previous contracts at the time future contract ended on the 31st of March 2024 and that was after we were extended it a couple of times during the pandemic within the contract rules but at that point we needed to repocure. So there are new now NHS procurement rules that mean we can do it differently but at the time they weren't in place so we undertook the traditional competitive tender process for this. So between January and March 2023 so kind of a year and a bit before the contract was due to start we undertook a comprehensive programme of engagement with the public and with stakeholders to inform what we put in the specification for our new service. And we advertise the contract mid April 2023 based on that and we made the award slightly later on in the year after all of the bid review processes we awarded to Midlands Partnership Foundation Trust and then I mean they were our existing providers at the time, there still are providers and they're the ones that you will see if you go into the Haymarket. They put together a brilliant bid so we were pleased to make that award in water and 23. So then we spent the period post that mobilising and our new contract now started on the first of April, so when you go in to the Haymarket now we're kind of under the terms of the new contract. And what the main difference really was that this time we were procuring alone in Leicester City rather than previously we'd procured jointly with our partners in Leicester County and the and that that was for various reasons that partly related to wanting slightly different things out of our services and this goes back to needing to have a service that really works for your population. So, as of this time is just for Leicestershire and you'll see, oh no you won't see later on that's a different presentation. But what you'll see now is if you go to the Leicester Sexual Health website, what it will ask you when you hit the landing pages whether you live in Leicestershire County or Leicester City just so that it can make sure it gives you the right information so I don't know if you've been to that website but that's a change that you'll notice now but literally that's the only reason it does that so it shows you the right information. Okay so, consultation was a big part of this and why is it so important? It's kind of an obvious question but we know that health is not evenly distributed in the population all the way through your life, you're subject to all of the things around you from your environment, to your house, to your job, to your friends, to your society that impact how well or otherwise you are and that's true of sexual health as well. And we know that those inequalities start before birth hence why all of the things we do around contraception and looking after people during pregnancy and afterwards are important and they persist all the way through your life. And so it's really important to make sure we have services that work for people and work in ways that mean they can access them. Sexual health is no different so health inequalities there's the classic definition of differences, systematic differences in health between different groups and they are avoidable they're not inevitable. And as with all adverse health outcomes, poor sexual health we see people living with deprivation are more likely to experience those poorer sexual health outcomes. We also know specifically within sexual health that there are particular groups that are more vulnerable to poor sexual health that need special consideration when you're thinking about services. So it's really important that to the best of our ability when we're designing a specification we get the views of those people or if we can't find them the people who we know look after them and therefore can help us understand how best to do that. One side doesn't fit all so there is a brilliant national specification framework for sexual health services and that's where we kind of start from but we also know that we need to work with our communities to design a service that works best for them we can't just sort of slap that framework specification on it and expect it to work for us. We didn't want to make any major major changes to the model that we've got in Leicester, which is a hub and spokes or our main hub being at the Haymarket in town, because we know from our patient feedback and the stakeholder engagement that we did that that's that model, and that service is very well thought of and people like it, but we knew there were still important things that we wanted people's input into. So these are a few examples of the specific things that we wanted to know. So where we were putting any spoke, we call that hub and spoke but peripheral clinics is what we mean, and how often and what people wanted those to be like because we have noticed that some of our former folk clinics were getting less popular, and we weren't sure why. So we wanted to make sure that wherever we decided to put them this time, people were going to use them and they were going to work for people. We needed to know what sort of a balance people wanted between online and face to face appointments, because trying to guess you can't guess that, you know, for some, some people much prefer face to face, sometimes people like the convenience of online and certainly during the pandemic we saw online demand go right up, but what we didn't know was whether that was just because of what was going on in the world, or whether that was people's genuine preference. Equally, we wanted to know what people preferred between sit and wait style clinics where you just sort of turn up, put your name down to wait and get seen whether you want to be able to know exactly when your appointment was. We wanted to know where people like to be able to access different types of services, so where they like to go for STI testing, contraception, coils, implants, etc. And then we asked about how how we could make these more accessible and how people would like to see us work more closely with that communities to do all the other stuff that sits around this so things like outreach education, making the services more available in the communities. We had two facets to our consultation so we had an online public consultation through citizen space, it was open for eight weeks. And we also did loads of face to face session so I've just put a list here of some of the groups that we worked with these are all members of our Community Wellbeing Champions Network and we're incredibly grateful to them for facilitating those because they were so useful. Equally to anyone who responded to the online public consultation because I know it's obviously not what everyone wants to be doing with their time is sitting filling in like questionnaires, but we had so much really useful stuff that came back. We also spoke to stakeholders people working within the system topic area experts for the more specialist things so people from our sexual assault referral centre for example, people who work on women's health in prison. So we spoke to everyone we could think of who might have useful information when we were designing this classification. Amongst other things, this is just an example of some of the things we spoke about. So in terms of online appointments face to face, what people wanted to be able to get remotely without necessarily having to talk to anyone so our vending machine services, how people like to access their information, what sort of advice they felt they wanted, and how they wanted us to work with their communities and what role they felt that Community Wellbeing Champion organisations could play in helping me get their sexual and reproductive health good outcomes. So we found out loads of stuff, and I won't attempt to put it all in here, but we got almost 300 responses to the online questionnaire which was just really an incredible response we were so grateful. The majority of the responses came from people in the age range 18 to 55, I know it's quite broad, that's just the way it was categorised and they were fairly easily, relatively evenly spread across the decades within that range. But that was kind of what we expected and certainly that's where we see people using services probably the most. Slight majority female but not hugely, again reflects the balance of people who tend to use the services. But we had a range of gender identities, ethnicities, ages, and I haven't put the range in because it's quite broad and people might potentially feel that it was identifying but certainly we had a huge range of people who came to tell us what they thought. We grouped the face to face groups, we wrote them up, we combined everything we found out, we analysed it by theme and then we grouped those themes together to allow us to make a summary recommendation based on all of that really rich quality of data that we got out of our face to face groups and the free text responses from the online questionnaire. And what we found were these kind of five key themes so people had lots to say about interestingly sexual and relationship education, both in schools and also in other settings so in communities and training within those individual communities, lots of groups that actually it would be great if you could teach us to talk about this and then we can talk about this with our communities or our young people. People often spoke about various beliefs and perceptions around sexual health and whether or not they felt that it was something they were comfortable to talk about or whether they felt stigmatised, etc so that was really helpful. Specific barriers to accessing services, age appropriate services and the importance of that came up quite a lot so people who were younger wanting to have services that they felt were designed for them and that the other people in the waiting room were similar, equally people who were older wanting to feel like they were also welcoming our services and that this wasn't just something for teenagers so that was a really interesting and we probably expected it but it was really useful to see it written down there. And also people mentioned a lot about information sharing, signposting where can I go to find out exactly that point that Councillor Russell made earlier, you know where do I go to find out this thing I want to know. So we put together a sort of summary in the format of UCEDD we did and what we're going to do for the new contract and this is quite detailed and I'm not going to run through it but I've put the link at the end, you can go online and have a little look at it. Some of the examples where we found it relatively easy to do those things because we were wondering about them where people say for example about online versus telephone or walk-in bookable people really like being able to book their appointments online, that we increased the number of available appointments online. We'd had to reduce or suspend that during COVID because of ways in which we were having to organise a service to make sure everything was safe but we made sure that those were online appointment books were now fully operational again and that they're very popular. So we've enshrined that within our new service model that that has to be an option. We asked people, do you prefer face-to-face services because we weren't sure whether the popularity of online services during the pandemic was just reflective of what was happening. And most people were in favour of having a mixture of face-to-face services that they could book in advance and some that they could turn up and wait for. And we tend to see that younger people prefer sit-and-wait style appointments so they can just come into town with their friends and go and sit and wait for an appointment. Older people prefer appointments that they can book so they know when they're going to be there probably so they can fit them in around work, around other responsibilities, etc. And we now have a mixture of those things. We've reinstated walk-in, sit-and-wait which again we had to suspend during COVID and then again during MPOCs which we saw just a year or so ago. But those are fully reinstated and again we've asked our new provider to ensure that there's a proportion of those available at every place that we do services. And then we asked about how people wanted us to work with communities and whether they would respond positively or negatively in terms of seeing that work done out in their communities. And as I've already alluded to people seemed really keen for us to do more of that work and to engage our community wellbeing champions to support this. So there's a link online I think these are probably going to have been circulated with the PAT but also you can if you just put into Google Leicester Consultations sexual health it takes you to this as well. So where are we now? We've got our new contract up and running from the 1st of April which feels like quite recently but actually now quite some time ago it's been busy. But there's some things that are taking time so we'd love to have our single point of access phone number for LARC which we're working on it but because of all the things that it involves in terms of procuring a specific phone number a service and IT system that links everything up together it's taking a little bit of time. There's lots of bits of cross system work going on so I've mentioned the HIV action plan work already. It's also worked locally on implementing the National Women's Health Strategy which involves lots of different elements of what I've spoken about today. And then within that lots of specific bits so we've been looking at postnatal contraception we're going to look at terminations of pregnancy and anything else that happens to flag up. And within the consultation we identified a gap in kind of representation by our younger people in that kind of 16 to 24 age group where they might have left school but we're still in that group of younger people and we really want to kind of hear from them about what they need. One of my colleagues is working on a consultation plan to make sure that there's a way of feeding that into our ongoing service developments and not waiting until the next time we go to repair but working out a way that we can kind of access people in that age group to help us keep checking sense checking what we're doing and making sure that it's better. Brilliant so thank you very much that's my email. I don't know whether there's a random capital in there, but I'm Laura.French, I left the doc.uk or my colleague Dan, who did a lot of the engagement work and pulling it all together. It's one of the best people to ask about that particular work. So thank you and I can take questions if I have time. Thank you, Laura, excellent presentation and yeah we're not underestimate the amount of work that's going to produce that but also the amount of information that's behind all that that really is a kind of high level summary of a significant and really large amount of information that's been used to hopefully improve and certainly design better service. I think it's really exemplary consultation piece of work. I've got a couple of comments, first of all, from Councillor Russell, and then we'll go around for other questions. First of all that diagram, it is really powerful, the snake diagram. Councillor Russell suggested we should be showing this at the beginning of every health and well being board so we'll all know it's off by half. Oscar Wilde said talent borrows ingenious steals. The next proper question is really around the online versus face to face stuff so it's really to say you can't get coils online and wondering whether that's the emphasis on online might actually put people off the lark. Maybe that's one of the reasons why we don't have a large uptake and whether you've addressed that in the design. I think you might be right. I think something about the convenience of being able to just click online and go through a consultation and be sent a pill in the post nudges people towards that. And one of the crucial things I think is about the way in which we make people aware of their options and the benefits of each. So we're kind of doing in a few different ways. So the website has quite a good section now on contraceptive options and information, but I'm aware that you would have to sort of actively seek that out. So the other thing we're doing is working on what we do postnatally which although is a small group, they are people that really do benefit from a good luck service. And so we're training up some of our midwives to fit in plants so that they can do it on the world before people go home. That's in progress. I know our autistic colleagues also looking at being able to do coils at the time of caesarean sectional delivery. Yes, so that would also help with that. And what else was I going to say, completely forgotten. The other bit is about making sure that we're including particularly young people who are less socially confident or maybe see this as more of a stigma amongst families and communities and so on. And how do we overcome some of those barriers and the tensions between people who want it to be face-to-face but are not online and more private, but actually need to actually see someone in some circumstances. And I think that's why it's important to make sure that people know where they can go, that they don't have to go to their own GP because that can feel a bit visible for people. They can go into the haymarket or they can go to one of the other practices that we call our sexual health and community contraception. So you can go there regardless of where you're a patient. But we are keen on making it easier for people to do that. And the final thing we've done is used some of our money from our postnatal contraceptive project to fund some of the old school, what we used to call the red boxes. I don't know if they're still red but they've got basically a box full of contraceptive information, example coils, example implants. So we can take them to schools and community centres and do that kind of outreach of making sure people know what their options are and how to get them and hopefully empower people to kind of come. And we've certainly seen – so after our consultation group work, there were a few groups like our Bandit ASU Women's Centre for example where there were a group of people that said actually we don't know where we're going, we don't feel confident, can you take us? So we arranged some visits with a linked worker and we're hoping to make that more of a feature going forward to have people in community to help bring people in. Thank you, Laura. Radshan if you could question. Thank you. I agree with all of Robert's comments about the amount of work that's gone into this, so thank you. For anyone who's read the actual insights in that consultation document, it almost talks to the way that our young people want to access the vast majority of services now. Sorry, it's probably because it's all the way over here. It really helps – Sorry. Oh. Right, let's try again. Is that better? Right, okay. Anyone who's read the consultation, the insights that are on that consultation link, it almost talks to how our young people want to access the vast majority of services now. Actually not so much just for this one, so I would really encourage people who are designing services to read that. Certainly it's gone on to the insights hub for the ICB as well, so we will be reading and implementing a lot of this. But just in terms of that particular point, how are we going to make sure that we're doing this level of information gathering for some of our other services? Just interested in whether you've got those links already made, Laura, or whether we can help facilitate some of that when we're designing other services. Yeah, thank you. And I think – It's not come on though. Oh, it's green. Oh, it is. I'm sorry. I'm super into light. Oh, yeah. Yes. I agree, and it's something that Dan and some of the others have talked about, about whether we have a more systematic approach to whenever we're doing any service design, doing consultation like this. I know that it's something that he and our colleagues who work with the Community Well-being Champions Network are really keen on doing. And yeah, I know that in the ICB you've also got a brilliant kind of community – I can't remember what it's called, but the equivalent of the Community Well-being Champions Network. So I think it's a matter of leveraging that real asset, because they're just, yeah, incredibly dedicated to improving the well-being of their community. So making sure that we ask earlier rather than later at the stage where we're thinking about what should we be asking and how should we ask. But yeah, I'm incredibly grateful for the depth and wealth of information that everybody who answered our consultation, whether it be face-to-face or online, gave us. Because as you can see, that's just a fraction of it, but we couldn't have done it without people willing to engage. So I think people are keen and enthusiastic about doing that, we just have to make sure we do it in a way that is useful to them. Thank you very much. Do we have any other questions from any members? No, thanks very much, Laura. Absolutely brilliant, excellent presentation. So next we're going to be moving on to Mary Hall, Consultant in Public Health, who's going to be talking about the picture of TB and what our plans are to addressing TB in Leicester. Over to you, Mary. Thanks, Rob, and thanks for the help with the slides on this one. So this presentation is a result of the Health and Well-being Board Development Day and TB being raised as an area of concern, really, that we want to look more into. So I'm going to give you an update, a little bit of an overview, about what TB is, what's going on nationally and locally with TB and then what we're doing about it. So just a bit of an overview about TB. First of all, it is an infection caused by the Mycobacterium tuberculosis. It mainly infects the lungs, but it can infect any part of the body and it's only infectious in the lungs and in sufficient quantity of the lungs. So this is really important in terms of our control of TB and also our screening and finding cases of TB. So just hold on to the fact that it is only infectious if it's in the lungs and in enough quantities to have it in the lungs but not being infectious. If it is infectious, it's spread by breathing in infected droplets, so coughing and sneezing, but that generally has to be quite prolonged contact with somebody. It can be latent, that means it can be inactive for many years. So people can be infected with the bacteria, they can have the bacteria in the body but have no signs and symptoms and not be infectious. And we don't quite know why people might go from having latent or inactive TB into TB, but it will be something to do with the immune system at that period of their lives. And around 5 to 10% of people with latent or inactive TB will eventually develop the active disease. If it is infectious and it's not treated, it can infect around 10 to 15 people a year and these are all averages. This is kind of a routine case of infectious pulmonary TB. You may have heard of drug-resistant TB, that's more infectious and there are certain strains of TB that are more infectious. But generally, it can infect around 10 to 15 people a year if it's infectious. And it will cause a range of symptoms, so the classic ones will be that prolonged cough, sometimes coughing up blood, high temperature fever, night sweats, loss of appetite. But it will also depend on what side of the body it affects. So for example, TB can cause meningitis or enlarged lymph nodes if it's in the lymph nodes or swollen joints if it's in the joints. So again, it just depends what part of the body that it has infected. A little bit of history of TB in England and Wales over the last 100 years and some of the influences that have impacted on both the incidence of the new cases and the death from TB. So that solid line at the top is your incidence, the number of new cases, and the dashed line underneath it is the deaths from TB. And you can see that public health measures, that housing slum clearance, and I mentioned at the top line there, it is a disease of poverty. We know that it's far more common in more deprived areas. So housing and slums, poor housing and slums was a real hot bread of infection and transmission. So clearing of those housing slums had quite a dramatic impact on both the incidence and the mortality, which continued with the first introduction of antibiotics in 1944 and mid-1940s and the BCD vaccination. Vaccination is okay. That sounds a bit of a qualifier. We have a measles vaccination that will stop people getting infected with measles. It's really effective. BCD vaccination doesn't have the same impact. It does have some impact on reducing infection in children, and particularly with meningitis caused by this bacteria. But in terms of reducing transmission, it's not so good. So there was a nationwide programme on BCD vaccination that doesn't happen anymore and it's very targeted against the more high risk populations and children. The google therapy introduced in the 1950s is that combination of antibiotics and the isoniazid and rifampicin in the 1970s enabled an 18 month treatment to be reduced to nine months of treatment. And the bit to pull out of that is treatment is absolutely horrible. It's a combination of quite large tablets with quite unpleasant side effects. So going from 18 months to nine months had a significant impact and then the introduction of pyridine in 1980s, 1970s/80s reduced that treatment further to six months. Which is great, but it's still quite a long time to have to take treatment and with some of those side effects particularly when people start to feel better quite soon from their TB. So, just to note those, our TB rates in England vary massively across the country and I think you can probably just see Leicester there right in the middle of the black dot which indicates our incidence rates. So our new notifications are more than 40 per 100,000 of the population. We have the second highest rate in the country. Newham in London has the highest rate at fluctuating around 40 per 100,000 of the population. So not that much higher than us. We know that deprivation is a key indicator or risk factor for TB. So 13.5 per 100,000 in the 10% most deprived compared to 2.6 in the least deprived populations. That doesn't account for everything and that doesn't account for all of our cases in Leicester. And if you just see the next bullet point around 80% of our active TB in 2022 was in people born outside of the UK. And we know that just over 40% of our population in Leicester were born outside of the UK. And around 23% of those were born in countries with very high incidence of TB. So this for us is much more likely to be that combination of people born outside of the UK and deprivation but the higher driving factor is likely to be the people born outside of the UK. Both across nationally but also in Leicester. We also know that just over 50% of our cases had pulmonary TB, so infectious TB or some form of infectious TB. And then just under a quarter of those born in the UK have at least one social risk factor. So again when we're looking at reasons why we have these highest case rates. So social risk factors include a history of drug or alcohol use, a history of being in prison and something else which I can't remember right now. It's gone completely out of my head, never mind, it'll come back. But quite a different spectrum of risk factors in people not born in the UK. So the 15% of people not born in the UK have a social risk factor and that's more likely connected with homelessness or asylum seeker. So these risk factors are outside of where you've been born. The biggest risk factor is coming from a country of high TB incidence. Sorry, bit of a complicated slide but it's just showing you that difference in numbers and rates of TB in our UK born population and our non-UK born population. So on the left hand side of the chart you can see our UK born population and the actual charts are the numbers. So our biggest numbers in our UK born population were in the white population but a very low rate there just because of the numbers across the country in England of our white population. But if you look at the non-UK born population, much higher numbers and much higher rates, again just linking into what I was saying before. And the most common countries of birth with TB for our non-UK born residents are South Asia, so India, Pakistan and then a bit of Eastern Europe, Romania, Bangladesh, Eritrea. I guess the biggest driver for us in Leicester is those South Asian populations and the highest number of cases and rates in the non-UK born population is of Indian ethnicity. We know that numbers and rates were quite high from, and we'll see in some of the charts further on, from the 2005 peak, 2011 that's been coming down since then. The reason why we're flagging this now is that our numbers and our rates are going up and have been increasing since about 2018. And last year has shown the biggest rise in numbers since 2005, hence our twitchiness and concern about it. So just concentrating again on the non-UK born residents and the risk of TB in that population, so we know around 46% of people born outside of the UK were notified less than six years before entry. But 23% of those were notified within two years of entry. So that means they've come into the country, I know there's a lot of discussion on the news around so-called illegal immigration. Most of our drivers are people who are coming in on work visas or student visas, so just to be really clear about that. But you can see that the dark blue, so it goes from 2012 at the bottom up to 2022 at the top, the dark blue is the proportion of people with TB. New cases who've been in the country for less than two years and then two to six years, six to 11 years. There's a couple of things to pull out that. One, their increase in proportions of people with TB who've only been in the country for two years. Either they've come in with active TB and we've picked it up pretty quickly because of their symptoms or they've come in with latent TB and it's been picked up with the screening that we do and they'll come on to that screening. The other bit I think is worth pulling out of this chart is the over 50% of our TB cases who have been in the UK for more than six years. This is a huge proportion and certainly our clinicians in TB services see this as representative of a massive missed opportunity. We know, and I'll come on to the screening program, we had an opportunity to screen people when they first came into the UK for latent or inactive screening and this is seen as a missed chance to identify cases of inactive TB when people first arrived. That sounds quite simplistic, there will be some other factors in that and we know, for example, in Leicester we've done some work around work visas and people coming to and from their country of origin and that might make this slightly different. But overall, that large proportion of people who've been here for more than six years before identified with TB represent for us a missed opportunity of picking that up earlier. It was likely to have been inactive TB. Thank you. So just a little bit about our latent screening program which I mentioned. So this is a way of identifying people with TB that's not active, that's not infectious but which may become active and infectious at some point in their lives. It's only available for local authority areas where incidence is high, so over 20 per 100,000 and it is down to, as it was then, the clinical commissioning group, now the ICB to commission that service. This was first introduced in 2015. So it's available for all new entrants. We've got criteria down there. We've entered the UK within the last five years and have lived in a country with a TB rate of 150 per 100,000 or sub-Saharan Africa. We kind of lumped that all together because the surveillance systems in sub-Saharan Africa aren't so good, but we also know that there's quite high incidence of TB and that they're between the ages of 16 and 35. And the reason that age boundary has been put in is because over the age of 35, which feels really young to me but apparently not in the TB treatment world, is that the treatment for latent TB, the benefits of treating people with quite nasty drugs that cause quite nasty side effects diminishes on the benefit of actually treating latent TB. So there's more side effects on people with 35 and the effectiveness of treatment diminishes as you get older for latent TB. This is, again, not active TB. We, one of our registrars, carried out an audit of the latent TB programme in Leicester last year, looking at numbers of screened, numbers of screening that had been carried out across the city for our eligible population. And he identified a very sharp decline in screening after 2019, no doubt due to the pandemic. Screening is carried out in GP practices as part of that new entrance screening programme when somebody first arrives in the UK and they're going to register with a GP, then they should go through some of this quite early to check that they're eligible. That decline in screening has not picked up since the pandemic, so we are not yet in the same level that we were before 2019. There's been a lot of variation across the city. So it looked like people weren't being screened or GPs weren't necessarily screening according to eligibility criteria and perhaps more about signs and symptoms of potential TB. You're not going to get signs and symptoms of TB in somebody with latent TB, so again, there's some interesting findings from that report. I think bottom line is for us on that report is that there is an opportunity to identify many more cases of latent TB. Next slide, thank you. Thank you. That translates now into our TB rates in Leicester. Many of the drivers I spoke about on an England level are translated into the impact of what's going on in Leicester. So you can see from 2004/60 on a three-year average rate. We are looking to increase again, and last year we had alarms raised by our clinicians again that we would be going over 200 cases for the first time since the 2010s. And I think this is reflected in this chart here, and it is likely this chart is -- well, it will go up. So we have to work on published data. But early indications from our 2023 data show the steepest rising number since those early 2010s. Thank you. And why the reversing trend? A number of factors, and it's never ever going to be one single factor, but we believe that one of the driving factors is our changing patterns of migration since changing EU migration rules. So our workforce visas, for example, are much more increased for people coming from countries of high incidence. TB, particularly South Asia, and this is reflected very nicely in Leicester with our population, and we know that, again, in Leicester we have some large employers that will employ from different countries, but those countries tend to have quite a high rate of type TB. There's a little bit about delayed diagnosis driving this, but again, in Leicester, GPs are pretty clued up with the signs and symptoms of TB. There will be some practices where there's variation on that. But the delayed diagnosis on our -- we can see in our outcomes the time from first symptom to treatment, and we do pretty well on that in Leicester. So there's a little bit on that, but not massively. The screening programme, as I mentioned, is hugely varied across the city, and there's definitely opportunity to improve that. Access to treatment and the treatment itself, as I said, even though the time to treatment now is reduced to six months with the advance in antibiotics, that is six months of multiple massive tablets with a really disgusting taste and really horrible side effects, and we had a very good presentation at a conference in March from somebody with lived experience, and describing having to take those tablets not just for her but for her children and getting them down her children was incredibly powerful. I think all of us in the room. It is not nice treatment. If you have active TB within a couple of weeks, one, you're not infectious but also you're starting to feel better, so why on earth do you want to keep taking tablets for six months when you're feeling all right is really a testament to people's commitment, I think. And then if you have latent TB, you actually feel fine and you're taking tablets that make you feel very, very unwell. So, again, I think we have a very good completion rate in the city for people with active and latent TB, an absolute testament to our TB services and the support they give and the people who commit to taking it because it is not a nice treatment. There is huge stigma around TB. We, again, have had anecdotal evidence and information really of people saying they would rather access sexual health service, for example, and tell their family about that than actually saying that they've got TB. And the impact on that is we know that quite significant numbers of our population will go back to their country of origin for either treatment or diagnosis of TB rather than telling their family that they've got TB. So there's implications of the stigma and how they're feeling about it and you definitely need a lot of support if you're taking that treatment but also the risk for on the transmission to other members of your family. And then I've mentioned the associated social risk factors, so in Leicester that is definitely our biggest social risk factor is around drug and alcohol use and homelessness and having a history of being in prison. Thank you. So the particular twitchiness, I guess, and the risks that we are identifying and the concerns we have for Leicester is that continued rise in cases that we're having. As I mentioned, they're the sharpest rise we've seen in over 10 years, including our latent cases, and then our capacity and resources to deal with that. Our TB services are fantastic. As I said, they have some very high completion rates for both active and latent TB, higher than the national average with the numbers they've got. So there's a whole load of numbers out there that still need that same level of support and so that is a risk. Primary care are swamped, aren't they? Everything goes to primary care. We know that the issues with primary care have been there for a number of years but primary care is the driver for identifying people with symptoms but also for carrying out that latent screening programme so the capacity that primary care has to do that is an issue. And then the bit around community engagement and really meeting our communities and understanding and working with that stigma and almost de-stigmatising TB and making it okay to say I've got TB and I'm getting treatment. I've mentioned a bit about the treatment preferences and beliefs and about people wanting to go back to their country of origin for either diagnosis or treatment and the stigma. And again, that changing patterns of migration will continue and will continue to have an impact on our numbers. So what we're doing is a few different things. Last year when the case numbers rose to the level they were, we had I guess a high level strategic meeting of system leaders chaired by Rob to really raise the alarm and discuss what we wanted to do. As a result of that, we had a workshop, a stakeholder workshop at the beginning of this year and are in the process of developing a strategy development as a result of that. And that will drive some, we're just putting together the action plan at the moment about what we want to do and how we want to do it and who's going to do it most importantly. We are doing a TB needs assessment within our public health team. We're having an audit of our latest TB screening programme, there's a number of actions out of that. The Get It Right first time review is an NHS national programme which looks at services with a view to improving access and patient care. And that has taken place again in spring of this year and we're waiting for the report of that. It is likely to come with a number of recommendations. And we have a very prompt response to outbreaks led by our UK HSA partners and in Leicester we have a BC vaccination programme for eligible newborns so that AB is born to parents, grandparents from a country of high incidence mainly but there's a few other eligibility Alliance. Thank you. Just an overview of what the strategy has come up with around detecting controlling active and latent TB and a number of different aspects on that and this links with the England national TB strategy, which links with the WHO strategy to reduce TB cases and mortality by 90%. We are not on track in the country to reach that at all. Thank you. And then the next one, and then just really the last bit is what supports and what I guess the little bit of highlighting for the health and well being board is something around that sense of urgency. Our treatment service has a really high completion rate that I said but case numbers are still growing and they're still likely to go so unless we can do more, it will become more and more common in the city. So system wide approach to lobby for additional funding to raise awareness to embed a TB aware approach in our employees and workforce so that TB, it's okay to talk about TB it's okay to get treatment for TB. Increasing our latent TB screening programme and and a recognition of the most vulnerable populations and really targeting resources where the greatest need is. That's me. Thank you. Thanks so much, Mary, really excellent presentation. I think I'm tavers comes back. Yes, this is small numbers, but we're second highest in the country so what the board really is looking for is assurance that we're taking all the appropriate action that we can to, to, to address that I think it was that you have provided the shows to where we've got to for now, but I guess the important bit is the next steps and things like the resources that are going to be incredibly important. I think, I'm not sure whether you just mentioned that but Newham, who were the highest in the country had a significant input of additional funding, and they were able to do a lot of additional work and have managed to turn their rates round. We've had nothing. So we know what, what can we do to actually lobby and raise awareness around the need for more resources because it is preventable diseases, it's a difficult one to tackle but it's a preventable disease. And we want to make sure that it stops the trajectory that is currently on. So, I'm very happy to hand over to any other questions or clarifications from anyone else on the board. Yes, is it cash? I missed you. Yeah, hello. Thank you, Chair. The hospital respiratory nurse told me in the course of some conversation about TB that it's a requirement to be tested for latent TB if a family member has it, and that she's had a few occasions when people are reluctant, like they want to be at work, they'd rather be at work or just don't want to come in. Is there a factor in your research in public health about this matter? It's, it's not a requirement. We can't enforce people to be force people to be tested for latent TB. What happens if there is an active case identified, then the TB service will contact race and see members of the family who might be at risk of having TB and will offer the latent screening. Part of the work they do then is trying to persuade, negotiate, give the benefit to that person of why it's important. So it is always offered, and it is part of response to cases, whether people take that up or not is a different matter. As I said, I think the TB service do a really, really good job and the number of times that people don't access that is quite low. But it's not something that we can force people to do, unfortunately. And I think that also links around with the stigma and it may be then those people that then go back to their country of origin to get tested or to get treatment for it then rather than saying to their families. Thank you. Councillor Mitchell. Thank you. When a case of active TB is diagnosed, apart from close family members, I'm just interested to know how widely the net is cast to notify casual contacts and people maybe just living nearby and how widely, in terms of good practice, how widely should the net be cast? And how likely is it that even very casual contacts like sitting near somebody on public transport, for example, could result in infection? There are some really very effective guidelines and evidence-based guidelines in place about tracing contacts and who contacts are. So what UKHSA does, so the UK Health Security Agency who would lead on this response have what they call a ripple effect. So for example, if they identify somebody in an educational setting with TB, they will look at their close contacts, and that's normally people who have spent eight hours or more with them in the same room or in their household, because you would have done that on a household basis. And they will test them as they're in a circle almost. If they find any cases in there, then they might take the next circle out, which might be people that have been in the room or shared coffee with them or had their lunchtime with them, but slightly shorter period, and will test them. And so rather than going into a blanket, We're going to test everybody, one, it's not great for your mental health to think you might have been exposed, but also it's not effective, because you won't find they'll definitely do that very clear ripple effect. What they will also do as part of that is give what we call worn and informed letters to people in those circles who might not be being tested, but just to let you know that has been the case. So the risk of becoming infected from a casual contact is very, very low, if not nonexistent. Thank you, Mary. Great presentation. Thank you, really informative. I was just wondering in terms of the engagement with colleagues in primary care around -- you did mention that we might not be doing all the testing we should, whether that's highlighted anything or anything that we can do to improve that testing there? Yeah, thank you. Yes, it's a straight answer. So that is one of our actions on our developing strategy will be to work with GP practices. It's commissioned at the moment by the ICB, as I said, and there's a couple of things. There's one about raising awareness with GPs about signs and symptoms for active TB, but then also about who's eligible for that screening program and what the test is and what the referral pathways are. So, and our first, I guess, step in that is to identify a GP champion who can lead that and we've been working with our clinicians in UHF to do that, so I think we've got somebody in mind, but we can't name them yet because they've not agreed, but that is definitely the next step, yeah. Some persuasion to be done. Thank you. I've got two questions and then just want to acknowledge what you've already referenced around the clinicians who are really advocating for this and doing a very good job of that in a very difficult resource-constrained environment. So the two questions that I had. First is around the stigma. I'm really interested in this idea that there is stigma around it, especially the reference to sexual health, and I just want to understand, or ask if we understand, is the stigma within the community, or is it the community's concern about external perception and their concern around, for example, being able to get a job and children going to school, etc. And then the second question was around do we understand the impacts of travel, so for families and individuals who have families abroad where they return for an extended period of time, and then coming back to the UK, whether that's a driving factor as well. So, in regards to stigma, I think yes to both of those points, so from what we know, and we are doing some more work around this as well, the early indicators are there is definitely stigma about people worried about going to work, childcare, for example, so not wanting their external community to know. But it's more than that, it's also within the family, so we've had some really interesting feedback, which I found really surprising because we work in the field, you think, Oh, it's okay, you've got TB, just go get treated. It's not a problem, but absolutely not. So, within the family as well, we have had instances, our UK HSA colleagues have told us, of instances where family members will not tell other family members and will not allow them to contact trace them because of that stigma. And that often is when they will then return to their country of origin. They'll go, Oh, I'm going back home for three months, and then get the treatment there and then come back. I mean, the other bit on that and why they're going back and coming back, and I think that leads into your other question about extended stays and back is there is a bit of stigma or lack of understanding about the treatment process here and the pathways about whether that's free, whether it's available, where you go for it, if you're having daily treatment that needs to be observed. So sometimes they will do direct observed therapy where the nurse will go and watch the person have the tablet or they'll do it on a video. It takes time out of the day around the work as well. If you go back to, I use India because that's the main proportion of our population, will go back to India, you go in there, there's no waiting. You just go in, you get your test, you're told yes you have, you get your tablets, you get on with it and then it's done. Although there is some faffing around for want of a technical term for it. Although it's a really good pathway and it works really well, it just works differently from countries where you can walk into the door and, now I've got Sarah again here, that's what I'm asking. We, again, we're doing some more work on this. Yeah, we don't have to have a screening before they come in to get a work visa. We're not sure how effective that screening is to be honest, that's a chest x-ray before they leave. But what it doesn't do then is if you come in on a three month, you come in to work for three months and we know that happens in some of our bigger employees here and then you go home and then you come back and then you go home and home in this instance is your country of origin. There is no further testing of that. So either you've had your first one, that was a chest x-ray, that won't pick up latent heating necessarily, it won't. So that's not picked up or you go back and become infected and come back and go forward and come back. So those work to be done around there as well. So we've given a writing on this student market and the question about people paying for treatment. We know we have a number of groups of people in the city who are here who work in the informal economy, who go to GB because they don't ask for proof of their status, but when anything requires a secondary care treatment, they cannot go because they cannot prove or provide the appropriate documentation. Could that be a barrier in some of these cases? Yes, the perception of that. TB treatment is free, but people don't know that, do they? So yeah, absolutely. It could definitely be a barrier. And that's really, yeah, perhaps follow up on that work as well, because I think that would be really useful to feed in. But yeah, definitely. Okay, Rushworth. Thank you. Mary, the South Asian diaspora is very big and very broad. So do we understand specifically where some of the hotspot areas are with the communities, within communities, if that makes sense, so that we can absolutely target the messages in a way that those communities understand or they want to receive, please? At an England level, we can see by country of origin, so India, Pakistan, for example, we are getting that data from the national TB unit, we'll be able to do that on a Leicester-based level as well. It's on a country level. But our TB services have all of the individual case records, which obviously we can't access here, but we can get general, we're looking at getting generalisable data that would then help us to do that, yeah. Sorry, I just think that's going to be really important, because the differences within, even if you just look at India, communicating with one part of the population and one community is not the same as some of the others, with various different levels of stigma and different levels of understanding. So anything that we can do to support that, Mary happy to help from an advice perspective if that makes sense, but the evidence is going to be really important, please. Yeah, that would be really helpful, thank you very much, because I don't know whether we will not be able to go down below India level, for example, so yeah, I'll follow up with you, that would be really helpful, thank you. I think that will be important, wouldn't it, that's a really, really good point. Are there any final questions, I'm conscious of time slipping by, but that's a really fantastic report, I don't know if you want to bring that back at some point for an update on the action plan, so we'll get that booked in, thank you so much Mary. We've got three reports left, and about an hour, can you suggest that we just have a two minute break? Mainly because I need to get to the lake, and a glass of water or whatever, literally just for two minutes, and we'll get going again. Okay, thank you. (audience chattering) (audience chattering) So next we've got the annual report of the Health and Wellbeing Board, is Amy? Yes Amy's here, so you're hiding behind a feather, I'd like to invite Amy to come and present that to us. Thank you chair, I'm Amy Endicott, I'm one of the programme managers in the public health team, and I'm the chair of seven which is here to present on the Health and Wellbeing Board report that's been sent out with the meeting information, so just to provide some overview and context, the terms of reference for this board outline a requirement to provide an annual report from the board to the Leicester City Executive, and also to the board of the LLRICB, to ensure public accountability for the board's work and delivery, and that report has now been received by both the ICB board and the Leicester City Executive team, and has received their support and feedback which has been favourable, particularly in terms of the vast amount of progress and work that's been made during the reporting period, and the partnership working approaches that have enabled that to happen. The report has been compiled with contributions from multiple partners across a wide range of the system, so I would just like to express my thanks to everyone that's contributed to the report to enable the comprehensiveness that's been achieved. There's a couple of points around the timeframe which I just wanted to clarify, so firstly you'll notice that the annual report actually covers an 18 month period, and the reason for that is because there was no report published during the COVID-19 pandemic, and as such this report covers a slightly extended period of 18 months to bridge the gap a bit between that and the upcoming report for 23-24, which will be due later this year, and secondly the report covers the period from January 22 to July 2023, which was a little while ago now. Since the end of that reporting period there have been some changes to the staffing and also the revisions to the way the delivery plan is reported to provide much greater detail to demonstrate outcomes and impacts of the actions that are included within that plan, which has meant it's taken a bit longer to gather the data and information, but also that what's being presented to you now gives a much clearer overview of how that plan's progressing, and as mentioned there will be a more current report which covers July 23 onwards to the current time, which will be brought to you in due course. So I was really just intending to give a very brief summary of what's included, and then allow the opportunity for any questions or comments. So the report being brought to you today just covers an overview of what the Health and Wellbeing Board is, what its key purposes are and how it operates, it covers the statutory responsibilities of the Board in some detail and what's been done to enact them, and in particular an update on progress in delivering the action plan that's associated with the Health and Wellbeing strategy with added detail now on impact and outcomes where applicable. Included also is a summary of the work of partnership boards who work with the Health and Wellbeing Board like the Joint Integrated Commissioning Board, Learning Disability Partnership Board and Mental Health Partnership Board. There is an overview of key communications and engagement activity with stakeholders and local people, including sort of the importance and value of that activity and how it's used to shape and influence the Board's work in a positive way, and includes the key challenges and achievements during the reporting period. So it's being brought to the Board today for any comments, suggestions, questions, and for final sign off. The 2324 report is currently being drafted, and my understanding is that the format for the reporting against the delivery plan will change slightly to include an annual update on the priorities outlined in the strategy, which we designated as sponsor or watch priorities, as well as a more in-depth focus on the areas being prioritized over the coming year so that there is some coverage of all 19 priorities. But we would welcome any consideration of further elements to include, as well as any comments members would like to raise on the current report being brought to you today. So thank you for your attention, that was short and sweet. But if anyone has any questions or comments, welcome them. It was indeed, and again as with the other reports, there is a huge amount of knowledge behind us, and there has been a huge number of achievements. What I really like about this report is the way it highlights some of the key ones for some of the practical things that have changed as a result of those priorities and the work that has been done by all the members of the Board, and it's really about focusing on things that we can really only do together as well. So I think that's a really great achievement and a tribute to what the work that everyone has done. So has anyone got any specific comments they want to pick up on the report? Kevin? Just to say, I thought some of the case studies were really helpful to reflect the points of what you were getting across, so again, thank you for those, because I think you really sort of honed it in. Any further comments from anyone else? I think we are the Board, so we know what the Board has been doing. It's great to see. We have had a recent development session, shall I mention that? We had a recent development session which we started looking at reducing the number of priorities, so instead of focusing on 19, we're considering reducing that down to around four different priorities, which we'll come back to the Board for consideration, so that we can have a really focused look at the issues that are most important, but it doesn't mean we won't be doing some of the wider ones. And it was a bit chaotic, but what we got there was the development session conclusion. There was a certain point in the meeting where I thought we were never going to get agreement or actually finish this meeting, and then it suddenly all came together at the last minute, courtesy of the Chair. So that's going to be really interesting going forward in terms of that kind of renewed approach and focus. But if there's no more questions, thank you very much, Amy and the team, and to the new team that are taking it on as well. Okay, so next I'd like to invite Mark to come forward. Is it Mark? Alright. Okay, so shall we move on to Ruth's report, then? And then we'll come back to you. Thanks, Mark. So if we move on to Ruth's report around the access to maternity services and the disparities. And this has been ongoing for quite some time. There was a request from the previous Chair, and there's been significant progress made, but I'll hand over to you to present the report. Thank you, Rob. Yes, so I don't intend to say a huge amount but just a bit of a summary and a brief background. So this report here is to outline the work that is happening in regards to addressing race-related disparities in maternal outcomes and experiences. As Rob's described, it was asked for by the previous Chair of the Health and Wellbeing Board, so it's been a process of around 18 months now. Why was it asked for? So national data tells us that black women are more likely to die or experience adverse care during their maternity journey. Asian women also, but less than black women. But locally, we know that those statistics hold true, and certainly in the past few years, all of our maternal deaths have been in women of color. So the methodology for producing this overview and this summary was that we convened a group of experts and stakeholders to share and explore work that has already taken place, specifically to address race-related disparities. Part of the reason that this has taken so long is because every time we had a conversation, we realized actually there was a little bit more going on. So we had to keep adding to the number of people we needed to hear from and what needed to be included in the report. We've aligned the report to a national report called Five Times More, which outlines three key areas for action, knowledge, attitudes, and assumptions. There are six themes in the report that should underpin, our recommendation is, should underpin any work that is happening within maternity services to improve outcomes through the lens of equity. At the moment, we are really good at retrospectively looking at health equity or inequalities. What we want to move towards is a proactive approach to, how do we improve and deliver our services? The recommendations are all in there, and there's great detail in there about the work that is ongoing. We haven't specifically focused on an area of clinical concern except mental health as being the exemplar of how should we do integrated services. Interestingly, there is a piece of work happening across the system at the moment, supported by the NHS Race Health Observatory, that focuses on perinatal mental health. But the data has taken us to a different cohort of women than we expected. So really underlining why the first recommendation of using data to be specific about the problem really is important when we're talking about disparities. I would like to offer my huge and sincere thanks to everybody who's been involved in pulling this together. At UHL specifically, we will be using this report to align to a piece of work we've done to outline what are our next steps in terms of equity. But my strong recommendation is that the themes in this report, yes, should be applied to maternity, but also to all areas of clinical improvement. I'm very happy to take any questions. Thank you. As someone who was involved in the original CHEMP steering group that was set up to work on that. Again, I'd just like to reaffirm that there was a huge amount of work done by a wide range of different organisations and individuals. I think the surprise for me at that point was just how much work was already going on in relation to the maternity equity work and the huge action plans. Sometimes it's about making that more visible for the work that was actually ongoing. Nonetheless, this is an area of huge injustice and of concern both nationally but also of course locally because we reflect the national picture. I really agree that it's not the maternal death or the real surveyor end of this and the absolute tragedy, but it also reflects a lot of other wider experiences of health services and including other things around stillbirth and infant mortality as well. I'm just going to ask a quote. I can't read that. Let me read it out so people know what the question is. The question is can we loop this into the wider women's health strategy work. Yes is the short answer. Thank you. Has anyone got any further questions in relation to this work or any of the implications of it? Yes, please do. Just to say thank you for bringing this. It really is an in-depth report and one of the things that I really like about this or not like. It was a shocking report as well, but that thing about the importance of speaking up and importance of having a voice. I think this is really clear in the report. I'm really hopeful that these actions will be implemented across when anybody's accessing health. That whole stuff about inequalities, it's all in there. I thought it was very impressive, so thank you. I also just wanted to add there's been a number of events associated with this as well, both training and capacity building for staff, but also for wider engagement. We had some amazing presentations from people with lived experience at some of those conferences as well, which just brings how important it is to listen to the voices of people affected by this. I think that was really important in the way that the work continues as well. Thank you. Any further questions from anyone at all? Again, we'll ask for this at some point to come back and continue to monitor progress as this goes forward. Thank you. Mark? It's a shame that Amanda's not here, but she didn't send me some remarks which she wanted to make, so I'll read those out in that comment. OK, yes, please do. This is the report about Black mental health and me report. Don't forget to put your microphone on and just give us a bit of the background to this as well. Thank you for stepping in, Mark. Yeah, it is better, isn't it? So if you, if like me, you've been involved in healthcare strategy and implementation for a long time, you'll probably remember the Delivering Race Equality and Mental Health Initiative from the early 2000s. It's looked at in part over-representation of people from Black British backgrounds in mental health, inpatient facilities and actually it's also... Amanda's arrived. Yeah, it actually looks at under-representation of people from Asian and Asian British backgrounds. But our focus today is on people from Black British backgrounds and their over-representation in mental health, inpatient facilities. The Black mental health and me report was supported by Public Health in Leicester and delivered by the African Heritage Alliance. And it shows that the inequality that existed in the early 2000s still persists and that's really important for us to consider. The report is co-written by Mamadou Salah of DMU and Brian Simmons of African Heritage Alliance. It's based partly on engagement with local people of African heritage. But one of the most telling sentences, I think, is on page 125 of your pack. And it's this, In England, people from African Caribbean heritage are three to five times more likely to be diagnosed and admitted... ...three to five times more likely to be diagnosed and admitted to mental health institutions for severe mental illness. In the Caribbean, the rates of severe mental illness are comparable to those in this country for white people. Such injustice is going on, a lack of care, a lack of access, and I think that the Black mental health report, Black mental health and me report, really shows that. I believe that this report and the recent NHS Patient Care and Race Equality Framework offers us an opportunity to this Health and Well-being Board to work with local organizations, supportive people from African heritage, to address the inequality that's outlined in the report. And before I finish, I'm so pleased to be able to ask Amanda, to say into the African Heritage Alliance, to speak a little bit more about the report and its recommendations, which I hope you will see as a route map to be able to work with and deliver better mental health care for people from African heritage. Just before you start, I'd like to welcome you. I'm Rob Hammond, Director of Public Health. I'm supporting Councillor Russell who's chairing but has lost her voice. So a very warm welcome. It's actually perfect timing, Mark. It just started as you walked in. It would be lovely to hear from you. No worries. I've been hot-footing it from the centre, so apologies. So, yes, I'm Amanda Teets, part of the African Heritage Alliance and part of the leadership team there. And obviously, we were asked by the Council to kind of commission this Black Mental Health Report. I'd love to say the report is really innovative. It's telling us some new news. It's telling us something different about black mental health that we didn't know. However, the findings itself are telling us the same story about black mental health that we've heard for probably more than 20 years in the sense of black people typically are accessing mental health provision way too late. So typically at the point of crisis, they have a distrust of the system. There's not enough culturally competent practitioners that understand the nuance of black mental health, and so on. And I think if you looked at any black mental health report, you'd find very similar findings. I do think, however, what the report does do brilliantly is outline a sort of route map as to how we can address some of those issues. So I think the recommendations are really powerful in the terms of we're focusing on provision, and culturally competent provision, mental health provision that will help people stay mentally well. So part of what the report is trying to do is to outline what can you and us do to actually keep people mentally well. So there's a program of provision which is all about sort of focusing on the five factors of well-being and really tries to help people stay well. So we identify people before they get into criticality. It's also about building a sort of culturally competent health practitioners. Now we're not going to suddenly get a multitude of new black mental health practitioners into the system overnight. So what we're recommending is how do we provide education and training for practitioners to understand the nuance of black mental health. Because there is a difference of how black people present their mental health in comparison to our white counterparts or our South Asian counterparts. I think the other part is about raising awareness. So I believe that the African Heritage Alliance have become a bit of a voice for the black community in Leicester, and I think that they are really trusting us now. And obviously now that we have the centre as well, it gives us a real opportunity to talk to people about mental health. And because we've been managing the centre since January, we're actually facing the real issue of mental health. We've had people in the building not wanting to leave. They have people who just are having panic attacks and we need to manage them. It's a real reality for us in the centre. The other thing we're really kind of passionate about is having some kind of outreach or a black mental health lead. Someone who can hold feet to fire, understands the objectives and the measures that we're working towards, but also can be that liaison point between mental health practitioners in Leicester. So someone who comes from a mental health background and so they can actually help with that education and training role too. And then finally, I guess we're looking at this programme, we're not going to change mental health overnight. I'd love to say in six months, suddenly, everything would be wonderful. But reality says that it's going to take time to see the fruits of our labour coming to fruition. And so what we're really recommending is a kind of more of a five-year programme. But what I am really passionate about is making sure that we have measures and evaluation along the way, so that you as a board and others can be confident that you're seeing the right kind of levers being pulled and we're moving things in the right direction. And also we want to see that happen too. So I think, as I say, the report is not telling us anything new, but hopefully what you guys have an opportunity to do here is to make a difference to people in my community, who are really struggling with mental health. We've seen that through the pandemic, we've seen the health inequalities, the fact that Dr Ru even exists over there in terms of her role, is about the fact that we know health inequalities exist for people in my community and we really want to see those addressed. So I guess my plea, my beg, my ask, my request, is that the board really kind of doesn't request another report, more data, more evaluation, but actually just has a little faith and takes the kind of leap that we're all asking for, which is to do something about what we know is already a pressing issue for the community. So yeah, that's me, thank you very much. Thank you Amanda. I mean, I'm glad we waited, because that was so much better than I would have said and I hope that you'll take on board the things that Amanda has just voiced. Thank you so much. Thank you, I mean really passionately put and the report is a fantastic distillation of a lot of issues, but it brings it together really clearly in terms of those clear recommendations. I'm going to open it up to, I'm going to open it up to some questions first of all and then we'll move onto the next steps, which is important, but Bali. Hi, I'm Bali Thorne, I'm the head of Mental Health for Leicestershire Police. One of the things that we've done in the last 12 months following some significant disorder in Leicester last year was try and engage with some of our communities more than what we were doing in the past and I went to a community event where we were challenged about whether or not we were racist, particularly in the mental health space. This is really kind of aligned to some of the work I did last year. And one of the things that we were able to identify is when we identified that we are seeing people and there's a mental health element, we could break that down into ethnicities and then what we could then break down underneath that was the proportionality of those people who were detained under the Mental Health Act. And the thing that was quite reassuring was they were equal, but the thing that I wasn't able to do because we don't have, in the police, we don't have that level of kind of population data is to see whether the initial people that we were seeing, the way we had identified that there was a mental health element to that incident, whether or not that was proportionate to our communities. And I just wanted to say, like, I know you don't want any more data being done, but I would quite like to give our data to you in order to say, Can you help us identify if this is proportionate in the first place? Just because I kind of feel like this is a piece of work that we could do together. It's quite often some of the things that come here I don't feel like we can assist you guys, but I feel like that is something that we could be doing and would help us be accountable towards as well. Yeah, no, we'd be really up for that. Absolutely. That's one time where data works. Thank you. Thank you, Barney. I do think, I mean, data is important and certainly the public health team can help with that as it has been in other areas of your work. But it's also about perception, and it's about people's personal experience. And, you know, if you've grown up in an environment where you're feeling discriminated against, then you see it through that lens, don't you? I'll hand over to Ru. Did you want to come back on that? Thank you. Hello, Amanda. It's lovely to see you. Thank you for this. I think, well, there's two things that I wanted to pick up on. So this report talks about mental health, but I think for me, there is something around this isn't only about mental health, this is intersecting with health in general. So I would really welcome a conversation, particularly from the UHL perspective, around the intersection with the physical health and actually the experience of the community that you're talking about in our hospitals in a more general sense, because I suspect what you describe in here isn't limited to the experience of mental health services. But that leads me into the second point, which may seem contentious, which is that I think that we have to be, as organizations, more bold and more courageous about stepping into our conversation around systemic racism. So the conversation we have in UHL, and it goes back to the report that I presented, is there is a problem with our systems and processes which were not built for these communities. And for many of the communities that we talk about, we have to be bolder and more courageous about opening ourselves up to that discourse. And they're difficult conversations, but part of the way we do that is through improvement and using our data to evidence the disparities that exist that are built on a platform of racism. Certainly within UHL, we will embark on a process, which we have had to work towards, of having those conversations at board level, in senior leadership level. Because without that, we will not see systemic change. We will see tokenistic, reactive changes, and that will only lead us back to the same conversation in two or three years' time. So from my perspective, you have my word and my commitment that within UHL, we are committed to talking about systemic racism and dismantling it through our systems and processes. And I'll be back in your inbox later. I was waiting for this item today to go back into the inbox, so I will be there. That's absolutely fine. So first of all, I'm Jean Light. I'm the Deputy Chief Executive for the Lensorship Partnership Trust, who's the main mental health provider in NLR. Thank you for the report. I thought it was incredibly enlightening and really highlighted some significant issues that we do have to address, and I find it worrying that nothing's moved. And I think that's something that we really need to look at. I just wanted to share a few things that we're doing. Firstly, I completely agree with Ru in terms of that systemic racism piece. We've taken some active steps in LPT and across our group, so we're in partnership with Northamptonshire. So we've taken some steps around Together Against Racism, which is a two-trust-wide piece of the work that's been in place for a year now. We've started to see a gradual change. We're also implementing quality, diversity, and inclusion matron in mental health, particularly for some of the elements that you've raised here. So we're going to start to challenge more about some of the issues that we're seeing and listening to patients more in terms of what they're experiencing, both in the community and in the inpatient units. What I'm suggesting that we do with your report is that we take it into the Mental Health Collaborative, which is a group that's working across the ICB and with social care and police, et cetera, to improve mental health services across the system. I think this would be incredibly helpful in terms of how we are designing those services and ensuring that we're taking into consideration those recommendations within the report. I've also shared it with the mental health team in LPT, and I know that, Mark, you had a conversation with one of our colleagues yesterday in terms of what we're going to do with the recommendations of the report. So I just think it's incredibly helpful, and I just wanted to share that we've done some stuff, but there's a lot more that we need to do, and linking in with AHA will be brilliant on that, and I think we should do it via the collaborative as well as through LPT. Thank you. Thanks, June. Kevin. Hi. Great to meet you, Amanda. Again, just to say the report really enlightening. It is a shame, as you said, that obviously nothing new is what we know, but it means obviously there's evidence that we've got to do something to try and here. I'm Kevin Alan Kimani. I'm the Chief Exec of Voluntary Action in Leicestershire. So I think part of it is a bit of an ask, which is we obviously deal with a lot of voluntary organizations, some specifically dealing with the black community, others where service users come from the black community. So I think if there's anything we can do about either supporting getting information out or things that you may want us to maybe link you into, we're more than happy to do that and work on that with you. The other thing as well as part of what Jane was saying about things going on around the collaborative, COSEL-L, there's also the new neighborhood mental health cafes that have been set up. A number of them, we've supported health to actually get voluntary organizations to take those and start delivering those. I think it would be good to have a conversation about what can we do to ensure that those organizations who are delivering those cafes are aware of the differences and things that could be presented and maybe how they might need to talk about dealing with those. And I suppose the final bit for me is I know we're not going to change anything overnight, you're right. I wish we could. It isn't going to happen. But I suppose my question to you is, is there anything, I hate using the word quick win, but is there anything we could look at doing now which might, even if it's like process driven or whatever, which might start making things a bit easier for people to either access something or understand the support they can get, is there any quick wins that we could be considering around the board? I think sometimes, like for the South Asian community, we recognize that there's a different language. And sometimes I think because we're black and we speak the Queen's English so to speak, I think people forget or don't realize there's a nuance in kind of language to use in the black community that doesn't disengage or doesn't kind of feel like they're not represented in some way. So I think there's definitely something about language and the way that we present information. And I do think one of the quick wins is about the education piece. I know it's not quick, quick, but I do feel like just understanding the differences of how mental health might exhibit itself from more agitated than anxious, for example, for a black woman, is the things that we need to be aware of. And the kind of language that people might use when they're, you know, you go into a doctor's surgery or all those places where you may think someone might have mental health, but the way that they're expressing themselves isn't the language that is typical. So I think there's something about that whole language piece that would be good to articulate to others because I think we just don't recognize it and it's been a bit of an issue I think for a long time. Thank you. I think if there's no more immediate questions on that, I think the next thing we need to consider is what are the next steps in terms of the assurance that the board needs around this work progressing. So one of the places that we've suggested where this is going to be held will be at the LLR Mental Health Collaborative. And that seems, that feels like that's a good place. This board is about assurance, but the actual work that needs to be done is by all the individual organizations who are represented at their collaborative. So a request that Councillor Russell suggested is that we, that the collaborative brings a report back here in six months' time to consider what we've done about those recommendations and how we're taking them forward and what other work we're doing to progress that. Okay, there isn't. So with the other question about the location of the mental health crisis cafes, mental health cafes, so there is one at the Highfields Mappered Mental Health Centre, or there's not one at the Afro-Caribbean Center, is that right? No, that's definitely something we want to work on, so like we're looking at getting mental health stages and becoming a mental health friendly space, et cetera. So definitely some work we need to do too. Fabulous. Okay, so that's the request is to come back here in six months with that, but it's something that obviously we'll all be working on and taking it, you know, incredibly seriously. And it was amazing how many links to the previous report that were represented before you came around the black maternal mortality and experience of maternity services, and actually that frame around attitudes, knowledge and assumptions could very equally apply as a frame for this area of work as well. So it would be some very interesting common kind of references there around the whole arena, around prejudice and access and attitudes and so on. So thank you very much. Is there any final questions from anyone around that report? Okay, I'm getting another comment just coming in from the right hand side now, I can forget that. So I think I just wanted to finish on behalf of the Castle Russell of thanking everyone that's presented today. We've had some really fantastic, really high quality and really informative and interesting presentations. Look how much quicker the board is when I can't speak. Thank you for everyone's patience. So thank you for everyone. We've given you back some time. We've now moved to the new terms of reference so that before board meetings a year, so the next meeting will be on the 26th of September lecture in the year. Obviously the work goes on in between times. Thank you very much indeed. [BLANK_AUDIO]