Transcript

and members of the public to this meeting of the Adults and Health Select Committee. I'd particularly like to welcome two new co-opty counselors to this select committee, Borough Councilor Caroline Joseph and Borough Councilor Victoria Wheeler. Due to both suffering emergencies, I'm afraid they are both going to be on teams rather than in person, but I look forward to them being here at the next meeting. In the event of the fire alarm sounding, please proceed out of the council chamber, using the door through which you came, and take the exit immediately to your left. Please note that today's meeting is being broadcast live via the council's website as part of our webcasting facility and in line with our guidance on the use of social media. I'm happy for anyone attending today's meeting, including members of the select committee, to use social media, provided that this does not disturb the business of the meeting. Please can you ensure that your mobile phones are either switched off or put on silent. And please can select committee members and any officers presenting speak clearly and directly into their microphones. When called upon to speak, press the right hand button on your microphone and start speaking when the red light appears. Please remember to turn off your microphone when you have finished. And if you are on a shared desk or microphone, then you need to press the right or left hand button appropriately. For those officers who have joined the meeting remotely, please use the raise hand function to indicate that you would like to speak and please mute your microphone and turn off the camera when not speaking. I'd like now to introduce those witnesses with standing invitations to each select committee meeting. That's Maria Millwood, Board Director of Health Watch Surrey, who will be on teams today. Sue Murphy, Chief Executive of Catalyst. Patrick Walter, Chief Executive Mary Frances Trust. Oliver Herne, Area Manager, Richmond Fellowship. And Nicky Roberts, CEO of Surrey Coalition of Disabled People. Apologies for absence and substitutions. I'm afraid it's quite a long list. Apologies have been received today from Councillor Angela Goodwin, Councillor Robert Evans, Graham Wareham, Chief Executive NHS SABP, Sinead Mooney, Cabinet Member for Adult Social Care, Helen Coombs, outgoing Interim Executive Director, Adult's Wellbeing and Health Partnerships. Helen Co, Director of Operations and Recovery, NHS Surrey, Heartlands. Steven Dunn, Director of System Flow. And Victoria Weaver, very much intended to be here. She's been called to an NHS conference to speak at the last minute. And I think the same situation applies to Helen Coombs. So next item is minutes of the previous meeting on the 10th of May, 2024. It's for the select committee to agree the minutes of the previous meeting. Are we agreed?

Agreed. Thank you. Next item is declarations of interest. And I'll make a declaration of interest in that I am a community representative to NHS Frimley. Councillor Mawson I believe also has one. I do. I'd like to declare a non-pecuniary interest in that I have a close family member who works in Frimley Park Hospital. And I'll make one on behalf of Victoria because I know that she would have wanted that to happen. And Victoria works for a company that provides consultancy advice to the NHS generally, but not currently to either Heartlands or Frimley. No questions and petitions have been received. So we're ready to move on to the first substantive item, which is cancer and elective care backlogs. Can I remind everyone that there is a timetable, which is that we've got 1-1/2 hours allocated to this item at the end of which I'm going to call time in the interests of us not spending the weekend here. And therefore please can you keep your questions and answers a lot of interest in this item. So it's over to Surrey Heartland's NHSICB and Frimley Health to. [ Pause ] Is that better? So it's a good morning all. My name is Professor Andrew Rhodes. I'm a professor of critical care in the University of London, but I'm also the chief medical officer or one of the chief medical officers for Surrey Heartland's integrated care system and integrated care board. And we've come here to talk to you about our elective delivery of weightiness, which is effectively outpatient surgery and also diagnostics in cancer. I think you've all had the opportunity to see the paper we submitted. So if it's all right with you, I wasn't preparing to plan to go through that paper. But we didn't set any questions on it that you may wish and any key answers and inquiries that you hopefully gave us beforehand. Thank you. And in which case, I'll kick off with the questions. Your report outlines that the last 12 months have seen further challenges in terms of waiting lists due to the capacity lost due to the industrial action taken by your doctors. That comes on top of a position where already high waiting lists were further impacted by the pandemic and by data quality issues. Every single case on those waiting lists, of course, reflects a personal tragedy for parents for patients not receiving the treatment they need. So while it's clearly very difficult to mitigate the impacts caused by the industrial action, have the Surrey Heartlands Board got a system in place to cope with this? And if so, what have you done to mitigate the impacts? What is the plan and what is the outlook? When do you expect to have your waiting list back to the standards required? And how confident are you that the data that you do have is accurate? Thank you, Chair. There's a number of questions boiled into that. So let's take them one by one. First of all, our waiting lists have never recovered yet since the COVID pandemic since effectively we ended up stopping an awful lot of the elective services for a brief period of time. They're too high and I think they're not exactly high and especially if you think from the-- through the lens of our patients. Over the last year, there's been a number of challenges of which industrial action was one of them. Clearly, without doctors and without nurses and without other clinical staff, it's very difficult to run a lot of the elective services or at least run them safely. So it did have an impact on the waiting list and it stopped us reducing them as quickly as we were hoping to at that stage. I think it's fair to say that our hospitals have learned how to manage industrial action and to mitigate the impacts of that over time. And as the strikes played through, we were far better at not having to cancel quite as many patients each time and the impact on the waiting list has been less. I think probably the most important thing to reflect on in terms of that is that the industrial action is now over and the clinical groups broadly have aligned into agreement with the government and the issues at stake seem to be settled. At which point, the most important thing is that we're hoping the industrial action will no longer continue and that we won't have to face this problem over the next year. I think what you're really getting at is how high are the waiting lists and when are they going to come back to an acceptable level. My expectation is that they are still so high that it's going to take a number of years to get them back to where we want them to be. And I know that our political masters are suggesting that they're going to try and resolve or get them back to where they need to be over this next parliamentary cycle and that's what definitely we're trying to do. It's about aligning the capacity against the demand. It's about making sure we got the right staff in place and the right facilities and infrastructure to be able to manage the patient flows as they come through. But that's not-- there's no quick wins to be putting in place new operating theaters, new search teams, because we need the staff and the infrastructure to do it. So although we've increased capacity very significantly which has led to the waiting list coming down, they are not where they need to be in terms of constitutional standards and we're expecting them to carry on coming down over this parliamentary cycle in the next 4 to 5 years. And it will be 4 to 5 years, get back to-- Thank you for that. And next question comes from Carla Mawson. And after, sorry, Heartland's, I think you also got a question for Frimley that-- or Flynn who's online will pick up I'm sure. Thank you, Chair. I mean your report indicates that there has been progress in reducing the number of patients as you've just said and I'm talking particularly about patients waiting over 17 weeks. Although the report states that there are a very small number due to the impact of industrial action and patient choice. My first question to, sorry, Heartland's, is are any still outstanding which are not by the patient's choice or due to conflicting medical needs? And if so, how are these cases being prioritized? Thank you, Councillor. Yes. So the impact of having long waiting lists is that some patients wait in exceedingly long time to get their assessments and their diagnosis and therefore their treatment. A year ago, we were faced with patients waiting over two years for this. And we've been resolving some of these long waits and bringing those long waits down as quickly as we can. Our aim at the moment is to get all patients seen within 65 weeks. So the 78-week problem broadly has gone. There are a few patients that are still sitting at that level. But that's due to the complexity usually of their caseload rather than the capacity for us to be able to treat them. The patients are prioritized against clinical need and so we try and treat the most complex highest risk patients first and then the less complex or the less needy afterwards although clearly you'll understand the nuance in making some of those decisions is not straightforward and is by no means not as objective as we would wish it to be. So the aim at the moment is to clear any patient in our waiting list that's been waiting 65 weeks. Well, it was meant to be by the end of September looking at it. I suspect it's going to be towards the back end of this calendar year. So by Christmas, we're hoping we will have cleared the 65-week waits. And that would mean there won't be [inaudible] weeks or anyone's over that period. And then we'll focus on getting it down to 52 weeks which we will hope by the middle of next year we will resolve. So at this stage, it's about getting those very long waits down and getting those patients treated, prioritizing them in an order that their clinical priority dictates which is defined by our clinical teams. [ Pause ] Yeah, if you'd like to now ask a question about NHS Frimley, please note that Health Watch have also got a question at the same point ready and after you. So away you go, Claire. Thank you, Chair. So for NHS Frimley, the national target is that zero patients will have waited plus 65 weeks by the end of September whilst trust-- sorry, I've gone on to the wrong question here. I'm going to go back this stage. I do apologize. Sorry, Carla, can you move your mic a little bit as well, please. There we go. I apologize again. So for Frimley, your report indicates that since April 21, the total wait list was an upward trajectory prior to the implementation of the EPIC system at the trust, placing the figure at 65,466 in June 2022. Post-EPIC system migration, the wait list is increased to a peak of over 79,729 in December 20,022. Some of this is presumably due to data quality. However, the wait list size has increased again over the latest one to 89,095 from the figures captured in July 2024. So there's several questions in here. What actions are being taken by Frimley Hospital Foundation Trust to manage and reduce the numbers? When do you expect waiting lists to be back fully under control and exceeding the expected standards? How are you supporting patients with long waits to manage their condition, given the likely severity of symptoms? When answering, I ask you to bear in mind that referrals for elective surgery are usually made when the condition is already causing serious pain and impacting daily life. For instance, the NICE criteria for referral for total hip replacement requiring the following conditions to be satisfied. Pain is inadequately controlled by medication, functional impairment, and narrowing the joint space on radiograph. Thank you. And if we could just bring in Health Watch here with Maria before Frimley answer. Hi. Good morning. Thank you, Chair. My question sort of expands a bit on the previous questions. But Health Watch are still concerned that there could be improvements made to ensure that patients are waiting well. And I suppose this goes across Frimley and Heartlands. So our question is, do you regularly get feedback from patients on what has worked well for them and how their experience was whilst they were waiting and whether it could be improved? And if so, has that then been used to improve the quality of the wait journey? And will it be doing so going forward? Thank you, Chair. I think I will be taking this for all. Well, I'm Alex Stamp. I'm the deputy chief operating officer for responsible for plan care at Frimley Health Foundation Trust. And apologies, I couldn't be there today. Unfortunately, one of our sites is still in a height of escalation. So I've had to step in to to chair cycles this morning. So apologies for that. And if I just take the first question with regards to our weight in this position, with regards to EPIC in context. So our weight in this was growing up until we went live with EPIC. A lot of that was as a consequence of the cheer about pressure that the organisation was under at that time. We had a particularly challenging winter position with regards to UEC pressure, which put a lot of pressure on elective services and really did impact our elective pathways. I think I would say in response to that, I think we have got better at coping with elective challenges. We've expanded the Headwood Hospital, which went live in May 2022 fully. And actually, that's had a big impact in terms of being at a Gerft accredited elective hub, which has really helped with regards to elective pathways. I think some of the changes with regards to EPIC were a reflection of some change in practice in terms of how EPIC handled referrals, which were different and did result in a weight in this change, which wasn't accounted for previously, which does account for someone's bike. But equally, we did see quite a significant reduction in activity as our teams acclimatised to EPIC and became used to it, which did result in growth in our weight in this overall. I think we have generally got through that position. The greatness growth over time is a result of the level of demand we have on some of our services, in particular when someone called out there in terms of within the paper. I think we've generally got a position where we know what our weight in this is. And a lot of our data quality is of high quality. For instance, our validation levels in terms of our weight in this size and cleanliness is amongst the highest in region and activity in the country. So we do take assurance with regards to our position and the weight in this accuracy around that. I think our challenge is with regards to the demands on services, as Sari Heartland has outlined, this is a significant backlog as a result of Covid, which has put pressure on services. And actually, what we are doing at the moment is reviewing services line by line to actually understand where do they stand in terms of the demand that's facing them and actually what interventions do we need to come through that. I will stress there is still significant pressure, particularly on the Frimley Park and Wexham Park sites with regards to UEC demand. And we are working to balance that and we have got better at doing that. But that is a challenge. Similar to Harland's, I'd say this is going to be a multi year. It's going to say it's a multi year approach that's needed to fix this and to bring our weight in line with the constitutional standards. It is a significant challenge and one that we are not shying away from. Our weight in this has improved since this figure has come down. It's combined about 3000 as a result of some of the intervention we made. But there is further work that we know that we need to do to drive that. And that's going to require a big change, both within the organisation and working with the ICS colleagues with regards to how are we managing demand from primary care and our interventions we are looking at and are already starting to develop, which should improve that overall. If I come on to the sort of well, weighting well and approach, I think that I certainly say acknowledge, I think we have fairly active in terms of communicating out to patients with regards to what their state, their position on the weightiness when they've achieved a certain threshold. And we do encourage patients as part of that process to to outline any concerns that they have with regards to impact to their condition deteriorating. Our general policy is agreed with as an ICS is that that if the patient does have concerns, they should visit their GP as their first point of call and GPS have a route to expedite referrals into the into the hospitals as and when it is appropriate with regards to the health. What was question I must say I I'm not fully cited on feedback in terms of feedback from patients with regards to the process working on. It's not something that tends to come through from our patient experience surveys and feedback that we've had from our teams. But certainly we are very open to that. We recognise the processes are trusive and there are patients at the end of that. So we are definitely open to further discussions and reviews of what we can do better 'cause we absolutely appreciate there are patients who patients who are being affected by these delays and we don't. We don't shy away from that. I'm apologies if I if I have failed to answer one another question, please let me know. There was a few questions contained within that. Thank you very much for that response, Alexander. I think it really sets a scene that you are actually bending everything you can to actually address the waiting list. So I'm going to move on to Councillor Helen Clack, who I think has some questions about Cerner and it's more heartless question. Thank you very much, Chair, and thank you very much for coming to our meeting this morning. It's really nice to see you here and online, of course. Yes, my question is for Sari Hartland's professor regarding the Cerner electronic patient record system. During twenty twenty three, twenty twenty four, it was noted in your report that a number of data quality issues were identified following the Cerner installation, which resulted in some patients having waited extended periods of time. While it's positive to know that there have been a small number of data quality issues identified in the last 12 months due to the new system, which have now been addressed. I just want to ask, have all cases now been identified and what ongoing work has been done with all the trusts to identify and mitigate further data quality issues? Thank you. Thank you, Councillor. Cerner, for those of you who aren't aware, is our electronic system that captures all the patient records, all the notes, and it keeps track of the patients as they are on a waiting list and waiting for treatment. It was implemented in Guildford and it was implemented in Athens and Peter's Trust in 2022. And it's fair to say they had a rocky ride and they ran into a number of problems which led to data quality issues. Broadly, it's quite a complex system that needs a very high level of training for the staff to be able to use it and use it safely. And that training perhaps wasn't quite where it needed to be at the time of implementation, which led to problems. There's been an awful lot of focus now given the staff trained to using it properly, which could argue should be number four. But we are where we are and it's now been used an awful lot better. There have been a number of data quality issues that have been identified as part of that which have now been resolved. We keep a very close track on the data as it's coming through. I can't answer your question as to whether everything is being resolved. It's one of those Rumsfoldian issues, isn't it, what we don't know, we don't know, unfortunately. But the priorities are one, to get the waiting list down because it's an awful lot easier to keep validated, clean data on a smaller number of data than a large number, to get the training in place so that the staff are using it appropriately and then make sure that we've got the appropriate controls and mitigations to keep an eye on that as it goes through. We're confident that we're in a lot better place than we were. And I can't say with 100 percent certainty whether we're not going to see other problems come up again. We've seen it in other parts of the country from time to time. But that's our job effectively is to keep an eye on that, to manage, monitor, track it and progress it to make sure that it fit rapidly. Thank you. And next question is what I'm going to ask which is about diagnostic capacity. In Surrey Heartlands, your report notes that ensuring there is sufficient diagnostic capacity to support both cancer and elective activity to your system's ability to reduce waiting times. The current expectation from NHS England is that by September the 30th, you know, we should have reached the point where no patient should wait more than 65 weeks for elective care. That's still a remarkably long wait given the awful impact on patients of long waits for treatment. Are you able to reassure us that this target has now been met? Explain how you continue to improve and what is being done to speed things up. And I also note that the Royal Surrey has I believe just opened a new cancer center as well to provide more diagnostic capacity. Thank you, Councillor. There's a number of different parts to this question. Diagnostic capacity, actually we do pretty well in diagnostic capacity, but we recognize that if we can diagnose earlier, it enables us to treat sooner. So increasing our ability to diagnose earlier is really, really key. And the diagnostics within our hospitals became constrained a number of years ago just by physical spaces. Every time we put another huge scanner in, it needs another huge room to put the scanner in and we were running out of space to put scanners in rooms. So that the national focus has been to move as much of our diagnostics as we can out of our hospitals into our community. In Surrey, we're seeing that happening in Milford, just south of Guildford. The Woking site is being used now to develop community diagnostics. We've got a site over at Caterham that's being utilized for community diagnostics. And you may be aware of the conversations through about the Belfry Shopping Center and using some of the space in the Belfry and Redhill in order to develop that. And the aim and the idea for that is several. One is to increase capacity to enable us to diagnose earlier. The second is to get it out of hospitals that tend to be big busy places that are difficult to access until the general public in terms of parking, getting it somewhere a little bit closer to where our residents live. And the shopping centers are an excellent example for that. People tend to go to shopping centers-- well, shopping, I suspect. But actually, it means they've got good parking, good access. And if they need to have a health test at the same time, it seems a sensible kind of way of one invigorating our assets on the high street, but also making sure that our patients can access the treatment. So we're looking at transforming the way we deliver the diagnostics, both in terms of geography out to the hospital, also closer to our primary care colleagues so that actually they don't need to go to the hospital and we can relook at things. And then that will enable us to diagnose sooner. The link to that and the waiting for treatment tends to be slightly more tenuous because diagnosis is one thing but actually delivering the assessments and then the operative interventions is another if the resident needs an operation. So at the same time, we're also looking to increase the capacity we've got to deliver surgery. And that takes us a little bit longer to develop. Our primary colleagues have already discussed how they've done it over at Heatherwood. We're doing something similar so we've got a big build going on at the moment in Ashford at the Ashford Hospital site which we're developing as an elective operating site in line with government or national policy which is to split elective procedures from emergency procedures so we don't have an emergency department on the Ashford site which means we can be more confident that actually when we have operating list, they can carry on because the patients can come in because we're not beholden to what happened the night before in terms of the emergency services. So we're building a lot of extra capacity at Ashford which will be coming online towards the back end of this calendar year. We're also, as you mentioned, redeveloping and redesigning an increasing capacity in our cancer center in the Royal Surrey Guildford. Together, that's going to give us significantly more capacity to deliver interventions. We will hope and we're almost certain that that will lead through to reduced times waiting because the waiting list will start coming down. Thank you for that. It's a very positive trend. I think I'm particularly driven by the outputs from the National Diagnostic and Imaging Program. I'll just, you know, note for the record that NHS Frimley is also in the process of building a new diagnostic and imaging center on the existing Frimley Park site which also then will provide them 74 beds. It's a trend across the NHS and I think a very welcome one to actually change the position on diagnostics. Next question. Just have a question for the speaker. You've given a very clear and detailed outline of what you're planning to do but I don't see any timeline and a lot of what you're planning to do is time expensive. So could we have a timeline now as to what kind of dates you're working to? It's all very well, bringing all this together and developing as you go along but it's the timeline that's critical for those people who are still not getting the care they require. The timeline for the elective center as I mentioned will be that it will be delivered and working by the back end of this calendar year. The ability to fully utilize the capacity within that elective center requires the staff to be appointed and that's an ongoing process. There are some staff groups which are more critical than others. Anesthetics be one of them, not because they're just critical within the operating theater but there's a national shortage of some of those staff groups which may or may not delay our ability to get going. But the plan is for the back end of this year and so Christmas, we should be having our elective operating center up and running. [ Inaudible Remark ] On the after site, that's a significant amount of additional capacity which we're putting into the system. At the same time, we're working with all of our organizations so that they're no longer looking at their capacity just within an organizational boundary. We're looking at across Surrey and the patients are beginning to be asked to move around a little bit just for the free capacity so that we can make sure that they're treated in an earlier fashion. Unfortunately, my view still remains that you're looking at two years before this is fully worked with and operational with all the delays in finding the right staff and I understand that very fully. But equally, the amount of collaboration at that point becomes key and what is available for anybody who needs surgery to be able to access it quickly. Because we're looking at an area that is quite intense and life-threatening. So it's still in my view about two years before we're back to a situation where we can deliver those things. To be honest with you, Councillor, I think maybe more than two years. As I said at the beginning, our ability to get back to the constitutional standards is something I suspect and take a multiyear approach and the national guidance or the national pushes to do it within this next parliamentary cycle, so within the next four years. We're not entirely confident that that's going to be delivered in all parts of the country. We're ahead of the game actually in Surrey. Our waiting lists are coming down faster than anywhere else in the country but we're resolving the problem but we've still got a hell of a long way to go. [ Pause ] Yeah, thank you for that answer, Professor. Yeah, I think Councillor Furey makes, you know, the point where, you know, it's tragedy that anyone has to wait. The comorbidities that pile up on them, the pain that they have to suffer and go through, the inability to actually get back to a normal life, you know, huge impacts on people. So everything that you can possibly do, you know, is wanted, is how I would go about it. Councillor Micaela Martin, I think you're next. Thank you, Chair. I would like to ask a question about working collaboratively through the NHS to reduce wait times. It says on your thing, Restoring planned service equitably is the core principle of the NHS elective recovery program. Trusts have continued to work closely with regional NHS colleagues to reduce the volume of patients waiting for elective care. I would like to ask a question. What are some of the achievements in collaborative approaches and what remains some of the difficulties and how are improvements being made? Thank you. Thank you, thank you, Councillor. A little bit like I suggested for the last question. So as we develop the elective center, we're putting that in terms of ASHRAE now. If I take a step back, it's not the most sensible kind of geographical position to put an elective center in terms of Surrey. It might be better in the middle of Surrey rather than on the edge of Surrey. So it does mean that actually some patients can have to travel a little bit further for their procedure. So as part of that, there's an awful lot of work going on to make sure that we're looking at our waiting lists now rather than just within organizations within hospitals but across Surrey. So we've got a view of all our waiting lists across Surrey and we can segment that waiting list now in terms of geography, in terms of ethnicity, in terms of deprivation so that we can make sure that we're addressing the inequalities that we see across Surrey when we're looking at those waiting lists. We now have digital tools and we're developing digital tools to enhance and to improve our ability to move patients between different organizations so that we can identify where the free capacity is if it's there and then get our patients treated quicker. So it's that collaborative working within the organizations. It's looking at it across Surrey rather than just within hospitals which to be honest with you five years ago was exactly what happened. And now looking at our waiting list so that we don't have disproportionate waits in one part of Surrey as opposed to the other. So we've got the equity of access and the equity of access to our improved outcomes. And I think it's Councillor Mckay and Marsha. Sorry, another question. However, before you go on to that, I'll also, you know, say, you know, it's, you know, really an important thing here to actually understand the data quality issues that we're facing and what you're doing to actually get them 100% right. And I believe Health Watch also wants to ask a question in here so we'll, you know, if you could do your bit, Michaela, and then Health Watch and then I think then if we can seek an answer. My question really is about the referral to treatment target. Whilst the constitutional standard referred to as the 18-week or referral to treatment target is where 92% of patients should be waiting more than 18 weeks from referral to first consultant-led judgment treatment, Surrey Heartland's ICBs 18 weeks performance, currently June 24, currently sits at 62.6%, 95,702 patients out of a total waiting list of 152,859. My question is what is required to bring the constitutional standard up to the 92% figure and is this accurate at the moment and what are the main issues in meeting it and how are you working towards it? Thank you. Thank you, Councillor. When I talked earlier about constitutional standards, effectively that's-- this is what I was talking about. It's the referral to treatment standard where the national aim is to treat 92% of our patients within 18 weeks of them being referred from primary care. This is the standard that's going to take the parliamentary cycle I suspect to get back on top of so we're looking at 3, 4, 5 years to get back on top of this. The key thing is to get our waiting list down. Prior to COVID, we had about 90,000 patients on this waiting list across Surrey. At the moment, as the paper suggests, we've got about 150,000. So we've got about 60,000 more patients waiting than we did beforehand. We need to get that waiting list down to about 90,000 and then we will be back, not far off within constitutional standards. In order to do that, we need to treat more patients than we are now and we need to treat more patients than are being referred into our systems. And that's where the work in terms of increasing our capacity to deliver the interventions is playing out. There's also something about managing the demand or at least understanding the demand and making sure that we've got line of sight of where that's taking us because we know that our population in Surrey is getting bigger, is getting older and is getting frailer which undoubtedly will lead to increased demand for our services over the next 4, 5, 10 years. I think the Surrey council data suggests that by 2030, we'll have another 30 percent of our population over the age of 85 and the reality is that's the group that most often access our services. So at the same time as we're managing a problem from the past, we're also looking at managing or mitigating a rising demand coming through in the future. Yeah, and if we could, you know, maybe probe a bit more about the data quality issue that you face with, you know, an increase and represents a large, you know, wedge of patients that weren't previously identified. Yeah, absolutely. And, you know, considerable concern about the length of time that their way to it's really making sure that, you know, everything is being addressed to make sure that there isn't any recurrence of that and that those patients that have been waiting a really long time are being, you know, moved out of the system first. So, you know, a lot of concern about that with resolving the issues around it and I think Councillor Clark wants to answer that. Thanks, Chair. I was intrigued by the waiting well initiative that you've introduced in Ashford and St. Peter's and I just wondered if you would. [ Pause ] Yeah, I can. I'm not-- I don't work within Ashford but they've got-- they've introduced a patient portal so patients have got that kind of interface via an app so they are working with how that is enabled so everybody can access it even those who don't have access to the app. But fundamentally, they're in regular communication so every four weeks, they have a process mechanism. The patients can come back to them with questions and concerns and particularly where they feel their condition has deteriorated. What they're seeking to then do is put additional support and wrap around that for a wider, multidisciplinary team, potentially when they have capacity to support patients who are in the family well, it is still early days and it's something that they're sharing nationally. They've been to many conferences to talk about it and we're absolutely looking at that across the system to cascade that out to other partners as well. Yeah, Councillor Fury. Thank you, Chairman. I'm part of the portal and it isn't working. It will take time. The basic problem is that if you operate the portal perfectly, you can actually get a message through. Well, what happens then? It doesn't flow. I mean, a classic case was I was referred for a particular procedure and the consultant told everybody by referral what was happening and the GPs ignored it completely. It did not help me but that's a personal issue. The point is and again, we're coming back to timing on all of this. You can get as much information as you like but unless it travels through to the patient and provides a more happy situation. The best example I can give you is I recently had, I was told I was going to have a face-to-face with my consultant who was looking after my vascular problem. So we got together and on the phone and he said, How are you feeling? I said, Fine. I said, I think it's all right, but summed up the conversation and the validity of what he was asking and I was giving, nothing. I didn't know how my vascular system was working. He wasn't with me, couldn't examine me. There is an amazing gap between collaborating partners that still needs to be addressed urgently. Otherwise, we're going to just continue with this problem. And can I just one other question? Since the return of the doctors to the frontline, has there been an increase in productivity or are we still stretched? Thank you. Thank you, Ken. So I'm not sure I-- well, I don't think there was a question in the first half of that, was there? [ Inaudible Remark ] Yeah. If I may intervene here as well 'cause I'm-- I would say, you know, personal experience from the end is also, you know, the accessibility of communications needs to be considered. So I'm really going to ask, you know, both ICVs the question. What are you doing to make sure that patients actually get communications that's valid, that gives them an appropriate message about what they should or shouldn't be doing, gives them the support that they need, particularly during the waiting period. And I'd really like to understand that. And if I, you know, go along with Councilor Fury, I got the letters from-- for a hip replacement that I was awaiting at the one and a half year point. And I'll forgive 'cause the pandemic was on various issues but the question that was posed to me was had I recovered from the condition. You know, it's very rare for people to recover from a, you know, bone on bone hip is all I would say. And, you know, so appropriateness, appropriate language and bearing in mind also that a very large part of the population do not understand non-complex, you know, words, three letter acronyms from the NHS and all the rest of it. So I really want to understand what you're doing on accessibility of communications. Yeah, I agree with everything you say, Councilor and communication is absolutely key. So the patient portals are being rolled out across all of our organizations. I think it's fair to say that it's a journey and it's a continued improvement journey and a continued improvement process that the feedback we've had is that they've been very well received and it enables people to access their correspondence and I have myself with my own personal health problems able to access both primary care and GP through the NHS app now which is a way to go a lot further forward than we were a few years ago. Whether or not each individual correspondence within that is appropriate, I think what you're saying is a bit more challenging as you anticipate an offer of staff that flag things up and play things through. I think the plain English language point is really important and I think that's something we're seeing come through more and more. I was with a primary care service last week down in the south of Surrey who have implemented some artificial intelligence algorithms onto their correspondence which pick up the referrals and effective like you say, you go through them and put them into a plain English speak not just so that the patients and the residents can understand them but actually so that the hospitals can understand what the GP is saying as well because it's a two-way thing and the initial feedback we've got from the hospital is the quality of the referrals has improved dramatically far better than they ever were because they now understand what the other clinician was trying to say to them. So I think we're seeing innovations coming into this space which is helping us communicate better and I think it's much needed and very rapidly needed because I think there's still a way to go. So there's a number of things there I think, isn't there? The patient quarters are helping us. The NHS app is clearly there and it's signaling and channeling the information. That doesn't help people who can't access the digital NHS app and we know that there's people out there that have this problem and that will have to resort to their old hard copy, snail mail papers and there's a lot of thought going through as to how we can improve the language within any correspondence that goes through and like you say, make sure that the right correspondence is sent out which doesn't inflame people rather than soothe them. I can say that I've had many conversations with the NHS about the need to improve accessibility and that in doing so, it actually improves it for everybody. So I'm really glad to hear that even the medical professionals struggle to understand the other medical professionals. It's not just doctors' bad writing. However, the other side of it is relying on a patient portal. This enfranchise is a large part of the population who can't use technology for one reason or another and I also know that Councillor David Harmer and I think Councillor Michaela Martin have things to say on this as well. Thank you, Chairman. Well, since I managed unintentionally, you understand, to disrupt one of your meetings of this committee, I feel that I've made comment and the fact of the matter is that I had an operation earlier this year. I have no idea what they did and my GP doesn't seem to know either and that's a bit of a problem and it may be that that's a result of the interesting relationship between the Royal Surrey and St. George's Tooting which of course is not in Surrey and that may be the basis of my not knowing what was done which was all prepared at the Royal Surrey but actually done at St. George's. But it just seemed to me that it would be quite helpful to patients to know what's going on. [ Pause ] Absolutely. There's an expectation that the patients absolutely should know what's going on both before they sign up to a procedure and after the procedure to know what happened. And broadly, as a principle, that's exactly what should and does happen. That doesn't mean to say the principles always followed and we know that all our patients, most of them are absolutely excellent but some of them aren't quite always as on the board as they should be and I apologize if there was a slip there but I think the majority of our patients do get to sign appropriate consent forms and do get told afterwards exactly what happened. It might be what you're describing is as a slip up communication between London and Surrey. I don't know. We can take out the-- [ Pause ] Michaela Martin. I think health watch just said that they-- their question's already been asked so. I was going back to the patients who have no digital awareness. How are you going to make sure that they can still get access to their records? And this is really worrying me since a lot of people over the age of a certain age have no digital awareness. Thank you. So this is the reason that we still default back to the old paper records. It's for these patients. So the correspondence won't be purely digital although there'll be a lot of efficiencies when we move in that direction but actually we still send hard copies out and for that reason. There's a lot of work going on to understand the group of patients who have less access to the digital kind of innovations and to support them and where necessary to have other ways of communicating with them and for that reason. We're aware that a portion of our population won't either-- can't or won't access through the digital rates and although that's becoming more and more commonplace so we can't leave them uncommunicated with so we've got other ways of channeling that information. [ Pause ] Thank you for that. You know, what we'll say is that I think we've identified a recommendation that we're going to be making to you so, you know, it's very obvious it's something that is going to be a-- need to be a real feature I think of, you know, things as we go forward. It's one of the biggest complaints that counselors get from residents in relation to health services that they get sent messages that they don't understand. So it's clear that things need to change. [ Pause ] Anyway, we seem to have killed off a few questions in the process so I'm really pleased that we're making good progress on time. And I think really, you know, in terms of the actions, you know, to deal with backlogs, can you talk a little about how you might be working with other organizations that can take up some of the load such as the private hospitals, other health facilities, maybe working in partnership with neighboring trusts as well in order to actually make real effective use of capacity. And I also note that, you know, for instance, NHS Frimley are now working their Heatherwood location very hard. It's, you know, in operation carrying out elective surgeries for a phenomenal number of hours per week with-- they've actually got it down to seconds between patients going in and out of theater which is remarkable. So if you could talk a little to that please. Yes, of course. When we talk about capacity to deliver interventions, we talk about capacity in all the different sectors. So, we have capacity within our traditional NHS organizations within Surrey. We have capacity that we can access within other NHS organizations outside of Surrey. For instance, the gentleman-- the counselor previously acknowledged in Georges but there's plenty of other organizations around the periphery of Surrey that we can-- we can move and utilize capacity but we also have considerable capacity we can access through the independent sector on pure NHS means. And that can be through our-- let's call it traditional or private organizations but also a number of other kind of health organizations which may be for-profit or non-for-profit but sit within the Surrey, so I think so. So we've got the ability to access all of that capacity as and when we need it. And clearly, you'll have seen the government's policy which is for us to fully utilize all the capacity that's available to us to get the patients treated. They're waiting this down and the patients treated sooner. So that's what we do. And I think you asked me a second question about how well-- I think it was how well are we sweating the assets that we've got. I think that's broadly translated. That's exactly-- Yeah. What we've seen over the last few years is all of our organizations operating and utilizing their assets far more-- far better than they were. So like you gave the example of number of hours in a week, they're actually actively operating. So we've seen all of our organizations move from five-day operating to six-day and sometimes seven-day, we've seen it from traditional eight to 10-hour days, move up to 10 to 12-hour days and all of the organizations doing that. The challenge actually isn't the physical space to do it. It's the ability of our staff to keep up with that demand because we haven't been able to massively grow our medical workforce. It takes 10 years to train a doctor. And so if we're working 20, 30 percent more now, that means the same people are working 20, 30 percent more than they were beforehand and that limitation stops us really managing to push the operating hours up for each of the organizations as much as perhaps would be needed to really bring the rest of the staff quickly. So we can't operate 24 hours a day, seven days a week because we don't have the workforce to do that and we have to be very careful that as we push our workforce, there's a danger that we won't burn them out and two, if they become tired, they start operating in a less safe fashion. So there's a balance that has to be played in terms of how we can sweat our assets like you're describing but also how we utilize and deploy our workforce safely both for our patients and for themselves. I also note from, you know, experience at Heatherwood and the Get It Right first time report on the subject that, you know, running, you know, many of the same type of surgery, you know, back to back has incredible efficiency gains. So again, it really underlines, you know, having an active surgery center is game changing because you're not faced with the random emergency care arrivals that they divert from the production line approach. So yeah, I look forward to being able to do the same is what I would say. I'll also point out that Heatherwood, you know, scored best in class as well when they were assessed. Councilor, we fully agree and that's what we're working on doing. I think the one reflection is that a modern estate that's well kept, looked after and built for purpose enables the productivity gains. Some of the state that we have to operate in is old and is not maintained to the standards we'd want to for financial kind of reasons and we just don't have the money to keep some of them up. And that leads or inevitably results in productivity not quite where we want it to be. So there's definitely something about having a fit for purpose modern estate and with an adequate and well-trained workforce that's utilizing all of these national metrics you described to Gerft team fully to make sure we've got best practice ingrained and embedded so that what we're doing is the most productive, efficient and high quality that we can aspire to. Could you actually expand a little bit more on the constraints of the estate and what's actually being done to deal with that? It's obviously not going to be, you know, an overnight fix. I don't think anybody and obviously there are all kinds of financial and management issues. But it would be helpful to actually understand what the actual overall strategic approach is. So the strategic approach as you described is to split our elective plan care services away from our emergency sites so that we have pure operating sites for elective surgery which aren't beholden to the whims of emergency kind of issues outside of their grasp. And the second thing is to make sure that they've got all of the adequate infrastructure that's well maintained and in place. So a good example for that would be that we have to have adequate air handling in terms of not just temperature control but our operating theaters need to have the air flow at very high levels to make sure that the infection control aspects are well maintained. We've had problems on a number of our sites with an old age-- I'm going to call it elderly, aged struggle which leads to reduction in productivity. We've got plans in place to maintain and to improve and to refurbish them but clearly that takes a bit of time and also the financial kind of support structures that enable that to happen in a timely fashion. Okay. An obvious constraint as well is the amount of time patients stay in a hospital postoperatively to actually improve on that situation. Yeah, there's a number of different parts to this question. Partly, one is that we're moving an awful lot of our surgical interventions to what we call day case surgery so they have your operation and you get discharged from the same day without ever going into a bed in the hospital. That needs the right facilities to do it. So in some parts, sorry, we do that very well and others we don't have quite the amount of day case infrastructure and support to be able to do that. The other is to make sure that all of our processes within our hospitals are aligned to getting the patients mobilized and home in a timely fashion as quickly as they can in a safe fashion. A good example for this would be after, I think a few of you have said you're either waiting or you've had hip replacement surgery. The ambition is to get our hip replacement surgery out within a day of surgery and some parts of the country are doing that about 70 or 80 percent of the time. We're not quite there. Our average length of stay is about 2.8 days for hip replacement surgery. And the challenge is the quicker you get them out, the more support you have to have outside of the hospital to stop them coming back in, if that makes sense. And we can see that as a variation within Surrey, Ashford, St. Peter's, and Guildford are actually quite good. They've got a very low length of stay for hip replacement surgery. Whereas East Surrey over in Southside is sort of slightly higher. The flip side to that is we have more emergency readmissions over at Guildford and Ashford's, because the patients are going home a bit quicker than they are in East Surrey where the readmissions are lower. So there's a balance to be played and that plays into the fact that it's not just about the surgical team and the hospital getting the patients up and out. It's about the support package we then wrap around them to make sure that they remain and it keeps them well and improving after that. It's a complex thing. There's a huge amount of work going in for all of the patient pathways to be able to support that work. [ Pause ] Thank you. And I think Alexander Stamp wants to come in as well please. Yes, thank you, Chair. I just want to come into the physical estates point that, sorry, Arthur's made. Because I didn't want to emphasize, you know, we've got, you know, a really good estate, which is, you know, very well utilized and very productively utilized at Heatherwood. I do want to emphasize that the Frindley Park Hospital site is still a site which is impaired by RAC. We do have two theatres out this financial year as a result of RAC. RAC is likely to be an ongoing challenge for the organization up until we are into the new hospital which at the moment is indicated on plan for 2030. And so I didn't want to, in the interest of transparency, I want to emphasize the impact that RAC is having. We are working to mitigate that. We have plans in place which often involve decanting this to Heatherwood as a buffer, but that is an impairment in terms of the sites, which is quite unique to the Frindley Park site in terms of our estate within FHFT. But I did want to emphasize that that is a challenge for us that the teams are managing on an ongoing basis. We have a RAC program of inspections, which is going to be a multiyear program as we run up to the new hospital. But I did want to come in and emphasize that point with regards to the physical estate because it is a particular challenge at the Frindley Park site that we are dealing with. Yeah. Thank you very much for that. I also happen to be chair of the Frindley Park Hospital Joint Health Overview Select Committee. So yeah, it's a very pertinent point to raise. [ Pause ] Okay. I think we're getting down towards things. I think the other one was in your report you indicated that you were scrutinizing the specialities in detail as well in relation to waiting times. Are there any particular issues that you've identified there that we really ought to be aware of and following up on? The specialties which have the biggest problem tend to be orthopedics, formal orthopedics which has come up a few times, tends to be kind of hip replacements, knee replacements, shoulder replacements, that type of surgery, the challenge there is that the volume of patients coming through is just more than can be managed at the moment which is meant that the waiting is stretched out. And that's why we're focusing the Inactive Center at Ashford on formal orthopedics to start with. Other specialties that are challenging are ophthalmologies of cataract surgery. That's because again the high volume of patients requiring cataract surgery and this outstrips our demand. So we're putting an additional capacity again at the elective site on Ashford but also we're seeing a number of other providers come into the marketplace to support us on that journey, non-NHS, all around Surrey actually to support that process. Some of the major cancer pathways remain challenged because of the complexity and the rarity meaning that the complexity means really special arrangements, head and neck surgery, max fat surgery is a key point in that. And I think the report highlighted some complex gynecological procedures especially for endometriosis which is challenging because it's no longer a single surgical team with some of these complex procedures, it means gynecologists, it means general surgeons and sometimes radiological departments all to coordinate at the same time and same place for quite a long period of time and the complexity of arranging some of those things is just as challenging. So I probably know the ones I'd highlight. Every single specialty has their own particular niche problems but I think they're the bigger ones that you might want to be aware of. Thank you for that. We got any more questions in the room or online? I think we're-- For patients. Number two, keep the Adults and Health Select Committee updated on the Surrey-Hartons NHS ICB cancer groups that experience inequalities. And third, to improve accessibility ensuring that communications is effective and does not disenfranchise those who do not-- are unable to use technology in one way or another. I think that's where we are and thank you very much. We're actually running a little ahead of time so I'm going to suggest we have a slightly longer break than normal and take 20 minutes. Thank you. Thank you. Also note that, you know, unfortunately, you know, two of the council's present have got time pressures and won't be with us for all of the meeting. Yeah. Thank you for coming and we look forward to hearing more about, you know, how things are progressing. Okay. I'll just go as we are. I'd just like to remind everybody that today is World Mental Health Day. And this year's theme set by the World Federation of Mental Health is Workplace Mental Health. The theme highlights the importance of addressing mental health and well-being in the workplace for the benefit of people, organizations, and communities. Sometimes in the stress or pressure situations and environments, it's all too easy to concentrate just the task in front of us and forget about those around us or also experiencing those stresses. The key action we can all take to think about those we work with and encounter during our work day and to make sure that we treat everybody with kindness and concern for them as an individual. Reaching out to those around you to ask, How are you today? is sometimes all it takes. So please, let's all take two minutes now to just make that effort. How are you today? [ Inaudible ] Thank you. Right. We'll now move on to the substantive item which is Right Care, Right Person, where I believe we now have a presentation. So over to yourselves. Not so much a presentation, Chair, more of an introduction. So if I start off and introduce my colleagues, my name is Liz Oliasz. I'm the Director for Mental Health Emergency Duty Team and the Prisons Team within the County Council Adult Social Care Directorate themselves. And then I'll just open up the item. Hello. Hello, Chair. I'm Simon Brown and Cave. I'm the Deputy Director for Adult Mental Health Commissioning at the ICB and also in with the Council. Good morning, Chair. My name is Alex Jones. I'm a Consultant Nurse for Surrey and Borders. I work particularly in the area of crisis care. And my colleague, Helen Wiltshaw, is online from CCAM. Helen, if you could introduce yourself, please. [ Pause ] Yeah. I don't think she's online. Okay. That might mean a couple of questions will have to be sent in, responded to by email. So just to open this topic. Right Care, Right Person is a police policy that's being rolled out nationally. It was modeled in Humberside and the National Federation of Police Chiefs Council, Department of Health and Social Care and various other partners have signed up to roll this out nationally. The paper presented today outlines what Right Care, Right Person is and how it's been implemented in Surrey by the partners in response to Right Care, Right Person. It's not our policy [inaudible] because it obviously impacts on our day-to-day work. There is a clear government structure within that that's police-led and that's broken down to gold, silver and bronze levels and that's all outlined in the paper. Those levels have continued since the implementation of Right Care, Right Person, partly to review and monitor the impact of Phase 1, but also to plan for Phase 2. It's important to note that Phase 1 was only implemented live on the 22nd of April this year. So it's still relatively early days. It's six months that we're looking at, but and Phase 2 is actually still being scoped and we'll talk a little bit more about that when we come to it. But I think it's just really important to stress that this has been a partnership piece of work. Although we're responding to the police policy and I can't stress that enough, we have worked in collaboration, we've shared information, we've regularly met and as I say the levels are tactical, operational and strategic to actually make sure that this runs as smoothly as it can for the residents of Surrey. I'm going to stop talking and ask my colleagues if they want to add anything. Yeah, I'll just reinforce that. It's a collaborative piece of work. There is a formal framework of gold, silver and bronze tactical operations. We also additionally in the ICB have a partnership meeting where we talk through the issues on a regular basis and bring people in from other areas to reflect on their work. Just to say also that the police have shared their policies procedure. They did a training session for the groups so that we could see what their staff were being trained on so their core handlers are trained. They shared that training with us. They have shared their policies and in fact they delayed the implementation at the partnership request when the whole issue about, it wasn't an issue. We were planning for children to be involved and then it was very clear that under 18s are not involved in Right Care Right Person. So just to explain that, if a child is involved in any way, shape or form, even if it's an adult issue, if we're calling the police for a welfare check and there is an adult, a child under the age of 18 in that household, they will deploy as normal. They won't apply the Right Care Right Person principles they will deploy. So we asked for a delay in implementation which they, I think they delayed by about six weeks at the time just to give us time to make sure that practice was embedded within, we can move on into the questions. Okay. And the first question I have is Councillor Frank Kelly. Mine is obviously to do with staff training. I know it's very, very early on in the process. But making sure that staff understand what is expected of them is really, really important. As somebody who did 35 years for Surrey and Borders, training is imperative in whatever we're doing. But how are you monitoring this initiative to make sure that you're working effectively collaboratively? And when you're coming up against issues and problems, how are you dealing with those to make sure that nothing gets stopped partway through the scheme? So I'll start and then my partners can chip in. So we've all done our own training based on what the police shared with us. This is monitored as I say at Bronze, Silver and Gold. We continue to meet after implementation. We are doing for the foreseeable. The Bronze group looks very operationally. They look at case studies and prior to implementation they were looking at case studies and looking at people's potential journeys. That has been escalated up to our level at Tactical Silver where we look at some of the learning. Where there have been issues, we're very quick to raise that with the police and we will challenge data if we're not happy with it. But certainly from my perspective, I rolled out the training, staff awareness sessions. We captured about 1,000 staff and had to make sure that, you know, we do a refresher and that people are absolutely sighted on this. And at the Silver meeting, prior to go live, we all did a red and a green as to where we were for several weeks beforehand, were we ready for the implementation? So I think that the current structure within the, I keep referring to it Bronze, Silver, Gold, but that's how the police refer to it, is actually where those issues are highlighted and discuss your care, it's on my radar the whole time. It's something that's raised and we have a dedicated email, so if there are any specific issues, staff can raise them, they haven't today. We have also, you know, we've tried to share that guidance, particularly myself and Soren Borders, that we've issued to all staffs, all staff have guidance and at the back of that guidance is the escalation process, that initial call. I'll hand over to my partners to stop the call. Thank you. It's very similar to kind of Liz's response. We've socialized our staff, we've looked at the training provided by the police. I sit on the Bronze and the Silver meetings and one of the very helpful parts of that is to look at case reviews and to try to detect and correct quickly in regards to any kind of issues that we've had around the process of Right Care, Right Person. But outside those meetings, we're often having regular interfaces to kind of check. One of the things we've also talked about a lot is looking at the good practice that's taken place and to make sure that we're highlighting the things that work well in regards to people getting the support they need from the right service and how we make sure we really sort of emphasize and amplify that. In regards to the Bronze, if there are issues that come up, as Liz has said, we go back to the teams, we make sure that they're aware of the escalation procedures that are in place, that there's not a delay. Some of the learning that's come through initially when we started working with the police on Right Care, Right Person was around welfare checks where people may have been used to using online reporting for welfare checks where you need to talk to a call handler because they will go through their script using their Thrive model of risk assessment or risk formulation. And we're very quickly able to kind of get that message that it needs to be a telephone dialogue, a care right person. Yeah, please do, Frank, and I think the health watch won't come in after you as well. Yeah, very, very quickly, with regards to the training itself, are you doing face-to-face or online training or a mixture of both? Because I've always found that face-to-face training seems to embed this sort of thing a lot quicker than doing it online. So I did it online in order to get to as many people as possible. And we had an opportunity for question and answer and we shared the training pack. As I said, I'm looking at doing it again. And so I can certainly review whether we do some in-person training. But to get that really, get as many people through as possible, so we went for the online. Similar approach from SABP, although what we have done to try and socialize the teams further into it is have those sort of face-to-face discussions around business meetings, governance forums. The other part that we have also looked to doing is using the PSURF, Instant Reporting Framework, to think about where reports have come in and how we huddle with the teams very quickly to get that learning sort of re-embedded. Thank you. And now if health watch would like to come in here, Maria. Yeah. Hi, I'm Maria Millwood from Health Watch Surrey. This is a bit of a broader question based on this, but it's around the relevant training being integrated across the whole of the system, including organizations like Health Watch Surrey that have an advocacy and support line. Because often we've seen an increase in the number of people who are content in our help desk who are in crisis, and when we're signposting them, they don't always want to go back to where we're going to be signposting them to. So it's a question really about how it's integrated with all the other training that's available to voluntary organizations that support people. That is a good question, Maria. So we certainly encourage the police to make contact, and I know that they rolled out some of the training for some of our voluntary sector colleagues, and we asked them to contact the Surrey care providers, but it is something we can take back if you feel there are still gaps in terms of what the police are offering. As it's their policy, they kind of led on their training for partners. They trained us, and we trained our staff, but we can certainly take it back to the silver group and encourage them to review if there are any gaps. Okay. Okay, thank you. I think it's good because we could then report back some of the learnings that we're having as a result of the changes that have happened to the police. Thank you. Thank you. We're actually going to skip the next two questions that we were going to ask, which were to Southeast Coast Ambulance Service, because unfortunately they've been unable to get online. And what we will be doing is submitting those to them in writing and asking for a written response. Fundamentally, the questions that we're asking are about the impact on their staff, managing their staff with the changes in process, the resource implications on them, and how they were going to measure the impact on staff, bearing in mind all of the other issues that they have to cope with. I think Helen just joined. Helen's just joined. Just joined, yeah. Helen, would you like to actually take on the questions? Because I think you've had them in writing. So if you'd like to just come in at this point, that would be great. Hello, Chair. Sorry. Apologies. I was struggling to get in with the link that I had. So I was just scanning my emails and found another link. So -- Yeah. We kind of picked up your technology issues. So thank you. So you are -- sorry, but if you could just repeat the question. Is it the first question? Okay. The first question was about non-deployments redirected to Southeast Coast Ambulance NHS service. I'm particularly asking how the staff managing with the Right Care Right Person Initiative and how CCAM are monitoring that. No problem. Thank you for clarifying. So as far -- at the moment, we've -- Right Care Right Person has not proven to represent a noticeable increase in the police activity being redirected to ambulance. And the escalation process followed has proven supported in providing the discussion where alternate agency attendances are required. We've got -- that said, we are seeing an increase in mental health calls. So as noted in the report, it's very difficult to associate the Right Care Right Person Initiative specifically with increased activity that's reflected in all ambulance trusts, actually. So what -- but we have a really clear process for managing any instance that come up that result from a mental health call that we believe could be as a result of Right Care Right Person. So that's raised escalations are made from operations providing an internal data X process. And those data Xs are monitored for any specific case reviews. And those case reviews are then brought to the attention of partner colleagues for discussion at the -- either specifically for a specific case or at the weekly bronze meeting. I suspect you've probably spoken about the governance process that's in place at the moment. So it's fair to say that those data Xs are being handled through a standard process. We are getting a recurring theme that when crews encounter a patient with a history marker for mental health concerns, including violence or aggression, that they're anticipating a police presence prior to making contact with the patient. But in some cases, the police are not responding as it's seen as a perceived risk, but not an actual event. But what they have done -- so in that case where the emergency operation centre feels that the police do need to attend and that will work through the agreed escalation process that has been supported and signed off with all partners, police have also assured -- trust that if a crew are experiencing violence or aggression, then they will absolutely respond. So it's about the escalation process on the day, supporting frontline crews and escalating that from our emergency operation centre command to the police command where needed. And if after event that we're picking up incidents that we felt could have been dealt with better between the partner agencies and that is being fed back through the partner group forums that we have, specifically the bronze group, or if it's a specific case review that we think warrants an earlier discussion, then we will get together the partners to do a specific case review in that case. Does that answer your question? Yeah, I think that goes to that one. The next question is -- oh, yeah, Councillor Furey is also -- unfortunately, it's at the very far end of the room for me and it's very hard to spot. I can't even see you from this end of the room. But that's another matter. The question I wanted to ask was this. I was on the Policing and Crime Commissioners Committee or the board and this object, this subject came up about why we needed to release police from going to an emergency and then having to stay there four or five hours until he was seen because of the NHS situation as we know. And I believe wholly that this would be a game changer because it's the wrong people, they're doing the wrong job for which they are trained for. There should be some outcome other than that. And you note -- I note within the report that there were areas in which the -- on page -- it's not page, page 8 -- anyway, on one of the pages, data provided by Surrey Police is highlighted in the first 30 minutes of pages 1 and 2, there were 4,233 RCRP related calls. Of these, 1,562 did not meet the criteria for a police response which left a total of 495 cases which were not adequately sorted. The other thing is CCAM is not here because it's no longer in this area operating. EMAID is not doing this area. Have we actually got the same agreements with EMAID that we had with CCAM? That's number one. And number two, since the police started this PCRP, how much more work has this given to our corporate family in terms of involvement which wasn't there before because the police stayed by the client and you weren't required until something had been diagnosed and dealt with? And finally, is there a specific point of contact where triage can occur prior to a mistake being made and the person being -- that's going to be collected, has now suddenly had a marker which is a requirement that the police should be there? How do we manage that? Sorry, three questions but I think they're important. I can answer question one and -- well, I will attempt to answer question one. So just a point of clarification, Councillor, for May. What area specifically were you talking about? I didn't quite hear. [ Silence ] You have to use your microphone, John, because they won't be able to hear you otherwise. It's the whole of the county. That's where the agreement on PCRP now operates. Police put it in place in Surrey because of the amount of time that was being tied up with police officers waiting for a client to have been taken there to be actually seen and a triage occurred. Now that they've stopped, I indicated that the first question was the -- since the started, what increase has Surrey's support been required to provide if possible before and after? That was number one. [ Silence ] I can't answer for the police specifically. I can only answer the South East Coast Ambulance Service, I'm afraid. But what I can say -- They're no longer operating in Surrey. South East Coast Ambulance Service covers the Frimley Patch, the whole of the Surrey ICB, Kent and Sussex. Okay. [ Silence ] So I don't know who EMED is, but South East Coast Ambulance Service absolutely responds for Frimley, Surrey, Kent and Sussex. So yes, the agreements that we have in place across all partners, all agencies, but particularly the escalation process. So where there is a specific contact point and the appropriate agency does not seem to be responding, then that's how the -- when the escalation process would be used, Councillor. And that is in place for all of Surrey calls that sit under the Surrey ICB footprint. And the second question -- I'm not sure that I answered the second question. I'm just wondering if I could ask you to repeat that, please. [ Silence ] Good Lord. The second question was what increase in support has been required since the introduction of this PCRP in terms of our support services within Surrey and within the Council? Again, I can only answer for CCAM. So with regards to right care, right person, our CRP, we've not proven to represent a noticeable increase in police activity being redirected to ambulance. But what it has done is improved the communication between agencies with regards to cases. So by having in place the specific policies and flows around right care, right person and the escalation processes between the contact centres, then it's indicating when a different response is required to what the police may be responding under their current RCRP. As I said, there are a number of instances where -- cases where we may have had a call relating to mental health, where we get on scene and we believe therefore that we require the police to attend particularly where there's a history marker patient and the police may not have responded to that. However, if we feel that there is any risk, immediate risk to the patient or to crews or crews are experiencing violence or aggression, then the police will respond. And that is all facilitated through our emergency operation centre and through the contact centre. I think also it would be helpful to talk about the activity that's coming online with regards to the recent launch, Councillor, in terms of the section 136s. So right care, right person was launched the second phase in September. There has been some data where we've arrived on scene and we've been requesting assistance from police and they haven't in those cases always responded. So there are instances where, you know, patient may have capacity and not want to attend ED, but in the best interest of the patient, we believe that a section is required to support that patient in their best case and their best interests. And at that point, that's where we would be escalating again to the police to support on a warranted section 136. May I come back, Mr. Chairman? The question really was about, again, I go back to the report, there were 4,033 R.C.P. related calls. It then indicated how many there were and 37% police non-deployment has remained. The question was how much more have we as a county with our services had to increase to get more involved earlier than we have previously done? That was the question. Yeah, I think that's more appropriate to go to the officers than the CCAM. [ Inaudible Remark ] I gathered that. Once you continue. Hello, Councillor. So I attend the silver tactical group and the consistent message that comes across from all the stakeholders present is that we're not-- I'll let the council and my colleagues from-- sorry, I'm bored to talk specifically, but that's the overall message, we're only six months in. The bronze group is doing sampling of the calls that have come into the place to work back and to see if there are consequences and activity that we don't have visibility on and what the-- some of the longer term [inaudible] to date. I am surprised at that and I would expect that to be an increase once the police get used to using it to allow them to leave a hospital having dropped a patient or what have you. It will be interesting to keep an eye on that because it could be a complete drain on a lot of our services, we are in certain areas particularly in our health services, short in terms of staff, we don't want another pressure point to become an immediate and apparent thing. I think the other thing is that I-- my third question was about communication. If the police get to the hospital, is there a specific point of communication that they can access in order to stop their attendance being involved and bring somebody else in, because that was the name of the game for the police. Thank you. I suppose just to say with the hospitals, that setting could be an emergency department if the police had concerns around someone's physical health presentation and right care, right person isn't exclusive to mental health, it covers the health spectrum per se. We do know that other areas that have implemented right care, right person have sought additional funding to support transfers from the police into different services. So we know Hampshire, for example, do commission a private ambulance service to wait with people and I think that might be eMed, forgive me if it's not, but we also know that Humberside where right care, right person first originated from, again, looked at additional funding to support the network and in Kent there has been some funding to provide a single point of contact for the police to try to help with decision making around 136. So there are different strands where other areas are putting specific funding to help the system. That hasn't been the case in Surrey to date. I think your words are very poignant about the monitoring and keeping an eye on that. We do have existing systems in place to monitor 136. So we have subgroups looking at and I'm part of one of those groups looking at police activity when they do place someone on the 136 and we will look at body worn footage, we will look at what the officer's decision making has been. We look to see whether there has been advice from a registered health professional before a 136 is initiated. But in regards to that handover process, we don't currently have a system in place so officers would still be attending emergency departments and then it would be for officers in the emergency department to make a decision as to when officers can safely leave that person in the care of the emergency department. If we have vacancies or spaces in our health-based place of safety, we have four health-based places of safety beds which are currently at Farnham Road Hospital, separate from the hospital. Officers will look to depart very quickly from those environments because we would seek our own staff and mental health professionals to take over. So another big piece of work is us constantly trying to make sure that we've got space in the health-based place of safety so that we can prevent conveyance to ED when the person doesn't need that care because we can also discharge officers back into the community much more quickly than an ED department can. I hope that helps with some of those questions. That does help. Glad to hear that. I'm glad to know that Mr. Newty will depart from here and ask for further and greater funding from the labor government in time before they get to their budget day. Thank you very much. Thank you and just to-- for the benefit of anyone listening to the recording who isn't familiar with the terminology, section 136 of the Mental Health Act provides the police with emergency powers to act to protect an individual who has mental illness or that they believe is suffering from mental illness with the proviso that they are expected to do their best to also get their concurrent advice from a registered medical practitioner, registered nurse or accredited mental health professional. If we can move on to the next question, it's about communications and training to CCAM staff. The report notes that the trust has continued to roll out face-to-face conflict resolution training for all frontline staff and that includes how to communicate with highly emotional, mentally impaired and deliberately difficult individuals and providing the staff with things like breakaway techniques. Can I ask how that training has gone? Has the extra responsibility on the workforce been manageable without additional resources? And what sort of reporting is in place to where that training is coming to play and also the degree of coverage of the staff involved? [ Pause ] Thank you, Councillor. I can take that question. So in terms of the conflict resolution training, that's been in place since April 24 and we've covered at least 700 individuals during that time. There's a short break over the summer and the training has restarted in September. The complete roll out will take a further 12 to 18 months given the requirements of abstraction from their current rotors to enable that. But we have managed 700 in the first six-month period which is excellent. And the training-- the conflict resolution training itself is specifically adapted for ambulance staff from the police training. And that focus has been on threat assessment, removal from the situation in place and calling for help and the strength focus as part of that training is very much more around clinical restraint, i.e. sort of a soft hands-on approach where needed rather than physical restraint which would be more within the police remit. I'm really happy to say speaking with the training coordinator earlier that although it's early days, we're starting to see a reducing trend in staff assaults in recent months. And that does feel like it's an effective correlation with the enhanced training that being provided through the conflict resolution training. Also, just to mention the great partnership working with our AMPH service and ourselves, CCAM, in rolling out other mental health-related training which is all about bringing up the level of understanding of frontline operatives and in supporting themselves in the situations where they are dealing with highly emotional, complex, and sometimes deliberately difficult individuals. So we have a number of other initiatives, mental health first aid which is actually for-- is trust-wide about support for anyone to become a mental health first aider and being able to support colleagues, patients, family, et cetera, around them. Also, some assist training which is around-- specifically around supporting patients with a threat of suicide or with suicide ideation. And then other workforce training, supporting frontline services with complex-- functionalized service staff with complex mental health patients. And there's been around 500 to 600 staff going through those various courses this year and that also continues. So there's been a significant amount of training in the last year. Specifically with regards to the workforce and additional resources, we've not seen the need to put on additional resources at this point in time. In fairness, a lot of these incidents we were handling before, but they may-- they may necessarily-- they might have been with the police and the attendants and then calling us after an attendant. So it's not seen as significantly increased activity. However, when crews are on scene and they are struggling in any instance, then on the day they have their own operational team leader which they would link into to request support on scene. The DATEX system is really about providing feedback after an event if there's anything that they felt that they needed to-- they needed to raise for further investigation. And in terms of supporting staff and how they are managing, we also have our well-being hub and our trauma-informed management process as well. So if staff have been on a specifically difficult incident, they may be brought into the trauma program for support and discussions around particularly different difficult cases which may include cases with patients with mental health presentations. And as I say, a lot of the support is actually on the day through the operational team leader. Thank you, and I believe Councilor Caroline Joseph has got a question about lessons learned. Thank you, Chair. And when reviews have been conducted where the appropriate responding agency wasn't initially identified, potentially leaving a vulnerable person without the care they needed. With regards to these cases, where the appropriate agency wasn't identified and recognizing that such cases have been minimal, what lessons have been learned that have been shared? Thank you, Councilor Joseph. I'll take that. For fear of repeating myself, as I say, there's not been a visual impact in significant amount of activity increase in activity, and as I said, the DATEX process is used to identify in incidents where we have concerns for the safety of patients or how that has been managed in the incident review. However, we -- I'll be honest, you know, we recently are seeing some concerns and some DATEXes being raised with regards to a cohort of patients in the community who our crews are seeing who have deemed to have capacity over their own decision-making. They don't want an intervention, but in that case, you know, at times the only option is for us to leave them at home with a safety plan, and we feel that there are some cases that are starting to come through where that requires -- where patients may require a specific care plan to be reviewed and being discussed at a multi-agency level. Now, the process before was with the SHIP program. That's no longer operating, but through joint partner working between agencies, police, and ourselves, we're focusing on designing that process for individual needs and as to how individual specific care plans can be improved so that, irrespective of where that patient comes into, whether it's initially into the police agencies or CCAM, that there's a clear plan between all agencies for supporting that patient most appropriately. Probably also worth mentioning at this point that high-intensity users has been identified as a ICB workstream as part of the recently formed Surrey Community Collaborative, where we're looking -- where the ICB is looking to align place work, best practice across the whole of Surrey, and establish where there's a funding process that is needed to better support consistency across Surrey. That's quite a new setup, and there are governing oversight boards being set up, I believe the first one is going to be during October. So there's an additional workstream that's going to be homing in on high-intensity users of the overall health and care system. And as I said previously, around some of the Section 136s, we are beginning to see, which went live in September, we are beginning to see where a patient might have capacity not wanting to attend ED, but actually it feels it's in their best interest and requires review as to whether a Section 136 is appropriate. And at that point, police may not have attended. So that's where, number one, we would use the escalation process to get police to support in attendance and the most appropriate care of that individual. We're also having a partnership review meeting to think about reviewing and amending the current advice. The guidance is required by the specific case learnings that are coming up since the Section 136 roll out in September. That helps in terms of talking through some of the cases, lessons learned, and the process moving forward. Thank you for that. And the next call on Councillor Helen Clack. Thank you. This discussion feels as though you've all got this in hand and that it's more or less business as normal. However, new questions raised by Councillor Furey, for example, which I, and I'm sure many members around the table picked up about the data that in the 13 weeks of phase one and two, there was over 4,000 related calls and how many of those that the police did not attend. For residents, I think it feels a little bit concerning, really, because they are very used to when there is an incident involving a mental health crisis of the police being able to be there. And whether that's in a community place or whether it's in a hospital. And I recognize that what you're talking about is that you've had your training and that you're talking and you're learning and you have this crisis care concordant, which also that you're adding to. But I do wonder, really, how your staff are actually dealing with it. I mean, my concern is that, you know, a police presence often adds, you know, an air of calm and authority that perhaps other authorities might find more difficult to do on top of everything else that they're trying to do. And I'd like to know, are they really able to manage without the police being in presence? And in addition to this, we also have an additional blue light service, which is a fire service. Have we considered how the fire service might be drawn into this and perhaps assist, you know, in climbing down patients who are in a state of crisis and et cetera, and whether they could be used to support this. So I would like to be reassured and my residents to be reassured that this process, you know, from what you said, sounds like it is working and there is development, but underlying that, what is, how much confidence really do you have that this will work out for us? So I can answer part of your question. I'll hand over to my colleagues. Surrey Fire and Rescue have been part of the planning. They've been involved in strategic meetings, you know, doing our risk assessing. And I think some of them even came to my training session. So absolutely involved them all along in the process and where they can fit in and support that. If a person isn't, if the police aren't deployed, then the person should be given the contact of who to go to, who is more appropriate and in their policy and flow charts. And the police have got very detailed flow charts. It tells their call handlers, you know, in this scenario go there. So, you know, they should be given this and how that would impact. I'm not getting feedback that that's impacted. And what it has meant more is a change of practice. You don't just phone the police, which I don't think our staff are doing anyway. You go through a process before you absolutely, and I've said to them, you have to absolutely be right, think that to get hold of. And when we've had a look, they're staying with a relative. So we need to absolutely do everything within our own power to make sure that person is safe. And then if they're not, then we go to the police and then we can evidence what we've done. So a lot of it is around a change of practice. I think we had similar concerns from an SAP perspective initially. I suppose to just add to Liz's point, I agree that it's absolutely helped the teams who are working with someone from a mental health perspective really focus on some of that contingency and safety planning at an early stage. And that's included thinking about how we make sure that the person's support network is well joined up, especially if there are concerns around welfare and that we can explore that. I agree with you. I think sometimes police attendance can be containing and supportive. I think for other people, it can feel agitating and intrusive, not because the police necessarily doing anything wrong, but just again, that particular type of presence in particular context. The call handlers have had floor walkers in present for the first six months of the first phase of right care, right person. And that seems to have been really effective, that those call handlers have been able to draw upon officers who have had additional experience of working with those people struggling with different kind of needs in the community. And that's due to finish shortly, but I think that's a really good sign of the fact that the floor walkers have done a great job at enhancing the confidence of those people taking the calls. The other part I would say is that sometimes right care, right person can be initiated if a family member or a neighbor calls. So again, the training that we've offered to our staff to talk them through what would be expected of the police if it was a member of the public phoning. Again, the call handlers have been instructed to make sure that they're really ensuring that there is a handover, that it's not left, that someone has the duty. And we were very clear at the very beginning that no service would hand something over until there was that clear pathway. So the police saying we will stay with this until we have got the pathway, we've got the resolution, even if we do not deploy to scene at the time. Okay, thank you. To build on what Alex was saying, I mean, we also shared that concern that there's this gap. And although we haven't seen it and, you know, in what is still possible. But one of the things that the ICB has done is we've commissioned, is to explore that, but we've commissioned that mental health response vehicles which don't have the blue lights and not the negative side, the intrusive part, it's a gap. It's not a complete solution, but it's the beginning of one and that will be staffed by SAPP clinicians and they will, they might fill that space and we will test whether that's a space that needs filling. We don't want to over-provide, but that's. I just thought it's also helpful to mention, of course, the police have certain powers, particularly under section 136 that no other body does have. And again, we've been very clear at the very beginning that, you know, ultimately there will be times when that police presence is required because of the legal powers that they hold or can potentially deploy in those circumstances. So I just wanted to make sure that we're not kind of forgetting the fact that there are different kind of powers, including kind of 135, 136, where we would have to go through different processes which may well involve the police. I'm not sure whether this is also, I mean, what you're suggesting with additional vehicles as well that are unmarked. I'm interested in that. Yes, yes. So entirely separately from the police, right care, right person, there's been mental health response vehicles or a program of work within the NHS and inside the NHS long-term plan, and they are being variably introduced across the country as non-blue light responders to mental distress in the community. And that model is varied, but depending on locale, we can choose and vary it. And our approach is to, we've just done, we've just started the process of commissioning and mobilizing them, and they'll be, I will let Alex talk about the staffing, but there'll be two people in a vehicle. It's meant to provide a therapeutic environment. They've been ordered. Have you received extra funding for this, or has it just been something that you've put in your bag? It's like everything with additional funding into ICDs. Things are badged against it, and somehow it never seems to quite add up to the totality. But yes, there is additional funding, and we've used it. We have a crisis funding, and we're using that for this. And we're doing it as a test, because we don't have the data to say that it's a need. It's hard to commission, so we've done it. So we're going to collect the responses, whether that vehicle was necessary as a therapeutic environment, rather than any other vehicle. So we'll see as we go, but we're very happy to report back on how that goes. Thank you for that. And yes, from what I've seen of them, understanding NHS accounting practices is challenging at best. Sorry, Chair. Could I just add one very quick thing about the mental health response vehicles, just to give the context a bit more to the science. Another reason for the kind of pilot is that where there has been some of the evidence generated about mental health response vehicles in other areas, London have mental health response vehicles, so do Hampshire and the Isle of Wight. Those have been vehicles that have tended to be co-crewed by ambulance staff and mental health staff, but that's not the model that has been adopted for Surrey, Sussex and Kent at the moment. So the model that we're looking at to pilot in the Guildford area will be crewed by mental health staff, but with very close links with CCAN in regards to deployment. But again, another important reason to testing that out over that year period to make sure that we can understand what value that adds and also be able to compare that with other existing areas where they have co-crewed vehicles, and what are the differences between those two different approaches. Well, I think this committee would be very interested to learn how that pilot progresses. Thank you. And Councillor McKenna-Martin, I believe we're on to you next, and I believe Health Watch want to come in on the same subject as well. The test in the case of the additional non-light, I'm sorry, I think you already answered my questions about the additional non-blue light mental health response vehicles, but also the ICB are reviewing the models for safe havens, funding safe harbours and with partners, including the police, are facilitating communication and engagement around these alternatives to emergency departments. What are the challenges around ensuring this is effectively communicated so people know about, and will this be manageable? Thank you. Thank you. I'll answer that. So there are significant challenges, and I think they're manageable, or at least we have a plan for them. So the challenge is in changing the way the police operate around safe havens, that we have to get to the operational police on the ground and change their behaviour. So what the challenge is, is getting into the, is actually getting another body to cascade down and have an organisational response that reflects that. We spend a lot of time speaking to the strategic side of the police force, and so what we're doing is engaging them together in workshops with the safe havens to describe what they do and how they can be used to then develop materials and communications and ways of working that are effective in the land and stay. I think there's a couple of other challenges in that, in that we have quite a lot of turnover of staff in the police on the front line, and so I guess our learning from that is that we need to, the safe havens themselves, and we commission them to do so, have to regularly communicate out what they do and provide, and we are looking at some kind of physical resource for the police. That's been one of the suggestions that's come forward, so either on their personal devices in the cars or even something as simple but possibly effective as laminated cars that sit in the police vehicles to remind them, but I think it's a drip-drip and the constantness of that communication to get it into the bloodstream of just an automatic response, and that needs to be led in part by the police, in part by our providers, and as an ICB we will enable that and we will keep pushing it and it will be part of the new, we're reviewing the safe havens and how they operate and they will be part of that review and that, and our commissioning our contracting with them and going forward we take it, you know, it's very important to us that our alternatives to ED are used as alternatives to ED and not, and don't become something else because we're not focused and we don't have a clear line of sight on that activity, so it's very front of mind, there are challenges, and those are the ones I think, I think those are them. Thank you. The report talks about the Surrey County Council task and finished group meeting with Surrey and Borders Partnership, and Surrey and Borders Partnership participating in the gold, silver and bronze meetings. Can we really have the level of competence, have you established the level of competence, all of the risks and challenges are now properly understood and that we've actually got a process in place for incorporating any lessons learned that require changes. So if I start and Alex might want to contribute. Yes, it was really useful. So we set up a task and finish group within Surrey County Council and that included Britain Officer, we felt it useful for our two groups to come together and share those common risks, so we had a really good conversation. The best learning that came out of it was Surrey and Borders shared what they had drafted for staff guidance, which obviously we needed to amend to be suitable for our staff, but that was really helpful because that way we got that consistent approach. So it's having that consistent understanding of what the risks were and what the mitigations were against that. I also met with the county looking at, we'll pick that up, reconvene that group or look at it in terms of our risk assessment. One of the things I've set myself tasked to do is after six months, which is now, is to review and get a consistent approach. If you want to add anything, Alex. Only to say, Liz, that I think the involvement of having a superintendent from Surrey Police's perspective who was reaching out to partner agencies had face-to-face contact and continued to be accessible throughout that process really helped us to have transparent conversations about the concerns and at a level where it felt that there could be action taken. But no, outside of what you've mentioned, there's nothing else to add. Thank you. Thank you for that. I'm now going to bring in Maria Millwood from Half Porch. Hello, I've just put the question in the chat because I thought we'd gone past it, but it was going back to the safe havens. My question is more from the patient's point of view, but I was wondering whether you're collecting patient experiences at the moment under the newer model and measuring this to understand the impact on vulnerable people and to use this feedback in improving the services. So you're talking about reviewing the safe havens and safe harbors. So it's about whether you're involving people within that review as well. So two strands to that. Yes and yes. We're just kicking off reviewing the safe havens. The safe harbor are a new initiative. It's daytime support and we're not reviewing those directly yet. They're mobilizing. But the safe havens have been around for many, many years. It's time that we look to the models and what patients, users of those services think about them and what their experiences are absolutely central to what we're going to do and they will be part of it. We are talking inside the ICB. We have a group of people in the new function in the ICB that do co-productive insight work with people and I suspect we will and to drive out those experiences. We're also reviewing because what they want and their experience of it is the service. Alongside that, we have more quantitative work where we're looking at where people went and what impact they had and whether we genuinely prevented escalation. We don't know all the answers but we are asking people directly. Okay. All right. Thank you. Thank you. Just on that subject really. So just to sort of build it up I think. Are you actually evaluating and hoping that the outcome for the patient or the person will be better under this scheme? Is that your sort of, is that an ambition? Not just that the police will be less used in their services but actually the outcomes for the people are better than they were before. Absolutely. Entirely outside of right care, right person and the police. This is because these are core bits of provision services under the long-term plan that the NHS has put in place in order to look after people to prevent them getting less wealth and escalating into crisis. And that's their core need is that those services stop that and that they're actually finding those people and supporting them. And before that, so yeah absolutely that's what it is. It's not to do with right care, right person. Although I think right care, right person has got us all to really focus on what the unintended consequence of it is that we've all really thought about what are our provision and that's a good thing. So yes, we're looking to improve that service and make sure that there's good learning across as well between the different safe havens and because there's several and they're operated by different people. So we're trying to make sure that any good practice is shared. I'd have to say that I'm really pleased to hear that safe havens are being looked at and thought about because I think the right care, right person pushes our thinking in that direction. So it's a good thing. What I would actually say is what is your thinking about the future challenges? You know, we have all these changes going on. There is also a bit of an issue in ways of change. It creates pressures on some staff that didn't exist maybe in the first place. Have you seen anything in the way of things like turnover or is it too early? You've talked about the impact on services not really being an increase but a shift in how you do things. Are there any risks that actually you will link and result in significantly more work? I think one of the most significant challenges which connect to the kind of crisis pathway which right care, right person sits within is that the evidence base for what really works for people during a crisis is still developing. So although we have some evidence around things like crisis resolution and treatment teams, when it comes to safe havens, safe harbors, crisis houses, crisis cafes, although there are really promising evidence coming through about how they can work, the kind of evidence base itself is still building upon. So from my perspective, we need to still keep a very close eye on each of those developments and how they interface with partner agencies like the police in regards to right care, right person. I think the other part is, and it was brought up earlier, the importance of thinking about the more collaborative partnerships with third sector and other providers. We know that when people present in crisis, the components of that may well be mental health at times but can also be domestic violence. It can be around financial struggles, housing struggles. So again, trying to pull all of those strands together can be challenging because different organizations tend to have kind of lenses into each of them. So I think some of the work with the crisis care concord app that we've talked about to try to make sure we're really coordinating some of those approaches and really looking about how we're evaluating the impact on the people that we serve and making the difference there. I think the other thing for me is around staff, and we've mentioned this, that particularly paramedic colleagues see an incredible amount of trauma, an incredible amount of stressful situations. So if there's the potential of us increasing the times when we are needing to support people in those crisis situations, we need to make sure that we've got a robust system around the staff in order to make sure that they're protected and they're safe. Che, you're opening your remark about World Mental Health Day and taking time really resonates in regards to that. So I think those are the other lenses that I'm really interested in, is about how do we make sure that we're really developing effective collaborative working, understanding that those relationships always need tending to. They're a bit like a garden, aren't they? You have to keep on paying attention to it and looking after it, and that we are making sure that if we are experiencing more trauma for our staff that we've got the provisions in place to support them. But those would be my points. And I would confuse going up, so it's being mindful of that for our staff as well. Thank you for that, and employee assistance programs are incredibly helpful. And as a former mental health worker myself, I recognize this statement of reaching the point where you don't need a total change of direction, because that's what I did. So thank you for bringing to that. And that also brings me to our recommendations, which really center around-- Sorry, Chairman, I've got one question to ask. I thought we got to the point. In the report that we had on the agenda on page 77, Surrey's care section has a higher than average staff turnover, 36 to 28 nationally, higher than average vacancy rates 14 to 10 percent nationally, 28 percent of the workforce-- Excuse me, Councillor Furey, that's in the next item. Mental health improvement plan. That's in the mental health improvement plan. I'm terribly sorry, my apologies. If we could hold there and return back to the recommendations, because the recommendations here actually are aligned along a similar direction, you know, that we see the need for measurement reporting and including reporting of, you know, how things are going with staff are very important. So that's the two recommendations that we've put up, that we have a common approach across everybody that's involved in this to monitoring and reporting, that you put an emphasis on identifying and preventing vulnerable people being subjected to less than optimal support. Do you want to know about the vehicle? Well, I think we'll add the vehicles in the moment. But the recommendation that the deliverance taken to maximize the uptake of training and a slight extra on there, I would suggest following our discussion that staff welfare is a major consideration in that as well. Is that agreed? Agreed. >> Thank you. We've got a break now. >> Thank you very much. >> And thank you for coming on. I note that I think apart from SAPP, I think everybody is the same for the next meeting, or is it-- or are we the same for the next meeting? Sorry, Liz. >> Simon and I are staying, and most of the responses to the question will be online, so Lucy will be introducing it over here online. Thank you. >> Thank you for everybody, because I think it's been a really good and useful session. And so if everybody's actually in the room or online, we'll restart at 1.20. So good afternoon, everybody. We're now for our final substantive piece, which is the mental health improvement plan, with a focus on working age adults. And I believe we do actually have a presentation for this one, I suppose. >> So I'm going to allow Lucy Gate, who has coordinated the writing of this report, introduce herself and her colleagues on screen, and then I'm going to hand over to Lucy to present this item. >> Okay, thank you very much for inviting us today to this Adults Health Select Committee to present the paper on people of working age in Surrey who are not working because of mental health issues. And to introduce myself, my name is Lucy Gate. I'm Public Health Principal for Surrey County Council and co-chair of the Mental Health Prevention Board. What I'll do is I'm going to pass you over to the team online to introduce themselves, and then I'll summarise the paper, and then pass you back to Liz, who is there with you in person, who will lead on fielding the responses to your questions. So Rebecca Bricker. >> Hi there. Thanks for having us today. I'm Rebecca. I'm the Communities and Prevention Lead sitting within Adults Wellbeing Health Partnerships at the Council. Thank you. Lorna. >> Hello, everyone. My name is Lorna Payne. I'm Chief Operating Officer at Surrey Borders NHS Foundation Trust. Nice to join you today. Georgina. >> Hi, everyone. I'm Georgina Foles. I'm Associate Director for Community Transformation. So I've been leading the Surrey Heartlands Community Transformation Programme. Thank you. >> Thank you. Simon and Liz, who I understand have already introduced themselves in the previous item, unless you want to add anything, Simon or Liz. >> No, that's fine. Thank you, Lucy. Thank you. Okay. So just before we go on, I just wanted to acknowledge that today is World Mental Health Day, and that's celebrated every year on the 10th of October. This year's theme is set by the World Federation on Mental Health, and the theme this year is on workplace mental health. So this is very relevant and very timely, and we welcome this opportunity to speak with you today. The paper that was shared with you was a collaborative paper developed by partners across Surrey County Council, including Public Health, the Communities Team, colleagues from Adult Wellbeing and Health Partnership, and the Economic Development Team, who have been fundamental through the development of the workforce wellbeing work for a long time, but in recent time, which I'm sure Rebecca will give you more detail on in response to some of your questions. Surrey Heartlands ICB and Surrey and Borders Foundation Trust, who join us today. So the relationship between health and work obviously runs in two directions. Work of sufficient quality has a huge positive impact on health, while good health also enables people to participate in the workforce. So we are looking at kind of two-directional, and it really does show the importance of the prevention program and the mental health support that's happening across the partnership. Nationally, people with poor mental health are more likely to be excluded from work or suffer an inequality when they are at work. In Surrey, we know from our annual population health survey, shows about 1.5% of the population working age are unemployed, compared to 3.9% in England. In Surrey, lower unemployment rates due to an inactivity, due to long-term sickness, compared to the national average, are very much masked by our areas of affluence. And there are some real gaps in some of our priority neighborhoods. And the overall picture does also mask some of our populations of identity who we know are disproportionately affected. So these key populations who we know are disproportionately affected include our priority neighborhoods, but also adults who are in contact with secondary mental health services, have low paid and secure employment, which obviously, as we know, exasperates health inequalities. This is a particular issue with Surrey's high cost of living. And we see this-- a real example of this is through Surrey's care sector, which we know has a higher than average staff turnover, higher than average vacancy rates. Another priority population of identity are those experiencing multiple disadvantage and those with severe and enduring mental health conditions who we know are excluded from employment and are more likely to experience inequality when they are employment. So some of our priority interventions and opportunities to really prevent an early help include the work that's happening by the mental health services and local authorities to support with addressing wider determinants and the opportunity as large employers to support further with the populations that we serve and that our residents who are employed by these organizations. Easing the strain of financial pressure through things like debt advice and services and access to emergency crisis funds and reducing stigma. And we also, in the last couple of years, have had some really strong nice recommendations. That's really strong evidence based on organizational wide approaches to support prevention and early help. And early help for those who are on the cusp of being signed off from work. And that's really where a lot of the work and a lot of the paper that you would have seen outlines the work well program. So early interventions essential to really have positive emotional well-being and good health as we know supports economic activity. So we've got some really strong new developments in Surrey. A lot of it's very new. So Surrey is taking a proactive approach to addressing some of the concerns around health and well-being and through the employment programs. These are outlined through the paper. There's a plethora of them with the work well program specifically designed to support people from leaving the workforce. And this has received a very recent $6 million investment from DWP who Rebecca Bricker is leading and is joining us today from Birmingham because of the work that she's doing to lead that program. How we use Surrey, we've got a workforce well-being program which is a holistic program addressing stigma and providing scaled interventions for workplaces with a real focus of supporting the underserved communities. So current work underway is really to integrate what we have and to join this up and part of the work well bit with DWP was to develop an overarching work and health strategy for Surrey which is aligned to both Surrey Heartlands and Frimley ensuring a robust strategic approach. The overall work of the strategy is we'll be looking at the health needs, assets, and activity and co-designed amongst those working in those areas and the communities that's aimed to serve. So the overall aim really is to have a system-wide mandate to address work and health, joining up those strategies, formalizing the collaboration, and increasing connectivity between operational providers. So alongside this, which is reports into the health and well-being board through priority three, we also have across Surrey Heartlands the one system plan which is the strategic mental health overview for mental health provision and recognizes the importance of economic activity and its contribution to mental health. So that was a kind of brief summary of the paper which you have all seen. So what I'll do is I'll pass you back to Liz who is there in person and can lead on the responses to your key lines of inquiry and fielding them back to this group. Thank you. Thank you for that and thank you for mentioning that it's World Mental Health Day because it's something we regard as utterly important. Liz, over to you, I think. Well, no, if we work through the key lines of inquiries, I'll just reflect that to my colleagues. Right. Fine. I welcome in the report the very first paragraph talks the 21 health and well-being strategy key neighborhoods where, you know, a lot of Surrey's problems are centered. There are obviously smaller pockets as well scattered throughout the county to consider. So first question really is what does the data actually tell us about the number of people, working agents, sorry, who are not working specifically because of mental health issues? Where do you think there are gaps in our current provision and what can we do to actually fill those gaps? And I believe that Lucy and Rebecca are going to answer this question. Thank you, so in Surrey, we know that we have around 100,000 fit notes, so that's people being signed off for work due to ill health. The majority of these we know are due to mental health or MSK related. We don't know how many of these are individuals who are getting repeat notes. It's difficult to kind of give a real indication, but it does show that we do have a population level need. Rebecca, should I pass to you on? Absolutely. Yeah, I mean, there are gaps in our understanding at the moment, so we're trying to take some steps now to address that. So we do have the information we need to really provide a good service to residents and help those most in need. Some things we've done already, so we've done some research with people living in poverty, so who are working but are still not able to make ends meet. We've done some research with people who would be described as furthest from the labour market, so thinking about our No Left Behind objective and trying to understand their experiences. And we've also done some research with employers to understand what that means to them. Now, from all of that, what we're starting to see is mental health as a common theme through all of those cohorts. And actually, interestingly, from our employers, we're not seeing a diagnosis of mental health as being a kind of definitive thing. Actually, there's a whole spectrum of mental health that is affecting people of all kinds, whether they're in work, out of work, and to different extents as they move through their careers. So based on that kind of initial understanding now, we are trying to do some specific and targeted work around the impacts on employment, and that is both looking at the impact of sickness absence for businesses for their kind of economic productivity, and as well as the knock-on effects that has for us as a system in terms of demand for services and waiting lists and things like that, but also then the impact it has on individuals in terms of their own well-being, their likelihood of kind of recovery and thriving, and getting back to good quality lives after a kind of incident of some kind for them. So we're doing that research now. That will include both quantitative, so some data around that, but also some qualitative studies. So there'll be experiences of residents and what that's actually felt like to them, and what their experiences and work have been. We've got a whole range of ways planned. We're going to engage with people on that. I already mentioned some specific cohorts that we've connected with. We're also connecting into things like our men's pit stops, which are our men's mental health groups. To understand that, men often don't come forward for help, and we've known that for a long, long time around mental health. So actually, that would be a good way to tapping in some of those cohorts. So the research will take a bit of time for us to actually be able to reach those people and to make sure we have got a valid response. But those are some of the ways we're doing it. Another thing we're also hoping to do, which I'd love your support on, is to actually look at our own staffing. So thinking of Surrey County Council, Surrey Heartlands, for example, as anchor institutions with huge numbers of residents on our own staff lists, whether we can do anything with our own HR departments to actually understand a sickness absence amongst our own colleagues, and how that's impacting local productivity. So lots going on. I'm absolutely happy to bring some of that back to you as the findings emerge, either through a meeting like this or through some other member briefings, so you can start to grapple with those findings as they come forward. I think it's one of the major interests as well, is not just employment, but careers. Satisfying employment is the real key to dealing with mental health issues, increasing people's level of happiness generally works well with mental health. So what is our focus really on the skills development and career development? How much are we doing on that and what's our thinking around that direction? Rebecca, can you pick that up? Yeah, absolutely. Absolutely. So we're doing quite a lot at the moment and trying to work in a very person-centered way. So recognizing that every individual is different and wants something different out of employment and what a good life looks like to them. So we have, as we mentioned at the start, secured two kind of Vanguard programs with DWP funding. That's given us about 12 million pounds to invest in supporting people into good quality work. We're delivering that in partnership across the system with our health colleagues, with our voluntary sector colleagues and our district and boroughs as well. So a good system-wide approach to that. As I say, both of those offers of support to residents are working in a person-centered way with residents, but they also include provision to work with employers. So to encourage places of work to actually be good places for people's mental health for those employers to have structures and supports in process that help their staff stay well and healthy in the workplace and working with some business public health team around that as well. As I mentioned, we've also done this work around in-work poverty. So trying to understand, as a different group of people, how mental health is actually impacting their ability, like you say, to move on into really strong healthy careers that take them forward in their lives and into their futures. We produced a film on that, which I'm happy to send around, and then you can all actually see what some of that research is saying around that. But in response to that, what we've actually put in place as well is a program called More and Different, which is sponsored by Lord Patel, and we're doing that with a number of other local authorities across the UK. That program actually is about identifying entry-level roles and how they could develop into long-term careers. So we're specifically working with a group of about 12 employers and a cohort of people who we know to have mental health issues to support them to access roles, which may be low-skill, low-income junior roles in the first instance, but then be supported to move on from those roles with transferable skills into areas in the council where we know the skills demand and there are long-term careers available to them. So we're just beginning that work at the moment. So I think over the next kind of year as that progresses, that would be really interesting to see the difference that makes helping people kind of build on their own aspirations and giving them those opportunities to have long-term fulfilling careers, but starting somewhere that is accessible to them. So absolutely happy to share that with you as well in due course. We have done some other things, too, just to kind of draw your attention to them, trying to work in a system way. So we have created some spaces for all of our skills and employment support provision to come together. So we have a network now and those kind of methods will help us improve across the whole system. So all of the work we're doing, it will help us bring that together and actually ensure there's practice improvement for all those organisations and how we support people into good quality work. Thank you, Rebecca. We also have in adult social care, the adult social care academy, which looks internally to our own staff, looking at preceptorships, newly qualified therapists, occupational therapists, looking at the apprenticeship program to get staff onto the side social workers, but also looking at career progression for non-registered staff who don't necessarily want to be a social worker in OT. What career progression can we look at for perhaps finance staff at particular career routes? So our head of the academy has done a lot of work around the area, linking in with universities, and I know that Surrey Heartlands also has an academy that we link in with as well, looking more widely across some of our other cohorts, like social care providers, home-based fairing. I think the next question is Councillor Helen Clack. So, Rebecca, I think you've covered quite a lot of the questions that we were going to ask today anyway, but just for clarity's sake, I suppose, I think we can go back over some of them. It is quite, it is, it's great that we've got this improvement plan. It's absolutely fabulous, and actually yesterday, I don't know where the camera is actually, where am I speaking actually to, because it, over there, maybe, I don't know, I don't know. It's that one, right, I'm facing the wrong way. Okay, go straight. Yesterday, we had a members development day for elected county councillors, and part of that, we had a marketplace presentation downstairs, and as part of that, we had a stall that was around employment and skills and supporting people, and this extra money from the DWP was raised in that process as well. I know that some of these improvements are already underway, and I think what we would like to know is how you have discovered that you've done things, you're doing things differently to what you've done before because of the improvement plan, and can you give us some examples of those things that you've done differently because of the improvement plan? Rebecca, I think you're allocated to this question. Okay, I was going to say, yeah, thank you. I think you might have already answered it, Rebecca, but I think you said so much, and I think we just need to clarify. Sorry, Rebecca, to interrupt, but when you're speaking, could you slow down a little bit, please, because it's garbling on teams. Of course, no problem, no problem. So in terms of innovation, so the two programs I mentioned already, WorkWise and WorkWell, they're both innovation programs, so the idea of them is that we can test and develop our practice and learn as we go through, and through that then inform national learning about what the DWP rolls out more widely. So there's lots of opportunity here for us to test new things locally, but also inform national policy, which is really great. In terms of what we've specifically done locally around that, so one of the things we have introduced is time-unlimited support for people. So our WorkWise program, you can access that program for as long as you need, and you can come back round through it as many times as you need. So things like that is actually very different to employment support that's gone before, that may be for a specific amount of time, and then all the criteria change, for example, and you are no longer eligible. So we'll wait to see the difference that makes to residents, actually kind of sticking with them long enough to really get them back to a stable position. So we'll wait to see in our evaluation what that does. Through WorkWell, our other program, what we are introducing through that is very rapid support. So when we know people end up off work under a fit note, which as Lucy mentioned at the start, the majority of those are actually for mental health reasons, your ability to access support while you're off work under that fit note is slim. So actually you'll tend to kind of have to wait, and then you'll access the support probably when your fit note has run out and you've gone back to work. So one of the innovations we're trying to put in place is very rapid support to get to people as early as we can in their kind of mental health experience and see how that prevention actually makes a difference to their long-term development of needs and their ability to get back to a successful thriving life. So those are kind of two examples of things we're testing out locally. In terms of understanding whether those have actually worked and the difference they make, well there's national evaluation going on for both of those programs and there's also local evaluation happening. So locally, very specifically thinking about our residents and kind of our specific situation and what we've got to offer locally and how that can help. So doing kind of research and checking those outcomes at both those levels, which is really helpful to make sure our innovation is working for our residents but also helping us to learn from other areas of innovation too. Chairman, I think it would be sensible to ask one of my questions at this point because it's, you know, Helen's sort of starting that question. Very quick. If it follows from Helen's, then... Yeah, that's the idea. So we understand, we advise that the government has provided us with about six million to help with these matters. So I guess we'd quite like to know what mechanisms you have to utilise that resource exactly on the lines that you've just been talking about and how will we, as the guardians of that resource, if you will, demonstrate to the government and to the public how it's been utilised. Rebecca, can you follow up? Yeah, absolutely. So I'm absolutely happy perhaps to send around some more detail about exactly how those programmes are working. It may be easier with some materials in front of you to understand that. We have offered that service, both of those services, that DWP funding you mentioned, those are available to all of our residents across the whole of Surrey County Council. And they're available in different locations for them. So we've tried to make those services as accessible as possible. As I say, perhaps if I send something around, you can understand the actual support that's offered as part of that. But it does include somebody to kind of stick with the person and support them to navigate a whole range of holistic support services that could include anything from actually kind of skills development and coaching, mental health support, support to access challenges like childcare or transport that may be stopping them being able to get to work easily, for example. So all those things happening, happy to set that out for you in terms of then how we understand and kind of hold ourselves accountable to delivering those things in a good way and to a high standard. We do have, as I mentioned, those evaluations in place, understanding our own processes and our own delivery, so monitoring our own services, but also trying to learn at a greater scale than that about what's working, what's not working, what we may want to continue in the future, and there'll be chances for us as an organisation to come back through that and to review at different stages and see is this the right thing? Is this what we want for the longer term? Thank you. That's very good. Thank you. And Councillor Cushick. Sorry, they're just building on all this. I think you mentioned, Rebecca, working with the boroughs and the districts on this, and I know that they are in receipt of the UK Prosperity Fund annually funding, which is funding that's supposed to support businesses and their employees. And I'm just wondering, are you co-ordinate? Did you say that you were working with the boroughs and the districts to do this and how you distribute this funding jointly? Are they using their UK prosperity funds to help you with your project as well? So this, the work we're trying to do is about system coordination. So there's something about allowing additional boroughs who have got autonomy with their shared prosperity fund to do the things that they think are right for the residents, allowing them to pursue those ambitions, but also doing that within an environment where we can collaborate, connect, complement each other. So as Lucy mentioned at the start, we're developing this kind of worker health approach, which aims to bring together all of the people who are doing things into one space, whether or not they're funded by us or funded by the DWP, everybody who's doing things, to bring them together into one space so we can actually start to get an understanding of our whole Surrey work and health offer for people. Because if we can do that and we can bring those things together, then we start to be able to maximise what the districts and boroughs are doing through things like shared prosperity, not duplicate it, but actually complement it with things we may then do as the county council. So there's that kind of bigger piece of system working going on anyway in a collaborative way. In respect of the two specific programmes work-wise and work well, that Surrey County Council is currently holding the budget for, absolutely we're working with our district and borough colleagues on that where possible. Now some of that means actually passing some funding to our district and borough colleagues for them to deliver part of those models, other ways we're doing that, maybe actually through accepting referrals from them that are coming through their housing services and other things like that. Working with other services they deliver, like their social prescribing services for example. There's a whole range of ways we're connecting with our district and borough colleagues and making sure this works as a whole system together, that is more than just about necessarily this money. Thank you and Councilor Rebecca Jennings-Evans, over to you. Thank you Chairman, so my question is more about costs and impact. What is the current cost to businesses in Surrey and Surrey's economy from staff who are unable to maintain a role due to poor mental health and is it too early to show the improvements and comparisons in any one area? What does the data tell us? Okay, that's Rebecca. So at the moment we don't have a huge amount of localised data around that, so we can see some things from national pieces of research that have been done, but part of what we're going to be spending this money we've just received from DWP to do is to actually understand that local picture. Now what we're trying to do in the first instance is gather a kind of snapshot about that at the moment as a kind of baseline, but then also monitor that over time to see how we're making a difference to it, how it's changing based on other changes. So our new government for example, the policies they introduced may well change what that looks like. We also know that in Surrey we've got particular areas of skills demand for example, which are very important to us, so thinking about kind of green skills for example, our health and care skills. So we'll be doing some work to understand actually what that means locally in terms of our particular areas of interest as a local authority, as a local place. So absolutely happy to share that with you, but I don't think we've got the data to hand at the moment to really be able to answer your question fully. Thank you for that. One question which we talked about various people being involved, can have we got, sorry, adult learning properly into the mix as well? Is that for me? I think so, Rebecca. Okay, yes. So absolutely, yes, we're connecting with Surrey adult learning and understanding what that looks like. They've got a particular drive as you probably well know around connecting with them, they're left behind in some of our priority neighbourhoods and things. So yes, still exploring what to the extent that that may look like, but absolutely they're there within our kind of collaborative network, so able to contribute and connect with all the other partners and equally I feed into their kind of board of governors and things. So yeah, trying to build those connections, but more to do, I think, in actually the practicalities of what that exactly looks like and how we can best connect together. Thank you. I was prompted by a meeting I was in on Monday when it didn't look like they were terribly connected, so I thought I'd pop that into the questions. Councillor Caroline Joseph. Thank you, Chair. It's a question regarding the emerging One System One Plan approach. As a result of the community mental health transformation programme and a new place-based integrated model of primary and community mental health care, what does the data tell us regarding improved patient-reported outcome measures? That's where Surrey and Borders colleagues will pick up that question. George, do you want to kick us off on this one, because we've had some really good outcomes in relation to our work in this area. Thank you, Lorna. Yes, so we've been rolling out the community mental health transformation programme. It's now sort of four years in its making, so we have achieved the rollout of the specialist integrated mental health services in primary care across all of the SABP footprint, and so what's been really important is to really understand the impact that that is having and, of course, looking at the improved outcomes for people. So we commissioned a company called Unity Insight to undertake an independent evaluation, and that was completed. It was around March, April this year, and we've got some really positive findings that indicate improvements in access, experience, and outcomes. So we're more than happy to share that report, Ros, and go through the detail. Of course, saying that, there's always more that we can do to keep the improvement ongoing, but there is the evidence to indicate that the improvements are starting now to come to fruition. Shall we just keep going? I think the next couple of questions are still on the same topic. Would you like us to keep going on those in terms of the quality of care through MDT working? Yeah, if you could, please. Okay, keep going. Yes, so we call it the second phase of the community transformation program that we're now sort of embracing. Basically, it's a continuation of the work that we've achieved so far, and some systems nationally stood down the formal element of the transformation program, but we as a system wanted to carry on. And so what we're now in this phase is really looking at that true integration with the places and with the neighborhoods. So whilst we've really embedded this new primary care service in our PCNs that we're now wanting to bring all of the community services together along with all our partners so that we're really working collectively to address the needs of the local community. So this is very much this important phase as we're sort of moving into that. And so we've got a slightly different governance structure where we're now working with each of the places to really scope what the integrated teams will look like, and then we're starting to sort of build on what we've already put in place. So I think this really positive feedback that we're getting around the work that we've undertaken so far, we've rolled out what's called pathways forums across all of the SABP footprint, which is an opportunity for all agencies as well as GPs to come together to really have those conversations around how do we meet people's needs rather than the person being at risk of being bounced around the system. And they're really well embedded and we've got really positive feedback around the pathways forums. And we're just continuing to push harder with that true sort of integration and it's all as partners working together in those local communities. So I don't know if that answers the question. Is that okay? I thank you for that. And Councillor David Hart. Yes. Mental health issues cover a wide range of difficulties, if I could put it like that. And some of them will be obviously much more severe than others. Some of them will be much more long-lasting than others. And those two things may happen in combination. And so I guess the question is, what are we doing to support those people in the community and try and keep them out of hospital for as long as possible, at least, or transitioned out of hospital if they're already there? And then having done that, to try to get them back into the world of employment. And so that's the question, what are we doing about it? But equally, and you might want to take this first, is what's the scale in comparative terms with your overall work and with the overall scale of the population of such problems? And finally, given your answers, I shall ask you, how well are you doing at fixing it? So I think we've got a few questions in there. So I'm just trying to make sure that I understand fully what you're asking, Councillor. In terms of the scope of the services that we provide, we obviously provide talking therapies as well as other providers do, then psychological support, right through to secondary care. Community-based support, as Georgina's mentioned, is really where we're trying to intervene earlier, support people on a journey that, as you say, they may have enduring or may not have enduring mental health issues, but be able to support them as soon as they present, really. And working very collaboratively with other partners, including colleagues who are in the room, and adult social care, as well as those in the voluntary community sector. So that work is really important in terms of being able to support people. If you can take me through the other questions. Does that answer your first question, Councillor? Well, I was really saying, you know, let's understand people who are obviously not immediately able to behave, you know, within the community, to live within the community, and live in the world of work. How do we keep them, A, out of hospital, and B, not just wasting away in the community? Okay, so we have, Georgina, do you want to talk a little bit about the Home First initiative that's going in place? Yes, certainly. So it was last January, actually, we mobilized a new service that people now hopefully heard about, which is the Home First approach. So that was a recognition that the people that we're most worried about can sometimes get forgotten. So it's for people who predominantly have very complex needs, including sort of psychosis, and a multiple range of needs. So what we wanted to do was to really prioritize our attention and our resources on that particular cohort. And the intention was really to stop people going into hospital as much as we can. Or indeed, if they need to go into hospital, that actually we reduce the length of time that they are in the hospital, so that they can keep living well and independently as possible in the community. So we used data insights to help inform us as well in terms of targeting those people that we all know very well across our system. But as I say, the intention was really to really enable people to stay living well at home. We have now 85 people under that approach. And it is quite unique in many respects in that we're using the data to inform our approach to working with people. But more predominantly, it's around really supporting that individual to understand the times when they may become unwell and what can we do differently and creatively to help them stop becoming unwell. And a lot of it is that that early intervention and responding very quickly if there's any signs. So we've undertaken several evaluations over the period of time because it was a new approach. And we've got some really positive data, both in terms of helping people not go into hospital. But in fact, when they do, the reduction in the length of stay in hospital and also the reduction in the use of Mental Health Act, which is really positive. And when we hear the stories from people, they really do talk about how the hope has come back so that it's not just this repeat cycle of trauma of being admitted, that actually they've got staff working alongside them and their carers and families to help them stop going into hospitals. So it is a new approach. And we really closely monitoring the impact. But so far, it's really positive. And actually, it's had a national recognition as well. So we're really pleased with that. Thank you. So I just wanted to build on what George was saying, Dan. So with the infersive evidence and all the recognition under that team's done, the ICB has chosen to invest further resource into that team, which will come on stream over the coming months in particular to address the personality disorder, residents of personality disorder who we under-provide for currently. But we're going to step up to do that. I think one of the other things that in the second phase of the community mental health transformation that George is leading on that's important to your question between these different groups of people with different types of mental health needs is that that will draw in specialists. Oh, sorry. I switched off, sorry. It's much more on recovery. So when we're working with people who want to identify their goals, want to identify their long-term plans, because we want to get people back into employment and whether we have to do it through voluntary work or retraining, that's one of our focuses. And when we work with our providers to actually focus on them. Thank you. Councilor Rebecca Jones-Evans. Thank you, Chairman. How can we ensure that the most urgent mental health needs are identified? And just as importantly, what is being delivered to support some of the most vulnerable people within the community to ensure a greater focus on reducing health inequalities so no one is left behind? How are we measuring? What are the methods that we are using to measure that success and what levels of success are we achieving? In effect, what more can we do? I'm going to let my certain board as colleagues start with this response and then. Yes. Okay. Thank you. So according to NHS England's mental health population needs index, Surrey Heartland's integrated care system has one of the lowest levels of population need. That's how that is calculated, but has one of the lowest levels of mental health spend per person. So that's very challenging in contrast to this. And I've heard the earlier conversation that you've had in relation to those pockets of deprivation. So we also know that within Surrey, that there's higher than average in excess mortality for people with severe mental illness. So we know that whilst on the surface it looks like that, we know that there are really significant challenges for people. So there's a high level of inequality, really, for those that are suffering severe mental illness. So in order to, and my federal public health colleagues give us some data on that, and to understand the mental health needs and health inequalities faced by people, there's a model that we've developed using patient level electronic records. And some key findings from that include that Surrey's definition of severe mental illness includes a broader set of diagnostic codes compared to the QOF definition. Now, if councils ask me what QOF stands for, I'm going to struggle. Lucy, did you want to come in? Do you want me to come in there? Yes. Thank you. I've forgotten what it means. No. It's the quality outcomes framework, which is used in primary care and has associated registers. I can just come in on the SMI point. So we have done, we've been working with Surrey University to understand who are a population of severe and enduring mental health needs, as Lorna was outlining. Surrey is recognized nationally as having low level of need. And it's because the needs calculated based on our demographics, it's an estimate, rather than actually our QOF registers, our quality outcome framework registers, which are in general practice. Now, we know that these only include certain coding and diagnosis, which can happen across the system. So we have been working with Surrey University, we've been working with King's College London to understand what some of their wider coding, what we call kind of ICD-10 codes, which are in secondary care and wider, what we call snow-made codes in primary care, to understand what our level of need may be. And what we've done from that is established it's significantly more than we have on our QOF register or on our kind of national estimates numbers. But from that, we can also start to do some kind of what we call kind of population health management work to really understand how we can target and prioritize interventions for the population who we know are experiencing those symptoms, who may or may not be on register. And so with that, we have done some modeling work, some scenario modeling work to understand what some of the high impact changes might be for that population and looking at things like A&E attendance and hospital admissions across the life course. That's happened. We've done that analysis and that's currently being shared with partners. We have an SMI Health Inequalities Board, which is co-chaired between myself and partners at Surrey Heartlands on the Surrey Heartland side. And we will be looking to put together a kind of multi-agency action plan to support with implementing those recommendations. Sorry, back to you, Lorna. I hope that's summarized. Oh, that's helpful. Just in terms of some of the differences in what it looks like numbers-wise. So we've looked at, you know, potentially nearly 22,000 individuals that we think probably would fairly fit into that category. But on the co-op registers only about 5,700. So there's a very big difference in terms of what we believe is a real need against with what we're actually got on the co-op register. So we know that the key neighborhoods of deprivation are significantly statistically higher proportion of people with SMI. And you've already talked about that today in your meeting. And we know that there are gender disparities as well, so that we know that there's nearly twice as many women as men in the SMI population, although more men with SMI have more, likely to have more mental health admissions. And that may be down to other factors, not just their diagnosis. It may be down to more what their living circumstances are and what support they've got. Across all age groups, the SMI populations have seen substantially longer A&E weights than non-SMI population in the A&E departments. And I know that's something that is very much a daily issue for us, possibly reflecting some inefficiencies, how we actually manage mental health emergencies. But I would say that in terms of the kind of community interventions, that's an area where I think our community teams, wherever they are, try their best to support people as long as possible in their own homes. Can I interrupt just for a moment, please? Can we be careful not to use three-letter acronyms everywhere because they may not be apparent to the public? So SMI, severe mental illness? Serious, severe mental illness. Okay. Thank you. And an accident in the department for the A&E one, sorry. I think we also know that in the talking therapy referrals and completed treatments, there's a big difference as well there. And the talking therapy is the one I mentioned earlier, which is psychological interventions as distinct from more of the secondary care. And that can cover a broad spectrum of people who will never touch secondary care, but on the talking therapy side, they will include people with serious and enduring mental health issues. I think in terms of the importance of community interventions I've mentioned, we've referred already to home first. And I think I wouldn't want to underestimate the importance of that about people needing to be, once they've had an inpatient admission, being able to return to their own home ideally and being able to have a good life. And those partnership workings across partners to be able to support people is really what we need. I think your references earlier to employment is a key factor for people with serious mental illness, that they are able to get good employment and the work that is ongoing with Richmond Fellowship, I'd just like to just mention is going to be very important to be able to ensure that people do get work. And that has been very successful in terms of helping people get good jobs and jobs they're interested in. So I think it's important that that's more likely for people to stay in work, if they've got jobs that they are both good at and they're interested in. Councillor Gillian Evans and then Councillor Helen Clark. Thank you. I just wanted to come in with a comment on that. It does worry me, the equations and the codings that are used, just that it's not completely an accurate reflection of the lived experience of identifying those who are most in need. It's really vital that we are getting meaningful measurements that will impact and have the desired effect on those that are most suffering. I agree with you. I think at times it's difficult. There are times when diagnosis is not something that is straightforward and that does take at times some time. But it's also the case, the way the formulas have worked out in terms of how it's defined can be quite, doesn't favour the Surrey community is what I'm saying. Thank you. Councillor Clark. And I think it's just another comment about the cost to the economy and to Surrey businesses and how we maintain people in their jobs. I was very interested to read this morning, I think, that Greggs, for example, employ a great deal of ex-prisoners in their organisation. And that's a great thing that they should be lauded for, as well as their very nice sausage rolls. This sort of idea, though, that you engage with employers to positively encourage them with positive support to take on people who have challenging mental health issues seems to be a very good way forward. And I can understand from some of the things you're saying that you do have programmes in place. I just feel that that can include working from home, of course, in employment as well, which can be sometimes one of the biggest problems people with mental health issues have, is travelling, et cetera. So I just wanted to know how much of your focus actually is working with the Surrey economy and to address the situation. The numbers are huge when you look at the hours lost. And it feels that there should be more that we can do, which builds on really what Rebecca was asking. I think it would be helpful just if we talk a little bit more about the work with Richmond Fellowship that is really doing all of the work around employment. I don't know if, George, you want to add some context around how Richmond Fellowship works. We've had a lot of work with them over many, many years, and it is a good example. And they work with a range of employers. I think I read the same article about Greg's, by the way. And I think that is going to be a very important part of recovery in terms of avoiding admission, both employment and accommodation, which are probably the key for us all, is something that I think is a priority. Thank you, Laurie. Yes, that's fine. Really, just to give you an operational example is how we've integrated employment support with our core offer, both within primary care and secondary care. The provider has what they call link workers, and they're very much embedded in our core community services, actively involved with case discussions and ensuring that people get the help much, much earlier. We've got some fantastic outcomes reports from-- they've actually just recently changed their name. They're now called Way Through. But they are just seen as a core member of our team, and we work incredibly closely with them. And I think they're the only provider that actually has dedicated link workers across all of the PCNs now as well. So I think we just work in very much an integrated way with them, and they're just really good to work with. But equally what's really important is the outcomes that they achieve. I suppose I was suggesting that to be proactive, it would be a great comms thing, I think, to have a program that actually went out and sought employers who would be positively signing up to supporting employment for people with mental health, as opposed to just supporting people who are currently employing people with mental health issues to actually proactively, like Greg's, do something about this obviously huge issue in our society. I think we completely agree. I think all of us would sign up to that. I know Timpson's also-- the Schumann's also do a similar scheme that would be very supportive of that, and see how we can take that forward. Thank you. And Councillor Frank Kelly. Thank you, Chair. I did have several questions. I think they've probably-- most of them been answered. So I'll just give you one last one, which is, what will be the benefits to all residents from the all age and place-based approach to developing a mental health system for population health gain, which is being developed in public health communities and places and other partners? And what are the possible drawbacks or issues you might find with actually implementing this? Thank you, Councillor Kelly. And I'm going to ask Lucy to pick this up from public health. Thank you. And I think I'll bring Rebecca in as well at some point to answer some of that previous question as well. So what this approach does is the idea is that we're working with what we call population health management, so understanding the level of need in different places. So there's two levels to this, really. One is working with place, as we understand, across the kind of NHS footprints, and working with them to understand their populations for serious mental illness, common mental disorders, which include depression and anxiety, and some of those real kind of lower level need like sleep, which we know can escalate into a higher level need. So working across the board with those issues, looking at the data with the primary care teams on those place footprints. And we've started a prototype on that with Northwest Surrey. The second part of this is working closely with Rebecca's team, the communities prevention team, and Dan Sherlock's team with team around the community, and starting to really embed interventions where people live and work. So the first one is the How Are You Surrey workforce well-being program, which we're working now to closely align with Rebecca's work that she's outlined. And part of that is supporting organizations to prevent mental ill health, but also to support those individuals who are looking-- that they are starting to experience mental ill health to access early interventions, but then at a community level to work with the communities that we're all in in these workplaces that we're kind of in today to really strengthen the connectivity, which we know is a prevention intervention. So that's a key one that we're doing, prioritizing the care sector and routine manual workers in priority neighborhoods is what we are doing with that. And we are hoping for that to really embed with the work Rebecca's doing to start to then, once we've supported those organizations, to be ready and fit to support mental well-being and resilience, that then they can-- they're in a place where they can bring people in who may be more vulnerable and give that kind of skills escalator that Rebecca was outlining at the beginning. The second part we're doing is supporting community resilience through the team around the community model, which Dan Sherlock's leading on. And that's with a toolkit program led by community leaders on the five ways to well-being to build community resilience, to be led by communities, and for them to develop their kind of tailored, unique action plans, which to do exactly that. One of the key five ways to well-being is learning and being part of something meaningful, connecting, and meaningful employment, which kind of brings us back to the point that you raised at the beginning of this session. And we're looking with one key neighborhood at the moment to launch that. The materials have been designed, the co-production has happened, and we're looking at a launch of that imminently. We're also linking in with, from a kind of real prevention and communities resilience element and the healthy schools model, so that we bring all those kind of key organizations and key employers together in those priority neighborhoods. Is there anything you wanted to add, Rebecca? Not hugely, that's really helpful, everything you've said there, Lucy. Just to add in a bit about the employers, which I mentioned, you mentioned your previous question. So we have got a specific service that supports employers to take on people with all kinds of disabilities, including mental health concerns. And that actually supports them as an employer to place that person within their team and then to help that person stay in that role and succeed. So that's a very practical kind of person-based support we're offering. But as Lucy mentioned, there's also an offering to all businesses, whether or not they're actually taking somebody on now to help them generally better understand. And one of the things that has come up is that, yes, we talk about severe mental illness and there is an extreme need around that. But there's also this whole spectrum of mental health. You've got lots of people living without a diagnosis who are actually still struggling in their work. And that's what employers are saying to us. It's not as clear cut as here's somebody with a labeled severe mental illness and here's somebody without one. So I think that work to generally encourage employers support, as Lucy described, is really important. And there's appetite for employees to have that. Our economy and growth colleagues, when they do business engagement, that's what they're hearing from businesses, that they want that support. So, yeah, an open door really, yeah. Excellent, thank you. We're going to skip past the question David Harmer had, because it's already been asked and answered, and move on to Councillor Helen Clack. Thank you, Chair. So we've talked an awful lot about this already, but just to finalize this into some kind of understanding. The report refers to the number of people out of the labour market due to ill health being at an all-time high. And ill health is rising. A lot of that started with COVID, didn't it? And it's only managed to get worse. And the government is telling us that this is rising and worsening and we've got to do something about it. So these measures that we've been talking about today that are going to be taken within the county, will they have the positive outcome that we all want from this improvement plan? I'm going to invite Rebecca and Lucy to answer that, if possible. Do you want me to go first, Lucy? Go ahead. So absolutely, the reason we're doing these initiatives, the reason we bid to be national kind of vanguard sites for these two programs I described workwise and work well. I should have mentioned earlier, we've also secured local sports employment, particularly for people, a vanguard program, particularly for people with low disabilities and autism. For example, the reason we have done those things is because we believe they will bring about the change we want to see and our residents want to see in terms of helping get into work. Whether that actually comes to fruition, of course, we need to monitor that. That's obviously our ambition and that's what we're nuances in refining our processes over the coming two years of those funding agreements to make sure we can do that. So I hope so. But the proof is in the pudding. Yeah, I think to add to that, the kind of programs that we've all outlined across the system are evidence based or at least evidence inspired and being tested. I think that that's absolutely key. The governance around these primarily fits with the one system plan in relation to the work that George and Lorna have outlined from the community collaborative and from the secondary care providers and from the health and well-being board priority two and priority three from the workstreams that myself and Rebecca have primarily outlined. The next step, which I think is outlined in the paper, is how we actually integrate these initiatives to really understand how the system is working to support the populations that we've all talked about. This kind of iterative identification of need and understanding and how we pull that together in one place to really synthesize and understand what the level of need is, where the need is and what level of intervention is required. And I think that will be ongoing. But like I say, I think the governance fits in three separate places. And the challenge to us now is to pull that together and see how we can integrate that to understand if the system response is correct and where it can be improved. Thank you. Any more? Can I just jump in to start to build on that? Yes, please. Just sort of looking forward to the question is, will it make enough? Will it be enough? And, you know, we're doing good things and you've heard about them. The government is quite rightly drawing attention to it. But in the NHS, so is the department. And the new 10-year plan, we expect, following Lord Darcy's report, will include more emphasis. And therefore, we expect more funding in the area of employment. But the NHS is meant to now support people into the wider economy rather than just look after people when they're unwell. And so that, I think, will be a theme. And we expect funding to follow. Although with regard to any mention of additional funding, I'll just quote my Welsh mother. There's our fella's net. Thank you, everybody who's participated and presented on this. And I think if we now move to the recommendations, please, to what degree and what they will achieve, and that you have the effective reporting on the implementation we've seen that they are actually achieving, or if not, identify what corrective action can be taken. Agreed. Are we agreed? Thank you. Thank you, everybody that's put together that, because I know that it's a really good piece of work, and really satisfying to read all the things that were happening. Item eight is the recommendations tracker and forward work plan, which will be on the 4th of December of this year. Thank you very much, everybody. And I hope you have a good journey home.