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Adults and Health Select Committee - Wednesday, 4 December 2024 10.00 am
December 4, 2024 View on council website Watch video of meetingTranscript
Chamber at Woodhatch Place. There is no fire drill expected today. In the event of a fire alarm sounding, everyone present is asked to leave by the nearest exit, which is at that end of the building, a room, and assemble at the top car park, reporting to a member of the building management team. Staff will be on hand to guide you to your nearest exit. Please ensure your mobile phones are either switched off or put on silent. In line with our guidance on the use of social media, I'm happy for anyone attending today's meeting, including members of the committee, to use social media if this does not disturb the business of meeting. Today's meeting is being webcast to the public and recording will be available online afterwards. I'd also like to mention that this meeting allows participation by video conference via Microsoft Teams, and that some attendees, and that some attendees are participating remotely. For those taking part remotely, if the chat feature is enabled, please do not use it. It's used to limit the transparency and open discussion that we aim to maintain in a public meeting. For those officers who have joined the meeting remotely, please use the raised hand function to indicate that you would like to speak, and please mute your microphone and turn off your camera off your camera when not speaking. And for those officers and members who have joined us in person, may I please ask anyone presenting to 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. If you are sharing a desk and microphone, then you need to press the right or left-hand button depending on which side of the microphone, depending on which side of the microphone you are sitting on. I would like to now introduce those witnesses with standing invitations to each select committee meeting. Samantha Botsford, Healthwatch Surrey Contract Manager, on behalf of Maria Millwood, Board Director at Healthwatch Surrey. Sue Murphy, Chief Executive Officer of Catalyst. Patrick Walter, Chief Executive Officer Mary Frances Trust. Olive Ahern, Area Manager, Olive Ahern, Surrey Sussex and Kent for Richmond Fellowship. And Nicky Roberts, Chief Executive Officer of Surrey Coalition of Disabled People. Apologies for today have been received from Councilwoman Michaela Martin, Maria Millwood, Carl Morseau, I thought I saw Carl earlier. John Fury is here, and I think we've also got Councillor Robert Hughes. I also have apologies for being late from Councillor Rebecca Jennings-Evans. Okay, excellent, great timing. So, on to the minutes of the previous meeting. Is everyone happy that we approve the previous meetings as printed? Agreed. Agreed? Thank you. Okay, declarations of interest. And that's to receive any declarations of disclosable pecuniary interest, significant personal interest or any gifts or hospitality received. No declarations that I received in advance, but, yeah, Councillor Fury. I wish to declare an interest in so far that I am in receipt of a care package from Surrey County Council. I do not feel that it inhibits me in any way from returning to this meeting and voting. With your agreement, I shall do so. Thank you, Councillor Fury. Any others? In respect to today, I would normally declare an NHS friendly interest as a community representative, but I don't think we're doing any NHS business today, so that's good. Moving on. Questions and petitions. None have been received. And so, we can move on from there. The recommendations tracker and forward work programme is the next item. Are there any comments members wish to make on? No. Okay. Okay. If we're agreed, then we proceed with the recommendations tracker and forward work programme as printed. Agreed? Agreed. Agreed. And then the next item is cabinet response to select committee recommendations. And we're requested to merely note the most recent cabinet responses. Are we agreed? Are we agreed? Agreed. Agreed. Agreed. Okay. And now we're moving on to first substantive item number seven, the draft 2025 budget and medium-term financial strategy to 2029-30. So, I'd like to introduce this as the first real item of today's select committee for members to undertake formal public scrutiny on the 2025-26 budget and medium-term financial strategy, to test for sustainability, value for money, risk, proposals for adult social care and public health, and to ensure alignment with the Surrey County Council's objectives and guiding mission of no one left behind. And I would now like to pass you over to the cabinet member for finance to provide a short presentation with colleagues. Councillor Lewis, over to you. Thank you, Chair. Good morning, everyone. So, this session is to scrutinise the draft budget for next year, for 2025-26, and that's both the revenue and capital budget and the medium-term financial strategy for the next five years to 2029-30. I don't think we need much reminding that, you know, local government and the sector faces a difficult financial climate at the moment. It's extremely challenging, and it's extremely challenging, and Surrey County Council is not exempt from the challenges which the sector is facing. And in recognition of that, as a result of that, the budget and the draft budget that was approved by cabinet last week has required us to take some difficult decisions in order that we continue to ensure the council's financial resilience. As you know, as you know, a lot of work has taken place over the last few years to ensure that the council's finances are in a strong position, that our reserves are healthy. And we intend, and we intend, as a cabinet and as an administration, to continue that strategy. The budget-setting process is sort of really carries on throughout the year. We, as a council, approved this year's budget at the beginning of February, at the full council meeting, the budget meeting at the beginning of February of this year. And really, as soon as that meeting was over, and this year's budget was agreed, work began on next year's budget. And the way it works is that there are monthly iterations of the budget, which come to CLT, and at various stages to the cabinet, and those monthly iterations look at the pressures which exist within the system. We operate, as you know, within budget envelopes, and so they look at the pressures, and they look at the efficiencies that have been identified, and there's normally a gap, and with each iteration, further work is done to close that gap. We do believe in the importance of consultation, and, you know, I think we committed to consult on the production of the budget, and, you know, we have done, I think, a large amount of, given people a large amount of opportunity to input into the budget-setting process. All four select committees have had a number of sessions now on the budget, and there have been the deep-dive exercises, there's been briefings to the opposition parties, we've had member development sessions, and, importantly, we've had external consultation with our residents, and the first phase of which was while we were putting together the draft budget, and the second phase kicked off immediately after the draft budget was approved by cabinet last week, asking residents and other local organisations for their input on that draft budget, and suggestions for closing the gap that still exists. As I say, as I say, you, as a select committee, along with the other select committees, carried out your deep-dive work into two selected areas this year, and the recommendations from those deep-dive exercises were considered, and will continue to be considered by the cabinet, both when we put together the draft budget, and when the final budget is completed. So today is really an opportunity for this select committee to look at the full draft budget, as I say, was approved by cabinet last week, and particularly to look at, you know, the areas which pertain to your remit around adult social care and public health. The timetable going forward is that the final budget will come to cabinet in January, and the full council meeting will take place at the beginning of February. It's important to say that the local government, or the provisional local government settlement date is the 19th of December. So although we have a reasonably good idea in terms of what that settlement will look like, both from the budget that took place at the end of October, and from a ministerial statement that was given at the end of last week, that both those exercises to paint the bigger picture in terms of what money is available. What we don't yet know is exactly how that money will be distributed to the different local authorities, and exactly how much we will get coming in. So until that detail is known, it's difficult to finalise the budget. So the draft budget still has a gap of £17.4 million. As you all know, we have a legal responsibility to balance the budget. There are different options, which we'll talk about later in the presentation, about how that gap could be closed. And they range from increasing council tax. We have assumed in the draft budget that there's a 2.99% increase in council tax. We've only just had formal confirmation from government that we will be allowed to increase it to the 5% that we have done in the last few years without triggering a referendum. So we could add an additional 2% as an adult social care precept. But there are other ways, of course, of closing that gap as well. And, as I say, until we know exactly what the funding formulas are and how much money we've got coming in, we won't be able to make the final decision in terms of how that gap is to be closed. And it's that sort of area that we're really looking for your input on in terms of ideas for actually how we can close that gap. So we look forward to hearing any suggestions that you might have. Despite the challenges that we face, and I think, you know, looking forward, you know, as I said at the beginning, this session is to cover not just the budget for next year, but the medium term financial strategy. And looking forward over the next five years, for councils such as Surrey, the financial situation is again, we anticipate, is going to become even more challenging than it is at the moment. On the positive side, the government have said that they will be giving us a three-year settlement. So that's good news. On the negative side, we anticipate that the various formula which are used will divert money to the more metropolitan areas. And under the fair funding reform, the likelihood is that local authorities such as Surrey will lose money rather than gain money. So looking forward, the medium term position, you know, I think is challenging. And again, that emphasises the importance of ensuring that the budget that we agree for next year is really sound and puts this council on a very firm footing going forward. But despite the challenges, you know, we are ambitious as an authority. And in the slide, you can see that there are a number of areas where we intend to continue to invest. And, you know, I think it's right that we should do so. It's all about choices and it's all about prioritisation that that investment will continue. I've spoken about the options for closing the budget gap. And, you know, that is part of the work that will take place between now and when the final budget comes to Cabinet in January. And particularly once we know the outcome of the local government settlement. And finally, I mean, I mentioned about the medium term, you know, we have developed a one council approach to transformation. I think the transformation work that's underway is really, really important. We touched on this yesterday at the Children's Select Committee. You know, when we look at driving efficiencies through this council, you know, it's not just about cutting money out of the budget. It's about doing things differently. It's working in a more joined up way. And the transformation work is partly designed to actually change the way in which we do things, to change the processes, to enable us to deliver the key frontline services that our residents expect, but to do it in a more efficient and the more effective and the more cost effective manner than we're doing at the moment. And so I think the transformation investments that we're making are incredibly important as part of the budget going forward. You can see on the slide, you know, the bullet points, I'm not going to read them out, the main focus areas for that transformation work. And here in adults, you know, you, along with other parts of the council, have invested and have got money in the budget to continue the work that you're doing. And I think, finally, I'd just like to recognise the outstanding work that took place in terms of getting the good outcome for the CQC inspection. And that really was excellent. And I think that reflects the, you know, a huge amount of hard work that's gone across, taking place across the whole service, but also reflects, you know, the investment and the commitment that we've made to adult social care for Surrey County Council. At that point, I'll hand over to Nikki. Thank you. Good morning. Nikki O'Connor, Strategic Finance Business Partner for Corporate Finance. In the interest of time, I'm not going to go through the slides in detail, but I'll just pull out some key headlines in relation to the draft revenue budget and, indeed, the draft capital programme. So the overall revenue envelope in the draft budget is just over £1.2 billion, which is a £34 million assumed increase from the current financial years budget. As Councillor Lewis just set out, that assumes a 2.99% council tax increase and largely a rollover of the government funding that we're receiving this year into next year. The budget, the government's budget in October and the policy statement released last year confirmed that we could raise council tax up to 5%, so that's up to 3% core council tax, an additional 2% adult social care precept. And again, as Councillor Lewis set out, did give us some indication of the funding that might be available next year, but absolutely no certainty on the specific allocations for this council. So there was some new funding announced in the budget. There were increases to the social care grant announced as well, that the increases were on a national level and the allocation that Surrey County Council receive is extremely dependent on the formula and the allocation methodology adopted. So a significant range in terms of what we could receive. I think it's also fair to say that in the policy statement last week particularly, the government were very clear that new funding allocations will be targeted specifically at areas of high deprivation, although as yet no indication of how deprivation will be measured, but also at councils who have the lowest ability to raise income through council tax. So that £34 million assumed increase in the overall budget, in the overall funding, is offset by identified pressures across the council of £108 million, which would therefore require £74 million of efficiencies to be identified in order to get to that balanced budget position. So far at the draft budget stage, we've identified £57 million, and that's where the gap of £17 comes from. In terms of the capital programme, as part of the work to develop the 25-26 budget and the medium-term financial strategy to 2029-30, we have to look at the capital programme as well. We've reviewed the programme line by line. I'm sure you're all aware the cost of capital construction has increased significantly over recent years, as has the cost to borrow with successive interest rate rises recently. We have seen interest rates starting to fall, but the forecast is that they won't fall anywhere near as quickly as they've increased over the last couple of years. So the overall cost of our borrowing is higher than it was a few years ago. So, as I say, we've carried out a line-by-line review of all the schemes with a particular focus on those that require borrowing to ensure that the capital programme is, one, affordable in terms of the impact of the borrowing costs on the revenue budget, is deliverable and is proportionate to the overall scale of the budget. I'll probably leave it there and hand over to Rachel. Thank you. Rachel Wigley, Director of Finance Insight and Performance. Good morning. So, Councillor Lewis has already talked about the £17.4 million budget gap and the options that we may have to close that, and obviously one of those is the provisional local government settlement and seeing what that will bring or not. So there's no certainty, but we wait for that and we are expecting it around the 19th of December, so fairly late in our process. So that is one of the ways that we may be able to close the budget gap, but as I said, uncertainty. We will continue as officers to look at reducing our pressures and increasing efficiencies where we can and putting proposals together. And we will continue to do that until we get to a balanced budget. The other way that we could also look to close that budget gap is our use of reserves. Now, as officers, we are recommending that we only use reserves for one-off expenditure. So, as you're more than well aware, I'm sure, we've worked really hard to build up fairly depleted reserves back from 2018-19. And our current level of reserves, which are around 12% of our net budget, are considered appropriate, given the risk environment, the financial risk environment that we're working in. So we would recommend that we only use those for one-off expenditure. And then finally, the other option to look at is an increase in council tax. So we currently have 2.99% built into the proposals that you see in front of you. And the government have announced that we can go up to 5%, so the other 2% is the adult social care precept. Obviously, that's a decision for Cabinet and full council to take, but it's part of the options to close the budget gap. For every 1% rise, that brings in £9 million. So finally, just looking at the medium-term position, really following on from what we've all been saying, significant uncertainty into the medium-term. We've had many years of single-year settlements, which makes medium-term planning very difficult. We do have that commitment, as already been mentioned, for multi-year settlements going forward, but we don't have for this year. The timing and the impact of fair funding reform remains unknown. We're expecting it won't be before 26.7 at the earliest, and we have assumed flat funding within this medium-term financial strategy. So by 29.30, looking at all our pressures and the efficiencies that we've been able to propose so far, there is a budget gap overall of £193 million. That's directorate pressures plus capital financing costs and the flat funding that I've talked about offset by efficiencies. So obviously, as we progress into next year, we'll continue to iterate that position, and we should know more when we do get to a multi-year settlement. And as I said, the final point is around the reserves. We have resilient reserves at the moment to weather any future challenges, but we are operating in a fairly high-risk financial environment from the things that you've heard about today. So thanks very much. Okay. We'll take Sinead Mooney first, please. Thank you very much, Chair. Can you hear me okay? Yeah, you'll be fine, Sinead. Thank you. I don't want to kind of repeat messages, but there's a few things I do want to highlight to the committee. And, you know, the draft budget position for the directorate outlines, I think, some really concerning areas that we all need to focus on collectively. So the draft budget position shows a net expenditure budget requirement of £524.5 million for the year 2526. And that's an increase of £18.5 million, mainly due to pressures, but offset with some planned efficiencies as well. But I want to highlight really to committee members that the directorate's budget requirement is projected to rise significantly to £620.8 million by the year 29-2030. So this directorate, the budget compromises the three key areas. We've got the adult social care budget, just over £473 million, with a public health budget at £38.6 million and communities and prevention at £3.6 million. I know that the committee will be aware that the adult social care and public health services do fall under the jurisdiction of this particular select committee. So the primary budget challenge for the directorate is the expenditure on adult social care packages. And I know we will hear a lot more about this from Will and the team when they go through their slide pack. The expenditure has been increasing at an unsustainable rate. This is expenditure around care packages and does account for 88% of the whole budgeted pressures over the mid-term financial strategy period. To address these challenges, and I know select committee members will be aware of this, we are implementing an ambitious transformation and improvement program, which is aimed at enhancing the customer journey, develop market shaping and commissioning strategies, and improve prevention efforts to reduce care package spending. Of the £98 million in planned efficiencies for the 25-35 year NTFS period, £83 million are contingent on the successful delivery of these plans. The program is being supported by an £8 million investment from corporate reserves, and this was approved by the Cabinet in June 2024. The announcement in the autumn budget, including the national living wage uplift from April 2025, changes to employer national insurance contributions, and social care funding, will all need to be carefully considered in setting our final budget. The draft local government finance settlement in December 24 will provide further clarity, although Surrey's public health grant may not be confirmed until February of March 2025. Chair, that's all I'd like to say on this particular issue. Just repeating messages, I think, that committee members have already heard. But I hope that my messages kind of reinforce the very clear pressure that this directorate, this budget is under. Thank you, Chair. Thank you, Councillor Mooney. And if we could now have Claire Edgar, Executive Director for Adults Wellbeing and Health Partnerships. Good morning, everyone. Apologies, I'm not in person. There was a slight problem with diaries, etc. So I'm ever so sorry I'm not with you today. And I also have to dip out later to meet with the deputy leader. Yes. And I just wanted to reiterate, obviously, some of the points that Sinead has obviously just mentioned, and of course, some of finance colleagues. And what we're really clear about in adults and wellbeing and health partnerships, though, is the need for transformation, as we've talked about earlier today. And there is a clear, ambitious program that we've designed before I arrived, but also alongside the corporate work that's happening across the organization to move us into a one council approach. There is obviously clear efficiencies that have been aligned to some of our transformation and improvement program that I believe the committee have been well cited on in the last few months. But what we did want to also highlight today is obviously, as again, finance colleagues alluded to, is that part of our improvement program and transformation is really around looking at how we do things differently, not just reducing service delivery. This is about genuine transformation and practice change and how we work much more closely in the prevention space. There is lots of work we need to do with partners, as people can imagine, in terms of how we come online together, how we work closely strategically to generate new ways of working, particularly around prevention and early intervention, as I think it is widely believed that that is the best approach in terms of reducing demand into our services. Demand into adult social care is probably the biggest pressure that the organization faces at the moment in terms of its budget. So we are paying really close attention to how we manage that moving forward. Part of the transformation element in terms of being able to do that will look at a strength based approach in how we assess people. And that involves essentially working through people's ability to do things for themselves or indeed looking at how we can support them to do that through new and creative ways such as digital and care tech. We do recognize, however, that there's some significant challenges in that approach as well, and that perhaps we haven't moved at pace historically, but it's certainly our ambition to do that in the future. That will also mean that we will also mean that we will have to make sure that we are aligned with the corporate transformation and how we work together so that we don't create dependencies or challenges for each other. Some of the work that you will be familiar with already has started to come through and we've started to see some of those efficiencies take shape. But we do recognize that there's further work we need to do, particularly on reducing the demand into services, but also particularly looking at how we carefully plan for people's care moving forward. So further work will be done and hopefully as we go through today, you'll be able to get a sense of how that's going to look and also how we're going to achieve that. We've got clear transformation and improvement plans that have been through various iterations and through council conversations that you've also been cited on. But we do recognize that there's some significant pressures in there, as again, our finance colleagues touched on in terms of, for example, changes in the national budget around national minimum wage and indeed employers national insurance contributions as well, which we will also be very mindful to given the amount of services that we procure in the social care market. So I think that's all I'd like to say, Chair, but obviously here today to answer any queries or comments. Thank you. Thank you very much. OK, I think we are now done with the presentations. So we'll move on into the questions. And first up, I believe, is Councillor Helen Clack, followed by myself and then Councillor Rebecca Jennings Evans and then Councillor Robert Evans. So, Helen, over to you. Thank you. Thank you, Chair. Can you all hear me? All right. Good. Thank you all of you for your presentations on the on the adult social care budget and the problems that you're facing. And I my question is based on I'm I'm slightly concerned that a lot of the reliance on the transformation budget that transformation program to to get the budget into, you know, under control to deliver the services that our residents will require. You know, and that's our job to do is very heavily reliant on technology and AI, particularly delivering in homes. And I'm quite concerned as somebody who lives in a rural area where Internet can be quite poor. That and I know that happens, you know, that's that reflects across many parts of Surrey. How can we be sure that this development of AI and other remote tech can actually be delivered? How can we be sure that residents will be able to access this? And I'm also concerned about the fact that as the population ages and birth rates for that, you know, AI will be even more in demand. And as people age and they become more tech savvy, they will demand more tech support. So just really need to be sure that the systems that we're talking about delivering to to to to to meet this budget, particularly and listening to Sinead's targets between 25 and 20, 20, 25 and 20, 30. The huge savings over 80 million pounds that you've got to save so reliant on AI. Can you assure me and I'm not sure who would respond to this? Perhaps it's clear that you are we are able to deliver this. What's happening in Surrey that's going to enhance access to the Internet so that residents who, as they age, can actually access the services that we're offering via technology? Is that is that OK? Can anyone clear? Can I? Sinead, you might need to. Apologies. Yes, Claire, I think this is for you. I mean, I know it's a really good question, actually, from Helen. And I know there is a lot of work going on within the directorate, given the focus on this particular area and the importance of successful delivery. And I know that Claire will talk to those points. But there is a lot of work going on to kind of ready ourselves and ready those residents we support as much as we can around digital inclusion. But I'm sure Claire will cover the more the more specific points that's happening within the service. But if it's any reassurance to select committee members as a cabinet member, I'm certainly assured there's a lot going on in this space. Thanks. Claire. Thanks, Sinead. Yeah. So Sarah and John are in the room and are actually leading on this in terms of from a commissioning perspective and also from a transformation perspective. So I'm happy for Sarah and John to to kick off and provide some updates as to where we are with that, if that's OK, chair. Hello, everybody. I'm the director for transformation, Sarah. Hello. And yes, obviously, it is a really good question, Helen. And it's really important and integral to the program that we respond to that, because, as you say, there is a reliance on on digital solutions. But that isn't the only solution at all in terms of the delivery of the efficiencies. And I think in terms of where we are with the Internet access, the Office of National Statistics places us at about 50,000 who are excluded from that, which is about average with the rest of the counties. So Hampshire is 5.9 percent, 63,000, Kent 90,000. So it's quite interesting when we did the benchmarking. We're not actually an outlier, but I understand completely because we've got our geography is so distinct because we have very rural areas and I live in a rural area, too. So I completely understand the issues and urban as well. So just to kind of reassure you in terms of the context and the scale of the problem in Surrey, it is, as I say, we are on average with other counties. I think part of, and so absolutely in terms of kind of keeping pace with AI and the requirements for it, that has to be built into the program. And those insights are really important. So the data, the modeling, the kind of the what, the reliance and the kind of data bank kind of side of it is all part of the program. But also it's about digital exclusion as well and making sure that that doesn't happen because some people right now, we're talking about savings and delivering it in the next year or so, don't access the internet and won't access the internet. So we obviously are mindful of that when we're doing our planning and the impact of that on our efficiencies. But there is also a corporate digital exclusion program about and looking at that work and how we do that across all council activities, which we are part of our transformation program. So there is a lot of work going on about digital inclusion in that space and there is an action plan, which I think we might be able to circulate to the committee after just so you can see what the themes are and what they're looking at. There's a lot of work that's currently going on in public libraries, as we know, which I'm sure has been fed back around the public computer network and an independent skills program, which again is about trying to access the vulnerable to upskill them in all terms of access. So I think that's the kind of general landscape in terms of inclusion and how we're going to build out the networks. But commissioning has a really important element to that as well. So I was going to hand over to John, who's going to share what he's been doing in that respect. Thank you, Sarah. And yeah, so just to pick up on the digital exclusion point. As Sarah said, we actually compare reasonably favourably to other comparable authorities. But looking just beyond that, there's quite significant work we're doing with our current delivery partner, Mole Valley, as part of the broader kind of digital switchover. So there is a really strong focus on as you switch from analog solutions to digital, how you can have alternatives to kind of broadband, so mobile technology as part of the kit that doesn't rely on having broadband infrastructure in each and every kind of property. We have National Toolkit, which we're doing self-assessment against and working with national networks to kind of progress through that. So alongside that reasonably positive position that we're in, we're doing the detailed work. So we can be quite specific to certain localities and address any particular points in that regard. I think the other thing to say, I mean, there's a broader point in terms of use of AI, I think that is very much with us already. We know just from laptops in front of us, they use some levels of AI. And there's lots of positives that can come from that. But of course, a strong focus on data security and appropriate kind of use of that, and that is very much part of the work we're doing. I think Sarah's already mentioned the kind of corporate work in terms of digital inclusion that goes well beyond the department, is more general in terms of all members of the population being able to access digital kind of infrastructure, but also the training and support they may need to access that. Thank you. Thank you. Moving on to the next question. I'm concerned about the pressures that have been identified of 50 million plus, and the risk that these could turn out to be significantly higher than anticipated. So I would really ask you to talk to the key risk areas. And one that I particularly note is one that I raised last week with the Cabinet, that following the CQC assessment, excellent that we got a good overall. However, needs assessment was marked down as in need of improvement. It's obviously an area that's under pressure, and it's going to be very, very key to actually delivering against those pressures. So if we could actually cover that off within there as well, I think it would be very helpful to understand, A, that the process is robust enough to actually help deliver the savings, but also that it's robust enough that it still delivers to the residents the services that they are going to need from every day. Thank you, Chair. Oh, sorry, Sarah, did you want to come in there? Apologies. Shall I just start with the...? Well, I would suggest, Sarah, you start, and then Claire comes in after. No, and you're absolutely right because, yes, we do have a substantial efficiency programme to deliver. It's a high number. We can all recognise that. But to do it, we've got to improve what we do as well as, you know, and the fundamental principles underpinning the programme is improving that care and support because that's how we'll deliver our statutory function but also how we will make those efficiencies. So it's all based around, as Claire said earlier, prevention, earlier intervention, and that doesn't mean... And, you know, obviously we've got Ruth from Public Health there in terms of kind of longer-term prevention, but we're talking about provision of equipment in a really timely way, maximising that, making that more efficient, looking at our front door, making sure that's as effective as possible, and we know there is a lot of work we need to do there which will help us address demand but also get better outcomes for our residents. So they're completely aligned in terms of the ambition for the programme, but, again, recognising the fact that it is a significant amount of efficiencies to deliver and that will bring its own challenges. But I just wanted to reassure you that that absolutely is fundamentally part of the programme and the learning that we're taking from the CQC inspection is already starting. We've already got plans in place to address all the areas that they've highlighted and they were already ongoing because, obviously, we got earlier sight of those as they were doing their inspection and we absolutely recognise that there is some practice work to do that isn't necessarily related to the efficiencies, even which is still going to happen and is in train now. I don't know, Clare, if you wanted to? Yeah, thanks, Sarah. Thanks, Chair. Yeah, I think, again, a really, really interesting point and one that's really well made. It is worrying in some respects the size of the efficiencies that are required, but it's also expected because of the size of the budget that we have and the need for us as a local authority to be efficient and ensure that we get best value for money. And as everybody in the room is aware, this is the public money and indeed it's, sorry, residence money. So it's our duty as officers of the council to make sure that we follow that through and we check wherever we can within the directorate to make sure that we are efficient and that we are striving to make sure that we get best value for money. And as Sarah said, some of the work that we need to do, although we have a good from CQC, from CQC, which is excellent and well-deserved from the officers involved in that. I wasn't privy to be within Surrey County Council at the time, so won't take credit, but it is absolutely well-deserved. But we still know there's areas where we can make a difference in how we deliver care and what our care offer looks like to ensure further efficiencies are built into our budget. It will be challenging. There's no doubt about it. And it will be something that we need to pay close attention to in terms of the pace of delivery of this, too. I think what is really quite unique and a privilege as a director of adult social services is often when you look at the budget and look for these efficiencies, they can lead to better outcomes for people, too. I think there's often a preconceived idea that more care is the right thing for individuals. And actually, that's not often the case. Often what people want is less intrusion in their lives and more ability to live as independently as possible. So for us, it's about ensuring that from a practice perspective that we get that right. And listen really carefully to our residents about what their care needs are and what are the options available to them that actually meet their needs but are least restrictive in how we deliver that. And there's some evidence to say that that's not quite how we've been operating in Surrey. So for example, we know that we've perhaps moved people into residential and nursing home placements when historically they may well have been able to have some care at home. Maybe one day they would have gone into those settings eventually, but perhaps we've moved them in too early. So part of the transformation plan is to make sure that we don't repeat that and that we have a strong home care market. To make sure that people can stay in their homes for as long as possible and that the decision to move people into residential and nursing home placements is at the right time for those individuals. Because once people go into those institutions, it is that they were likely to be there for a very long period of time. So we have to get that that moment quite correct. And that's evident in working age adults, for example, people with learning disabilities and those individuals that are neurodiverse. We have nationally, not just in Surrey, but nationally, we've leaned to placing those people into residential or nursing home settings. I'm 48 years old. If you put me in a residential placement of 48, you know, you may be paying for those costs for another 30, 40 years, which is a substantial amount of money for the council to have to consider about funding. So for us, from a financial position, that's why we want to get it right. Right. But also from the independence of that individual living the best life that they possibly can. We want people to live in local communities and contribute to local communities. So some of this is about best practice, which hopefully will lead on to those efficiencies coming through as well. We do know that demand is, as we've touched on already, is one of our biggest challenges. And as Sarah said, part of our transformation work will be looking at our front door, how we speak to people within the county. What can we do and ensure a consistent approach in how we offer that conversation? So often in social care, we call that the first conversation. And what we really want to do is make sure that element is right and that if somebody doesn't require a Care Act assessment, which is quite onerous and quite lengthy and doesn't always lead on to a support plan, that we tackle the issue there and then. And then if they need to move into the second conversation, which is part of the assessment process, that we're getting the right people through that point. And again, we've done some work analysing that data and we know quite a lot of people who could have had some of their challenges resolved in the first conversation are moving to the second conversation. And that, again, can take a long time for us to resolve. So we need to make sure we're working at pace, we're assessing people in a timely but good way and making sure we get good outcomes, but that we're assessing the right people. And if we can resolve people's issues much earlier, that we should be doing that. And part of those issues could be actually linked back to things like aids and adaptation, grab rails going into people's homes earlier, for example, making sure that people get access to the disabled facilities grant that district and boroughs hold on our behalf to make sure that we are working to keep people at home for longer and intervening on those areas earlier. So some of this will obviously come through in our transformation plans and I'm sure over the next year or so you'll be able to scrutinise them in more detail, but there's already some key elements that we're working to as well. So best practice would tell us to be least restrictive and make sure that we can try and reduce complexity as best as we possibly can by intervening earlier. And that's very much the strategy and the work that we're doing through the transformation programme. I can see Sinead's got her hand up, so I'll hand over to Sinead. Yeah. Thank you, Claire. Before I hand over to Sinead, thank you for reminding everybody that helping residents live longer, have their lives at home is where we are at. Sinead, over to you. Yeah. Thank you, Chair. And thank you, Claire. You'll be glad to hear, Chair. I'm not going to disclose my age in a public meeting, but I'm grateful, Chair, actually, that you raised the CQC. And I'm sure select committee members have had the opportunity. If you haven't yet, please do take up the opportunity to read the report because in there it sets out in quite considerable detail areas of inconsistency. And Sarah's touched on, and Claire as well, that we're already up and running on working on those, but also does touch on the strengths that got this service to good. And I'd just like to take the opportunity, really, to thank Helen Coombs, who was here as an interim DAS. Many of you met her, who was given a brief and came and certainly delivered that brief. But I'd really like to thank the staff. You'll see from the feedback report that their involvement in the process, their contribution to making positive differences to the vulnerable people we support really did shine through. It's an absolute strength. And I'd be grateful, Chair, the committee could join me in recognising that and thanking our staff for that. I know we've got providers in the committee room as well. And I do wish I could be there in person because the providers also spoke strongly in support of adult social care and working in partnership to deliver good outcomes. And the other area, because it's all kind of interlinked and connected, Chair, because we were highlighted, I think, for good practice when it comes to supporting those people with short term social care needs. And we were an outlier because 86 percent of people who did receive short term support support didn't need ongoing longer term care. And when you compare that to our partners regionally and nationally as well, that is a really good result. So I think that the transformation plan drawing on that kind of support, helping people to remain independent for as long as possible is paying dividends for everybody. And I'd also just like to finally highlight, because I hope it gets mentioned today, is our ambitious plans, particularly around supported independent living. And the inspectors did indeed note that as an ambitious plan, but a really positive plan to deliver those 500 spaces to encourage people to be independent and to have choice and control. So thank you, Chair, for letting me jump on the back of that. Thank you. Thank you, Councillor Mooney. Thank you, Councillor Mooney. And I think Councillor Rebecca Downing's evidence is a supplement. Is that right? I believe it's been answered. Okay. In that case, moving on to Councillor Robert Evans. Thank you, Chair. I just want to push a little bit further on some of the assumptions that have been made. Sinead, Councillor Mooney, referred to that the demand in this area will be £620 million, or maybe, by 2020. I know those are forecasts, and forecasts are always difficult, but that's £100 million more. And a lot of this whole budget and papers is made on estimates and increased demand. But specifically, looking at the adult social care package, which is the biggest budget issue, how did you come to the predicted? Could you give a little more information to somebody about how you came to the predicted figures in the care package? And what is the risk in the next few years that the demand could be significantly higher? Thank you. Yeah, would you like me to come in there? Sinead, are you happy for me to? Yeah. Sure, please. So again, thank you. Sorry, Will, I'll let you come in in just a second. So Will House is our finance business partner in my directorate and has helped with some of the modelling for the future demand, which is really important in adult social care. And again, there's various ways we do that in terms of O&S data, for example, that tells us population data of people who are likely to become elderly and frail. There's also data that we can use that helps us tell us around young people that are likely to transition into adult services. And as you know, in Surrey, there's a large number of young people that are subject to educational health care plans. Not every young person subject to those plans is going to come into adult social care and require a Care Act assessment or indeed a support plan. But we do know that we want to make sure that we understand that demographic and how they might likely to come into our services. Not only does that help us build the budget correctly in terms of what the likely care costs will be, which also takes into consideration inflation, etc, as well. But it also tells us about how to design the services that we might need in the future, too, which is exactly the point that Sinead was making earlier. Some of that work has already been well developed in Surrey, which is fantastic. But we always know we need to be quite a movable feast in our department because of that demographic change potentially in younger adults as they move through. And there's an area which I like to describe as those people at the edge of the Care Act that perhaps don't necessarily have eligible needs that we would be quite strong on in adult social care. But our young people that are coming in who may be subject to a child protection plan who may have been at risk outside the family home. So, for example, child sexual exploitation, criminal exploitation, young people with substance misuse challenges that are coming through. But perhaps we wouldn't necessarily have traditionally seen them as coming into requiring adult social care, but may require a social work intervention, for example, and additional support in life. And that's an area that, again, we want to look at and develop moving forward and improve our transition service offer and make sure that we get it right, right back to those principles we just talked about, which is about people living in their own homes for as long as possible with the right and relevant care and support in place. But I'll hand over to Will because I'm sure he'll be able to tell you a lot more about the facts and figures. I'm very much coming at it from a practice development perspective. Thank you. Thanks, Will. Thank you, Claire. Yes, William House, Strategic Finance Business Partner for Adults Wellbeing and Health Partnerships. So I guess just to add to what Claire said and to answer your question about the assumptions. So we've looked at it in two ways. Firstly, sort of looking backwards in terms of what's happened over the last 10 years of care package demand changes, stripping out sort of factors such as a pandemic, which is obviously more unusual. And also, as Claire's mentioned, bringing demographic information to project forwards. And the pressures that assess out in the pressures, so the care package demand pressures, where it talks about the current trajectory. So we've modelled those based on what's, you know, if you like the current model and what's been happening, you know, at the moment. And if we don't make any changes, our estimates of how much more we would need to spend based on if practice doesn't change. And then within the efficiencies, we've then modelled the impact of plan changes to keep more people at home, as Claire and Sinead and Sarah and others have commented on already. Increased use of raiment and effectiveness of raiment services, the impact of technology, and a number of those factors that we've talked about. To then have an alternative target trajectory, which is effectively what we're planning, what the budget is planned around. So a lot of work has gone into modelling that across all of the different care groups across adult social care, because obviously it's quite a diverse area, lots of different types of needs within there. And, you know, we've looked at the costs of care within that as well. So I think, you know, it's a robust piece of work. Obviously demand is difficult to predict. There's always, there may be unforeseen factors, but I think it's a thorough piece of work that's gone into modelling. Thank you for that answer. Other question, really, about the budget that we've recently had. We've obviously seen, you know, there are major increases in national insurance. There are changes to the minimum wage. There are upcoming changes to employment law being proposed. What sort of level of risk do you see that all of that posing to the budget, and how we could contain it? Yeah, thank you, Chair. Really important question. I mean, I think, to be clear, you know, there is a quantifiable impact in terms of the increase in employer national insurance contributions. We're very much in close contact with our provider sector who are making their views quite loudly known at a local level, but nationally, and making representations to government on that. I think the key thing that has come out in conversations I've been having does link back to some of the earlier points made around how we go about managing demand, which is very much focused on the models of care. So whilst there is undoubtedly a quantifiable pressure, and at this stage we have no certainty or clarity as to whether there will be additional funding to help support that from government, it is important we continue the conversation with our provider sector around what the models of care look like that could help manage some of that pressure. But it is a big risk, and we're working with the sector to try and understand that, and the potential impact that that could have. We await the local government finance settlement whether or not there will be anything within that to address the sector's concerns, which I think we broadly support and recognise remains to be seen. Thank you for that response. Councillor Jennings-Evans. Oh, and Robert as well. Thank you Chairman. Following on from that question then, can you help us to understand what mechanisms and measures you're going to be putting into place to monitor the risk regarding governance and oversight? Yes, thank you. Yes, thank you. Yes, thank you. Yes. So we have well established kind of regular forums with our local care association, we represent a certain segment of the sector. We have those quarterly meetings, so that's part of our sort of established ways of working, and I think it was very much recognised in the CQC inspection as one of the positives. We work very constructively in partnership with the sector. We have signed relationship managers for each provider within commissioning. That's a really key conduit to understanding very early on if there are pressures within particular services that may require us to kind of have different conversations with providers. I think the conversations I've been having suggest that there may well be some consolidation in the sector, so smaller providers having to come together as groups or merging in order to kind of maintain their financial viability. We would of course work with providers around that. They are autonomous and they would make their own decisions, but as good responsible commissioners we would work closely with them on that to make sure outcomes for Surrey residents are maintained. Thank you. Councillor Robert Evans, can I remind everyone as well that we need to a degree to maintain a timetable, so please can we keep questions and answers concise? I will as ever be as succinct as possible, Chair, thank you. Just following on from the points that the Chair made a few moments ago, in the budget the Government announced an extra £1.3 billion in grant funding for councils of which it said £600 million were for social care. Has Surrey had any indication yet whether the money will be available for adult services, children services or whatever, and of that £600 million how much Surrey is going to be able to pocket? Thank you. Thank you very much. Thank you very much. So as I said earlier, you're absolutely right, there was an announcement of that national scale. We have had no indication of how much Surrey will get. It depends significantly on how much the Government do something called equalisation of the allocation, and we've seen different approaches taken in recent years over the allocation of social care funding. So if it's fully equalised for our ability to raise council tax, we will get a significantly smaller share of that national allocation than if it's equalised only partially. It genuinely could be anywhere in a range from very little, less than £1 million to up to £10 million. It's very difficult to project at this stage. Sorry, just to go back slightly. There seems to be an unbalanced situation with regard to transformation, with regard to the care package demand. It is going to get significantly higher if you are going to propose that more in-home care will stop the amount of money to be currently spent on care rooms, etc. You at the same time want to save £83 million across the MTFS period. How do you balance the two, and how do you achieve it? One is rising, and the other one you want to drop, but it's unlikely to drop. In your experience, I'm quite sure you won't disagree with that statement. So how do you do it? You're going to hit people who are on care packages to keep them at home, to save £83 million over the five-year period. It seems to be a ridiculous situation. One, you want to assure that you reduce that cost. At the same time, you're expecting to have the cost escalating upwards. It just seems odd to me, currently, the way it's set up. Clare, I think Clare has got her hand up. Clare, if you would like to go ahead, please. Clare, thank you, Chair. Thank you. And again, really, really interesting point and well made around budget setting and efficiencies. You're correct in saying that obviously there's a population increase and likelihood of people accessing services. But what we do know is that the cost of home care is actually much more effective and efficient in terms of managing people's care needs. What we also know is that, as I pointed out earlier, the timeliness of people being placed into residential and nursing home settings is actually really, really important. Because if, for example, again, taking the working age cohort, if we place people in too early, we are basically funding them for a substantial amount of their lifetime. And actually, it goes back to good practice for me, which is that putting somebody in a care home setting who has the ability to make some decisions themselves, live as independently as you or I, with a level of care and support that isn't as restrictive as an institution. Then one, that is the best practice and the best decision that we can make as practitioners. And two, it's actually more cost effective. So, for example, in supported living, in the model of supported living, the cost of the accommodation is often met through what would have been housing benefit back in the day, as opposed to the adult social care budget. So what we're doing is accessing other funds and arrangements to enable people to live more independently. Plus, there's a level of which we would describe that those needs can be met in a least restrictive way. So what we would look at is the individual strengths, how they may be able to operate and communicate effectively in the community, and what is the sort of care and support that's required. Often in a residential or a nursing home setting, you should be meeting the needs of people who cannot live like that. And in the working age cohort, that is now starting to be challenged. CQC best practice tells us that actually we should be promoting people's independence and we should be finding ways and ways and means of enabling people to live as independently as possible. And that although the numbers for that cohort appear much smaller in terms of those individuals accessing our services, the costs are increasingly higher. So what we're trying to do is building ways and means of working with these individuals as effectively as possible within our own strategies that our commissioning colleagues are developing, and indeed conversations with providers about how we can work together to work in a strength, strength based and outcomes based approach for people so that they can live at home for longer. So this is quite a complex conversation in terms of how we meet needs, and as John talked about, it really is about models of care. And one of the key elements for us in adult social care is that promoting independence right across the whole life course, not just recognizing the older adult group of individuals who may become frail and elderly and need our support, but also the other end of the spectrum of young adults that need our support and how we might need to look at how we've modelled the care historically. And again, this is a national issue, not just a local issue, and how we might move into a space where we can continue to enable people to live independently. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. I failed to find that explanation clearly in the reports, so I would ask that a report be granted to me, at least if nobody else wants it, to understand fully what it is and how it is you're going to achieve that. I understand what you're saying. You're picking up from other places and doing different things, but I would like clarity on that, because it is important. If we fail on either one of those, the budget deficit gets greater and greater and greater, and we know it's going to increase anyway. So could I have sight of something to explain that in some detail? How are we going to reduce the cost of care packages and how we're going to allow for the increase of the people coming in? And how it's paid for and who pays it? Thank you. If you could do that for me, I'd be grateful. Claire, do you mind if I say so? I'm very happy to progress that for Councillor Furey, and I'll share that with yourself, Chair. I just want to quickly follow up on what Claire said, because I know time is incredibly tight. But I went to see a resident, not in my division, the other side of the county, far away from Spellthorne, who had been in a care home and had left the care home. And they wanted to go home. She basically wanted to go home. And she did say to me when I met with her that there is no place like home. And she was so pleased to be back there to see her friends and her family members. So, you know, just to kind of reinforce what what Claire was saying and just to, again, touch on the better outcomes for residents as well, which is a golden thread throughout this whole transformation programme, as well as meeting the efficiencies. We're going to improve outcomes. That's the plan. Thanks. Thank you. Apologies. So sorry, Chair. May I quickly come back as well? I'm ever so sorry. I know time. Just very, very briefly, if that's OK. You're making things very difficult for me. Very, very quickly. Just to also say that there is some evidence in the pack around the strategies that we're implementing in Surrey, but also just to very quickly shout out to Surrey before I arrived, also contributed to the County Council Network and Newton Europe report into working age adults and how it's an unspoken and unheard problem and challenge for councils and indeed adult social care departments. And that report is available. So I'm more than happy, again, to share the link, et cetera, to the committee for a bit more information around the national picture and how we are trying to implement some of the best practice that's been drawn out of that and the evidence that that's produced as well, if that helps provide some level of reassurance. Thank you. Thank you, Claire. Moving on to Councilor Robert Evans, who I believe has a question about services, existing services to residents. Thank you. Really, yeah. I mean, if there are changes in the budget, in the social care and public provision, what are the anticipated changes that the residents might notice? How might they? I mean, it follows on a bit from Councillor Furey's question, you know, but what are the changes that individual residents can expect to see? Shall I just pick up some of that just to start with? That's all right. So I suppose what would the changes the residents would expect to see? So I suppose it would be a different way, a different front door into the Council, so a different approach when you first contact with a different response, which will hopefully be better and clearer and give the support needed faster and the right support. So that's a very key part of the demand management, because going back to what the efficiencies are, a lot of them aren't about dealing with, it's not about reducing the current budget, it's about responding to demand in future years, which we know is increasing. So if we've got a really effective front door, that will make an enormous difference to doing that, and it's a very key lever in terms of the transformation programme. So I suppose, yes, that would be one of the changes that they would see. Also, obviously, the options that we've got available for their care and support will be broader, more targeted. And going back to what we've already discussed earlier around the kind of strength-based least restrictive practice, which is about making sure that people have the right support and not over-provided for, which can actually deliver worse outcomes. So those are the kind of key changes, I think, that you would see as part of the programme. I don't know, John, Catherine, if there's anything you want to add to that, and Mark? I suppose the only other thing to say is the focus around prevention, early intervention, and Ruth, you may be able to say a little bit more about that, that's your area. More than happy to, Ruth Hutchinson, Director of Public Health. So prevention has been a key theme. I'll start, first of all, with the public health budget. As Sinead alluded to earlier, we don't get to hear about the announcement of the health budget often until February or March. The current Minister of Public Health has promised us that it will be earlier than that next year, so let's see, we've budgeted for a 2% increase. But with the main public health commission services, substance misuse, health as the school nurses, and sexual health in particular, the ongoing difference that residents will see is that key focus on prevention, in particular for substance misuse and sexual health services, as per the conversations around adult social care, the earlier we can intervene, the better it is, of course, better outcomes for our residents, which is the most important point. And then, as Catherine has said, there's something about adult social care and this key theme, and how can we continue to align our public health services, and this came out in our CQC assessment, so that they are aligned to the situation with regard to demand, and so as much as possible we can make sure that we're intervening early. So that shift that Sarah has described is the same theme with regard to the public health services. Thank you. Thank you for that response. I'll just pick up on the mention of public health and prevention. It's something of Cinderella historically in Surrey, I would have to say, in terms of the government funding. So, Mark. Thanks, Chair, and apologies for being late this morning. Just not necessarily in public health, but I just thought I'd mention, you were talking about change, talking about transformation. Just one example of that, which is happening at the moment at the Royal Surrey Hospital, where we're looking at how we can improve discharge from hospital, they are trialing out the process of where somebody would normally go into pathway two or three, so that's in either short-term or long-term residential care. They are actually sending those people home with a 72-hour care package put in place with them to determine exactly how they can be supported at home, what they need at home, and to almost effectively bed them in. And that has proven to be incredibly successful. So, not only does that reduce the costs which long-term care has, but it also means that that resident is at home in a familiar setting and will be there much longer. Generally, people going to pathway three don't often come out of pathway three from that residential home, so this is improving people's lives and at the same time saving money on the budget. So you can see very quickly how we can actually transform and reduce that budget down, but at the same time improve vastly people's health and wellbeing. Yeah, and I think it's very important to understand the deconditioning that occurs if somebody sat in a hospital bed for her excess days when they could be in their own home, gradually acclimatising, getting back to normal. Okay, moving on a little bit, I'm going to ask a question which I think the two Cabinet members will probably want to pile in on first, which is, among all the proposed changes to the Health and Wellbeing Budget, which are likely to spark contention, and how are you intending to meet those issues? Well, I'll go first because mine's easy. But the public health budget, as you know, is ring-fenced for exactly that public health. I mean, we are working on a 2% increase, fingers crossed, that we've been promised that we'll fund in January, but the likelihood is that will probably be February, March time. So, we will continue to do the work we do. We innovate, we look at change, we look at grant funding. I mean, the public health team, led by Ruth, are absolutely fantastic. We've got national recognition for a lot of the stuff that we do, and we do bring a lot of money into the county from external grant funding and projects from central government. So, from a budget perspective, obviously we'd want more. We have one of the lowest public health grants, but fundamentally we will work with what we've got, as we do every year, and produce an enormous amount of work with a very small amount of money. So, we will keep moving forwards and bringing more money into Surrey from grant funding as and where we can. Yeah, and with, you know, the push on using prevention, you know, public health really needs to come to the fore. So, I really do hope that we see more funding coming, you know, towards the public health and prevention agenda. Well, and I think the thing is, and the change that the public will see is that that will get stronger and stronger. That messaging is constant now. It's about prevention. It's about being active, about being fit, about eating the right things. Don't smoke so much. Don't drink so much. You know, we're not going to be whipping people, but we can support them to live better and healthier lives with some simple changes. So, that messaging will get stronger and stronger because we know that by just keeping people fitter and better in health, it keeps them out of the system. They're happier. We're happier. It's a win-win. And I'm going to ask Claire Edgar if she'd like to pile in on the contention question as well, please. Yeah. And I think, again, really good question. And it is all about the impact that we have on residents. And I think that's really important for us as officers to reflect on that when we look at our services and how we deliver them. So, I appreciate that question. There will be some big challenges. I think in terms of Surrey, we have got a number of cell funders. And that question around home care versus residential or nursing home placement is one that we can talk about with people that access our services. But we actually, you know, we do know that we have higher rates of people going into residential settings than virtually anyone within the Southeast region. So, we're right up there. And so, there's got to be a question about that also includes, you know, cell funders as well. So, there's a question for us about why do people think residential care is the answer? And so, when we are making decisions that home care, as Mark's just mentioned, is the right approach, we will hit some difficult conversations with families who have a perception that residential care is the answer. And there will be people who have already chosen that themselves, because they're funding it themselves. But we still believe the principle that there is a time and a place for residential and nursing home placements, absolutely, that, you know, they are needed within the sector without a shadow of a doubt. But what we're saying is, when is that for that individual? And we want to make sure we get that communication right for people. And in the self-funding element, that's really important, because it can have a massive impact on people's personal finances, because as you know, we charge for social care, and indeed, for care home placements in the sector as well. So, that level of conversation, I think, is really important, because when those individuals' monies do deplete, they come into adult social care to be funded. And that's, again, another difficult conversation that we will have about whether that setting is the right place for individuals and what care will look like for that person. So, there will be some challenging discussions with the public, no doubt, around that. And it's for us to communicate that effectively. That also applies to our health partners. When you do look at hospital discharge and the work that's happening and that Mark's talked about is excellent in terms of being able to demonstrate positive partnership working. But we do also know that sometimes health partners on wards in hospitals like to prescribe. What happens when someone is discharged and give information and sometimes even promises to individuals and families that we as social care don't necessarily agree with. And there is a reason why social care is different to health. And that is because we operate differently. We have different values, different principles and different duties and responsibilities. And part of our value-based social care is enablement, is empowerment, is advocacy. It's also about promoting people's rights. And that sometimes is about taking kind of, as I said before, the least restrictive principles and recognizing capacity. And if someone has capacity to make decisions that maybe we feel are unwise, but we've established that they do have capacity to do that, then we support them and manage that risk within the community. That can have a real conflict in that hospital discharge space where perhaps a medic or a nurse or an OT on the ward has suggested a care home and we're saying, no, with the right support, that person can go home. So some of these things are going to be played out, no doubt, and there will be challenges. And we just we we recognize that. And we do take responsibility for some of the changes in how we operate and how we communicate some of this going forward. Thank you. Thank you. We're now going to move on to technology enabled care because it's a major plank in the transformation strategy. So I'll kick off with the first question, which is the districts and boroughs all have existing offers of one sort or another of some degree of telecare. How are we going to integrate with that and manage the transition given such a varied environment? Thank you, Chair. And so I can pick up on this initially. Claire may well want to come in. And so I've touched on the points around the digital kind of switch over. We're working very closely with Mulvalley and others on that. And that will include a range of things kind of where we use code for and 5G and since in the alternative kind of hardwired kind of infrastructure. And we are working towards a cabinet paper in January in terms of our broader strategy around technology enabled care. And significant work has been undertaken since the additional transformation resource and team came into place in the summer. And that's all been around connecting up the different approaches. Our strategy moving forward is very much to ensure we have a good, clear, consistent countywide offer. And that we do that in a way that allows us to remain fairly agile and responsive as technology continues to kind of develop. And I think we would all recognize technology develops at a really, really fast pace. So it's important that we have a core element of the offer that allows us to kind of incorporate new bits of technology as and when they arise. And that we work with the right partners who are skilled and tuned in to that technological development that is probably not necessarily a skill set that sits with the council. So I think that's a very quick summary of our intent and direction of travel, which we intend to set out in a paper to cabinet in January. Thank you. Thank you. And yeah, Councillor Harper. Thank you, Chairman. Yes. I'm really very concerned about one aspect of what was said just then, but also a wider risk issue. With the rush to fibre, that generates, in my mind, some very serious risks for some of the things that you would like to do. I'm very comfortable with the other technological aspects. But the problem that concerns me is that in the event of a major electrical blackout, and we have quite a lot of those in my part of Surrey. I don't know about other places. But certainly for us, for example, at the time of the great storm in 1987, the whole area around me, when I say several square miles, was without power for a full month. Historically, the copper wires were saved today, because all that happened was that the telephone exchanges just, they had generators there anyway for their own purposes. They just switched on the generators, and they could enable people, anybody who had a copper line, and of course everybody did in those days, that they could then make emergency calls, or more importantly, in today's world, use AI. And so my concern is that with a rush to fibre, you can't transmit the electricity down the fibre cables, it doesn't work. There is a very simple solution to this. Unfortunately, since we don't have an appropriate person in charge of the regulators for telecommunications, nothing is being done about this. We really need to have, we should make our views known that we need to solve the technical problem at that level, because otherwise, not only do you not have access to emergency services, you won't have access to any of the AI clever stuff that we're relying on to solve a lot of people's problems over a period. So I just think that's a huge risk, and something that we ought to be addressing across the Council. Before we go on to answers to Councillor Humber's question, Councillor Goodwin's got a supplementary, relating to the previous question, we just need to settle please. Thank you. This is a question for John, please. You briefly mentioned that you're preparing a Cabinet paper about the text side of things. Would it be possible for the Committee to have an advance copy of that, so we can have a look and see if we can comment on that before it goes to Cabinet? Thank you. Thank you, Councillor. Yeah, I'm sure we, as we normally do, can engage with the Committee and get your feeds back into that process. I'll take that away. Just to come back on Councillor Harmer's point, an absolutely critical point you've flagged, and that is very much part of the digital switchover. So I refer to the use of SIM-based technology, i.e. 4G, 5G, so mobile phone technology. For bits of kit in people's home, where there is a high risk if there's a power outage, which impacts on the fibre broadband connection, as you rightly pointed out, there are things being planned and incorporated whereby that can switch to SIM-based technology that is not dependent on a power line in the old copper wire technology. So it is being thought through as part of the digital switchover, so where you've got critical bits of kit that people are dependent on have to remain active, solutions are being factored in to make that possible. If I come back, gentlemen, I mean, we know how to solve it. Technically, it's very simple. It had to be done for constructing the fibre transatlantic cables. But nobody seems to be particularly interested in doing it locally, and that seems to me a very significant risk, and I'll be interested to see what comes out of the discussions you just mentioned. Thank you. And Councillor Kelly. Thank you, Chair. With regards to the tech strategy going forwards, how are you going to make sure that your framework for monitoring it is actually robust, and that your KPIs are kept on target? Because we know it can work really well, but how are you going to make sure that informs how the strategy develops in the future? Thank you. Thank you. Yeah, critical thing to factor into any piece of service transformation or service delivery is the management of it. We're working really closely with corporate and departmental colleagues as part of the transformation to make sure we identify the right KPIs. For me, that is very much focused on being able to capture and evidence the benefits of technology. So there is a really, really strong link there with our operational practice workflow within LAS, which is the social care record system, so that we can understand, you know, what the situation was for a person prior to the package technology going in, what the situation is after that, the relative cost, but more importantly, the outcomes and improvements that are being delivered as a result of that technology. So in summary, I think what I can say is we are making sure we design the KPIs in upfront as part of the overall delivery model and technology solutions. Thank you. And Clare Aker, if you'd like to come in briefly, please. Yeah, very quickly, just to add to that really, and it kind of goes back to a previous point about monitoring effectiveness. And we know that some elements of our current transformation plan will align more to the corporate transformation activity. And this is one area that we're having conversations around in terms of how we sit it alongside a digital transformation element for the council. There is a council transformation board. So KPIs and some savings and efficiencies scrutiny will go through there. And there'll be some element, obviously, from the Section 151 and the finance team will want to obviously add a layer of scrutiny in terms of savings delivery, not just looking at the budget and seeing hopefully those savings come through, but actually understanding that the efficiencies have been made and that the programmes of work are working well. So there is quite a lot of activity in that place for the governance of this and making sure that we are held to account, even within our senior leadership team, just to provide some assurances to the committee. Thank you for that, Clare. I think it's Councillor Goodwin's next. Technology enabled care and homes tech and cost and savings. I'd assume you've been working with Oxford University and around Europe to monitor the effectiveness and cost saving impact of the motion sensor offer. Recognising that much of the investment in tech will centre upon avoided costs for which the return on investment is more likely to be seen longer term as opposed to immediately, how is the communication and tracking being managed? And how often do you expect to be informed of the updates concerning cost savings? Just as a second part of that, what is the plan to monitor and track – we're very keen on that, as you know – on how you're reducing the amount of money you will be spending through the proposed changes in the future? Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Can you hear me? So, just to come in on that point, I think it's a really, really positive thing that we're collaborating and working with Oxford University. I think that will bring a robustness to the way in which we design that tracking that I was describing kind of earlier, you know, anchoring it in good, sound research, evidence-based approaches. You're right, some of the kind of savings will be longer term, so you have to calibrate the points at which you kind of measure changes accordingly. But there are some, you know, sort of fundamental basics. So, if you are putting in technology as an alternative to – so, for example, motion sensors, I think we've shared with the committee real personal examples. There's an example I think I've shared before, Rita, who was supported to kind of return home. Some of that support involved motion sensors, part of the kind of reassurance of returning home as opposed to going into a care home. So, that's very much about where it is appropriate based on social care assessment and working with the individuals, replacing a person coming in and delivering hands-on care through appropriate use of kind of monitoring. So, in that scenario, you have a very clear and quantifiable change in the cost. So, that's just one example. Often, you know, cases will be quite individual and specific. So, it's about layering in those measurements to say what was the situation, what was provided, what are we providing now, what has that delivered both in terms of savings but in terms of benefit for the person. So, there's multi-layers to it. In terms of reporting to the committee, I'm sure we will make that part of future monitoring to provide assurance that our strategy and savings are delivering what we expected. Thank you for that response and I think the next question is… Victoria Wheeler. Thank you, Chair. It's encouraging to see the investment in tech care and I'm very interested. There was a comment that was made earlier that demand is difficult to predict and it's interesting to hear the experiences of what's being introduced from Royal Surrey. My question is how will you interface with GP systems, EPIC at Family Health and Oracle Health at Royal Surrey to ensure that we have accurate monitoring and actually so that we can move away from a demand that is difficult to predict and one that we can predict and we can measure the output from those systems and our population health to ensure that we've got accurate monitoring of trigger factors and to ensure that there can be intervention to prevent deterioration and to work with, for example, the EDD, the estimated date of discharge within those hospitals that are digitally mature and to interface that with our provision of care at home. Claire? Claire? Claire? I'm happy to… Thank you, Chair. Thank you. Yes, so the interface between health and social care systems has been a longstanding challenge, as I'm sure many of you are aware. aware and obviously as we work with our integrated care partnership and our integrated care board these are some of the elements that we are looking at there is some systems that we have access to and that we work really closely alongside so for example in the mental health space we can access various information there due to the nature of the work that our social workers and our approved mental health practitioners do and so there is activity happening but as you can imagine that that sits alongside our health partners so we need to work collaboratively in terms of that and also there is information sharing agreements already in place between the local authority and the nhs providers whether that be the acute hospitals or indeed primary care networks and gps but there is still work to do there absolutely ruth i'm sure would like to probably touch on the joint strategic analysis work that's happening in public health which is i have to say and sorry second to none it's it's excellent the the ability for us to to look at the data population health data in the county and what public health colleagues have produced is is very very good and very easy to access in terms of getting that information um for people to understand and translate as well um which is is really helpful from from my perspective and i'm really grateful for that i think the fundamental challenges around predicting demand really aren't um necessarily completely solvable so we do our best and we will continue to improve on that whether that be within the council um and we have some really good data rich um information sharing etc with internally as well so we can look at in terms of people who access benefits um we can use that data to tell us what that might lead to in terms of whether we need to provide different types of services moving forward we've used that in terms of you know crisis intervention funding arrangements and you know fuel poverty um so for example when you're looking at um household support fund um you know we can use data really really well um alongside our district and borough colleagues and we have done you know historically sorry it's got some um excellent reputation in in the data and evidence-based field but in terms of um which i think is probably more where you're coming from in in terms of looking at demand and being able to forecast demand um and therefore make sure that our budget is set in a good way and a solid sustainable way but also that our service provision reflects that that will probably always remain a level of challenge but we do as i say use those um data and evidence-based work streams i've just touched on but we also look at regional and national data as well so um myself and the team are members of the association of adult directors adas and will um attends um from a finance perspective as well so we have various partners um hr partners as well that work alongside um the regional uh colleagues to really get under what data um we have and that lends ourselves to some benchmarking as well so when i talked earlier about the fact that we are a significant outlier in the number of people we're placing into residential care that is us benchmarking ourselves um against the southeast region so and some of it against our statistical neighbors as well so a lot of work is done already to try and help us understand the budget understand budget pressures um and then of course there's the demographic information that we hold as well so we do try to do that as it as we are at the moment in terms of the care tech efficiencies etc as well the same sort of work will happen there um and we will monitor that as i said um through savings and efficiencies programs with will and partners in finance checking through and making sure that that we can correlate and we don't double count so where for example we may have said we've made an efficiency and somebody living at home for longer we're able to put that into one bracket of saving and efficiency and it might be care tech we might be able to identify that that was purely down to the fact that that individual received a level of technology that previously they wouldn't have done and that has meant that they've been able to live at home so there's there's various degrees of approaches that we've got um that enable us to one predict an element and i stress that an element of future demand and future need and then there's the other bit which is the governance and scrutiny around how we manage that moving forward i don't know john if you wanted to also come in specifically i'm going to stop you there because we have a bit bit of a timetable because you know we have people coming along you know shortly for the you know next item on the agenda so i need to actually sort of bring things to a close there we have one last question um which is how confident are you that the transformation work is aligned with the council's guided mission of no one left behind and that surrey county council's four equality objectives are being met i think that's yeah down to you claire but please keep the answer short yes thank you chair um yeah obviously we we've worked really hard to make sure that the transformation program aligns with the corporate objectives and you know the vision and values of the of the council um when it was very first set up uh predates me and that's clear in the transformation plans since a new chief execs arrived and you've also got a new director um in uh myself we've we've also made sure that they are aligned and continue to be aligned in that approach and indeed the new transformation program that the council itself has set recently clearly defines it in terms of the values and principles held by the council and in particular no one is left behind we welcome check and challenge on that and we do take the point very seriously around how we deliver services and just to reiterate you know we go back to the principles that we are transforming we're not just cutting services or reducing services what we're doing is changing our model and how we deliver the care offer across surrey and how we work really really closely particularly with public health colleagues and community-based colleagues to make sure that that offer is exactly that that we're not leaving people behind our my my personal value and that that i'm instilling in the director is about enablement and empowering people um to basically live the best life that they possibly can and we have a role to play in that but what that looks like will be modernized and a new approach um but again the one key area that we can look at to make sure that that is consistent and continues through the transformation program is is avenues like this so health select is is one of the key areas that we know we will be a health debt and then as i cant character thank you thank you claire um moving on now to the recommendations um if you put the recommendations up please sorry um so we have um three recommendations on screen yeah can you go full screening It's recommended that strong and effective risk management is treated as a key requirement in order to ensure that Surrey's adult social care services remain sustainable while delivering the services needed by Surrey's residents. Number two, it is recommended that needs assessment is appropriately resourced and robust as it is central to the reduction of costs. At the same time, it is essential that the weaknesses identified by the CQC are rectified. Number three, a plan will be required to support provision of technology-enabled care in areas where the provision of appropriate telecommunications services is weak or lacking. And then a fourth, it is recommended that there is investment in the tracking of spending against changes that are being made. Councilor Evans. Yeah, I mean, these are, with deep respect, they're fairly open recommendations, but no problem with that. On the third one, it says a plan will be required. Obviously, that is so. Do we want to put a date in it by whenever? I'm not making a suggestion as to what date it is, but it's not for me to suggest how long that will take, but I'm just saying we need a plan is a bit like Dad's army. Well, yeah, I'm the key is I think that we would like to see such a plan within the next six months and be able to then review it at that point. Sorry. Happy to respond. Yeah, I think that makes sense. We can provide a plan. My suggestion as well would be that within that plan, what we can set out is the current timetable for the digital switchover, which we know has been slightly delayed for national reasons and the inflations of the infrastructure companies, but yeah, happy to do that. Thank you. Members, are we happy with the recommendations? Agreed. Okay. Fine. We will then have a break before the next item, which is the dementia strategy, and I would suggest if we could be back here by five minutes past 12 at the very latest, please, and we'll go on from there. Thank you to everyone for coming on and resume now with the dementia strategy. That's the Joint Health and Social Care Dementia Strategy for Surrey 2022 to 2027, and online we've also got Simon Borner-Cain, I believe. So basically it's over to yourselves for the presentation first, please. Okay, thanks very much, everyone, and thank you for inviting us along today. So the committee have asked to review the progress made in our implementation of the Joint Health and Social Care Dementia Strategy. We have a system approach to dementia, so if I can introduce my colleagues. In fact, we'll go to Simon first, who's online. Hi, hello, everyone. Thank you for having us here. My name's Simon Brannacave, and I'm the director for adult mental health at the ICB. It's a joint role across with the council. Afternoon, everybody. I'm Negan Shekar, my public health principal. Good afternoon, all. My name's Damian Taylor, and I'm the general manager for older adult community. Now for Surrey and Borders Partnership. Okay, so the committee would like to see a focus on sufficient preventative measures for reducing risk factors for dementia in Surrey, as well as an outline of how we have been improving the dementia care pathway. So if we can move on to the next slide, please. Thank you. So to give a bit of... There we go. Thanks. So just to give a quick reminder of the context for our strategy, it's estimated that there'll be... Can you move your mic? Oh. Okay, is that better? Yeah. Oh, great. Thank you. Yeah, so by 2030, it's estimated that there will be almost 23,000 people with dementia in Surrey, and that's a 28% increase from 2020, when the estimate was 17,700 people. So we co-produced our dementia strategy throughout late 2021 and 2022. Throughout that co-production, the voices of people with dementia, their unpaid carers and families were central to the development of the strategy, alongside the national and local evidence of need. And as a reminder, the strategy is framed around the well pathway for dementia, which is a national approach, looking at five areas. So preventing well, diagnosing well, supporting well, living well and dying well. And in addition, the strategy has a clear focus on tackling inequality and making sure no one's left behind. And so that was, you know, that was two, three years ago now, but it does continue to be a local priority. And in the recently published ICS clinical strategy for Surrey Heartlands, there's a spotlight on dementia with regards to preventing ill health. And also nationally in the recent DARSY independent investigation of the NHS in England, dementia, again, is highlighted there as an area for improvement. So most people with dementia will have at least one other condition. And this is being identified as part of the developing work on frailty in the different NHS police-based partnerships within Surrey. The growing demand for services by people with dementia and their carers means we need to address this challenge with integrated and proactive care for all parts of the journey for people. That's our quick introduction. I shall move on to Negan now, who will talk through the work being done in public health and with other partners around reducing the risk factors for dementia. Thank you, Jane. Can you hear me okay? Perfect. Great. So as Jane said, I work in public health, but very much in collaboration with our NHS colleagues. So I'm just going to talk about some of the interventions and program of support that we already have in place to enhance prevention and reduce risk factors for vascular dementia. As you can see on the diagram on the left, so I'm apologies, it's quite small, but we know that risk factors for dementia are well documented. A lot of them actually impact us across the life course. A lot of them can be preventable because are related to our lifestyle factors, for example, smoking, alcohol, as well as some of the long-term conditions, such as high blood pressure, high cholesterol, which can lead to cardiovascular disease and diabetes. But also, let's not forget mental health and depression and social isolation, which, again, are really important risk factors that we need to consider when we think about prevention. Also, why do determinants of health? Well, air quality is another risk factor that's been documented to have links with dementia. So it's really important that we address the kind of the lifestyle and medical conditions, but also the wider factors, the environmental aspect as well. Okay. So in terms of what we have already in place, there are several interventions, as I mentioned. So in public health, we commission a smoking cessation service. So that's free for all of our residents. So last year, we had about 1,500 referrals to our service. The average age was 52. So I think that's really important to focus on in terms of that middle age before people get to the older age. So that was encouraging. And I think 52% of the kind of people who referred successfully quit smoking. So that's really great for us to hear. But again, a lot of work to do. We were awarded further funding from the government. So we are increasing our service capacity to further 1,500 in order to reach out to our communities, and especially with that focus on inequalities, and really make sure we address the kind of the seldom heard groups to reduce their risk factors around smoking. Other really important interventions that we have and we commission in public health are our NHS health check service. So that's offered to everybody from the age of 40 plus without any pre-existing medical conditions or cardiovascular-related conditions. The aim of the program is to identify people who are at risk at a very early stage. The key aspect of that work is that in our services, that's delivered by our GP partners, GP practices. For all the people around prevention, one of the key aspects that we ask our providers through our NHS practices to do when they offer those checks is to make sure that they flag if anybody is above the age of 70 to actually raise awareness about the dementia and make sure people have access to the right information in terms of reducing risk, but also being aware of their symptoms. Weight management services, again, we commission that we very much work alongside our NHS colleagues to make sure that that offer is available to make sure people stay in the healthy way. But also nutrition and hydration are really key, particularly as we age. So that healthy ageing and making sure that we've got, make sure that people are aware and have access to healthy food is one of the key aspects. And we recently launched our whole system food strategy to enable us to take that whole system approach. I'm just conscious of time, but one other thing, we do a lot of communication and campaigns to raise awareness generally about dementia and what people can do to reduce their risk factors. But also when they do have a diagnosis of dementia, when they do have that high risk, we work with our NHS partners to make sure that they can manage that. For example, how they can regulate or manage their high blood pressure, whether they are treated to target or not. Similarly with cholesterol and diabetes, I think those are really key areas of work that's already prioritized and we work with our partners to make sure that they are implemented effectively, as well as making every contact count, which is about training our healthcare professionals to make sure that they have those opportunity, conversation with our residents to make sure people are aware and are signposted to the right service. So I'm going to hand over to my other colleague to Simon, I think, I believe. Oh, no, Damien. Damien, okay, good. Thank you very much. And so this chart here is showing the estimated dementia diagnosis rate as of October. And you'll see on the right-hand side that actually since January this year, both Surrey Heartlands and Frimley ICB have been over the target, which is 66.7%. Currently, Surrey Heartlands sits at 68%. The Frimley sits at 68.3%. The England rate is at 65.7% and there is also a regional rate in the south. The southeast regional rate at present is 63.3%. Along with the estimated DDR, there's also some information around prevalence. So the diagnosed dementia prevalence, which currently in Surrey Heartlands is 4.8%, which is actually higher than the national and the southeast prevalence number of 4.2%. And how we get to the actual estimated dementia diagnosis rate is slightly tricky. But effectively, it's the number of people that are diagnosed with dementia divided by the number of people in a locality who are over 65. So this doesn't include those people that have young onset dementia that are estimated to have dementia. And that's calculated using prevalence rates from the cognitive and function assessment study, which is a very robust methodology that was developed by the Medical Research Council. In terms of the prevalence rates, these are determined by the number of people that have a dementia diagnosis that are on the primary care record as a percentage of the people that are actually registered with the primary care practices. So as an example, in Surrey Heartlands, the latest data was for September. That's 10,248 people of a total of 215,500 that are against that rate. So those that are diagnosed to give the prevalence. So keeping it relatively short and clear, in terms of our estimated dementia diagnosis rate, it is a strong indicator that we're actually working really well. Our diagnostics are working well. The joint collaboration that we're doing amongst the health and social care sectors and our VCSE partners is really working with the preventative measures, the outreach. And speaking with our public health colleagues, they were fairly certain that actually it's not as a result of higher prevalence because that's cognitive and function assessment study takes into account age, sex, and also the aging population of Surrey, and also that it's not a flawed methodology. So in terms of moving forward, how do we continue for that rate to increase further? There's a lot of learning to be had nationally, certainly from other ICBs, looking at the variation that does occur across the country. So the number one good reason, according to the NHSC, that the number one reason for good diagnostic rates at ICBs is that there's a significant emphasis on dementia, that there's linked-up working, and there's a strong dementia strategy in place. And I just wanted to mention that there's a few reports that will be coming out early next year around the use of the Diadem program, which is placing GPs into, or getting GPs to go into care homes to diagnose people with advanced dementia to increase the rates. We don't have that here. There was 14 test sites that have been running for about a year or two, I think. There's a report that's coming out next month that we're very keen to have a look at to start learning from, as well as how London, they have the highest rate, how London actually do it. So they undertook a coding exercise with their GPs to develop guidance, and we get GPs to prioritise the coding, so the actual diagnostic codes that relate to dementia so that they can be added on to their registers. And I will leave it at that for now in relation to diagnosis and hand back to Joan, I think. Thank you. Thanks, Damien. So we have, you know, we've got a good dementia diagnosis rate, so that's really good. It's an indication of how well we're working as a system. So once, you know, somebody is diagnosed, their carers, their families, that they need that post-diagnostic support. And we do have, you can see on the slide, we've got all the dots indicate where we've got support groups for people with dementia and their carers across Surrey. The different colours indicate the level of need the person with dementia has. So if somebody's got high levels of need, you know, for example, would need personal care if they went to a support group, the red dots show where those specific places are. The rest are support groups that are available for people with dementia and their carers. So all this information has been mapped onto Connect to Support Surrey, which is our information site. That people can explore and access local care and support in their area. In the County Council, we also run the Dementia Information Project, which aims to enhance the dementia care and support through Surrey-wide initiatives, such as building a network of dementia information champions and accessible training on dementia for unpaid carers. So, for example, our team recently conducted a survey to help co-design that offer for carers for people with dementia, finding out what it is that they wanted to know, seeing how best to deliver that training to people. So that is in the process of being co-designed at the moment, and that will be a new offer in the new year. We also have a focus on the needs of people with young-onset dementia at the moment. It's fewer numbers, but nevertheless, it's a difficult diagnosis to receive, and for families it can be tricky. So we're currently working with those with young-onset dementia and their families to help us find out what we need to do better. So it's giving us a better idea of the kind of geographical demand, looking at where the gaps are in the support offer and what would really benefit people and what would help. We've sent out some feedback surveys, and our next phase is to identify what have we got now, what do we need, and to continue that kind of engagement and discussion with people that this impacts. So moving on to tech, that's me again. So my colleague, my head of commission colleague, leads on this work. So we're looking at the technology-enabled care in homes offer to support people living with dementia, and it can support people who live with dementia to stay at home for longer, with increased independence and safely, and it can also provide reassurance for carers who care from a distance to see what's going on with their loved one. We've got several priority areas of focus for tech which can benefit people with dementia and their carers. So there are plans to digitise social care and virtual wards, looking at the use of new technologies and motion sensors to help expedite discharges from hospital and helping care homes to feel confident about taking people with complex needs. We also have plans in place to pilot some schemes, such as the Euromed's pilot, which is a smart medication management system that allows real-time monitoring of medication adherence. And if you're specifically interested in this area of work, there's a tech paper plan to go to Cabinet in the new year, which will provide more detail on the strategy to maximise technology for sorry residents. We'll move on to the next slide, please. But carers, we know support for carers is really, really, really important. We have a range available, a really broad universal offer for all carers, and there's specific support available for carers for people with dementia. So, for example, we've got Action for Carers Surrey. They have regular support groups, including specific ones, just for carers for people with dementia. Crossroads Care Surrey offer carer wellbeing breaks. We commission those carer wellbeing breaks, so that is for carers of all people caring for whatever their caring responsibilities, including people with dementia. We've also got some specific dementia support, which we recognised last year by doing a needs analysis that most requests that came through the carers' prescription were for support for carers of people with dementia. So we've kicked off some schemes, including a carers' group run by Age UK Surrey, the Tapestry Day Club, and intergenerational music making. So they all offer support for carers and people with dementia. Next slide, please. Thank you, Sally. And handing over to Simon to do the end-of-life care support and palliative care slide. Thank you, Jane. So I'll just reprise what the ambitions of the palliative and end-of-life care strategy are, and then I'll just touch on some of the improvements that we've made as a whole. Obviously, this strategy encompasses those with dementia, but isn't only for people with dementia, and so I'll address those areas where it's most impactful for the business of this committee. So overall, our aim is to make sure that care is coordinated to enable people with dementia to live their life as independently as possible. And so the six ambitions within the strategy that we've endorsed and that we're all signed up to are that everyone is seen as an individual with care tailored towards their needs. Everyone has equal access to palliative and end-of-life care. People are made to feel that they're comfortable and their well-being needs met, that their care is coordinated, that SCARF have the skills and the knowledge to provide best care for people in their end-of-life and with dementia specifically, and that communities come together. All the solid ambitions that you would expect there. Just to talk about some of the things that we've been doing and some of the achievements is that we've rolled out since we started the strategy, advanced care plans and things called RESPECT forms, recommended summary plans for emergency care and treatment across Surrey. And that's really important because while people have the capacity, it allows them to say what they want to happen to them sometimes for when they don't. And that's now being formally recorded. The focus now is on improving the quality and the number of advanced care plans so they become embedded. But we have made a strong start. We've extended to a select number of community pharmacies. They're able to provide palliative care drugs to support people in the community and to reduce the stress and strain and travel demands on families and carers. The Surrey Care Records, as I'm sure you all know, has been embedded as a single sign-in for each acute trust in Surrey to make it more accessible. And continuing health care are funding fast-tracked end-of-life pathways where the person's condition is deteriorating and they need support at an appropriate setting. So what we're currently underway doing with colleagues in the ICB is understanding bereavement needs and whether they're being met. And there's a review of lived experience there that says beginning. So that is where we are up to on the strategy. Can I go to the next slide, please? I just wanted to round up with a forward look that I anticipate some of the questions that you may ask. So we're continuing to understand and improve support for carers, as Jane was describing. We're going to develop a robust national and local data set to monitor progress we're making with people with dementia. And that includes analysis of dementia diagnosis rates by GP practice. We're particularly interested in any unexpected variation and what's happening in our priority populations and whether we're addressing health inequalities. That's work that we're just beginning. But yes, so that's the work that will be undertaken through the ICB and we're partners. And we are identifying all the special suspension support available across Surrey to address the gaps. There's a lot of work that's happening at place and it's variable in Surrey, naturally variable because it's driven in different places. But we are going to bring that together and look at it as a whole and learn from each other and look at the challenges and understand where we've got different services and which are best. And we are planning for the impact of the new disease-modifying treatments for dementia. And those of you that have been paying attention to the media and you will have noted that the first two of those treatments that have come through NICE have been rejected for the NHS. But there are many, many more that will come to fruition over the course of the next year and years. And we're hopeful that some of them will be agreed for use under the NHS. And as an ICB, we're colleagues in the ICB and inside my directorate, we're really, really keen that Surrey plays a leading role as one of the first centres to get access to these drugs and to set them up and to do any pilots or studies that are made available. And we're in conversation with NHS England in that regard. That's alongside our Deputy Chief Medical Officer, Dr. Deepa Dow, who is also really keen. So we are ready to go as soon as we're allowed to do so. I understand the reasons the first ones were rejected are largely to do with the cost. Other therapies will have different costs. So we are hopeful. And that's the end of our slides. OK. Thank you for the presentation. Before we move on to the questions, I have a note which is a number of the links in the papers don't appear to work. Could we please have a refresh table with all the links quoted and that they've been checked? Thanks very much. And first question, I think, is Councillor Abby King. Thank you, Chair. You spoke near the beginning of the presentation about preventative measures, outlining quite a few. I just wondered if you could delve deeper into prevention amongst adults with learning disabilities and learning difficulties and what you're doing in Surrey and also maybe touch on how you can promote these amongst the community. Obviously, there are things online, I know, on our social media, but are there other measures that are perhaps not limited to online? Thank you. I'll speak to what I can. Unfortunately, my colleague, Dr. Emma Hines, isn't here today and her area is learning disability, not mine. But she did give me some information around that there are a number of accessible resources that are being offered at the moment, particularly around brain health, healthy eating, lifestyle that their service offers. And these are often proactively provided when an individual is referred into their services. Excuse me. And if an individual does have a specific specialist learning disability health need, there's also a group, a healthy group, that's run by their multidisciplinary team that they're currently offering, and referrals to dietetics as appropriate. And that's all I can attest to them. Sorry. Thank you. Thank you. And just to add to that, so everyone, children actually from the age of 14 with a diagnosis of learning disability are eligible to receive an annual health check. And, again, that would provide a really good opportunity to actually identify those early risk factors around healthy eating, sexual health, alcohol, all of that. And I think there's a lot of work that's happening across our primary care to increase that opportunity and make sure parents are aware that that opportunity exists and when they're offered, they can attend their appointments. So I think that's a really good hook that we've got, and we're really working closely to raise awareness about how people can access those. And in public health, specifically, I mentioned making every contact count. So we developed two best-spoked, if you like, making every contact count courses for people and carers of people with learning disability. One is about healthy eating, in terms of how we can work with the carers to role model but also improve healthy eating for people that they care for with a disability. And the other one that we are working is around alcohol as well. So, again, just make sure that we've got that tailored approach for people who've got a learning disability. Chair, can I just come in on that? Yes, please. I do. I mean, it's just prevention, generally speaking, through public health is just about living better and healthier. The old adage, what's good for the heart is good for the head. You know, if we drink less, smoke less, take some exercise, two litres of water, all those simple things in life, if we do that, that will help to prevent the onset of dementia in later life. And I think we all have a responsibility, one, to look after ourselves, but two, to be advocates out there in the general public to try and get that message across to people is what we're trying to do in public health day in, day out, is simple changes in lifestyle will make a huge impact in later life if you just take them seriously, walk to get your paper every morning, drink a bit more water, have some of your five a day, you don't have to have your five a day every day, but just those small changes will make such a big difference and will stop that onset of dementia going forwards. And Councillor Evans. You're following on from Councillor Newty, who, as ever, speaks very wise words. But how, Councillor Newty or anybody else, do you get across to the sort of, by the time people turn up a GP surgery with the first signs of dementia? Arguably, you know, some of the damage has been done. How do you get through to the target audience of people in perhaps their 30s, 40s and 50s, that their lifestyle, as Mark has just described, how are we actually going to get through to them? Because I'm not sure at the moment that's happening. You know, and also there's the damage that some contact sports like football and rugby are undoubtedly doing, whether it's really getting through to usually the young men, but now women as well, who are playing contact sports. How are we getting through to these people that, or to everybody, that lifestyle choices could come back to haunt you when you get to 60 plus? Because I don't think at the moment we are getting through to them. I really don't. I think Councillor Goodwin as well, please, before anyone comes in with an answer on that. And I'll just say, I remember as a 12-year-old being encouraged to smoke and all the damage it did as well. So for me, prevention is obviously the key word here. And like with anything that involves our health, prevention is really important. But I'm just wondering, building on Robert's comments about, you know, trying to educate people more during their 30s, 40s and 50s, I think it should be much younger than that. I think it should be at school age when you have all your health and, you know, discussions and things like that. Because young people need to be made aware of the impacts because we've got so much information and data and everything as to what these can do, like smoking, your weight and drinking and all that sort of thing. But also they can look out for signs in their own family, like the parents and the grandparents and the wider family unit, because they may recognise some changes in that person. And it could be even sort of the, you know, the young onset dementia and things like that. It could be, you know, the ones that come in later in life. And I think it's about just making sure that they have that awareness and understanding of that. I mean, we all understand that we've got to, you know, be healthier with our choices and things like that, but not always what the impacts are. And that's changing on a yearly basis as more information comes to us. The other thing I just want to ask really is about the stop smoking support that you offer. You said you had 1,500 referrals last year. Well, out of 1.2 million population in Surrey, that doesn't sound a huge amount, but do you have any idea of how many people are smoking? Can I just remind members that, you know, we need to allow the conversation to happen on the floor, not privately. So, yes, I'm just wondering anything about the 1,500 referrals. How does that compare to people we know who do smoke and whether or not they're light smokers or heavy smokers and things like that? I don't know whether you have any information like that that you could perhaps share with the committee, not now, but, you know, perhaps in the future. And about the education side of things and everything, why aren't we, as a nation, not just Surrey, bringing that forward to a much earlier age? Thank you. And Councillor Newtie, over to you. How are you going to sort it out that 12-year-old Trevor won't smoke? Well, you see, me and Robert are lucky because we keep ourselves incredibly fit during the summer playing cricket and everything else that goes with that. But for the majority of people, they don't do enough exercise, as we know. We do, and we're very lucky in Surrey to have bodies like Active Surrey, who do a huge amount of work with the young and the old in improving physical activity. We're very aware at Active Surrey that sport isn't always the answer for people, that it generally is about just exercise, standing up, walking, smaller things like that to actually encourage the heart rate to increase and blood to pump around your body. So there's different ways, and things mean different things to different people. But Robert's right, that message is very tough to get across. When you turn on your telly or listen to your radio, you're being pumped full of adverts for chocolate and things that are bad for you all over the place and alcohol, and it's Christmas now, and we're going to overindulge and everything else. So we all have a responsibility, I guess, within our communities to promote this. You're not going to be very popular by telling people to drink less and eat less and to actually do more exercise, but the proof is there that it does actually work. Smoking cessation, I'll go back to what we said earlier. We have one of the lowest public health grants in the country. If we had more, we would do a lot more. We do what we can with what we've got, and we are quite successful. The smoking rate is generally dropping across the country, and hopefully with new legislation coming in, including new legislation with the vapes next year, that will start to see that reduce even further. But it's not a perfect world, but I think what we are trying to do is promote that, certainly through Active Surrey and through what we're doing in public health. And as Negan said earlier, every contact counts. And I think when we get that opportunity through GPs, through public health, through ourselves, is if we make that contact count, if we can just change a part of someone's daily routine to make them a bit more active or a bit more aware of what they're eating or drinking, then I think that will be a start and a move towards the successful one. Thank you, Councillor. You need to eloquently argue that we ought to get more public health grant. I absolutely agree with you. The committee absolutely agrees with you. We need to get our MPs in the corner and beat them up until they give it. Councillor Rebecca Jennings-Evans. Thank you, Chairman. I apologise in advance. I have sort of three questions to ask you. So my first is regarding prevention. What work is being undertaken? I think Councillor Newton has in part answered this. To help people to make and maintain certain lifestyle adjustments that help to reduce the dementia risk, even with Alzheimer's risk genes. And are you able to monitor whether doing this actually prevents dementia from progressing? So that's my first question. Do you want to answer that before I move on to the second? Yeah, I'll ask them. Okay. So my second question is, it's understood that one of the greatest risk factors predisposing certain people in getting Alzheimer's disease is age. Surrey has a large ageing population. We would like to understand more about what preventative steps are being undertaken in reaching people earlier and what developments are occurring in Surrey. My third question is more about diagnosis. So for those people that fall outside the norm, the level at which dementia is diagnosed, so a high-functioning, highly intelligent person who notices cognitive decline and is experiencing, obviously, distress because they notice their own decline, sees the GP over several years talking about their cognitive decline, but will not receive a formal diagnosis of dementia until they reach the norm, as in the normal level of dementia diagnosis. How are we catering for them? Because that's extremely distressing for both the individual and the family. Really good question. So I'll try and answer some earlier questions as well, if I may. So in terms of education and reaching out early to our population, so as I mentioned at the beginning, the risk factors manifest across the life course, so we have to make sure we start from a very early age with children. So we do have a healthy school approach in Surrey where it kind of provides that opportunity with schools to have those conversations about healthy lifestyle. And it's not related in a particular condition, but as Councillor Newtie was saying, was about kind of making sure and getting into a habit of having a healthier lifestyle which can, in turn, have life course benefits. So that's the kind of education piece. But we can always do more. So we do a number of campaigns to raise awareness generally about the risk factors. So I'll name a couple. So we recently did a comprehensive communication around smoking cessation. So that was really successful. Know Your Numbers. It's, again, another campaign, a national campaign, about raising awareness about risk of blood pressure and how that can manifest in a number of health conditions. So that's kind of our broader public communication. But I think in terms of, and going back to your question about what are we actually doing, so I touched on some of the interventions that we've got in place to reduce the risk of, risk factors in relation to dementia, which is kind of, especially vascular dementia, related to cardiovascular as well as dementia. So I mentioned NHS health checks. So, again, that's targeting people as young as 40. So, again, just making sure we identify anyone who's got a high blood pressure, atrial fibrillation, high cholesterol, that can, in time, increase their risk. We can identify those earlier. So that's one intervention. And especially alcohol intake is something that you're really kind of working on. And so we've got a collaborative group where we kind of bring alcohol and drug misuse together as a partnership. So we work across a number of our key stakeholders to raise awareness. And in terms of what we are doing around alcohol reduction, we're kind of working towards prevention, again, raising awareness about excessive alcohol intake, just to make sure that that prevention aspect is in place. But also early intervention. I mentioned MEC program, again, making every contact count, but also sharing intelligence to be able to understand, you know, who's at risk of excessive alcohol and how we can reach to our communities more effectively. So that kind of touches on kind of how we can target how to reach communities a bit more and reach to people who maybe don't engage with us as they should do. I think your third question was about whether, obviously, these are the interventions in terms of what we are doing to reduce the risk. But in terms of upcoming interventions, I think what we are working towards is having a healthy aging program in place. And I think that that is going to be really key in collaboration with adult social care, with NHS. As was mentioned earlier, there are a number of initiatives that are happening at places, at NHS places, around frailty, for example. But I think it's a real opportunity to actually bring all those strands together and make sure that we have a coordinated approach to healthy aging that kind of captures kind of that reducing risk, but also making sure that when people are on the pathway of dementia, early onset dementia, that they've got the support in place. But I think that coordination is really key. In terms of how we can monitor, obviously, we monitor the effectiveness of our interventions, for example, around evaluation. But if you want to really assess whether what we are specifically doing, reducing specifically risk of dementia, then that would require a research, a clinical research intervention. And there are a number of clinical trials that are, at the moment, happening nationally to really understand. Because I think linking the association between the risk factor and then kind of what we are doing, it requires a clinical trial setting to be able to confidently evidence that. I think that's... Just to clarify, my third question was concerning the diagnosis for people who are potentially high-functioning or highly intelligent. Yeah. Yeah. So, firstly, I'd commend them and their family for their health-seeking behaviour, because I think it's excellent to hear when people are noticing these things, that they actually do go to their GP to raise those. In terms of the distress from a mental health perspective, we'd strongly suggest that they have some intervention through our talking therapies, through our primary care mental health providers, because, actually, the research shows that the outcomes for older adults therapeutically are better in those areas. And as it progresses, and they're able to work with myocardial impairment as well, as that progresses, obviously, we would undertake in our secondary services, memory assessments, if required. But the primary issue around the distress, particularly the distress for the family as well, is addressing that emotional and or mental health distress through an appropriate avenue, and that would be that primary care setting initially through talking therapies, to work through what's going on to ensure that we're linking in that person with the relevant support networks that are available. A lot have been outlined earlier. And I think the other thing to note is that, actually, the distress for the carers as well can often be exacerbated. It could actually be worse at times. We've certainly seen that in our services. So it's ensuring that we take, like, a think family approach and actually look at them holistically and ensure that all of those needs are being met in any way we can from a mental health perspective, but also for social services, the wider NHS. I don't know if that answers your question. Simon, would you like to come in as well? I think you've got your hand raised on this question. Yeah, I think it's such... I'm slightly jumping back, but just addressing, but building on what my colleague was just saying regarding talking therapies and sort of reflecting on how we make a difference and, you know, by using the contacts we already have, we are building into our... We started our discussions with all our talking therapies providers, of which we have many in Surrey, about ensuring that at that time where you have people with risk factors for dementia-like depression and they're in the talking therapy service, that they are working and that they are exploring physical activity opportunities more formally as part of the offer. And we're doing that together with Active Surrey, I'm pleased to say, and came out of an excellent conference that they set up last month. So that's the next step. I think that is very much how we can make a difference beyond sort of societal things and, you know, sort of standard communications. It's really working those points where we know we can make a difference and where you have sort of teachable moments where you're already in contact with people through our services, health and otherwise. Thank you for that response. My concern is, so from my own knowledge and experience, that that, what you've just described, is not being put into practice because I know from this individual that for the two years that they experienced this, it was more of a note that was put on their medical record rather than any help or assistance being given. And I just wondered, how do we spread the word that that's a possibility? Are you asking, I'm sorry, are you asking me, Councillor? Whoever would like to answer the question. I mean, in terms of that work I was describing, just that's work that we've just begun as we start the recommissioning of those talking therapy services so that you would be right if in that case that we could do more about pushing forward on physical activity inside talking therapies and inside our PCN level support and GPIMS and all those good things. And that's where we will be putting in our effort going forward. Thank you. I'm going to ask about comorbidities because obviously things like heart disease, high blood pressure, diabetes, even severe arthritis are all things that could end up leading to a worsened state with dementia. What actions are we taking with those, in those areas specifically to recognise that dementia could be an outcome and to help manage that as best as possible to try and prevent that. And then after me, we'll be coming up to the Caroline Joseph because we'll switch to assistive devices and things like that. Great, so I start, colleagues, please do chip in as well. So as part of the NHS long-term plan, hypertension or high blood pressure management and detection, cholesterol and atrial fibrillation are key, as well as diabetes are key targets. And we know that dementia has also been mentioned in the clinical, sorry, Heartland's clinical strategy. So there is a extensive program at work as part of the NHS long-term plan in the ICB, and I work very closely with the CBD and the cardiovascular, clinical cardiovascular group, which we kind of look at reducing hypertension and also improving detection and management of hypertension, diabetes and cholesterol. So there is extensive amount of work that's happening and also with our primary care colleagues to address those. So there's a national target, for example, for hypertension detection and management. That's 80% of our eligible population to be treated and diagnosed. So I was just looking at the latest figures in terms of by age breakdown. We are actually meeting our target for treating and identifying our elderly population. So from 60 above, we are meeting our national target or very close to meeting the 80% national target. So that's really encouraging. work is in progress to improve that cholesterol management as well, as well as atrial fibrillation. So previously, what we've done, again, using the every contact counts, really simple interventions as a pulse check, for example, when people attend their flu clinics, because we know atrial fibrillation is a high-risk factor for dementia, especially in older people. So again, kind of using those opportunities in flu clinics, vaccination clinics to really identify high-risk population and at least kind of raise awareness about dementia as well. So I would say that that is covered in the NHS long-term plan, very much led by the NHS. What we do in public health is just to raise awareness about those risk factors around cholesterol, high blood pressure through our campaigns, we're also collaborative working around data and make sure we've got that targeted approach in terms of reducing inequalities, especially kind of looking at more deprived areas and also key neighbourhood areas to make sure that the kind of the targeted interventions are in place. Councillor Joseph. Thank you, Chef. Yeah, moving on to assistive technology. Simple fixes such as grab bars in the bathroom, ensuring materials such as carpets are secured in the home to prevent falls, etc. These things guard against preventable accidents that might see people needing to be looked after within A&E or nursing homes. Research suggests that a high proportion of people that attend with dementia are home safety related. What are the assistive devices being provided for people with dementia to use in their homes, i.e. technology-enabled care? Thank you. Yeah, so we've got all the things that you mentioned around grab bars, things that our equipment service would provide. So, as briefly mentioned in the presentation, motion sensors are really well utilised and they're the ones that are most commonly used so we can identify high-use areas within the home and then working with our partners at Moor Valley Life. A risk assessment can be offered within the home around reducing trip hazards and any responder services can go out and ensure those modifying actions can take place. So, they're trained to be vigilant of those kind of environmental challenges. We've also got all the smart technologies that were on the presentations so, you know, smart plugs, smart video rain doorbells, all the assistive technologies, the voice-controlled reminders, Alexa, and the like. So, yes, we've got various tech that can prompt and support people who are living with dementia at home. And I think it's Councillor Joseph again. Yes, it's me again. Sorry. The use of artificial intelligence can allow programmes to simulate human intelligence and problem-solving abilities. These programmes can also be used to learn, gather, and analyse information, make decisions, and self-correct when doing a task that might normally be carried out by a person. In some cases, they might be able to understand and respond to voice or instruction and what a person is doing, for example, when using voice-activated devices in a home setting or even by using mobile phone technology. What technology-enabled care is aligned with AI and are there any innovative technologies being developed? Not being an AI expert, I don't know the detail and the ins and outs, but our tech partners would know how those technologies assisted care works with artificial intelligence. So some level is inherently built into the new technologies, so we need to think about how we can kind of maximise that so people can achieve what they want to achieve by accessing those technologies and AI. So, as you say, like the smart home tech, the voice-activated devices. Also, AI is being used by some of our providers to contact individuals to remind them about taking their medication, times and when care calls are going to arrive. So we're looking to maximise this as it is well received with people who access our services. Again, we've got our technology strategy in development that will be coming to Cabinet early New Year. So that'll be a good source of information there also. Thank you. And I think it's Councillor David Harbour that has a question about safety and monitoring. Thank you, Chairman. Yes, to a large extent I think you've probably answered this already, but let's just have another, a little bit more. So, safety becomes more of a concern as dementia progresses, but also safety becomes more of a concern as age progresses. quite separately or in combination, if you will. So, what does the data tell us about the people living in Surrey with dementia that are being monitored? And do we have any corresponding statistics for other people in terms of safety issues? and what are you doing to ensure that the technology links where those are appropriate or available with the tech stuff? What works? What's being trialled? What's the overall picture? Thank you. Again, like Negan referred to earlier, we perhaps don't know the dementia insights specifically around our technology. The technology is kind of focused on the individual and their circumstances and personal needs. So, we don't know those kind of linked specifically to dementia at the moment. So, what we do do is rely on the kind of professionals' assessment and judgment to identify the technology that would work for that person, for their family in general and that kind of working on a case-by-case basis. So, we've got technologies to raise an alarm, to monitor movement and prompting and reminding as I briefly mentioned. There's also technology that uses images of family members or carers reminding individuals of their daily tasks. So, that's a kind of innovative new approach. Not commonly available yet, but again, it's part of that strategic planning going forward to make sure we're, you know, on the curve, ahead of the curve with regarding technology and able to support for care in homes. Just coming on that, do you think there's any risk of resistance arising from that, the sort of approach that you just discussed? Ooh, that's a good question. I suppose everybody's an individual people and their families will feel differently, I imagine, about the different approaches. I suppose, just thinking it through, you know, trying it out, having opportunities to try out the technology to see whether it feels right, see whether it works for people, I think might be a good idea. Certainly, our tech summit that we had the other week, there were opportunities to try out some of the equipment, so I think sometimes trying it out reduces the fear. Second seat. Okay, thank you. Thank you for that. The next question is Councillor Abby King with a question about support. Thank you. Yeah, obviously, dementia is a really tough thing for both the patients and their families. the Connective Support website is fantastic and there's a real range of organisations on there that do offer that support. Just wondering about any plans to develop the strategy or anything that we can do in Surrey to develop that support for families. Yeah, so we've got the, so we've mapped all our support groups. We keep updating that on a regular basis looking to enhance it by kind of adding in the work that happens with our health place partnerships. So some areas have admiral nurses, for example, so we would look to add those in the work I referenced earlier around the specifics around people with young onset dementia. People with young onset dementia may have very different needs so looking at how we can enhance the support available for those people and their families by working with those people and their families. So yeah, it's an ongoing piece of work for us across the system. Councillor Helen Clack. Thank you so much, Chair. You know, it's been a very interesting discussion this morning. I think everybody is affected by dementia in our society today. Everybody in this room knows someone or has cared for someone or knows a carer who cares for someone with dementia. And I think it's something that we have to make the business of our society at large much, much bigger. And I really admire and support what you're doing. I'm awfully impressed with that fantastic TV or radio advert that says, my mother died for the first time. Are you aware of that? Remember? And then she died for the second time and she finally died. I mean, every time I hear that, it makes me choke because I feel, you know, emotionally connected to that kind of, and I want to know more. And what it doesn't really do because I think it's an advert for sort of funding for a charity is tell me how I can find out more. And today you've shared some of your points with us and I was quite frustrated that the links to things like checking, you know, health and alcohol intake and all the other things don't work. So I think it's really important that members who are, you know, here today, but also the leaders in their communities can actually pass that sort of, those messages along. I've got parish councils, for example, you know, they would like to know more about the risks around dementia, about the food that we eat, the alcohol that we take, et cetera. So I think it's really important that we get those messages and I'd be really keen to see a lot more through your cabinet member, a lot more emphasis put into dementia awareness. I think it's about time we really recognize how much this disease and it's a disease affects so many people in our society. I also think from a technology point of view, so I'm just making a bit of a statement, I suppose, from a technology point of view, my Alexa says to me, good morning, Helen. And I think it would be great if she also said, perhaps, good morning, Helen, how are you? Have you phoned anyone today? Have you been in contact with anyone today? You know, have you eaten properly today? And these are sort of technological advances when people who are living with dementia, perhaps maybe with another partner, but also on their own, could be so much more supported by real technological AI developments. And I'd like to see, again, that sort of, I know we're talking about it in round terms, but I think in the committee, and I would certainly like to see real terms of how that development of AI can actually help where you have access to it. As I say, I think it's something that affects everyone, and we need to make sure that everyone understands. I was talking to my sister-in-law the other day, her husband's got Alzheimer's, and she was very frustrated that she didn't know the pathway to take. And I said to her, why didn't you go on to the council's website, the Surrey County Council website, and she said, what's that got to do with the county council? And I think that's really important, you know, that we, you know, we're not just a, we're a great signposter for all people who are reaching, what do I do now that I have a partner, a father, a mother with dementia? I've given up alcohol completely, actually, and part of the reason I've done that is because I'm so concerned about my brain's health. I don't know if it's made any difference, but I do think that promotion of things like dry January, et cetera, are really good ways to not just say it's good for your health, it's good to prevent dementia. I think we're all frightened of dementia. We see it coming around to so many of us in society. There's no cure for it yet. We really need to up the game in trying to prevent it. Sorry, I didn't really ask questions there, but I have a lot of, you know, concern about it. It's perfectly OK, Helen, because I'm going to join in on the same hobby horse because earlier during the budget discussion we were talking about the desire that people live a healthy, active life at home. That includes, you know, not just that they're physically functioning, but they're mentally functioning as well, so it's incredibly important. And with that, I'm then going to go to David Harmer, who's got some questions about the dementia information project. Well, by way of clarification, really. So your report refers to the two new roles that have been appointed in the team at County Council, well, County Council, anyway, running the dementia information project. The objective of the project, we're told, and I'll assume it's correct, is to enhance dementia care and support through strategic initiatives such as Dementia Information Champions Network and accessible training for unpaid carers on dementia. What are investments planned for this purpose? For the communication strategy, and can you explain further, are there KPIs set? And if so, could we know what they are and certainly can monitor how you're doing? Yes, of course. So there are key performance indicators attached to that project. So the detail are that there's a KPI around establishing contact with 90 of the organisations that are on our support map, if you remember our support map that I showed up, and also from those to identify two champions within each borough area in Surrey. So that work is ongoing. We've identified a lot so far. Again, that's continuous work. There's a network in place to support those champions where everybody's got access to the same information, communication, advice around dementia for people with dementia and their carers. and with regards to the communication strategy, we are linking in with our comms and engagement colleagues on this one to get the message out there. So through our kind of statutory body mechanisms, but also linking through the voluntary sector, through action for carers, through Healthwatch, Surrey, Luminous, who do work with us too. Could I just ask you, are there any geographical holes in your coverage? You might not wish to publicise it, but are there any that you could tell us about privately? Not that I'm aware of. Okay. Good. Thank you. Councilor Robert Evans. Covered. Okay. In that case, I'll move on to my question, which is actually the last one. So your report refers to further work being planned to analyse dementia diagnosis rates by GP practice level and further explore an act of any unexpected variation. And obviously, the particular concern is Surrey's priority populations and the 21 priority areas. The communities of identity and geography, they are often overlooked. And we're talking about the people who are most at risk of experiencing poorer health outcomes. we know that those areas have the worst alcohol addiction. The list goes on. I won't go through all of the things, but we know that all of those help. We know that people live shorter, healthy lives. They live longer in poor health, but they actually live less time as well. So what are we actually doing in communication specifically targeted to those priority populations and priority areas? And how are we measuring that we've actually reached them? So I think Simon's probably best positioned to cover how we're reaching and monitoring the priority populations. And then Negan, if you can do a bit about the prevention. Thank you. Simon, if you'd like to go ahead. Yes, thank you, Trev. So the work that we're going to do around looking at the GP practice level and PCN level together with our primary care colleagues, we haven't started that. That's the work we have planned. And so I guess what I can say is that our priority populations will be inbuilt into that work and that thinking. And we're really mindful of all those things you said about how actually we know it's located in certain groups. We also know with mental health, that's more dispersed. And I suspect, although my public health colleagues can tell me that people with an SMI have a higher dementia risk because of also all those other risk factors and physical risk factors too. So we've got the opportunity now to plan and wire that thinking as we go forward. But yeah, it isn't, specifically that isn't underway yet, but will be as the ICB starts to really get its arms around is health inequalities work. Thank you. If I just add to that. So just in terms of how we share information with our colleagues, with our population, just going back to your points that you made, so apologies if the link didn't work, but everything, all the information that we offer about our services are on the Healthy Study website. And it's just beyond what we do in public health. It's a partnership so we kind of add other information about domestic abuse and so on. So it's all information about health and well-being is on that. Just going back to your question in terms of how we target key neighborhood areas and population groups. So some of you may be aware of the health and well-being index that we've developed. So it's a dashboard that we closely monitor in terms of some of the key indicators that are in the health and well-being strategy, but we can look at it by place. Going down to key neighborhoods area. In terms of the population characteristics, it's a bit more challenging because we just don't have the data, for example, around our DRT communities. Data is incomplete, but nevertheless, we can use the indicator to actually add the high level and then deep down and we very much work with our place partners. So place-based partnership are a really good place to have those conversations because that's where we bring the NHS community but also the local authority and then we can look at that specific indicators that have been flagged for that area which encompasses that kind of key neighborhood areas and just work with some tangible actions that we could do and maybe use some of the hanging fruit. A lot of work's already happening in place. I think the key thing is about coordinating our efforts. But we've got, as I said, the health and well-being index. that is a really good tool for us that we use. Yeah, and I think of a major concern is it's all very well running communications exercises but unless you actually measure how well that communications exercise has reached people, you aren't doing what's needed to actually be able to focus it. And I'm reminded of something that I got involved in which was a cancer awareness campaign. and discovered that there was zero interest in it and that was when I decided to get really involved in NHS England and trying to improve the targeting of their publicity. So, yeah, it's really important to actually measure the delivery as opposed to just we've run something but nobody listened. No, I couldn't agree more. and in terms of evaluating our comms campaigns, there are a number of ways that we could do. So, we measure a number of clicks, for example, but sometimes we can also pick where those hot spots are coming from in terms of which areas are actually clicking more on those websites. but, again, maybe with AI and technology we can have that obviously aware of the confidentiality and what can be shared but you are absolutely right in terms of making sure that we reach to our seldom hot groups. Yeah, I'm fond of asking a random sum of people about the message and measuring their understanding of it having got through. Okay, we can move on to the recommendations now. So, if you'd like to put the recommendations up, please. So, our recommendation of the report identifies that priority populations such as BAME may have different levels of the risk factors for dementia. Gaining a better understanding on the prevalence of the risk factors and dementia in the priority populations and the 21 priority areas is recommended and consideration of population-appropriate health actions to reduce health inequalities. Number two, the effectiveness of communications around reducing the risk factors for dementia is critical. measurement of the effectiveness of communications and their ability to change behaviours is recommended. And number three, enhanced training and support for carers is recommended. And Councillor Evans has got its head up with our suggestion. I have. If I can go back, I think Damien Taylor indicated earlier on that levels of dementia were marginally but higher in Surrey than the national average. Is that correct? Yes, the estimated diagnosis rate, yes. And the performance rate, yes. On the basis of that, could we put in we need to try to better understand or discover why levels of dementia appear to be higher than average in Surrey? because I don't think we do really fully understand that. Yeah, I think it should be a case of understanding whether this is purely that we are doing better at diagnosis or whether it's because there's something happening that needs more effort. I don't know if you feel that's a fair point to add. Is that a fair point to add? I think it's fair. Yes, I think there's a lot of other issues at play around that though as we talked about with the ageing population, those sort of things, the demographics, age, sex, ethnicity. There's a whole range of things and that's why there's such a disbursement of the lowest levels of the DDR versus the highest levels, population density. There's a lot of things that go into that. I mean, it's something that we could certainly look to do and I think it probably comes back to public health and communication around how we engage to actually manage that. But I would say it's a fair point to add. So I think in terms of recommendations, it's a recommendation that there is more research to establish why numbers in Surrey are higher. and the obvious is whether or not it's just diagnosis that we're doing better at that than other people or that it's actually that we've got a more significant problem. Can I just add a recommendation about not just improving training for carers but also improving communication and training for members as well so that, you know, as leaders in their community so that they can spread some of this work to a wider area. I am really concerned that not enough people out there understand, you know, what the signs are and where to go for. So I've had dementia training quite some years ago but it really opened my mind. I don't know whether any other members around here have had any dementia training but it does really open your mind to what's available and what you can do to help and how you might share that with other people that you meet in your community. So I think it would be good to support all members not just this committee but other elected members across the area. So as a fifth recommendation then that is that information is produced to support community leaders and especially councillors in communicating information about dementia dementia prevention and the support that's there for both those with dementia and carers. yeah and that needs to include the hard to reach and councillor harmer I just would be I would wish following on from that to understand whether there is a geographical separation pockets where we're not functioning well enough or geographical pockets I mean or is it is the pattern universal across the whole of the county? I think council harmer that's already a known yes there is a geographical issue. Well I mean to what extent is that but I think if we're looking at the research then yeah the research needs to look at priority areas obviously as part of that. So are we okay with all of those Sally? Yeah and are we all agreed? Yes okay agreed thank you very much for coming on today and presenting on what is just such an important topic the only thing that I would say is your graph is a little frightening it looks like 68% of the population over 65 have dementia which is a kind of worrying thing I think I was alright when I woke up this morning but thank you very much indeed it's a huge problem it's a growing problem we clearly need to do rather more about it than we have in the past thank you very much okay thank you everybody for partaking today the date of the next adults and health select committee meeting will be on Thursday the 6th of March 2025 where in terms of the what we have one of the major things will be primary NHS care for both Frimley and for sorry Heartlands including the moves of the various drop-in centres urgent care centres minor injury centres towards the urgent treatment centre model that NHS England is now proposing fate on up they should don't know where the snap they have had
Summary
The meeting covered two topics: the Adults, Wellbeing & Health Partnerships Directorate's budget for 2025-2026, and the implementation of Surrey's dementia strategy. The committee made four recommendations on the budget, and five on the dementia strategy.
Surrey County Council's 2025/26 Draft Budget and Medium-Term Financial Strategy to 2029/30
Councillor David Lewis, the Cabinet Member for Finance and Resources, presented the Adults, Wellbeing & Health Partnerships Directorate's draft budget for 2025-2026, which, if adopted, will increase spending by £18.5 million to £524.5 million. Councillor Sinead Mooney, the Cabinet Member for Adult Social Care and Health, highlighted that spending on adult social care is unsustainable, and accounts for 88% of the budgeted pressures over the next five years. The Director for Adults, Wellbeing & Health Partnerships, Claire Edgar, confirmed that to deal with this the council has developed an ambitious transformation programme.
Councillor Clack was concerned about the dependence on AI and technology to deliver savings, given the poor internet access in some areas of Surrey. Sarah, the Director for Transformation, confirmed that the council is developing a corporate digital exclusion plan to improve access, but that digital exclusion will be factored into the savings calculations.
The committee was also concerned about the pressures on the budget, and the risks of these being higher than anticipated. Sarah and Claire Edgar both reassured the committee that the transformation programme is fundamentally about improving care and support, and that the CQC's recommendations were being addressed.
The committee was concerned about the increase in the National Living Wage, employer National Insurance contributions and planned employment law changes, and their impact on the budget. John, a senior officer within the Adults, Wellbeing & Health Partnerships Directorate, confirmed the council is in close contact with care providers about this. He also said that the council is waiting to see what support will be available in the local government finance settlement.
Councillor Furey raised concerns about the ambition of reducing the cost of care packages, whilst also anticipating a significant increase in demand. Claire Edgar argued that providing care in people's homes is cheaper than residential care, particularly for younger working-age adults, and that the transformation plan prioritises enabling people to live as independently as possible.
The committee was concerned about how residents would be impacted by the proposed budget changes. Sarah, Director for Transformation, said that there would be a new front door
to access services, a stronger focus on prevention and a wider range of options available. Councillor Nuti, the Cabinet Member for Adults and Health, reminded the committee that the council's ambition is to enable people to live longer, healthier lives at home.
The committee was interested to learn more about the council's plans to support the provision of technology-enabled care. John, the senior officer within the Adults, Wellbeing & Health Partnerships Directorate, explained the importance of ensuring a consistent approach across the county, given the current patchwork provision offered by district and borough councils, and said that the council is working towards a cabinet paper in January setting out their strategy. Councillor Harmer, a member of the committee, was concerned that the rollout of fibre broadband to the exclusion of copper wires presented a risk, because the power cannot be transmitted through fibre optic cables, which meant residents could be left without access to essential services during power cuts. John reassured Councillor Harmer that the council is working to ensure that critical devices, such as those for falls detection, would be able to switch to SIM-based technology during power outages.
Councillor Nuti and Claire Edgar both agreed that the most controversial element of the budget proposals was likely to be the shift from residential care to care at home.
Recommendations
- Strong and effective risk management is treated as a key requirement in order to ensure that Surrey's adult social care services remain sustainable, while delivering the services needed by Surrey’s residents.
- Needs assessment is appropriately resourced and robust as it is central to the reduction of costs. At the same time, it is essential that the weaknesses identified by the CQC are rectified.
- A plan will be required within six months to support provision of technology-enabled care in areas where the provision of appropriate telecommunications services is weak or lacking.
- There is investment in the tracking of spending against changes that are being made.
Joint Health and Social Care Dementia Strategy for Surrey, 2022-2027
The committee received a presentation on the progress made in implementing Surrey's dementia strategy. 1 Negan Shekar, the public health principal, highlighted the range of interventions in place to prevent dementia, such as the stop smoking service, 2 the NHS health check, weight management services and healthy eating initiatives.
Damian Taylor, the general manager for older adults at Surrey and Borders Partnership NHS Foundation Trust (SABP), 3 reported that the dementia diagnosis rate in Surrey was exceeding the national target, and was significantly above the England average. He argued that this reflected Surrey's joined-up working, and the emphasis on dementia locally.
The Head of Commissioning for Mental Health, Jane Bremner, reported that the council has mapped all of the support groups across the county for people with dementia and their carers, and is developing a network of dementia information champions. She also said that the council is developing its technology enabled care offer.
Simon Brauner-Cave, the Deputy Director for Mental Health Commissioning, reported that the Integrated Care Board (ICB) 4 are funding fast track end of life care pathways, and that they are planning for the impact of new disease modifying treatments. 5
Councillor King was interested to hear about what preventative measures are in place for adults with learning disabilities, as they are more likely to get dementia. Simon Brauner-Cave confirmed that the Learning Disability service proactively provides information about brain health, healthy eating and lifestyle when a person is referred into their service. Negan Shekar added that all children with a learning disability diagnosis are eligible for annual health checks from the age of 14.
The committee was concerned about whether sufficient is being done to communicate the actions people can take to prevent dementia, given that damage may have already been done by the time a person starts to experience symptoms. Negan Shekar outlined a range of communication campaigns that the council has undertaken. Councillor Nuti argued that the council needs to do more to promote healthy lifestyles, working with organisations such as Active Surrey. 6
Councillor Goodwin suggested that prevention messages should be targeted at school-age children. She also asked how the council measures the effectiveness of their communications. Councillor Nuti explained that the council uses click-through rates, and targeted information. Negan Shekar added that the council monitors engagement geographically, and at a population level using the Health and Wellbeing Index. 7
Councillor Joseph was interested to learn more about the assistive technology the council provides for people living with dementia at home. Jane Bremner explained that this includes grab rails, motion sensors and smart technologies such as smart plugs, smart doorbells and voice-activated reminders. Councillor Joseph also asked about the council's use of AI. Jane Bremner confirmed that AI is used in some of the technology provided, such as in voice-activated devices and to remind people about taking their medication.
Councillor Harmer asked what data the council has about the people being monitored. Jane Bremner confirmed that the technology is used on a case-by-case basis, and that data is not routinely collected.
Councillor King asked about plans to develop the strategy to provide more support for families. Jane Bremner confirmed that the council are looking to enhance their provision, for example, by doing more to support people with young onset dementia. 8
Councillor Clack argued that more needs to be done to raise awareness about dementia. Councillor Harmer asked about the council's dementia information project, and what its key performance indicators are. Jane Bremner confirmed that the council aims to establish contact with 90 organisations on their support map, and identify two champions in each borough area, and that they are working with the council's comms team to raise awareness.
Councillor Evans noted that the dementia diagnosis rate in Surrey was higher than the national average, and asked why this was. Damian Taylor said this could be because the ageing population in Surrey is higher, and because the county is doing a better job of diagnosing people.
Recommendations
- The report identifies that priority populations such as BAME may have different levels of the risk factors for dementia. Gaining a better understanding on the prevalence of the risk factors and dementia in the priority populations and the 21 priority areas is recommended and consideration of population-appropriate health actions to reduce health inequalities.
- The effectiveness of communications around reducing the risk factors for dementia is critical. Measurement of the effectiveness of communications and their ability to change behaviours is recommended.
- Enhanced training and support for carers is recommended.
- Information is produced to support community leaders, and especially councillors, in communicating information about dementia, dementia prevention, and the support that's there for both those with dementia and carers.
- More research be conducted to establish why numbers in Surrey are higher than the national average.
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The dementia strategy was co-produced with people with dementia, their families, carers, and other stakeholders, and was published in 2022. It aims to improve the lives of those affected by dementia, making sure no one is left behind. ↩
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The stop smoking service is delivered by the One You Surrey partnership, and offers free support to help people quit. ↩
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Surrey and Borders Partnership NHS Foundation Trust (SABP) is a mental health NHS trust that provides services to people of all ages in Surrey and North East Hampshire. ↩
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The Integrated Care Board (ICB) is the NHS organisation that plans and buys healthcare for the local population, and is responsible for bringing together NHS providers, local authorities, and voluntary organisations to improve the health and wellbeing of the local population. ↩
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New disease modifying treatments (DMTs) have recently been approved for use in the UK. They work by slowing the progression of the disease, rather than just treating the symptoms. ↩
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Active Surrey is a partnership of public, private and voluntary sector organisations that aim to increase participation in sport and physical activity in Surrey. ↩
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The Health and Wellbeing Index is a dashboard that tracks a range of indicators related to health and wellbeing, and is used to identify areas of need and to target interventions. ↩
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Young onset dementia is dementia that develops before the age of 65. ↩
Attendees
- Angela Goodwin
- Carla Morson
- David Harmer
- David Lewis
- Dennis Booth
- Ernest Mallett MBE
- Frank Kelly
- Helyn Clack
- John Furey
- Michaela Martin
- Rebecca Jennings-Evans
- Robert Evans OBE
- Trefor Hogg
- Borough Abby King
- Borough Victoria Wheeler
- District Caroline Joseph
Documents
- Agenda frontsheet Wednesday 04-Dec-2024 10.00 Adults and Health Select Committee agenda
- Dementia Strategy - Final Report
- Public reports pack Wednesday 04-Dec-2024 10.00 Adults and Health Select Committee reports pack
- Cabinet Response to Recommendations
- Public PackMinutes Document for AHSC 10 Oct 2024 other
- Final Budget Covering Report - AHSC
- Joint-Dementia-Strategy-accessible-FINAL
- Final AH Select Committee Ppt slides Budget - Dec 24 Draft Budget other
- Dementia Strategy- Appendix 2 Mychoice Booklet
- Dementia Strategy- Appendix 1 Healthy Surrey dementia prevention content
- Recommendations Tracker December 2024 other
- AHSC Forward Plan March 2025 other