Transcript

We thought it would be a good opportunity to kind of fill that slot by giving you a preview of some of the findings, some of the analysis, some of the issues that we've been looking at in putting together the annual public health report. So you haven't actually got the report yet, because it's not yet finished. We are still working on it, but it is substantially done. So it will be probably weeks rather than months that it will actually be ready and published. There's a team of people in public health who've been working on it, and I'm pleased that a couple of them are here. Well, there's a few people from public health here today, but a couple of them are going to come and take you through a presentation with some of the headlines, which hopefully will prompt some discussion and some thoughts about areas that we need to focus on going forward for the future. So if I could ask my colleague, Aideen Silk, who's head of public health programs in the team, and Ben, Dr. Ben Gregory, who is a public health registrar. We're lucky enough to have him as part of his training to be a public health consultant for a year. So Ben's with us until August and has been doing quite a lot of the legwork on the annual public health report. So I think you're going to kick us off. I think we should have started going through the slides. Sorry, I should have said. Essentially, I've covered most of this already. Just to say that annual public health reports are one of the statutory or mandatory functions of directors of public health in local authorities. So every year we are expected to produce an annual report that looks at the particular priorities and challenges for the health of our of our residents, our populations. We tend to focus in particular areas rather than covering everything, because the Joint Strategic Needs Assessment is the process of looking as a sort of helicopter view across all health outcomes. So this year we've decided to focus the report on health inequalities, as the chair has said. So that's that's that's what we're going to to take you through. So handing over onto you, Ben and yeah, next slide. Thank you, Steve. So, yeah, good morning to everyone. As Steve said, my name is Ben Gregory. I'm a public health registrar here at Greenwich, and I want to thank you all for the opportunity to present our upcoming annual public health report on health inequalities. We hope that you'll all be able to gain further insights into the disparities within Greenwich and the actions that are being taken to promote health equity, which, of course, we will extend upon in the report in full. So just coming on to this slide. So central to the report are the Marmot principles, and these have been developed by Sir Michael Marmot. And these principles highlight the critical role of the social determinants of health, things like education, housing, employment and environmental sustainability, which are important across the life course of individuals. We can think of these as building blocks of health. So when they are present, they foster resilience against life challenges, but when absent, they exacerbate poor health and inequity. Importantly, these factors often are beyond individual control, too. And in Greenwich, these principles guide our strategies to tackle health inequalities. Can we move on to the next slide? Thank you. So locally, addressing inequalities is embedded across several key strategies. So our Greenwich plan prioritises combating discrimination and advancing socioeconomic equity. The Greenwich support strategy targets poverty drivers, while the health and well-being strategy adopts a life course approach, identifying priorities from prenatal care to ageing support. Additionally, the Children and Young People's plan emphasises inequality and discrimination as priorities for action. And our cross-sector collaboration is vital here. And by embedding health equity across policies, both the symptoms and root causes of inequalities can be addressed. Additionally, sustained commitment to these strategies will be key to progress. You can move on to the next slide. Oh, yeah. Thank you. That's great. So nationally, the 2019 NHS long-term plan established action on health inequalities as a priority for the NHS over the next decade. And as a result of this, and also a growing recognition of the impact of health inequalities during the COVID-19 pandemic, the NHS National Healthcare Inequalities Improvement Programme was set up in 2021 and introduced the Core 20 Plus 5 approach. Now, this is a strategy to reduce health inequalities in England by targeting the most deprived 20% of the population with poor access, experience or outcomes from healthcare. It focuses on five clinical areas that have the greatest potential to narrow the gap in life expectancy due to health inequalities among children and adults, respectively. This framework provides a strong foundation for our local efforts here in Greenwich, ensuring that our interventions are aligned with broader goals and best practices. Next slide, please. So our approach to addressing health inequalities in Greenwich is multifaceted and it includes several key components. Taking a life course approach recognises that health inequalities can accumulate over a person's lifetime and that early interventions are crucial. Place-based interventions tailor our efforts to the specific needs of different communities and populations, such as through neighbourhood working. And additionally, by intervening at different levels and types of risk, we can mitigate any synergism between different risk factors for ill health. Across our actions, we aim to build on community strengths, prioritise prevention and allocate resources proportionately, which means that universal services, but with intensified support where needs are greatest. Next slide. So health inequalities extend far beyond differences in illness rates. They include inequalities in the wider determinants of health, such as housing, education and employment, disparities in the quality and experience of care, access to information and services, and behavioural risk to health, such as smoking and cancer screening uptake. Each of these factors drives greater inequalities in health status. In Greenwich, we recognise that addressing health inequalities requires a holistic approach that goes beyond healthcare, and later slides will detail some specific initiatives. However, the report will go into greater detail. By addressing the interconnected factors, we aim to disrupt cycles of inequity. Next slide, please. So people with less access to resources and less favourable living environments generally experience worse health and shorter lives than those in more favourable positions, and this trend has been recognised globally and is known as the social gradient of health. In Greenwich, this can be seen through the gaps in life expectancy at birth between different wards across Greenwich. Previous data has demonstrated that for males in Greenwich, life expectancy ranges between 82.2 years to 76.7 years, a difference of 5.5 years. For females, the range is even wider, from 85.6 years to 78.5 years, a difference of 7.1 years. These gaps primarily demonstrate the impact of differences in geographical area and deprivation on health outcomes. While the latest life expectancy figures for males and females in Greenwich are similar to national values, they do still lag behind London, which suggests there's potential for further improvement. These disparities aren't fixed, and they can be changed with sustained multi-sector actions. Next slide, please. So, on this slide, sorry, I can appreciate the font is slightly small, but on this slide, we've done an overview, basically, of the key areas of health inequalities within Greenwich, at least some of them. We know that individuals of black or Asian ethnicity are at higher risk of cardiovascular disease, and that obesity rates are estimated to be higher among individuals with autism, learning disabilities, or black ethnicity. We know that Greenwich has the fourth highest smoking at booking rates among London boroughs, and that nearly half of all residents in substance abuse treatment have an unmet mental health need. And finally, that cancer screening uptake does generally decline with increasing deprivation. So, we can't capture the full breadth and extent of health inequalities within this brief report, but we've sought to shine a light upon key inequalities. I'll now hand over to Aideen, who will take us through socially excluded groups. Thanks, Ben. Thanks. Thanks, Ben. So, what the next couple of slides are just trying to do is to kind of pull out some of the major themes, the different body of work that is being done across the system to tackle health inequalities in collecting the work for this report. We've collected over 22 pages worth of inequalities actions sitting primarily through public health and in partnership, but actually, we know that's much beyond that. So, by definition, this is a spotlight and a bit of a highlight. But we very much wanted to kind of pull out some of those core themes and some of those areas for potential action probably going forwards. So, the first one of those is our inclusion health groups. So, this is an umbrella term often used within the NHS to describe people who are socially excluded and at severe risk factors for poor health and, therefore, at significant risk of health inequalities. This is probably an area of further investigation in terms of really understanding what these populations look like in Greenwich and the numbers they are. But what is clear is that the inequalities within those groups are persistent. The graph shows the standard age all age-caused mortality rate and that compares our inclusion groups against the deprivation across all of the 10 deciles of 3,000 households owed a duty under the Homeless Reduction Act in Greenwich at the present. People with drug and alcohol dependence in Greenwich, there's approximately 3,000 using opiates and crack cocaine. Just over 3,000 dependent drinkers are nearly... Which brings me on to a bit of a highlight in terms of children and young people. What the evidence suggests is that inequalities in childhood set through in terms of adverse childhood experiences within their early childhood and poorer outcomes and also those inequalities pertaining through into childhood. The quotes on the slide come from the Children and Young People's Plan and really recognise it. And a number of those occasional opportunities are crucial for children because they lay the groundwork for their future success and well-being. However, we have a higher child poverty rate compared to both London and England with nearly 40% of our families living in poverty and having an income of less than 35,000. It's also very unevenly distributed across the borough. Ben mentioned that one of the approaches that we are taking in terms of our responses taking actually needs a higher in certain areas of the borough because it is unevenly distributed. For example, one in four children in parts of Woolwich live in poverty compared to one in ten in part of global majority groups. Next slide, please. So, in Ben's slide with the bubbles, we talked about health behaviours and the impact of those in terms of our health inequalities outcome response that happens across the borough with over 200 organisations providing food aid. Nonetheless, our most deprived adults and their families and children and the impact that that has in terms of people's birth and health outcomes. So, we just wanted to highlight a few examples of some of the work that we're doing. So, this one is a joint project between Lewisham and Greenwich Trust Public Health. Next slide, please. One of...we've talked...I've mentioned already around poverty as a driver in health. We know that the wider determinants, those things which affect where we live, where we work, what we do, what we eat, are some of the biggest determinants of inequalities within the borough. So, again, thinking about some of the challenges that we face, we have lower education attainment amongst pupils proportionately affected by poorer housing. And in Greenwich, we have overall higher housing costs and more of a reliance on renting than other parts of London. Access to services is a key in equality in terms, particularly for a lot of our inclusion groups and real response. The Greenwich supports anti-poverty strategy, really focusing around making a sea change difference in terms of the impact of the poverty response we have in the borough, cost of living, very much an income maximisation-led approach. Our three advice hubs across the borough, food poverty response, persons in school, temporary accommodation, healthy start, fuel poverty response. So, really trying to take quite a comprehensive approach to starting to turn the tide around the anti-poverty response. Next slide, please. So, just to summarise in terms of the way that we have responded, we have a range of different ways in which we're looking at it. So, very much taking a community and stakeholder-led approach, listening to our communities, having a resident-led approach. So, that might be through resident engagement in service development, lived experience panels, our community champions programmes, and very much hearing that voice underpinning where the action that we're taking against healthy inequalities. Taking community development-led approach, a volunteering-led approach, community training, skills development, very much kind of looking at how are we taking action at that hyper-local community level in line with a place-based approach. Health inclusion, taking a proportionate universal approach, understanding who experiences the greatest health inequalities, hearing from them, and thinking about what action we can put in place to address them. So, for example, recently started is a rough sleeping joint strategic needs assessment and a sanctuary summit using the data and the power of the data that we have across the borough to very much understand what the needs are, where the barriers are, and where we can take that forward. So, we've mentioned about a targeted screening campaign. There's a picture on the slide around our more recent breaths. And really training our local barbers to understand how to talk about health and health inequalities that might be within the clients in whom they are working. Really thinking about how they can help support and guide people to start to seek earlier help. So, our barbers have told us that they've really appreciated the training. It's helped us to keep my customers safe by taking a quality-led approach to delivery of public health services and our programs of work, to require our commissioned services to understand that, who's accessing it, communication with the large and major organizations that we have within the borough. The final set of recommendations are around influencing, supporting policymakers and professionals. So, very much for dying earlier than they should, because it is not an equal playing field. So, very much, we can make every opportunity count in terms of our decision-making, perhaps connections and conversations around health inequalities. Thank you. Thanks, Ben. Thanks, Aideen. So, a bit of a sort of dip into what you will see when the final report is published. There's an awful lot more analysis and examples of interesting practice in there. And I think as we finalize the report, ready for publication, one of the things we still need to do some more work on is trying to kind of distill the narrative of the sort of so what. So, there's a huge amount in there. We know that those drivers of health inequalities are very broad, very complex, and that there is no silver bullet to tackling health inequalities. We need to understand that the work has to happen in different ways for different outcomes with different communities in different parts of the borough. And we can't think that we will solve it without those kind of complex range of responses, really. And I think the sort of marmot challenge is about the social determinants of health, but it's also about that proportionate universalism way of thinking, which is the one-size-fits-all broadens health inequalities, and we need to be adjusting how we deliver our services and our strategies so that the resources that we invest are proportionate to the level of need for the different people within our populations and our communities. So, yeah, hopefully we'll be finishing the report up fairly soon, but very interested in your thoughts, responses, any questions or comments that you have on this kind of taster of the report at this stage. Brilliant. Joy. Thanks for that very comprehensive mini-view of what's to come. I think my question is not on the, I suppose, any specific element of the proposed new strategy. I think for me, one of the things I struggle with when I see these new strategies is that it's hard to see, and often there's no information on what was achieved in the last strategy and how the learning from that has shaped the new strategy. So, I know it's not a specific question about anything in particular in the report, but I think in terms of the overall narrative, you know, what did we achieve in the last round of strategies and how was that learning used to build on this one? Because otherwise it sometimes feels like, I'm sure I'm not the only one, it almost feels like every X number of years we take a blank piece of paper and start again, which I'm sure absolutely isn't the case. Is there any more questions? We could take a few. Yeah, okay. Gabby and then Andrew. Thanks. A mixture of observations. Thank you. A very sobering report and a very, very helpful to see that. I guess, and I fully accept there isn't a magic bullet, and I fully accept there isn't that we're dealing with, you know, a vast diversity of needs and inequalities that need to be dealt with. I still wonder whether there is some room in terms of thinking about the strategy going forward in thinking about a cost-benefit analysis. For every pound we spend here, what is the benefit that we're going to get and what are the outcomes that we are going to get? Because there is just so much going on there. There was a good example there of the smoking cessation, reducing births to smoking mothers by 1.3%, I think it was, or round about that, that equating to eight. And actually, what does that mean then in terms of outcome? So how much money did we spend on that one? How much outcome did we get? I just think that money is going to be tight going forward. Therefore, we need to work out how to get the best bang for the buck and what are the metrics that we are, because you gave us lots of data, quite rightly, and it was really helpful to get that one. But going forward in the strategy, what is it that we're going to monitor in order to decide where to invest? And I wonder whether that could be part of it. And then my second point picks up a bit on the population health side of it, but it's perhaps not so much inside that one. But in my last few months going across South London, I'm seeing that everybody is doing population health, quite rightly, and population health is a local thing. But there doesn't seem to be enough synergies going on between kings, which has got one of the best universities in the country for doing population health. And actually, we're not leveraging all of that one. We're doing up... Now, some population health should be done locally, because it's about local knowledge. But some of it's about access to data. Some of it's about the sophistication of techniques and expertise. And I just think we're missing an opportunity by not working better across South London and instead doing everything in penny packets everywhere. So, thank you. That's given you quite a lot to come back on. So, we'll start with that and then we'll do the next one. Shall we do those first and then see if there's a round two? So, Joy, your point, first of all. I mean, I think it's an absolutely valid point. This report is a repository of our understanding of health inequalities rather than a new strategy per se. So, it should be a pointer to some of the things that, as Gabby was saying, around the particular issues in relation to substance misuse, for example, that we maybe need to pay more attention to when implementing our existing strategies or our commissioning arrangements. So, it isn't a new strategy, but it is meant to kind of support and inform strategies going forwards. In terms of the points that you made, Gabby, I think one of the things I'd add on that substance misuse point, which we've been looking at as part of the work we're doing on an addiction strategy. So, smoking, as we know, is one of the most, is in fact the biggest preventable cause of avoidable early death, poor health and inequalities in our populations. Our smoking prevalence in the UK has come down from a period when more than half the adult population smoked to it's about 12% now. In Greenwich, it's about 11%. In our substance misuse service users, it's 75%. So, hugely different. And I think it sort of chimes with those general slides that Aideen was showing us around our health inclusion groups and people who are experiencing homelessness, people from Gypsy, Roma, traveller communities, etc. You saw the slide where there's a strong social gradient in health outcomes between the deciles of deprivation, but when you just compare that to the health inclusion groups, that gap is absolutely massive for that sort of collection of people with those highest levels of need. Completely agree with your point about population health and how we can use that to be more sophisticated in understanding where we're missing people, that difference between what our expected prevalence would be versus what we've actually captured. And I know, I think Sam is sitting behind me. Sam's doing quite a bit of work looking at what the data is telling us and where we think we've got missing intelligence. So, one of the things we need to do better on is not just using population health systems, which is really important, but actually the coding and recording of what's actually going on needs to be better in the first place because otherwise we're not really looking at what we think we're looking at. I think your point about children is an interesting one. Not to sort of try and answer that question here. I mean, obviously, when we have recently redone the Children and Young People's Plan, there's a lot of analytical work that sits underneath that and that kind of wider framing of the social determinants of health are critically important for children as they are for the rest of the life course. So, some of those statistics around things like child poverty, really, really important. Educational attainment, we know we made a huge shift in Greenwich in key stage one and two in our more deprived children actually doing much better than in comparable boroughs, but that not necessarily translating into the sort of more formal secondary school educational outcomes. So, a bit of a sort of drop-off between the primary and secondary phase. Lots of issues in children. Andrew, your points. I think you're absolutely right where we've got that kind of insight around cost-effectiveness and where we can apply that. We absolutely should do. And I think that might be something going forward in terms of those metrics that you were talking about where this board could have a role in kind of advocating for making sure that we're really tightening up on what we're actually measuring and monitoring over time. And your point about King's and the population health approach being more joined up across south-east London, I'm sure you're right, but there are other people in the room, I think probably Gabby, Helen and Sam, who probably have more knowledge of where the headroom is around that than I do. I don't know if anybody else wants to comment. Do you want to comment on that, Gabby? Yeah. So, I've been engaged in an approach and we could extract more value out of that if we did it across south-east London. And we might bring in the HIN or something like that to help us do that. Or King's Health Partners. I think there's a bit of a couple to refresh because I think King's Health Partners do have... You're absolutely right that there's these post-based things together more fundamentally. Brilliant. That's really great. And I think just on the report, when that does come together, I think it would be interesting to make sure that children's population is reflected in there, as Gabby said. Even though if we can bring it all together in one place, I feel that could be really helpful for partners to be utilising it. And possibly maybe when Sam's made more progress with that kind of analysis, I think it was around A&E admissions, that could be interesting to bring back here to the point about those gaps in data on people that we're not reaching potentially. Okay, over on to this slide. So, Rachel, Kate, and then Nick. Thank you, Chair. And thank you for the presentation. It was great. It looks like it's shaping up to be a great report. I have four very brief points I will ask. The first one is really around the geographical differences. What I think would be great to include in this is to look at, well, is to include a map, particularly to look at the neighbourhood approaches. I mean, my ward particularly, we're taking a neighbourhood approach to Horn Park in a more holistic way and looking at the particular isolation on that one estate, which is very different to other parts of my ward. So, I really wanted to sort of drill down into those sort of micro geographical differences. And you say, you know, that one in four families in Woolwich and less than one in 10 in Elton, but it seems too broad to really break down into looking at, because, you know, that's taking Elton, which is, you know, 80,000 people as one block. Secondly, I just wanted to talk about like adverse childhood experiences, which I think obviously comes into lots of these different categories and when we're looking at outcomes. But we see this a lot when we go to the SAR board or we have domestic homicide review. What actually is effective when we're looking at child-based trauma? And how are we addressing those risk factors specifically within a population of children that are moving through with a particular trauma? Financial reality has meant that we are, we have reduced our children's centres provision in the last year across the borough. I'm a big believer in the Sure Start programme, but obviously it's not what it was to be and we don't have as many centres or as open for as many hours. Just what the impact on that loss of capacity with children's has been. And my final point was around the pilot projects on hoarding, which I don't think we saw hoarding mentioned in the presentation specifically, but this is something I thought was new from when we had done the last programme. So I wanted to know where that fits in. There's actually quite a lot there, so maybe you respond to that and then we'll go to Kate and Nick. In terms of the geographical analysis, I think there's some of that in the report. So we obviously didn't cover everything that's in the report in today's presentation. So you will see some of that when you get the fuller report. But we can always do bespoke pieces of analysis where the data allows us to do that. So we can do maps on different topics, different subjects further down the line if there are things that the board is particularly wanting to see that's maybe additional to what's in the actual report. So, yeah, definitely. And at a more granular level than main town centres. I think your point on ACEs is something for a longer conversation, but absolutely really, really critical and really impactful around those lifelong inequalities that some children will experience because of those adverse childhood experiences. The children's centres, you know, Marmot always says start with preconception and early years, the first 1,001 days of life being the most important in shaping the prospects for the future life of children and young people. So I know that the children's centre changes has been done as with as much care and sort of sensitivity to that issue as possible. But, you know, in an ideal world, we would not want to be reducing any provision for early years. And the pilot programme on hoarding, I don't know whether, Nick, you might want to say a bit about that because it's still happening. Yeah, I mean, I think in terms... I think the really good points that were made about some of the safeguarding partnership work across the piece and how that joins up around some of these multi-factorial drivers to safeguarding, which I'll perhaps touch back on in my comments, if that's OK. But it's definitely something, Rachel, we can share with you in terms of where the pilot programme's at and the plans for how to roll it out further. And happy to share that perhaps at the Safer Greenwich Partnership board with yourself. Kate. Thank you. I think a lot of what I was going to say has been picked up by others around the room. I think on the place-based aspect of it, I guess it'd be really good to understand what we can do, how the hospital can feed into that with various neighbourhoods. I'm guessing you're probably linked up with the work that's happening across in Lewisham. They're doing quite a lot of work with GP practices at the moment to try and target particular cohorts of patients. And, you know, it'd be good if we could see some of that happening over on this side of the... South East London as well. I guess another reflection I just had when you were talking, I think the sort of alcohol teams, we've got alcohol teams, we've got smoking cessation teams based at the hospital. And I get, are we joined up sufficiently? Is there more we could do? I know all of those budgets are under loads and loads of pressure at the moment, but is there more we could do? Obviously, we've got a whole outpatients coming through the system daily. Is there more we could do in a more joined up way, maybe? And then I think, I mean, it sounds a really exciting report. I think, as you said, Steve, it's really complex in terms of the response that we're going to get. And I guess how can we link him with others who are working on this? I don't know if there's some kind of academic kind of work around impact and how we know if it's working. You know, how do we assess if it's working or not? And I don't know if that will come through when we see the final report. But yeah, really exciting stuff. And I was going to ask, and apologies, I might have missed this at the beginning of the meeting. When is the sort of final report anticipated? Do we have a date yet? We don't have a date, but what I'm saying is weeks rather than months. Okay, perfect. Yeah, do you want to come back on those now? Yeah. Shall I kick off? So the place-based work, absolutely. I think that probably, Gabby, some of the work that you're doing around the development of the four patches, the hospital will absolutely need to be playing into that. I think your point about some of the addiction-related services that you have in the hospital, we're working on an addiction strategy at the moment and making sure that all of the different parts of the system are joined up and talking to each other and well-connected will be an important part of that. So we need to make sure we have... I mean, I co-chair a South East London group on tobacco, so I'm quite familiar with kind of what's going on in all the different trusts around tobacco treatment and I know that our community Stop Smoking response is joined up with what's happening in LGT, but always worth checking in with that. And again, I think your point on impact of what's working and should we be getting, which I think is a similar point to Andrew's earlier, should we be getting some kind of external challenge and support, maybe academic, around looking at what more we could be doing? Councillor Oliver and I have had conversations about whether we might want to get Professor Marmot and his team to come to the borough. They have this initiative where they go to different places that invite them called the Marmot City model where they use the evidence that they've developed of effective impact in terms of those main social determinants of health and review what the data tells them. So it would be kind of, we've done some of that, we've done a lot of that with our own health inequalities on your public health report, but they would come in, look at what we've already got, maybe look at some other stuff as well and play back what they think we should be doing. Now it costs a bit of money, quite a bit of money. So that would be a consideration, but there might be a kind of, we could maybe negotiate a sort of shorthand version, particularly as we've just produced, we're just producing this annual public health report. So that might be something that would also, I think, up the ante a bit around his name and if we got Professor Sir Michael Marmot to come and maybe speak at a sort of mini conference or something in the borough, that might well be worth considering around raising the profile of what we could be doing more on this subject. I'm going to just take the chair's prerogative to jump in on that. I do think it could be something really interesting and I think to your point about how do we convene, we're all doing work in this, but it's all about how do we kind of all come together and have a sense of focus and then see that the impact and difference being made and I think that's the really hard part. Plus, I think it also not only requires that short and really long-term commitment for it to really make a difference. So, yeah, I think something like that would be really interesting. Also, just the other point on the addictions piece with the, I think, again, there seems something really interesting there with the addiction strategy that I know that Wendy and team are kind of putting together and that joined up piece, but also that complex discharge part as well, which I think would be interesting to see how we can, I guess, convene on that. So, just maybe a note. Nick. Thanks and thanks to Steve and the team for the report. I suppose my reflection on it is this is a fantastic opportunity, I think, because the Director of Public Health report, I think, is a challenge to us as partners and the system and as much as we've got questions for Steve and the team, I think we should have questions for ourselves as partners and organisations that are working in this area because I think there's an awful lot that's happening and an awful lot that's being delivered across the partnership. But I think this probably gives us the opportunity to springboard off and have a particular focus on health inequalities in the year 25, 26, perhaps combining some of those ideas that have been laid out around, you know, the Marmot input and other things. But I think I was reflecting on a few things. Firstly, the power of some of that JSNA work that can then look at how we actually target some of our resources which are under ever more stress and focus. And that actually does tie in with some of the data around the inclusion health. And when you look at the inclusion health categories where people are obviously experiencing those health inequalities, a lot of those, I think, have crossover and they, you know, people are experiencing more than one of those health inclusion issues. So they may be, you know, suffering homelessness, drugs and alcohol, smoking. So, you know, we can start to really think about who we need to target to make a difference perhaps in the short term as well as having that more universal offer for the longer term population. I also think that we've got pieces of work that are already underway that can support this. So, I know Gabby's mentioned the neighbourhood work. But if I think about some of the stats I saw, we talked about, that talked about how people in adult social care and particularly carers are experiencing health inequalities. We've got a carer's strategy. can we get around that carer's strategy and give it some more purpose and pace in this year with a focus around health inequalities. Equally around those who are refugees and migrant populations. We've got a borough of sanctuary. How do we utilise that in order to, you know, make that move? So, I do think it is about how we take that message out and I think that convening something that looks at the data and looks at it in depth and then comes up with a plan for the year that can really have a focus would be time well spent and would really galvanise some of the work of the board, I think. It sounds like there's a conference brewing of sorts but I do think that it would be really powerful to do something in partnership because it's, as you say, come together around that data but then all the different partners and bring that in. Is there any other questions? Okay, yeah, Nupa. Do you want to come up and use one of, this mic here? That's it. Thank you. It was really interesting to hear the report and see the data. It was just really a comment around, we've got lots of really good data. Oh, I've got an official. But it's also, I think there's something around us also being cognisant of some of the things that our data hasn't caught up to. So, for example, we're seeing a lot of vaping in children and teenagers and a lot of our data around smoking tends to capture cigarette smoking but we're seeing a lot of acute admissions in young people, acute respiratory admissions in South East London because of vaping which has also, you know, it's sort of been something that was not predicted where vaping was brought in as yet another option for nicotine replacement therapy but we didn't put it on prescription. And it's a really significant problem and, again, I have not seen the data on it but once the data catches up again it wouldn't surprise me if we see a big inequity in the teenagers who are smoking overlapping with all the other inequities. So, it was just something around, I know I've picked out something very specific and we're talking about a more kind of wider strategic approach but I suppose it's just us being cognisant of the fact that there are some things that we could get working on now because we're seeing in other parts of the system in terms of data like the acute admissions with children and it's just really important because I think that's become such a significant problem now and I think probably our smoking data in young people is not very accurate because we're not capturing the fact that lots of them are vaping instead of cigarette smoking and we know most of them go straight to vaping they're not trying cigarettes which again is something you know we've got this whole unregulated industry these vaping shops are popping up all the time the colours the flavours you know we've got such a significant problem with it so it was just a sort of spotlight where we don't have as much data but we still know it's a problem and I think Rachel might come in as well but I think that's a really good point actually because the addictions work that is going on there's something that we can look at that and I think the youth service have been talking about this I think we've Stephen, myself and the youth services engagement with young people and trying to so yeah maybe there's something where we kind of come together on as you said we've got some really good work on smoking but where's the where's the vape part in that and are we doing everything we can just briefly it's something to think about with the licensing strategy coming up I'd have to look at what the statutory framework is because obviously this is mostly driven by the statutory regulation of where you can have licenses and what grounds you can object to say you know a certain density by which I think that you can you can limit license premises within a certain thing so I think it might be something we ought to talk about with the licensing strategy coming up in the next few months thank you and then is there any other hands oh yeah Andrew so I just it's not really a question it's more a comment to tie back to what we did at our development day last time I don't know a few months ago whenever it was when one of the things that we talked about was whether some of this work would lend itself well to get the interagency inter-department world to a more mission-led approach you know the Mariana Mazzucato world that she's doing in Islington that sort of work that she's really driving forward to develop a mission that we can then bring in many of these things around because at the moment it's feeling like lots and lots and lots of projects and then you've got to tie up all of those projects well if we could get if we defined a mission that we really wanted to achieve as a borough and then we could bring all the forces into it that might be really interesting no I definitely think that's a good point and potentially when we can talk outside of this about how that report acts as a springboard for it and then potentially that event as well if there is something that we convene around and is that agreeing on missions like you said having a few small things because it is overwhelming when you look at this list there's just so much to do and you're like where do we focus our energies I guess the only other thing I would that really there was two things that stood out for me and all of it was really interesting but I was just going to pull out two one was on the dental decay and I did think potentially a while back I think Joy and myself had met London Dental Council but I know there's been changes on the ICB side so maybe I thought it could be something where they could if we could come back at some point and have a presentation or discussion about the strategy around that I don't know where things are but one we could think about in the future just to I just think the numbers I think we were a bit I think we were around 30 something percent and London average 27 or 33 so yeah one that I think is of concern and it would be interesting to dig into that and then the other one that really stood out for me was the maternity one Greenwich with the second highest rate of death in babies and there was a particular over representation of black British mothers as well and that so there was I think for me I know there's a maternal health report potentially coming to scrutiny I think in the future so I think there could be some really interesting information within that that we can kind of utilise but that definitely feels yeah the stat really stood out for me and again it feels like an area that I would love to kind of understand a little bit more what's going on and where there's probably a partnership piece there as in it's all of those outside what can we do so yeah I think two kind of comments but I don't know if there's any I don't think there are any other questions but I guess I'll hand back to you Steve if there's anything else you wanted to summarise on or come back to that Just on the maternity issue there is a scrutiny report coming next week and ICB colleagues who lead on those issues are coming to present quite detailed report so it'll be interesting to hear the discussion at scrutiny but we can obviously share that paper with this board people might like to have a look at that we can get that sent around it's a presentation rather than a report and I could talk about vaping full hours but we probably we probably need to move on on the agenda but it's a yeah it's something I have very strong views on brilliant thank you so much that was really great thanks for for pulling that together and for really really interesting discussion so thank you so much brilliant thank you okay we'll have to have a whole another session just on vaping to to delve into that so taking us on to our next item we've got we've got the better care fund I think just to I think presenting will be Nick who's going to take this through take us through this as well and just a note that there was a change in the appendix publication wasn't there I think just to note if anyone had read the papers previously but we'll hand over to Nick who will just take us through the report to give us a sense of an update on the better care fund thank you thank you so you have the better care fund update in front of you my name's on the report but I did want to note that this is a product of joint work between myself and Gabby and the team as well as the integrated commissioning colleagues Lisa and colleagues who've worked on the detail here so I just wanted to to reflect that so it is a technical paper really because people were probably familiar with the fact that the better care fund is government funding which is a key enabler of integrated working so it's a requirement on local authorities and the NHS to agree an annual settlement and an annual plan around the better care fund allocation so that's what you have in front of you usually we'd be bringing you this in June because that's the usual planning timeline they brought the planning timeline forward and require sign off of the better care funding agreement in March so that's put a constraint on time and it's why you don't have the final draft version of the better care fund submission in front of you but given time we wanted to bring this here today I can give you a brief update on the key points to note and then the idea is that there's through the chair sign off of the better care fund agreement that happens alongside sign off of the better care fund arrangements from the ICB and from the council side as well but I did want to touch at the end on the importance I think of the better care fund which is the opportunity to work in an integrated way to fund things in an integrated way and to develop services in an integrated way across the system and that was really the thing that I didn't want to lose in what is actually quite a technical report around a better care fund sign off coming through the governance process process so the main changes that we see which come really as on the tail of the government shift in policy has been to reduce the number of key performance indicators that we've got in the better care fund arrangements and so it's always been something that's been focused on admission avoidance and on making sure that discharge is to a good outcome for people but the KPIs have been focused on admission avoidance the length of time it takes for someone to be discharged and then the destination so trying to avoid people going into institutional settings so I don't think anyone would disagree with that but that's the shift in terms of metrics in terms of funding it's a story really of of little change in terms of a year on year change there's been a modest uplift in the ICB minimum contribution a bit more of an uplift in the local authority contribution and then a bit more a bigger uplift 13% uplift in the disabled facilities grant which gives us some opportunity to look at how we utilise that funding in more creative ways perhaps so those are the main changes in terms of both KPIs and the shift to reduce and the shifts in funding but I suppose what that does is it presents some real challenges because a lot of the funding is linked to arrangements which will obviously be subject to national insurance inflationary uplifts contract arrangements so that settlement doesn't really keep pace with what the market is what we're seeing in the market in terms of those pieces so it's a difficult settlement in terms of the BCF settlement but that's where we are I would also say that the BCF is a pool and it's a fund but the things that it funds often are funded with elements coming from other funding streams as well and what I think we're really good at and progressive and mature at in Greenwich is actually looking across those funding streams and not seeing the Better Care Fund in isolation of the contributions that we make into services through the ICB or through the council so there is that join up there's that approach through our joint commissioning arrangements and then the final points I just wanted to raise are that I think that what the Better Care Fund has been an enabler of is work and significant work that we've done through colleagues and through partners in terms of our home first approaches so a lot of what you see funded through the Better Care Fund streams relate to things like reablement frailty work work on trying to avoid admissions and to support people into their in their homes or back into home from hospital I think the significant focus we've got and shifted to has been jointly to look at assistive technology enabled care and we're at the cusp of launching a new assistive tech service across health and social care which is quite unique and that's going to happen in the course of the next month or two and practitioners are being immersed in training at the moment to see how they can access that we've done a lot of work with our residents who are open and keen to be supported through that assistive technology and I think it's a key lever in terms of our strength based approach to supporting people to live well and to you know and to the rest of the live the wells that are in the health and well-being strategy so I didn't have much more to add than that hopefully that's a summary that encapsulates both the governance points but also some of the things that the better care fund funds I don't know if Gabby you had anything else to add from your perspective conscious that it's very much a joint effort yeah thank you I think that's a good summary and then I think the as we go forward so I don't see any oh yes Andrew thank you two quick questions one of which I think you've largely answered Nick with your very helpful summary because reading this and seeing that the budget was as you said very little change from year to year actually understanding what proportion of that budget is if you like transformational and how much of it is that we're funding this because we've always funded this from what you're saying there is quite a lot of initiative and new stuff going on in there and I guess it'd be really good in future years to sort of get a sense of that we are always trying to do something transformational that is improving the service sometimes you know we also have to keep the lights on it's a balancing act between keeping the lights on and doing stuff but that was that was a comment but also to think about the metrics that are on page six because I was a bit confused about whether the metrics on page six were a projection or a target because the commentary seems to suggest they were a projection but you were talking about them as a target so I'm just sort of interested as to which they are thank you yeah sorry so the I think the metrics you have in the report on item six relate to 24-25 so is that what you're referring to oh I see so 24-25 okay so that they're a projection of what you're going to get to yeah so generally speaking that's why I talked about the can I just clarify are we talking about 4.12 the Greenwich BCF metrics for 24-25 is that right Andrew 4.12 yeah so so what usually happens is we've usually had a year end seen what we've got as a metric obviously we're not quite we're not at the year end yet for this year so we haven't got the final the final metric so it is a projection when it comes to setting the targets for next year what we're very conscious of is that really we're not getting any significant uplift and therefore when we build in our ambition for that target we're likely to be looking at targets that are similar to this year but we're working through some of the detail on that at the moment but to your point usually in the planning cycle we've had enough time to consider last year's performance in more detail to inform this year's target we haven't got that luxury this year given where we are but I think we've got an ongoing dialogue with the Better Care Fund team to recognise that time scale and that time frame and the fact that if there are any significant changes in performance we may need to have conversations about that councillor taggart Ryan thank you and I apologise if you've covered this and I've not understood it Nick but just looking at the proposal for our scheme allocations which is on page 36 of the pack between 24 25 and 20 there's quite a significant difference on a number of the a number of the queues between what's planned and what is proposed particularly like on brokerage support or goldsmiths out of hours is this what I've just got quite understanding where that difference has come from so I can understand the confusion given where we are and what we're presenting here because we're not presenting the 25 26 proposals because we're still working on those given to the time frame so this is illustrative and demonstrative of what we've got this year to help the panel I think understand that we'll be putting in a similar plan for next year but in terms of the movements what we have got within the local arrangements is the ability to through the governance that we've got the joint governance that we've got to make adjustments in year if particular things need additional funding or resources as a result of demand so some of the lines may move in year so we've got the planned allocation and then we've got the proposed but what you will see overall is that the spend and the BCF overall spend is all expended it's just about how we work throughout the year to make adjustments to meet particular requirements so if we need some additional funding towards community equipment for example we may make a joint decision to make some of those shifts in year does that help one of the things that might I think one of the issues or complications with this is there's a really tight deadline within which that we have to submit the better care fund so what you've got here is proposals including previous years and what what's been brought to the board today is kind of that overview and then they're like will be determined outside of this meeting within the governance process that you're seeing here what might be helpful is to set up a briefing outside of this to go through it because that's something that I've done if you've got specific questions that you really wanted to delve into because it's I've discovered it's quite complicated and the more questions I had the more more questions I had thereafter so it might be one of those things that might be worth to just take you through but overall no significant changes to the allocations the significant change would have probably been our assistive technology investment which is something that I think is very excited about no I agree and really happy to provide a briefing or answer any specific questions outside of this but going back to your question councillor tagger ryan to use the brokerage example that that is an example where the money has been moved to funds for example winter pressures which you'll see has gone up so there are movements but the overall total remains the same and then any more questions no so if the board is happy to note that as per kind of I think the notes in there regarding sign off then agreed yeah I think it's just it's just making sure the board is aware that in agreeing it then it's agreeing for councillor Lollivar as the chair to sign off on behalf of the health and well being board the final detail which will also have gone through the ICB and the local authority governance as well okay agreed I think and thank you very much I think Kate and Nick both have to leave us now so thank you very much for your time perfect okay so the next item we have item seven so the health and well being board review and forward plan this was to give you a bit of I guess a recap of the discussions that we had previously following our reset and I think am I handing it over to Steve yeah happy to pick it out as I wrote the report as you say it's a bit of a run through of the story so far around some meetings that we had last year which Andrew referenced earlier in relation to thinking about the way that this board operates I think particularly what I wanted to get a steer from today is the table on in section six which is on page five of the report table one which is really looking at a proposed forward plan for the meetings coming up so those of you who were at the December meeting Helen who is sitting behind me gave us a presentation with some updates to the JSNA headlines and then we split into two groups and had some discussions about the conclusions from that and the things that the board was most interested in thinking about going forward as possible deep dive topics or report subjects for future meetings so I sort of captured what was fed back from both of those two groups and table one has the list of the main things that I think came from those discussions so it was really to sort of check with you all now that a couple of months have gone further down the line whether this does feel like a useful list of subjects for forward plan conversations I think if I just I've tried to sort of group them into different headings so there's the first one you'll see is headed public health outcomes so looking at the burden of mortality and morbidity related to the growing levels of obesity in our population we talked before about maternal health and well-being and I think women's health was sort of part of what was being looked at as well in relation to mortality musculoskeletal conditions are the number one reason for morbidity in our population I think we had some discussion about is there more that we could do to think about the prevention end of musculoskeletal conditions important though the kind of treatment end of things is what more could we potentially be focusing on around stopping those conditions from happening in the first place and then kind of straddling across two is the addictions work that we've already been talking about here and then in the wider determinants of domestic violence and abuse that is programmed for the next meeting so there will be a kind of deep dive on that housing and health was a subject that in the group that I was in I think there was a fair bit of discussion there and the next paper that's going to be presented is actually proposing that the director of housing and the cabinet member who leads on housing join this board given the really significant impact on health and well-being that different aspects of housing and homelessness have on our population then there was a discussion about equality diversity and inclusion and the growing evidence base around the health impacts of discrimination racism on individuals mental and physical health and well-being and I know that the organisations that are part of the health and well-being board are doing a lot of interesting work and it would be quite useful I think to share some of the different responses that we have as well as that sort of more science around our growing understanding of the impacts on health outcomes and the health inequalities that we've been talking about related to quality diversity inclusion the lady to my right is quite an expert on the subject and I think would be happy to help with pulling something together for a bit of a deep dive around that issue workforce challenges and opportunities were one of the things that was discussed further analysis into preventable deaths amongst women in Greenwich is something that came out of the discussion following Helen's presentation so that's something we are looking at and then chair you mentioned earlier the more granular analysis of emergency admissions to hospital so looking at who are the people from within our population who are needing to be admitted in an emergency situation in a more granular detail in terms of the demographic profile and Sam has been doing some work with LGT around what that looks like so we can definitely bring something forward on that so the sort of general question for you all really is does that still feel like there's a lot of things in there does that still feel like the kind of basket of topics that you have an appetite to consider and if so would we want to try and cover two per meeting in which case we get through most of those within the next municipal year's programme or would you rather take a slightly slower burn and do one per meeting in which case it would need to be programmed over a two year cycle so so so yeah that was those were the conversations that I think you and I have had Mariam reflecting back the things that came out of the discussions that happened last year so basically would be really good to sense check with those here that if this does feel representative the only comment I would make and again let me know if those don't agree in the room but with the equality diversity inclusion one I think when you talked about the health impacts of discrimination I thought that could be brought out a little bit more in that description there I think that that feels like a really interesting particularly with the Marmot discussion that we've had I know that was added recently so that feels I would potentially either add that in or rework the wording for that just so it's a bit clearer and then or is it one and a deeper dive what people would feel and it could also be the varying how you're receiving it because for example to you know is it a more detailed report and one and the other ones a presentation it's kind of a bit like how would people like to work it plus I am also still keen for us to get out here so how we can out of the town hall so if we can tie that up to having those meetings on site and visits and tying that up together I'm really keen to do that so yes I'm a councillor tackle everyone I think I would be in favour of tackling one topic in a meeting I think to do justice to these topics which are huge domestic violence and abuse I don't think you can schedule in an hour and leave it at that especially as we've got the strategy coming up I think you do need to give justice in the time frame for each of these I just wanted to ask Steve on the addictions I want to pick up with you about the dip proposal and where if we can discuss that I don't know if we may be here or maybe can talk to you afterwards because yeah I mean I can give you my position on that which people may not know what you're talking about the drug intervention program which is a sort of arrest referral scheme where people who are arrested who have substance related needs are sort of required to attend drug and alcohol treatment services and there's a provider within custody suites we don't have a standing custody suite in the borough so our residents who were arrested go to Lewisham or Bexley Heath police stations to be processed so that's so and but then they both already have these drug intervention programs so what our proposal is that we enhance what is already in existence in those two police stations with some additional capacity funded by Greenwich so they don't sift out the Greenwich people and process the Bexley and Lewisham people which is what it seems we've got at the moment so I think it's definitely something we are intending to sort if if that gives you some reassurance and in that way seems the most sensible rather than trying to set something else up to work with the existing providers to sort of grow the capacity Thank you perhaps could request a meeting with you to go into how and when we intend to sort it but I appreciate the commitment to sort it Great any more questions yes Gabby Andrew I'll be quick just to say this seems resonant to what we talked about last time I think they are all interesting remain interesting I guess what we did talk about last time is whether we needed to spend some time on working out before the meeting which one of these we actually can make a difference because it might be interesting but this isn't this hasn't been put in here for the amusement of people like me to come here and listen to where is it we can actually make a difference and that might need some preliminary work by people and then we just focus on three of these things one a year so I'm happy for these all to be worked up I think they need to be worked up and then prioritized would be my got sight of the imminent report and so this feels very fitting and I think you've definitely kind of gone through this and there's a sense that it's aligned I scoping out the potential from each of these things they might be interesting and significant challenges but which are the ones where we think we might be able to make the most impact is a really good challenge brilliant so we'll I guess agree this in principle but taking into account that additional review of it and I think it looks like one item yeah I mean we've got a little bit of time to do that because we know that we're doing domestic violence and abuse at the next meeting so it won't be until September that we have another slot to fill as it were so I think there's the time to be able to do some of that more more processing brilliant thank you I think oh no I have another item yes okay so that brings us to a close on item seven so item eight as Steve already alluded to this is additions to the board membership so we're proposing to add the cabinet member for housing and the director for housing and I think in the light of the discussions that we've had those wider determinants of health and the importance of housing we think it's really valuable if they would be here so are members happy to agree the recommendation to add them to the board yes agreed brilliant thank you that's great and I think I just say they're both keen to join they are oh sorry yes we have asked and they've said yes I think actually cabinet lead even asked it originally I think she'd be at a very good South East London listens event and she was like I need to be on this board at first I thought she was saying she wanted to join the ICB but we've established no it was a health and well-being board so thank you very much I just think before so as we come to conclusion of the meeting I guess I wanted to take a moment because as some of you might know that Steve our director of public health will be leaving us so today marks his last health and well-being board and as I understand he's been with the board since its inception in 2013 but you're leaving us in a really good place with a really great forward plan and also it also brings I guess a very short career of 34 years of service to Greenwich Council so I just want to thank him so much for everything he's done he leaves a really brilliant legacy behind including live well which is something we're immensely proud of a huge legacy and also his service during COVID the pandemic it was he played such a key role keeping us all safe and remaining a very calm leader in a very scary time so I just want to say thank you very much on behalf of the board and for myself just say thank you Steve for all of your work for the borough and for the health and well being board specifically so thank you 12 years the voluntary sector before that so 34 years in the borough yeah this year so it's been a lot of changes through that period and it's been a great place to work which is why I've stayed and lots of great colleagues to work with many of whom are still here so yeah thank you it's been good being part of this board and I think you will go on to good things in the future and glad to have been part of the story and that brings our meeting to a close thank you very much