Transcript

Okay, good morning, everybody, and welcome to the combined meeting of the Health and Wellbeing Board and Surrey Hartman's Integrated Care Partnership. We're still slightly sort of feeling our way around the combined boards, but hopefully everybody is sort of comfortable with the way things are. are moving forward. This meeting will be live streamed, just so that you're aware, and there may be some members attending remotely, and just the way it works in terms of the Council's constitution at least, those attending remotely can speak, but don't have a vote if it comes to it, which I don't think it will do, just so as you're aware. We're not expecting any file alarms, so if there is one, then please use the exit, or nearest exit, and then regroup up in the top car park. Of course, you're more than welcome to use social media of any sort, but please, if you can make sure that it doesn't interfere with the meeting. Ideally, could you turn your phones to silent, or turn them off? That would be helpful. And just for those not familiar with the sound system here, if you push the right-hand button on your unit there, that would be helpful. And preferably turn it on before you speak, and preferably turn it on before you speak, and preferably turn it off when you have spoken. But we will remind you otherwise. Okay. I think that deals with the housekeeping matters. So we'll deal with apologies for absence first. We've received apologies from Julie Lowellin, though I see Neelam. We're substituting Julie, thank you very much. Apologies from Sam Burrows, and most of you will know that Sam is the interim chief executive of Frimley ICS, following the departure of... Sorry, I'm stumbling around here, I'm just trying to look at... Yes, Fiona, indeed. Apologies from the chief constable, Tim DeMayer, but substituted by Sarah Graham, and then apologies from Rachel Wardell. County Council is in the middle of our review of our children's services at the moment. So she's very much tied up with that. And apologies from chief executive, Terence Herbert. And then we have attending remotely Nicola Airy, Siobhan Kennedy, and Sue Trezman. If there are any others that I've missed, then... And Sinead Mooney is attending remotely. Then we'll make sure that we are recorded in the minutes. Then the minutes of the previous meeting was held on the 11th of December 2024. And those have been circulated and any comments, I think, will have been taken on board. So can I take it those who are agreed? Thank you very much. Item three, does any member have any interest to declare specifically in relation to the items on today's agenda? No, I can't see any of those. Then before we just move to item four, many of you will know, or hopefully you will know at least, that the government published a white paper in December regarding local government reorganization and devolution, to unlock devolution. It is this government's intention to enable mayors to be elected across the whole of the country. And we've spoken about that before these meetings and indeed we'll do so later. From the Sarri's perspective, we have to put in a submission, final submission on the 9th of May, but an interim submission that will go in this Friday. A lot of work has been undertaken by the 12 councils, both in terms of members, leaders and officers. But once we put in the final submission, then in May there will be a lot of work to do to get to the point where we're ready to have an election for new unity councils next April, next May. So, and I can see Anne-Marie here as the leader of Woking will no doubt agree, and Mari, that it is all-consuming. So, from a personal perspective, I'm proposing to appoint a co-chair in the event that I can't attend these meetings, which of course I will try to do. As it is the health and well-being board, as well as the ICP, there is a requirement that that is an appointment from the county council. And on that basis, I'm proposing to, I've asked Mark Newty if he would take on that role alongside, obviously, with Chavez and Paul. But it's really just a sort of a backup in case the meetings clash. So, hopefully everybody is comfortable with that. So, Mark, as you know, is the cabinet member for public health. I don't know who you are. I don't know who you are. I don't know who you are. You jumped to the opportunity, it's my recollection. And then I did want to just reflect on the Fiona Edwards and her announcement that she has taken, I think, already taken on the role as the director, regional director for North East, the North East in Yorkshire. Of course, obviously, there's a lot of activity at the moment around NHS England and a lot of uncertainty. But I also noted that Claire Fuller, Dr. Fuller, has also been appointed as the co-medical, national medical director. And I'm the first, yeah, interim for the next two years during the sort of transition and the first GP to have held that role alongside. So, that's excellent news. So, as ever, a great breeding ground within Surrey. Okay. I was going to mention Ruth Hutchinson, but I think, Ruth, this is not going to be your last meeting, or is it? Two more. Okay. As you know, sadly, Ruth will be leaving us at some point in the future. But we will save our comments until your last meeting. Okay. Right. So, shall we then move to item four, questions and petitions? There aren't any questions from members or from the public, in which case we'll go to the petitions. And we do have one petition today which relates to pharmaceutical needs in Thames Ditton. And we have two presenters with us today, so Karen Randolph and Sian Bates. Hopefully, somebody's explained to you how the process will work, but very welcome this morning. And then you'll present your case, and then that'll be responded to by Louis Hall, if that's okay. Thank you. Good morning, everybody. Thank you for this opportunity to present the petition from Thames Ditton and Western Green Residents Association. Just as an aside, we're not the Thames Ditton and Western Green Neighbourhood Board, as inadvertently referred to in the agenda paper. With me today is Sian Bates. Sian is a local Thames Ditton resident who has spent the vast majority of her career in senior positions in the NHS, including as Chief Executive of South West London Primary, more recently Chairman of Kingston Hospital NHS Trust. Until February 2023, Thames Ditton had a pharmacy, Natalie Boots. After its closure, the Residents Association was approached by a large number of residents very concerned about the loss of the pharmacy. I would like to quote just two of the many personal stories we have received. As a mother of a toddler, the current situation makes life very difficult and potentially dangerous for a sick child. If I see a doctor at Giggs Hill Surgery and they prescribe me medication for my toddler, walking nearly an hour round trip, I don't have a car, is unacceptable, particularly when you want to get your sick child home as soon as possible. And another, my husband is a type 1 diabetic and we really miss having a pharmacy at Thames Ditton. Boots was always busy as there are many in the village who cannot travel to collect their prescriptions or for other pharmacy needs. It was so helpful to be able to ask for help with minor ailments rather than wait for a GP appointment. We have many, many more stories like this, from young parents and the elderly in particular, the very demographics which are most likely to ping into A&E. Our petition has, with little effort on our part, accumulated almost 1,200 signatures. I hope you have in front of you a heat map which clearly illustrates where these signatures come from. You will see that there is a very large number of local residents who are desperate for the reinstatement of the pharmacy in the village. We recognize that a huge amount of work has gone into producing the PNA, applying the data and coming to a fair assessment for such a large and varied area as Surrey, with its population of 1.2 million residents, is a mammoth task. But the vast majority of this data is only available at a macro level. In many areas, there is a paucity of data at the locality level. We believe that we have produced sufficient information at the local level in the form of the petition itself, as well as the personal comments of many local residents to prove that there is unmet need in this area. And we are aware of at least two potential applications. So we politely ask that the report's conclusions be reconsidered by the Steering Committee before being confirmed by this Health and Wellbeing Board. The draft unconditional conclusion that there are no gaps in the current provision of pharmaceutical services across the whole of Surrey, and despite the loss of at least, I think there are more, but at least 19 pharmacies between 22 and 24, is clearly incorrect and misleading. Thank you very much. Thank you very much, Karen. So, I've provided a response on behalf of the Health and Wellbeing Board. So, thank you very much, firstly, for your interest in the findings of the Pharmaceutical Needs Assessment for Surrey, which was published in draft form in November 2024, and is due for discussion at today's board. And hopefully, some of these things that you've raised in these details will be discussed as part of the item further on. We acknowledge the petition signed by the residents of Thames, and requesting for the area be permitted to have its own pharmacy. And this response outlines the role of the Health and Wellbeing Board in assessing pharmaceutical needs, and our influence on pharmacy market entry applications. So, Surrey Health and Wellbeing Board, like all Health and Wellbeing Boards in England, have a statutory duty to produce and maintain a pharmaceutical needs assessment, a P&A. The purpose of the P&A is to assess pharmaceutical needs. The development of the Surrey P&A 2025 is delegated to the P&A Steering Group, which is represented by subject matter experts from across the health and care system. So, that includes Surrey Local Pharmaceutical Committee, the LPC, Surrey Local Medical Committee, the LMC, Healthwatch Surrey, both integrated care boards, and Surrey County Council's public health team, population insight team, and communication team. The analysis of pharmaceutical need by the Steering Group took a series of systematic steps to ensure the findings are evidence-based and driven by an understanding of resident need, pharmaceutical provision, and clear and transparent consultation with providers, residents, and subject matter experts. The P&A was conducted in keeping with statutory requirements to ensure a fair, robust, and transparent process. And the assessment concluded, as Karen has alluded to, that there is no gap in pharmaceutical provision in Surrey. Under NHS Regulations 2013, a new pharmacy cannot be opened until a market entry application has been approved. Applications are considered by integrated care boards, which in this instance is Surrey Heartland's ICB. Applications for entry to the pharmacy market are made in relation to the P&A. There are various types of pharmacy applications, as per the regulations, depending on whether needs for services have been expressed in the P&A. If a need has not been identified in the P&A, prospective contractors can apply on the basis of unforeseen benefits. This means that there are benefits that were not identified when the P&A was written. These applications are assessed according to the information and evidence provided by the applicants. Two new pharmacies have been approved in Surrey, both in Guildford, as a result of this type of application. Health wellbeing boards are asked to comment on pharmacy market entry applications, but are not represented on the board that makes these decisions, the PSRC. Therefore, Surrey Health wellbeing board does not have any direct influence on market entry application outcomes. We contacted Surrey Heartland's ICB, and they have been unable to consider a new pharmacy in Thames Ditton, because they have not received any application for a new pharmacy in that area. We thank you for raising concerns regarding the future of pharmacy provision in Thames Ditton via this petition, and we hope that this response provides some reassurance as to the rigor of the P&A. Thank you. Does anybody want to comment on that? I mean, I think what that says is that in the event that there is an application or applications for a new pharmacy in Thames Ditton, then that will be seriously considered. Lewis has described the process as quite overly complicated, it has to be said, but this board doesn't have the authority to approve any new pharmacy on its own. So I think really the next step for the residents is to encourage a pharmacy to apply for a license, and then we can then follow that through the process. But hopefully that at least gives you reassurance that there is a kind of an opening there. But the key... Yes, Sian. Thank you so much for that clarification, and I do want to reiterate that I thought the work that you've done was, you know, extremely helpful. I suppose all we're asking for at this meeting is for this petition to be registered, for it to be noted that we believe there is unmet need that has been identified. And for that to be noted so that when the two applications do come forward, that that is supporting evidence in terms of our challenge, I suppose, to the PNA. So we'd be very, very grateful if that could happen. Thank you. I don't see any problem with that at all. Anne-Marie? Thank you. Thank you. I just wondered if you do have anyone in mind, if you've got any plans to reach out to pharmacy providers and see if you can get an interest so you can follow this process. We are aware, or at least we have been contacted by two potential pharmacists. One has already started an application, but I've obviously only got one side of the story, but it wasn't his decision, but it had been. It was withdrawn unilaterally. The process, I think everybody probably understands, the process has been described as perverse and worse in Parliament. So it's a very complicated application process before it gets to the stage where it's considered by the Surrey Heartlands ICB. Louie, I think you want to come back in. Yeah, it's just to say that the PNA Steering Group and also the ICB as well, we're happy to, and we have been supporting for any pharmacies who are looking to go through the application process and try and guide them through that process and guide them through what the PNA has been saying. So yeah, we're happy to support in any way that we can. Sorry, Mark. Very quickly, I was just interested to know if you knew the reasons why that the Boots pharmacy had closed. I would... It wasn't lack of business, I understand, even though they had been running it down for the last year, clearly. But as Boots was, our pharmacy was one of, I think it's nearly 600 pharmacies run by Boots that had been closed around the country. Presumably, as they're American owned, for their own commercial reasons, rather than anything that relates directly to the individual community at Thames-Titton. Yeah, in fact, the one in Claygate was also closed as well. Okay, thank you. What we're going to do now, though, is bring forward item nine, which is the Surrey Farmers Institute called Needs Assessment PNA 2025. And you're more than welcome to say, for that item, that it makes sense to, I think, to follow straight into that. So I think back to you, Louie. Thank you. Many thanks, Chen. As long as the Board aren't tired of hearing my voice for the last few minutes, I'm happy to carry on. So, good morning, everyone. Good morning, everyone. Thank you very much for giving us the opportunity to come and speak to you about the Pharmaceutical Needs Assessment in Surrey. I'm Louie Hall, consultant in public health, and I chair the Pharmaceutical Needs Assessment Steering Group. What we're looking for from the Board today is two things. So the first thing is to sign off the final draft of the report so that we can move to publication. And the second is to agree to support the recommendations in the report. The Pharmaceutical Needs Assessment, as I've mentioned in the petition response, is a statutory duty that the Health and Wellbeing Board have to publish it. But that, the development of the report, is delegated to the PNA Steering Group. I'm really pleased to say I'm not the only person from the Steering Group here today, so I've got a number of members here. So I just wanted to introduce that with me, I have Linda Honey, who is Director of Pharmacy at Surrey Heartlands. Yinka Kuya, who is Community Pharmacy Clinical Lead at NHS Frimley. And Julia Powell, who is from Community Pharmacy, Surrey and Sussex, and represents our local pharmaceutical committee. So if you have any questions or queries that you have between us, we'll be able to answer those. You will have received the final draft of the report and also the cover paper as well. So I'm not going to go through that in any length of detail. But what I thought it might be helpful to do is just to spend five minutes running through a few key details, if that's okay. And then we can open up to questions. So the first thing to say is that the PNA is developed in line with national guidance on how you write a pharmaceutical needs assessment. This is developed, this is written by the Department of Health and Social Care and is informed by legislation. And what's great about having this guidance is it keeps the report focused on meeting the needs of its audience. And the audience of the PNA are those who are looking to manage the pharmaceutical markets. So those who receive applications for new pharmacies or changes of ownership or changes in premises, they can look at the PNA and the analysis and that can help to guide their decisions. So what it's different to is it's different to something like the Joint Strategic Needs Assessment, the JSNA, which we can locally define the scope and we can set what chapters we want to do and what we want to go in. It's different to that and we're guided by that legislation and that guidance. The overall purpose of the PNA, amongst lots of things, but is to try and identify gaps in pharmaceutical provision. So we do lots of maps around where services are, where they're not, and then have to make a judgment call around where those services aren't, should there be services there and try and identify gaps in pharmaceutical provision. That is made by, those decisions are made by subject matter experts in terms of the steering group. And we also look at a broad range of intelligence. So quantitative data, I won't go through lots of details, but residents on, you know, details on residents and their demographics and where they're situated and population density, conditions and where they are, looking at GP data, looking at hospital data. And then also looking at the views of residents and qualitative information as well. So there's lots of reports out there in the public domain, thanks to Healthwatch and Luminous, provide insights in terms of residents' need and around pharmacy access. But we also run our own surveys as well. So we have a professional survey and two resident surveys as well. And they were really helpful in terms of giving us a snapshot around patterns of usage around pharmacy as well. So they informed our decisions. And then we use all of that information to, in a nutshell, try and decide what reasonable access to a pharmacy looks like in Surrey. And we look at different travel times and then we apply that and then see if there are any areas of Surrey which don't meet what we would consider to be reasonable in terms of access. And those areas are potential gaps in pharmaceutical provision. Through all of that process, we recognise that Surrey is diverse and in terms of the geography and the people as well. And so the level of need throughout Surrey is likely to vary. And we look at variation of need and whether different parts of Surrey might need to be prioritised in terms of having a greater level of access. But what we concluded largely from that work was that we already know the areas where there's a higher level of need and where outcomes are worse in Surrey. It's in the health wellbeing strategy and it's key neighbourhoods. So key neighbourhoods were prioritised in terms of access to pharmacies, particularly around out of hours access. So I wanted to reach key neighbourhoods were key in our decision making. So the conclusion, as we've heard, is that there are no gaps in current or future pharmaceutical provision. But we will continue to monitor that. That's the statutory duty as well. So as there are changes in pharmaceutical provision, we can continue to check to see whether that changes our outcome. And what we have now is we have a method that we can replicate so that we can measure that consistently over the next three years, which is the lifespan of the P&A, and then we publish a new one in 2028. So just to say the work hasn't finished, we'll continue to monitor and keep going with that. So I'm almost finished. Just before I finish, I just wanted to highlight two additional recommendations in the P&A. So the first one is around key neighbourhoods for them to continue to be a priority when it comes to planning and commissioning pharmaceutical services. So this is really recognising that a number of organisations commission pharmacies to deliver services. We have flu vaccines, we have pharmacy first, we have stop smoking, we have NHS health checks. So we have some control, as a number of those organisations are represented on this board, we have some control around where those services are being delivered. So it's about prioritising and thinking of key neighbourhoods in that planning. And then the last one is for pharmacies to continue to be supported and be further supported in the offer of these additional preventative services like Pharmacy First, like smoking cessation. Because what we found from the P&A was there is a high uptake of pharmacies looking to want to deliver these extra additional services. But that's not necessarily going to pharmacies to have these services delivered. So I think a really good example of that is Pharmacy First. So Pharmacy First is an initiative to try and reduce burden on primary care and urgent care. And I think it was 98% of pharmacies have signed up to say they want to deliver this service. But the proportion is nowhere near that actually being able to deliver that service because residents are either are not aware of it or they're going elsewhere to have a similar service. So it would be really great to discuss if possible how the service system can support pharmacies in doing more to deliver that, taking that more community orientated approach to healthcare delivery, which appears to be the direction of travel. I'll stop there, thank you. Thank you, actually. Can I just ask a rather stupid question probably? But I understand why you would need to have a P&A to make sure actually that those key neighbourhoods, did have access, easy access to a pharmacy. But the pharmacies are commercial operations. So why would we not approve anybody that applied on the basis that, you know, the government's agenda and all government's agenda, I think, is to use pharmacies more to take pressure off the NHS. So why would we limit the number of pharmacies? I'm happy to give one of you on that but I don't know whether... Julia, I don't know if you want to first or... Hi, so I'm Julia Powell, Chief Executive Officer for Community Pharmacy Surrey and Sussex. So, unfortunately, the way that community pharmacy is funded is we are funded out of what we call a global sum, which is a fixed sum of money. That sum of money, obviously, is only sufficient to keep a number of pharmacies open. So what we have is if we have an open market, we will just dilute that global sum down so that the community pharmacies that are then existing will have less and less funding, which just means that we will lead to more closures. Also, what would happen is that we would have saturation in areas where we perhaps don't need a pharmacy, because pharmacies would open next to GP practices or in areas where they feel that they would be able to commercially make money and obviously stay in business. And we would probably see detrimental effect then on those pharmacies in rural areas where there is a higher need for those pharmacy services because of that global sum being sufficient to keep the number of pharmacies open that we currently have. And that's why we're seeing a number of closures is due to the fact that they're trading at a loss currently. But those closures are self-selecting, are they? So where we have a higher density of pharmacies where we don't actually need those, do we take any positive steps? Look at the closures. They're not necessarily happening in the areas that you would like them to happen. There are nationally more closures happening in areas of deprivation when really they could be happening in areas where there is more saturation. But obviously, if you're in a wealthy area as a community pharmacy, you can offer additional private services which actually bring in additional income. In areas of deprivation, you can't offer the same private services, and that's why they are then reliant on their NHS funding, which for most pharmacies, the funding for the global sum equates to 95 to 99% of their business. Therefore, if the funding from the NHS is not sufficient, that's why you're then seeing those additional... Anne-Marie. Can I just continue on this point and sort of expand my knowledge, I suppose, really? With the funding from the NHS, is that intended to cover things like the fact that a pharmacy has to give free prescriptions to a whole range of people? What's it intended to actually be covering? So, the funding from the global sum is all of the money that the pharmacy has for dispensing their prescriptions, for buying in medications where they might meet some retained margin because they can buy it at a lower rate than what they obviously get reimbursed at. If you look at things like prescription charges, that doesn't come out of the global sum. A prescription charge is not kept by the community pharmacy. It is just a tax which is returned back to the government. So, the prescription charges are not kept. Currently, the rate for dispensing a prescription is £1.27. So, that then is to cover all of the costs of that business. So, that is to cover all of their rental costs, their operating costs, obviously their staffing costs. And what we have seen is because we've got a flat rated global sum over the last five years, the costs, obviously, of running the business have increased substantially. But the remuneration back for the NHS dispensing side and their services has obviously not increased at the same rate. So, community pharmacies now have seen, over the last five years, basically a cut in funding of 30%, which is why we are seeing the loss and closure of pharmacies. Basically, their operating costs now exceed what they are being reimbursed back for their service provision. Kate. Thanks, Tim. Kate Skribins, Chief Executive of Health Watch Surrey. I just wanted to come back to the role of the Health and Wellbeing Board today in our decision as to whether to approve the Pharmaceutical Needs Assessment, and just get a little bit more detail on what that means in terms of cases such as the one that the Residence Association in Thames-Ditton has brought today. Because I just think it's quite important to understand what the implications are of the decision we're making today. So, Health Watch Surrey was heavily involved with the steering group. We're there to represent, to some extent, the voice of residents, although it's not the only way that resident insight feeds into the Pharmaceutical Needs Assessment, as Louis was outlining. We felt that the process was very robust. As Louis explained, there are pretty sort of defined criteria on which the needs assessment is based. But there was flexibility built in this year. There were things such as walking distance for residents was incorporated. So, there has been some sort of flexibility added to the national criteria, which we really welcomed. And I think that meant that the decision, the recommendation has been sort of more broadly representative of the issues that residents tell us are important to them about access to pharmacy. Nevertheless, the process is quite high level because it covers such a broad geographical area. And it doesn't necessarily drill down to the issues at a very local community level that are important. And I think there are some aspects of the importance of a community pharmacy that may go beyond some of the immediate needs. So, a community pharmacy can be a place of focus for a community. There can be, you know, specific things that are specifically important to local residents about their ability to access a local pharmacy in terms of community cohesion, etc. That may not be things that are necessarily looked at as part of the needs assessment. So, I think it's important to us as a board to understand, as we're considering this decision today, what does that mean in terms of the implications for the unforeseen benefits? So, Louis, you outlined that there were two in Guildford that have been approved under the unforeseen benefits rule. I would just like a little bit more understanding of what sort of unforeseen benefits can be argued would give legitimacy to a decision to approve another pharmacy. You know, is it something that's reasonable? And would issues around importance at that very local community level be things that we can be reassured today would still be taken into consideration? Thank you. Thank you, Kate. So, in terms of your question around the two applications that were approved in the Guildford area, they are both applications that were considered obviously on the current P&A, not the one that we're discussing today, that had no gaps identified but had had pharmacy closures since the P&As. Mark. Thanks. And sorry, Louis, if this is in the detail, I can't see it there, but we've suggested there's a relatively small amount of pharmacies where you walk 30 minutes to or more. And I know this is quite relevant here. Does the P&A stipulate a time of distance to walk which is unacceptable and hence would expedite the need for a pharmacy in an area? Or is there a service from that pharmacy that would deliver emergency medication if it was required and the person then couldn't walk that distance so they don't have a car or they're incapable of walking that distance? I know we've got online services, but they don't tend to operate on a sort of hourly same day basis. It tends to be sort of 24 hours or 48 minutes. Thank you, Mark. So, yeah, so the way that we kind of, I talked about lots of intelligence that we take into account and what therefore we're trying to do is then decide what reasonable access looks like in terms of pharmacy. And we didn't have one rule that fits all of Surrey because Surrey is different. So, you know, you might expect access to be different in kind of more built up urban areas compared to more rural areas. You might expect people maybe to drive more in a rural area compared to an urban area. We looked at out of hours access as well. And we actually found that, I thought that residents would actually prefer to have kind of more out of hours access than Saturday and Sunday access. But the results, the snapshot from the survey that we got was actually that residents don't mind when pharmacy was open. Actually, the biggest response was actually no preference or kind of just during routine hours. So we had different rules. We had 20 minutes driving for some areas, 20 minutes walking for some areas out of hours. We said there's probably less demand. So that's 30 minutes driving for key neighborhoods. We actually found that they were really well supported in terms of pharmacy. So the vast majority actually were able to access pharmacy within five minutes. But we wanted to make sure that they could walk to them within kind of 20, 30, 30 minutes. And we found that that was the case for all of them. So if any areas didn't meet those, what would be considered to be reasonable, then they would be the areas that we would highlight as potential gaps in pharmaceutical provision. But we didn't find that that was the case. So we're saying that 30 minutes is that reasonable time. That's that cutoff time. Because I'm sort of if I wasn't very well and I've been to the doctor and I'm not sure I'd want to walk 30 minutes. You know, especially for side that I've got bronchitis or the bad cough or I've got flu or, you know, I mean, and if you're not lucky enough to have a partner or someone to do that for you, that's quite a distance to walk there and back on the basis that you're not very well. So it wasn't 30 minutes blanket. It depended on where. So if it was a town or a priority blanket decision across every area in Surrey. Yeah, that was the case. And just to say that it's a good question. It's good something to discuss because we recognize that not everyone in Surrey is the same and that there's different levels of need. And there are some people who have more of a barrier to access to pharmacies than others. And we had this discussion in the P&A steering group about how do we incorporate the needs of all residents within the constraints of the guidance and the legislation as well. And what I mean by that is what we should be doing in the P&A is highlighting gaps in geographical areas. Because we're meeting, we're trying to support the market to try and identify gaps that we can address. So what we can't be doing is highlighting gaps in groups of people who are distributed across Surrey. So we couldn't necessarily in the P&A highlight gaps in people who have a physical disability or sensory impairment, for example, because you can't fill that gap. So how do we address those, how do we incorporate those people into our decisions? So the approach that we decided to take was let's try and understand who those people are, who have a barrier to access in terms of pharmacies and where it's a challenge. And where are they distributed geographically and are there areas where certain people, there's a high proportion of those people who might have a challenge and try and prioritize that area. And we concluded from that that it was key neighborhoods and so that's why they're a priority. We recognize that there are people who don't live in key neighborhoods who are still going to have some challenges around accessing a pharmacy. And there's a challenge there. And this is going to be my personal perspective on this, not necessarily the steering group, is that there are lots of people who have challenges in accessing services. But those barriers and those drivers probably aren't unique to pharmacies. It might be that the same challenges are for opticians, for GPs, for hospital, maybe non-healthcare, post offices, shops. And we started to get to this conversation about how do we as a Surrey system support these people to access all of these services. It's not so much a pharmacy issue necessarily. It's a health and care issue. How do we do that? So my feeling is that it's probably less in scope of the P&A and more in scope of the other statutory duty of the Health Malbeing Board, which is the Joint Strategic Needs Assessment, the JSNA. And with my other hat on, what we're doing is trying to publish more chapters around groups of people, understanding their health need, understanding their barriers to access and trying to develop system-wide recommendations to address these challenges for these groups of people. So we publish chapters. There's a chapter at the moment on unpaid carers. There's a chapter on armed forces just published, people with multiple disadvantages, learning disabilities. And we have a chapter scheduled for 25-26 on people with physical disabilities and sensory impairment. So I feel like within scope of there, we have the scope to define what goes in that chapter and the recommendations that we give to the whole system to try and address these challenges. But again, that will tie in with some of the work that's happening around local government reorganization and the towns and villages work that we have been as a system working on over the last two years. So we'll pick that up a bit later. Conscious now, we're at the timing. So take two quick comments, if that's possible, please, from Paul and then Sue, and then we'll conclude. Great. Thank you, Louie. First of all, I think it's a really great work in here. It's really interesting to see the whole analysis in one place. Quick point and a quick question. Quick point is, I just wanted to stress just a little bit, the bit about emergency hours. I mean, anyone who's ever been a parent will know that your children never need a pharmacy between the ages of nine, between nine and six. It just doesn't happen that way. So I just wondered about the representativeness of the survey work as to whether that gives an accurate picture about the access to emergency hours pharmacy. Because I think that's a much more difficult space to operate within rather than going into most high streets and finding something open between nine and six. That was quite striking and I wouldn't want to underestimate the issue around that. And then the second question, really, which, just to pick up from your recommendation, is what can the organizations around this table help and support with? And I'm thinking with the VCSE networks we have as well as others around this repositioning of what pharmacies do. Because I'm very struck by 95% sign up, but no one knows. Because actually it delivers a better service, a quicker service often for citizens than actually trying to wait with greatest respect to a GP appointment and actually gets them a result much faster. But clearly there's a communications gap here that we need to find a way across. I'll take Sue's question first as well, if you don't mind. Sue? Yes, thank you. Yes, thank you. This is a question about carers. And I'm just thinking that we know we have more than 100,000 of them. And so many of them will be involved in going to pharmacies in order to get medication for the people they're looking after. So I wonder if that's been a consideration. I understand what we're saying about looking at geography rather than groups of people. But in terms of what's an acceptable time to leave someone that you're looking after, perhaps with dementia, in order to access a pharmacy, get the medications that you need for that person and then return to your caring role. And is that something that we have included? And forgive me if we have, and it's just something I haven't seen. Thank you. And, Lee, finally, if you can just pick up, really picking up on Kate's earlier point in terms of, you know, confirmation, reassurance that there will be flexibility going forward in this plan. Because, not least of all because of what's happening at a national level and kind of reorganizing around how some of these services are delivered. So just reassurance that this isn't in a static document or maybe even a static approach, that there will be some flexibility. Yeah, thank you very much. Just on Paul's point about the emergency care and urgent care, which we definitely take on board. And there are alternatives which are beyond kind of community pharmacy access. So, for example, you can call NHS 11 prescriptions as well, and they can support you in trying to access that. I mean, I suppose there's some options there, which are beyond where kind of pharmacy, specific pharmacies are. On Sue's, just to Sue's point, you didn't really miss, it was kind of what, it wasn't, there was a couple of lines in it. So don't worry if you missed it amongst the 200 paid document. But in terms of unpaid carers, we found that there is a significantly higher proportion of unpaid carers in key neighborhoods, actually compared to other areas of Surrey. So we particularly looked at out of hours access for key neighborhoods and also prioritizing access and found that actually they were well served in those key neighborhoods. And again, I suppose it's about within the constraints of the P&A, in that geographical area, it was key neighborhoods which we focused on in terms of prioritizing unpaid carers. And just with Kate's point, I suppose it's difficult for me to answer, because as a member of the Surrey County Council on Health Wellbeing Board, I'm not involved in what's seen as unforeseen benefits. I don't, the answer is I don't know what's, I don't know what's considered. If there's anyone else who's able to answer that. Nobody's putting their hand up on that point. Well, I think we've made the point that, you know, it's not just in terms of local need, you know, but it is, it's also just in terms of what the government are going to, you know, as they reorganize NHS England, what they are going to expect pharmacists to do. Because I do think that, you know, and I know there's a kind of conversation with pharmacists at the moment, but I think it's not just about, as you've made the point, it's not just about dispensing prescriptions. It's all the other things that they do in terms of public health support around, you know, non-smoking and all that sort of stuff. So I just think we want to be comfortable that there's a structure to the approach, but there's not a rigidity that won't allow, you know, flexibility if appropriate. And it sounds as if the unforeseen benefits is a pretty open field in terms of what could be justified as an unforeseen benefit. And if those, you know, and some of that will be perhaps private, privately funded work, which won't then impact on the overall funding pots. Okay. Well, I think we've probably gone as far as we can today. So let's... I'll be really quick. And I think the work's really wonderful around pharmacies. And it's just a note of what happened during COVID and how the communities pulled together to help deliver. And I know it's more than prescriptions here. And there are wonderful driving groups out there. And I don't know what's available in terms of Ditton exactly, but there are ways of supporting people getting access to some of those needs via those community groups and driver schemes particularly that will help. Yeah. Okay. Thank you. You're coming up for somebody else there, but... Okay. Well, I think we have two recommendations. One is to agree the findings and the recommendations of the Surrey P&A 2025 and to sign off the report. And the second is to agree to support the recommendations of the Surrey P&A 2025. Are we happy with those? I think we've got some background, but I think those recommendations seem okay. Okay. Good. Thank you very much. I suspect that's the longest conversation we've ever had around the P&A, to be honest. So thank you, Karen and Sean, for raising the issue. Right. Shall we then go back to item six, which is the new community safety partnership? And I think, Sarah, you're going to open that for us. Sorry. Yes. I am here. So my name is Sarah Hayward. I am the Serious Finance Programme Lead for Surrey, which is the Office of the Community Safety and Partnership Lead. So I have lots of background and experience in working with partnerships. And I'm here to talk on behalf of the partnership and the establishment of the new community safety and prevention board. And I know you've got a very busy, busy agenda. And the purpose of this sort of briefing is just to kind of keep you informed of the work around the new the new partnership. And there was a paper brought to you in December that agreed the strategic oversight of community safety would move from the health and wellbeing board into the new community safety and prevention board. And the ask was we came back and gave you regular updates on what was happening in that work. And so this is this is why I'm here. And so just very quickly to remind you, as I said, the agreed separation was back in December. And since then, we have had a working group coming together from a range of partners to sort of look at what that new board would look like and how we would how we would structure it. And who would be in the membership in the terms of reference. So that work has been taking place since January. And we looked at and you have apologies to said you do have a briefing pack that came out later or not in the members. So a lot of this information is in there. And we took a lot of our sort of initial work from the feedback from the consultation we did at the end of last year and wanted to recognize what was suggested being needed and the focus of that new board, particularly around that single sort of place for strategic leaders to come together around community safety, the oversight and also phase two in terms of looking at the landscape that sits underneath the community safety and sort of decluttering it and making it a simpler governance structure. We also took away from the consultation the really clear message around maintaining that place based work. So the work our community safety partnerships do in our district and borough areas and linking with communities and making sure that that relationship remained strong. And so the sort of aims of the new board are really to map that around leadership and oversight, that clear governance structure, supporting the thematic groups that sit under and I'll talk a bit about those in a second. And we really wanted to make a sort of cornerstone of the work of the new board around data intelligence and insight. We're doing it in sort of lots of different places and we've had needs assessments that have been done, but they're not being joined up in taking all the opportunities around that data intelligence we can do. And opportunities around co-commissioning and particularly linking into the new piece of legislation about duty to collaborate. And also then putting ourselves in a position where we can respond to the new government's sort of safer streets mission and that work around halving knife crime and violence against women and girls in the next decade. So we really wanted to make sure we're in a place to deliver that. So the working group also looked at what key pieces of legislation underpin the new board. There are nine in total that we can identify and one coming through government at the moment. They date back from 1998 right the way through to 2024, covering things like domestic abuse, ASB, counter-terrorism, and then more recently serious violence and that victim and prisoners work. So a huge amount of legislation and a huge amount of oversight that the board needs to have. And then what we did jumping to membership is we made sure our membership reflected that legislation. So those organizations or departments within organizations represent our core membership. So the terms of reference itself is in development. I can send around a draft copy after this meeting, but it picks up on that aim around bringing those leaders together to hold those pieces of legislation to account, to look at data intelligence, the collaboration, early intervention and prevention, supporting vulnerable groups, and promoting community cohesion. They are the sort of reference alongside the more administrative things around, you know, times and dates of meetings. As I said, we can share those terms of reference after the meeting. The governance structure that sits under, I want to touch on the themes that run across. So we have an operational group around vogue and domestic abuse and social behavior and community harm, serious violence, which includes knife crime, place-based violence as some of our hotspot work, and serious violence involving children, prevent, which is our link to the counter-terrorism work, serious organized crime, and hate crime and community cohesion. So a huge amount of work happening in those operational groups to maintain those discussions, because there will be clear links into those working groups. So focusing now on membership, as I said, the core membership is based on the legislation. So we've taken and looked at the legislation and identified those individuals that need to be represented in the board itself. I want to head off any questions around. We did put the district and borough chief execs in clusters. That wasn't a nod to any local government redesign. That was a recommendation that came out when we had a community safety board, and it was felt having three chief execs present would allow that resilience and also feeding those local needs. We did meet with the chief execs two weeks ago, and they were going to take away that recommendation and look at how best they are represented at this board from a local government perspective. The only other gap we have currently on the board of membership, the membership of the board is our integrated care partnership, one of the care board representative. We still haven't been able to identify the right person for that position. So I'd be really grateful today if any one person to represent the integrated care partnerships. The other then list of individuals that are named in the terms of reference and the membership is those who are the chairs of our other strategic partnerships. We want to make sure from the outset there's a real connectivity across the world in the community safety prevention board and also then across to other strategic partnerships. The list of sort of things that I mentioned, it's really important that there's lots of crossover and work that takes place in both of those or all those strategic boards. We want to make sure that there is those early discussions around aligning goals and making sure we're not duplicating effort and conflicting across those different boards. So there's the boards there are listed. So this board, you've got the two safeguarding boards around children's partnership and the adults board, the safeguarding board, combating drugs partnership board, youth justice board and then the local resilience forum. We will ask for representation. On the membership, it's really important to say that is just the core membership. There will be other invited individuals and guests depending what the agenda is and depending on what the theme of the item is. For example, should we have a update on domestic abuse? We would expect to invite individuals who are experts in those fields and to give that update on that work from their voice and what's happening in their work stream and their core membership who will, as I said, relates back to the legislation. I know you've got not a lot of time so I won't go into too much more detail, but there's a slide also on the importance of data performance and making sure that we make that link from the outset and also set some clear performance and outcome measures around the board. And also there is a slide at the end around the relationship with our community safety partnerships and making sure we support them at that local place-based level and then we ask for them to be experts in those areas and come back to us with knowledge of what they're doing and what they're achieving in their local areas and then how we can support them to live with that. As a brief overview of what's happening at board, it's obviously at the moment we are presenting this to lots of different partnerships and strategic boards so the discussion is changing what that looks like. Excellent, thank you very much Sarah. Any comments? Paul? Yeah, thank you very much for that overview and I've also had a chance to look through the report. This might be an incredibly naive question. This is not my air of expertise at all, very long time. But you talk a lot about the community and the community safety board but there's a lot of very statutory organisations in here and I can't see what other people would recognise as the community in this structure very easily. I can see local authority chief executives and I can see senior police officers. I can't see anyone that I think the public would look at and go, they're there for me. And I worry about that because I think it creates a disconnect between what you're trying to do and the impact you're trying to have, whether that's in the core board or the supporting board. And I realise that basing it in legislation is the right start point but I wonder whether we can be more ambitious than what's in legislation and actually be thinking about creating something that looks to the public like a partnership by bringing in voices that are perhaps a bit disruptive and bring a different take on it that might give us a whole different shape. Yes, it's not a question that's come up before so thank you very much. I mean I certainly will take that back and feed that back to my colleagues. I think where the, and Mari's here from community safety partnerships and I'm going to sort of maybe pass over to there because I think what's really important is there is 11 community safety partnerships across the Surrey at the moment that do or can do represent that place and that community. This is at the sort of the strategic level and yes I absolutely agree we need to understand the voice of the communities and the individuals in that but from that very local level and representation it's probably best sitting at those community safety partnerships. Can I just come back on that? I think that's right up to a point but that always becomes a filtered voice. It always becomes someone hearing it and then editing it down and sometimes I think even at very strategic boards you need to bring voices right into the centre of that. because you know from my own experiences in different sectors nothing shapes your view than hearing that at first hand. And of course I think you need to find the right people to do that whether that's through lived experience or whether that's through organisations working with people with lived experience. But there's plenty of expertise around within the within for example the VCSE sector who could bring a strategic voice to what you do and could actually enrich that experience. Thank you Chair. And just to Paul's point and Sarah's comment around the community safety partnership. the community safety partnership for RUG in Banstead. There is numerous VCSE representation on that board and we do also have a visiting member of the community who comes as well. And it is really hyper-local and it feeds into our community development work so it really is bottom up. And I think you know there's always the challenge isn't there? A bit like this room isn't it? We bring all the great and the good together to oversee and provide governance governance and how do we effectively get that voice in the room. I think it is a fair challenge and it's something we can talk to Sarah about. But from my perspective the representation in that room from those CSPs, the communities and those hyper-local issues are very loud and clear. So just to provide some assurance around that. Thank you. Tomo, where do those report back to at the moment? We do work with the OPCC and there is representation on those boards as well from the OPCC. So all 11 have a member. It's usually Sarah, she gets to go to 11 meetings which is great. But they effectively cover that district and borough so they don't formally report anywhere currently. But this will give that better, affect more street. We have obviously local council and county councillors on those CSPs as well. Yeah, but I'm not aware that that goes through any governance structure within? No, just within the own authorities, it sits with them. Because they have also responsibility for domestic, what was DHRs, Domestic Homicide Reviews. She now has a new acronym that I can't remember, so apologies. But they have a, districts and boroughs have a statutory responsibility to handle those. So, but it's the government sits within those local authorities currently, but this will help that. Thanks Chair. They're called Dada's now and it's horrible, horrible name. And I think the governance point is kind of what I'm alluding to here. In the Adult Safeguarding Board, we were setting objectives recently and I was very mindful. Some of them actually felt like community safety objectives. We were touching on modern slavery, for example. And we had a big focus on domestic abuse. Not to say that they don't come under adult safeguarding, but they most definitely fit in this world. And I can see, obviously, you're clearly aligned to the safeguarding board. But as we've just touched on, there's 11 community safety partnerships at the moment. I know this is the right direction, but I guess it's just trying to make sure how do we, before those objectives are set by yourselves and indeed the safeguarding boards particularly, how are we going to make sure that they are aligned wherever possible and we're not duplicating? So, one of the first documents we have to produce is the community safety agreement. We have done this through the Health and Wellbeing Board in the past, but we will have to reassess that and we look at that. That's based on, was, and the previous one was based on looking at what relates to the adult safeguarding and then there's that agreement across who owns that. Adolescent safeguarding, particularly for children, is a big one where there's a huge crossover amongst children. So, when we're not cuckooing, there's obviously a huge link over. So, when we're designing that agreement, we will look at the best place to put that. And if it sits within a community safety and prevention board, great. If we think it fits better, there will be a consultation as we go through that development of that document. Hi. Hello. Do you, firstly, I'll take the challenge around the no representatives on this membership from hell to talk about that, because I think we definitely have a role there in community safety. And so, we'll take that offline and pick it up and come back to you. And the second point for me is around unwarranted variation when you have hyperlocal delivery of some of these objectives. And I guess picking up from the safeguarding board perspective, do you think this new governance will support identification of unwarranted variation in delivery or outcomes if we want to be outcome focused? Because I work in Spellthorn, and we're about to have a presentation about the arrowthorn, and it's really poor. And I would like to see how we're making sure that everything we do is able to focus where there's unwarranted variation. So, are you hopeful that this governance will enable you to do that? Yes, I am really hopeful. I think probably from a community safety, it has been missing at strategic level. So, we do have it through the community safety. What is happening in Surrey and in our communities will drive that work. So, if we need to do something in one area and not in the other, then we'll have the data and the skills that have been missing over the last couple of years in some of the development of our work. If there's something particular, so if it's a particular theme that needs, then it will sit within those thematic operational groups underneath. Yeah. And just, if I may. So, I would really like to see in this document the use of the words towns and neighbourhoods and the use of the word priority would be my plea. And just to build on that point, obviously the expectation is that we will have unitaries, a limited number of unitary councils from next May. And also the expectation from the white paper, I think, is that the mayor, the mayor of Surrey or wherever it is, will take on responsibility for blue light services. So, will the police and crime commissioner role will morph into the mayoral strategic authority. So, I think, you know, we are, we're not quite the start, but we're part way through a kind of a significant change in the way that this, this, we're all going to operate as partners. And, and there's, you know, and we had a good conversation at our council meeting yesterday around the, effectively the role of the unitary, which will be a strategic, strategic authorities. And how do we address that real local engagement and that's the VCSC, it's, it's health, it's the police, community safety, it's local government. And, you know, the, the work that we need to do collectively to retain that, that local identity, that, that community engagement. So, so, you know, and then probably in that sense, building on the community safety partnerships is probably the way to go. But I think, you know, I, I, I, again, it's the same, but I wouldn't want us or, or yeah, I think there needs to be recognition that this, this is going to have to evolve this structure because it's, it's going to, it will change into something different almost certainly down the line. So, sorry, I keep interrupting, but, um, Claire and then Sue. Thank you. Thank you. I wanted to make two points. The first, um, in my capacity as cabinet member for children and families to really, uh, recognize what Sarah was saying about the strengthening of practice in the adult safeguarding world and how this has been really important. But the second point I wanted to make was really something I think is kind of related to what Paul was saying as a locally elected divisional member. I think what I see in my community is the concern about antisocial behavior and, uh, community harm. Uh, and my concern might be that this is an area that would get drowned out amongst things like serious unorganized crime and, uh, and serious violence. Whereas, um, in our context here as a health and wellbeing board, actually, it's the impact of continual and, um, unrelenting antisocial behavior in a community which has impact for older people, single people, disabled people, means many of them are afraid to leave their home. Although they may not act, uh, their perception of being safe in their community is so badly affected. And I'm not, um, actually, I'm seeing that on the rise rather than being addressed through any, uh, change in arrangements. Uh, and it is a concern for me as a, as a community leader. Thank you, Claire. Thank you, Claire. Thank you, Claire. Um, Sue. Thank you, Tim. Um, so my point relates to can we use and bring lived experience into our strategic boards, picking up on that theme from earlier, and to reflect on the fact that in terms of the role that I currently occupy, you know, that's been a very innovative role. Um, established by our system to bring the lived experience, um, of unpaid carers in this case to, um, right to the heart, really, of the governance of the system. So if there are things we can learn from, what does that role look like, what does that achieve, you know, how has that raised visibility and brought the lived experience and the voice of, in this case, carers, but it could be other communities, uh, very happy to support that, you know, to discuss that if there was a wish and a will to bring that sort of experience into other areas of governance within the system, as we've been discussing. Thank you. Thanks very much, Sue. Okay, I think, well, it's a good conversation, so there's a bit of feedback there, uh, and obviously you'll be collecting that as you, as you go around, so, um, I think it will be good to, um, uh, put this back on our agenda, um, at, at an appropriate point, uh, when you've got to, uh, to sort of a, a, a final landing, but, um, you know, it, it, it, it clearly is, it is, it will lead to time with the sort of the broader, broader pieces of work that we're, we're all working on, but, um, you know, it's, it clearly is, it will lead to time with the sort of the broader, broader pieces of work that we're, we're all working on. um, we're, we're all working on, but, uh, um, thank you very much, Sarah, for help. Um, sorry, Monique. Yeah, just, uh, one further comment on representation. I mean, it's something we deal with in the research domain as well, bringing the voice of participants in, at the beginning of doing research. Um, we do know that effort is needed to support people in doing that, to give them training, um, to actually do activities in such a way that people can actively and comfortably participate, but also to re-enumerate their time for that, because otherwise it is very difficult to bring in the voice. So I think it is something that's very useful to think about and what work might need to be done to allow that to happen in the most strong way. Yeah, no, very good point. Thank you. Okay. Um, then thank you, Sarah. There are no recommendations, so we're just, we're just noting the report. Thank you. Uh, okay. Item seven, then, uh, health wellbeing strategy highlight report. Um, Mari, I think you're going to lead us off. Thank you. Thank you, Chair. Morning, everyone. Um, my name is Mary Roberts-Woods, and I, uh, chair the Prevention and Wider Determinants of Health Board, which is a sub-board of this committee, and I'm also, uh, sponsored for Priority 1 and 3. Um, I'll look to Phil to clarify who's, uh, doing, uh, Priority 2 today. Uh, oh, hello. There you are. Sorry. Nice to see you. Uh, it's a long table, isn't it? And for some reason, no one is sat either side of me, so hoping I'm not going to take that personally. Um, anyway, um, to highlight, uh, Spotlight this time around on Priority 1. Um, so we've talked a lot around, uh, MEC, Make Every Contact Count, um, and, uh, in relation to the strategy that we have, um, this has been published on Health Surrey, and we've rolled out bespoke MEC training packages. Um, they're being delivered across the system from alcohol, smoking, well, uh, mental wellbeing, fuel poverty, and also food and wellbeing for carers of people. So, uh, progress is being made, uh, on MEC, and lots and lots of colleagues have been trained and are applying that in their daily interactions with our, with our residents. In terms of opportunities around Priority 1, Changing Futures Program, uh, is there to improve outcomes for people experiencing multiple disadvantage, and it's managed to secure funding from central government, from the National Lottery Community Fund, uh, and the Household Support Fund, which will enable us to, uh, pursue that further and, uh, make, uh, further strides. Uh, the Accelerating Reform Fund, another three-letter acronym as ARF, as if we needed any more in our lives, uh, is, uh, funded Specialist Social Prescribing Pilot Service to support prison leavers, um, and that is now up and operational and has been, uh, accepting referrals since January this year. The pilot is, uh, nationally unique partnership between, uh, Surrey-Kent Council, Guilford Probation Service, and the Kent-Surrey and Sussex Health and Justice Partnership. In terms of challenges, uh, we all know the, uh, illicit vape and tobacco market is large and ever-growing. There is concern over the capacity of the Trading Standards Team to deal with the issues given the forthcoming ban on disposable vapes in June this year, which I'm sure we're all very keen to see come in, um, additional public health funding for the underage sales officers ends, uh, in March this year. So, um, that is obviously something for us to consider how we, uh, may want to continue that effort. Uh, I'm going to be quiet now and go to two unless you want me to go to three, Tim, and whatever, Chair. Probably best to hear me in one go and, uh, not keep going. Uh, so, uh, priority three, um, to update in terms of the spotlight, uh, this, uh, board, there have been 18 signatories to the Good Companies End Poverty Pledge since the Health and Wellbeing Board signed it in July last year. There is a resource page on the, on their website to help organizations enact their pledge. So this is about how you actually make this happen and make it meaningful. Um, uh, so please do check that out and share that with your networks. Having signed the pledge, uh, Surrey County Council's Community-Led Poverty Action Plan is in development. And the Surrey Health Determinants Research Collaboration have just received confirmation of five years funding at the beginning of this year to develop an approach to research in community needs that will steer the action plan. And that is something, uh, my own organization is, is involved in as well. In terms of opportunities, Priority 3, um, 24-25 Household Support Fund, uh, or HSF 6, we're on 6 now, has been allocated to the provision of additional support for fuel poverty program, support for families involved in Surrey County Council's early health interventions, and to the provision of rough sleeper essentials, amongst other activities. Uh, there is also an, uh, uh, an estimated $458 million in unclamed benefits across Surrey, and the procurement of the LIFT dashboard, which is low-income family tracker, uh, has enabled, uh, which was enabled by the HSF 6 Fund, allows districts and boroughs to share data and identify vulnerable households and reach out to them, uh, with communications and support. Um, we've actually implemented this, uh, at Rygate and Banstead. We've actually put some resource behind it as well. And, you know, if we can genuinely get to people and help them, um, access the benefits that they are entitled to, and, and there are a lot of barriers as, as to why people don't do that, but if we can do that collectively, and sharing that data is critical to that, we can really, really make an impact for, um, residents and the communities. Um, the focus initially is going to be on, um, pension credits, um, and, uh, anything we can do to share the messages and get behind this. I really would encourage organisations to, uh, assist us. Also, Your Fund Surrey has awarded more than £1 million to the Stanwell Events Acorn Project, um, and they'll be using this to extend an existing community building in one of Surrey's key neighbourhoods, uh, and residents will continue to have access to those vital, uh, services around food bank, citizens advice, and, uh, sharing space with the Housing Association. Um, finally, uh, in terms of, uh, challenges, Surrey County Council is anticipating receipt of, yes, Household Support Fund 7, uh, for April 25 to March 26, however, no confirmation yet from the central government of the amount on the, of these grants that we're going to receive. Uh, I think Ruth is, uh, latterly going to mention, uh, a few words on the update on the index scorecard, chair, but, uh, I'll, I'll hand over at this point, happy to take any questions. Thank you. Thank you very much, Murray. So, who wants to go first, Ruth or Helen? Thank you. Uh, thank you, chair, and good morning, everyone. I'm Helen Rothstall. I'm the, one of the co-chairs of the Mental Health Prevention Board, along with my colleague, Lucy Gates, from Public Health. So, um, just in terms of highlights from priority two in this reporting quarter, um, you will see that peppered throughout our report, we, uh, focus on men's mental health, a number of initiatives, for example, the pit stops that launched in Elmbridge and Staines, our green health and well-being program, promoting gardening, use of green spaces, in terms of, um, supporting men's mental health, and a real focus on the mental, um, uh, organization, which is a voluntary sector organization, supporting men's mental health through awareness campaigns, but also through peer support circles online. Um, we've been, um, obviously running their services in Surrey. We've got 171 men who are using the mental health services, 215 organizations who are supporting the awareness campaigns, from GPs through to dentists, hairdressers, et cetera. Um, and, uh, their recent campaign, Turn Your Bar Blue, which is about promoting their materials through public houses and other, um, places of entertainment like that. Um, and it's very much about, at the start of the month, promoting their materials, um, um, we've found that, I think, six times more men are likely to reach out for help if that campaign is running in their local area. So, it's really important. Um, the services from Mentel have a positive impact on the outcomes for men's emotional well-being. So, 45% increase in positive well-being for those who use the services. And the reason that we've, um, put this as our highlight, I think, is it's so pivotal in our suicide prevention work. So, we know from our local data that men are much more likely to complete suicide in Surrey and actually nationally. So, um, they are less likely to reach out for help or recognize that they need help. So, this is a really important theme going through our prevention, uh, work. Just focusing on opportunities, um, I wanted to just, um, mention the celebration event of our Mental Health Investment Fund, uh, that was hosted in January by Mark Mooty and, uh, Sue Murphy. Uh, celebrating the success of that fund in supporting grassroots initiatives to improve mental health, uh, outcomes for local communities. The remainder of that fund, uh, is now being administered by, uh, Surrey Community Foundation. They've agreed to match, uh, the remainder of that fund, um, and their latest round of mental health scale-up funding, um, through that program, the first grant of that jointly administered fund, uh, was awarded to the Surrey Domestic Abuse Partnership, uh, to focus on young people up to the age of 30 in suicide prevention. Uh, so that's a fantastic piece of work. That will run over the next five years. So, we look forward to seeing the outcomes of that work. Um, the next round of the scale-up fund is now live. It will focus on supporting, again, who are affected by, uh, multiple disadvantage. Also, in successes, I wanted to mention something that actually isn't in the report, but, uh, I think it's important to mention, which is, um, our, uh, focus on, uh, positive partnerships with schools, a number of, um, counsellors and other senior leaders in the system, um, to go and see for ourselves, um, the impact of positive partnership between schools and county council. We saw some fantastic examples of young people being supported early on, uh, with their mental health and emotional well-being needs. A real focus on inclusion for young people, um, and changing to, um, to great success. So, for example, in college. Um, so really creating those foundations of hope for young people. Um, so that takes me on to our challenges. Um, and I wanted to pick up, following on from that, uh, one of the challenges that's outlined in the, um, the strategy index metrics, where, um, we've noted a decline in the percentage of children, young people accessing NHS-funded mental health support. So I think it, it, it kind of dovetails perfectly from the, um, the showcase of the school, um, because one of the things that we need to recognize is that in terms of our sophistication of our data flowing through into those metrics, we're not there yet. So there's a lot of activity that's happening, uh, across Surrey that is not yet floated, going through into the mental health data set. So, for example, a lot of the work in schools that I've just talked about would not get counted through this route. A lot of other work also doesn't get counted because we don't have a unifying data system. But we are working towards that, so I'm hopeful that within the first half of, uh, this next financial year, we'll have one unifying system that brings all of the MindWorks partners together so that we can flow data through into a single, um, uh, patient record system. So I'm hoping to see that that metric will change, but we also need to recognize that we are operating in a context. And we need to be innovative about our approach to engaging more children, but also recognize that we have to use our resources as well as we can to target those with the most, um, challenging needs. Also, then, our challenges, I wanted to pick out some of the funding challenges. So we've got a number of initiatives that are funded non-recurrently. Um, the first steps, phone line, which has been supporting people very early on in their mental health or emotional well-need, um, journey through phone contact, uh, through the website or texting. So that's been supported through non-recurrent funding, which has now come to an end. So that was COVID funding. So the team are trying to look at other ways of, um, innovating, using chatbots, for example, using QR codes, posters, and be signposted directly to, uh, support available in Surrey. Um, but it is a challenge. Uh, we are having conversations with places around the current funding for, for that initiative. The other, um, really important initiative has been our real-time, uh, suicide surveillance, uh, program. Um, and that has been supported through non-recurrent funding from NHS England. That has now come to an end. So we are, uh, uh, trying to identify and continue. Um, so I will stop there, I think. Thank you. Thank you. Thank you, Laurence Helen. Uh, Ruth. Thank you, Chair. So you, um, have heard our, about our delivery for our highlight reports for priorities one, two, and three. And as we emphasize, have emphasized in previous meetings, as well as, um, examining our delivery where we've had successes and challenges, of course it's really important that we're all, um, aware of the outcomes of our populations. And the index and the scorecard are a tool to do this. They, um, need to be read and used alongside the JSA. But I just wanted to highlight under recommendation number two was to note the updated, uh, health and well-being index scorecard and how that's developed. So this, as we've always said, the index and the scorecard adjective, and it's getting more and more sophisticated and we can do more with it. And as you will have heard through the highlight reports, we're really drawing on that data now and we're able to see where we're doing well and where we're not doing so well. So the scorecard now includes results, um, that have been updated since September 24. And we'll bring that back quarterly, um, to the health and well-being board. So we've got that overview. We've got some new data that's divisible by smaller areas in the scorecard, such as, um, life expectancy and other outcome data. It also includes the trend data for new questions included in the latest iteration of the, um, Surrey County Council and Police Residents Survey. Um, as part of recommendation number three, respond to the challenges presented by the updated scorecard. Well, you've heard some of the examples given, but just needed to highlight, as per our strategy, the scorecard and the index mirrors our strategy because it looks at geography, it looks at priority populations, and also indicators mapped across our three priorities. And one example of geography is that, as we know from our chapter one of our JSNA, uh, Spellfone's got the highest number of outcome indicators where results are poorest. Um, and as a result of the deep dive in January, there's been a collaborative group with representation across, um, um, Spellfone Borough Council, um, the ICS Place, Active Surrey, Public Health, looking at key areas of those indicators such as diabetes prevalence, alcohol-related hospital admissions, smoking prevalence, to really examine how they relate to those priority programs within the, um, strategy. So that's just one example. Just wanted to also highlight, I've talked about geography, but our overarching indicators of life expectancy, but in particular, healthy life expectancy. Uh, there was news, and it was in the national press, um, at the very end of December around healthy life expectancy. We've seen a slight increase in life expectancy, but across Surrey, the southeast, and nationally, there's been a real decline in healthy life expectancy, so we're not immune to this in Surrey. And so this has, uh, been 2.1 years for males and 3.1 years, um, for females in Surrey, which means we're having a larger, um, number of years where we're not living healthy lives, and so this is our overarching aim of our, of our strategy, but it's important to be aware of this. There's lots of detail in the scorecard, and I ask people to, um, to go into that. I won't go into detail now of where we've got areas of improvement, some have been mentioned, for improvement, some have been mentioned, but also success areas that we can celebrate across all three priority areas. Thank you, Chair. Thank you very much, Ruth. Yeah, and there's some, some really good stuff in there and very useful for kind of driving decisions and areas that we need to focus on. Um, we can't take any hands up in terms of all the updates, so there's some good stuff there, so thank you all very much. Um, I think we'll probably note those, those updates and move to item eight, which is the better care fund update, which I think, John, we can deal with fairly quickly. So I think we're, well, I think there's been a recognition that, that we need to, uh, do more sort of detailed pre-work on the better care fund, uh, which is, I think, what you're suggesting in terms of setting up a partnership, but over to you. Thank you, Chair. Um, yes, that's certainly one of the key points to, um, pick out, uh, in, uh, the report, which is an update report to, uh, health and well-being board. Um, I think key messages are we've made quite considerable progress over the last six to nine months with the capacity we have in the team, uh, supporting the management of the better care fund for the system as a whole. Um, we're in a much improved position in terms of our understanding of the detail around uh, the various services, uh, funded, uh, their performance contribution to overall outcomes. Um, uh, I think it's fair to say and draw people, take people's attention to the fact that 25, 26 is very much going to be a transition year. Um, the, uh, focus the better care fund based on national conditions remains largely the same. Um, there's nuances in terms of precise wording of those conditions but, uh, the intent is, uh, very much similar to what we've seen in previous years. Um, important point to note around one of the metrics which is a discharge ready date, um, familiar to some, I'm sure, uh, previous metrics around, um, uh, delayed discharge. It has some similarities to that. Um, there are some challenges around that. Um, we are working with our system colleagues, most notably, um, uh, the acute hospitals around making sure we have a consistent approach to recording and reporting on that. Um, there is still work to be done on that and we expect the position to improve as we go through the year. Um, I think the other point just to flag chair is really around some pressures around the funding, um, but we have had good conversations with system partners around, uh, that there has been some differential in terms of funding flows, uh, nationally, um, through NHS and, uh, social care routes, uh, but through those conversations and through the proposed kind of intermediate group that would sit below health and well-being board, uh, we're confident that we are able to work through that and that we will have a plan to manage the transition, uh, throughout the course of next year. Uh, final point to make, um, but not to go into any detail, it is important to kind of, uh, recognize, um, the forward direction of travel around devolution, um, and that will have a bearing on how, uh, things are approached in relation to, uh, the better care to arrive at in that regard. Thank you, John. Um, I can't see, I don't think I could see, um, sort of, uh, an indication of who would sit on that, um, partnership. Could you just give a bit of a flavor of that? So, it's, it's, what's proposed in terms of the detail is key exec leads from Heartlands, uh, and Frimley. I'm looking at my colleague along the table there, Joe, uh, being, uh, Heartlands rep and Nicola Airy from, uh, Frimley system. Uh, we want to make sure we've got representation from the, uh, local joint commissioning groups, uh, through one or two individuals as opposed to all of the, uh, chairs of those groups being represented, uh, and key representatives from, uh, Surrey County Council. Joe. Uh, thank you, Chair. Um, so, uh, Joe Cogswell. I'm one of the exec directors from the Integrated Care Board, um, and I'm the lead exec for the Better Care Fund, so, um, thanks, John. I wanted to start by thanking the team for all the hard work that they've done, um, as we get ready to sign off the plan over the coming days, and I wanted just to pick up a few of the points, um, that, that John highlighted in the, in the report. We had our workshop, didn't we, um, last year, and we talked about our ambitions as a health and well-being board, how we could be assured that we were getting the best impact for the investment that we're making from the Better Care Fund. You know, in the order of 100 million pounds, it's a lot of money, and, you know, we, uh, remain committed as system partners to working in a joint, joined up, and integrated way, and the priorities are important to all of us, and, in fact, this discussion is really well placed, um, on the back of the, the, the points that we've been talking about, um, earlier on today. I, I think the importance of a partnership group at this time is that we really do need to spend some time together working in a really sort of candid and transparent way, as we acknowledge that we're in, we're in transition for a number of different points. We're expecting the 10-year plan, we know we've got local government reorganization. I think if I'm being quite, uh, challenging about some of the, some of the elements of the Better Care Fund that we've invested over time from a, sorry, Heartland's perspective, you know, we need to challenge ourselves about the number of different ways in which we're undertaking pieces of work that are trying to work towards the same outcome, but we have a group model in two of our hospitals now. We really should have more consistency in our approach to discharge, in our approach to, to how we get people home, and in terms of our approach to how we support people to live independently, um, for as long as they possibly can. So, whilst we know that the, um, the Better Care Fund is likely to change in this current year, I think actually, not just because of the budget pressures that we face in terms of some of the commitments that we had already hoped that we would be able to, to fulfill this year, but actually we need to challenge ourselves and say, are we investing in the right things now, as well as what are we going to invest moving forward? So, I think one of the key functions of the partnership group, um, will be to undertake some of the work of that review, um, and I'm really pleased to say that in the challenging discussions that we've had in terms of the preparation of the plan this year, there's real commitment to making those decisions together, so if there are areas where we're not able to invest quite so much money this year, how are we going to transform our approaches to be able to alleviate or mitigate any challenges that would come from that, so my thanks to the team, I think it's going to be a really interesting year, but I think that, that we, as Surrey, have a really clear understanding in terms of our neighbourhood approaches, in terms of our priority areas, in terms of our real commitment to support independent living and to look across both acute, communitary, statutory, and voluntary and community sector in terms of how we are really utilising everything that we have in Surrey to be able to support our population, so thank you Chair. Excellent, thank you very much Joe, really helpful. Select first, Sue's got a hand up as well, she can select there. Hi, Select Sheffernan from Voluntary Support. My question's just going to be about how the voluntary, have you got an idea or a plan on how that could happen yet? No, not yet. That's acceptable given all the transition that you've just mentioned, but just for note. Thank you. Sue. Thank you Chair. I have a question about Section 8, so this paper, Section 8, and it's around the communication and engagement. I think at previous meeting we raised the fact that the communication through myself with unpaid carers was outstanding in terms of the range of helpful communications and conversations. It remains so, so I'm wondering when this is planned for and what will be the action, who will have that conversation so that unpaid carers are fed into that range of conversations. So perhaps that's a question to John Dillisane. Thank you. Yes, thank you, Sue. Apologies if we've not directly engaged with you. Carers Partnership Group does feed into the work around carers and the carers obviously is quite a significant area that the BCF invests in. We are, as Jo referred to, in the final stages of getting approvals for the plan that needs to be submitted by the end of the month so I can certainly pick up with you in terms of sharing the content of that plan at the appropriate point. Thank you. I think that's important because I am named in that paper so we just have to make sure that, you know, that is an action that's taken so that those conversations are complete in terms of the way the paper's drafted. So thank you for that. I thought you were going to say, Sue, the communication was outstanding, not outstanding. Right, okay. John, anything else? Anybody else? So that partnership group will be set up then, Jo, John, understand of it in the near future and then we'll do the heavy lifting around looking at how that fund, which we think is under $10 million or so a year, how that will be used but specifically around investment in prevention and early intervention. There was just one final quick point, Chair, just in relation to sign off of the plan which we're due to submit by the end of this month that's going through the exec leads, both Heartland's Frimley and the County Council. It will be with yourself, Chair, at the beginning of next week to give you adequate time to review so that we can submit by the 31st. Okay, good. Excellent. Thank you. There are the three recommendations then to confirm the establishment of the partnership group to confirm our support to the support to review the current investment prioritization approach and to confirm the support for the relevant system officers to update local approaches and data collection and so on. Are those agreed? Yes? Good. Thank you very much. Right. Okie doke. So we've done item nine. Item 10 then is the Surrey-Hartland's joint forward plan. Karen. It's very brief, Chair, because this is part of our planning process. So Surrey-Hartland's needs to submit plans for finance, operational, and workforce by next Thursday. And as we do a limited refresh of our joint forward plan. So attached in the paper is the limited refresh that we will put in the plan, but we will do a further deep dive and review in the summer when we get more guidance. Please. Okay, thank you, Karen. I mean, obviously it's a very fast-moving picture within NHS England, isn't it? So it would be helpful at the next board meeting to have a kind of a paper of some sort that sort of sets out your understanding of how this is going to work in practice because it's not clear to me. I assume there will be regional directors but everything else will sit within the HSC or something. It's all in the session. I know. It feels a bit like chaos. It feels like it. Okay, well, if we could perhaps just have a think if that's the appropriate timing to then sort of assess out how the 10-year plan, who's going to deliver, how it's going to be delivered within the health system. Okay, good. Thank you. And then ICB update for Hartlandsland and Frimley. Is that you, Karen? Yeah, I'm happy to pick up. So this is our chief executive update that will go to the public board this afternoon. But as you can see, there's a lot of activities going on. The main thing for us at the moment is the planning and delivering and living within our means, key target for us. but clearly activities that we're doing within our ICS strategy and some of the people, our values and behaviours and staff survey results that are due to be published imminently. Sorry, no, it's very similar whatever ICB you're in. So, as Karen said. Okay, good. I don't think there's anything else then to note that. Thank you very much both Hartlands and I and Frimley. Which then takes us to item 12 which is local government reorganisation. Having spent many hours yesterday, many hours discussing this, as I wasn't proposing to rerun those conversations. We have got Nicola Gilvington here who's the director of policy for and strategy for the county council. Can I just give two minutes on this? I'm very happy to expand or answer any questions but following the government's white paper we and all two-tier authorities there are 21 two-tier authorities left across the country have to put in an interim submission by this Friday which sets out how we propose to move forward with mayoral devolution. We've had many conversations with our neighbours neighbouring counties in terms of what they're proposing to do but ultimately they all have their own plans Hampshire, the Sussexes, Kent the Berkshires and so on so that has meant that Surrey is looking to go forward as a sort of single mayoral footprint even though we don't quite meet the government's sort of outline criteria of 1.5 million residents but we will have that if we build all the houses that we're expected to build but the consequence of that is that we we have to create a combined authority model which means that we have to have at least two councils to replace the existing 12 councils minimum of two but that we have to do which effectively means that the county council services will need to be split up and the district and borough services will need to be consolidated the Surrey leaders local government leaders have met on a very regular basis pretty much weekly and have been working through the data there are two repositories of data to get to sort of an indicative position for this Friday there are three documents that have come out of those those meetings the first part A it really just describes the county and the way the services and what a great county this is so it's a bit more of a sort of a pitch document and then there are two part B's one authored by the county council and one by the district and boroughs that sounds as if they are different documents they're not really where we have got to is that we have agreed I believe or we have agreed as 12 councils that there really are only two options available to us one is to create two unitaries to split the county either east west north south or three unitaries which is in the north south and east those are those two documents will go with the covering part A to government on Friday and it will be for the government to decide how they want us to take this forward they're equal weighted documents it is fair to say that the county council prefers the two unitary model because of the cost of disaggregating and indeed the concerns about the disaggregation in terms of getting that right and in particular matching the demand that we see in both particularly adults and children's services and the council tax base that will be needed to support it the majority of the district and boroughs prefer the three unitary model you know like the NHS I mean we are in such a state of flux you know with the conversation we had earlier about community safety so certain functions that are discharged by the 12 councils now will move to the mayor including economic development transport and so on with the unitary authorities left to do the heavy lifting of the delivery of all of that so you know we need to sort of feel our way through it Surrey because we are on the accelerated program is a bit of a guinea pig and you know so how the government approach us will part in part sort of set the scene for the others the elephant in the room for Surrey is the debt that exists across the county which currently sits at about 5.5 billion and we need to as part of these conversations with the government we need to have a clear solution that solution in our view is that the government write off the debts but that isn't proven to be quite as simple as we thought so we will have to have a plan B you may have seen you probably won't have seen but yesterday the government also appointed or are about to appoint commissioners to go into spell form where their debt levels are just over a billion and there isn't the same plan to manage how that debt is resolved I mean in fairness to Woking there is a plan and that is being worked through so we now have the two boroughs that have commissioners in there but that is kind of fine in one sense the debt needs will have to be resolved as part of reorganisation alongside so we are at a point where that submission will go in on Friday we will then I believe get a steer from the government we will get a steer of some sort which could be carry on and produce full business cases for two unitaries three unitaries it could land on one of those options or indeed it could come up with its own in theory which wouldn't be that helpful but it's not impossible and then we will get on working collaboratively as a group to produce the final submission by the 9th of May and then say with elections next year the bit that I'm particularly focused on in a sense the number of unitaries and there's been lots of sort of noise around this sort of 500 thousand population or more it has always been clear that that's a flexible number that the government will decide on what is most appropriate but 500,000 400,000 you know isn't local you know and we've kind of I think we all accept that that's not 400,000 in my view at least it's no more local than 600,000 so what is important and the bit that I'm particularly focused on is how we build on the work that we have been doing collectively around the towns and villages and neighbourhoods and to Charlotte's earlier point having the same language using the same language would be really helpful but for me it is you know the work that we the work that this board has done and led in particular around our communities going into North Leatherhead going into Guildford you know Spellthorn and so on seeing what is actually happening there using Ruth's data from the JSNA and bringing together the health the community safety the VCSE local government you know that is the way forward without question and that is what residents recognize their local community and want to be involved in how that local community is shaped and supported so I'm very keen that I will come back to this board and through the other partnership arrangements to work out how we can collectively create a structure that will deliver that real local support you know there are many other examples and called all sorts of different things local committees community councils you know in a sense doesn't really matter what it's called as long as it's consistent and understandable to residents you know particularly of course with the health and driving the integration of health and social care at that local really you know local level and the stuff we talked about at the beginning around the pharmaceutical needs and so on these are all organizations businesses people that live in those communities so that's that's the bit for me I don't think from a resident perspective they really care too much about whether they live in the borough of Elmbridge though it is the best borough in the county or indeed within the county the county council and so on our residents understandably are interested in best quality services that the local government and other partners can deliver at an affordable cost and that's what we have to keep focused on and to deliver so we're you know it's you know I think perhaps because the sun's shining and the daffinils are out I was feeling quite positive yesterday about the sort of future for all of us I think actually it is quite helpful that the health system is going to be thrown up in the air as well alongside local government because I think this is absolutely the opportunity to align and to really focus on that granular level and the stuff that the VCSE alliance are doing and so on and indeed the work of the police and our community safety partners it just all feels now as if with a real opportunity to break down all those barriers tip all into a bucket and come out with something that's better than what we've got now so that is the hope that is the aim and that is what we will see whether we deliver that or not but you know I think you know this board here you know brings together a lot of the system leaders is you know that you know having that sort of collaborative approach that collaborative working and the different perspectives and the point that Paul made in relation to community safety I mean you know there needs to be the right voices in the room and that's perhaps in the past what we haven't managed to do but let's hope we can so that's kind of where we're at but I don't know Anne-Marie if you or Mari want to add anything no I think that's been quite comprehensive you've covered all of the points but yeah happy to answer any questions anyone's got or any any clarifications I think that stands between you and lunch but yeah Toby sorry just a quick comment question it was around it was nice to see sustainability explicitly mentioned in the document and I think that's where there's also quite some opportunity to look in a more integrated way at the relationship between people and place and the natural spaces and so I think that's also a scope and that might be also a reach to which the public and local surroundings thank you and Paul I just want to thank you Tim for a very helpful overview I think the ones that are watching me is as both the local authority structure and the health structure are under very tight chain tables to come up with structures the risk is that we don't actually take the time to rethink the culture that sits behind the structure because you're under such deadlines to produce outputs of what systems look like and where functions sit and who has what jobs and that will be the lost moment is to rethink how these different bits of the system work together and feel and operate between local authority health the BCSE and others because some of it's quite complex but that's where the real power of the opportunity is and I just wonder how we can think about how we get that bit into the process rather than just take what you've just said there and just get back to having to hit the deadline of May the 9th before we lose that opportunity yeah so I absolutely I probably articulate effectively that the conversation that I want to us all to collectively pursue is around how we engage all of the partners in those local community settings so you know there is there won't be one culture it will be it will be based on a community whether that's a town or whatever but that's the conversation we absolutely need to take forward but I think just to come back I think that's absolutely right at a community town neighbourhood level but it's also going to be true at a local authority whatever structure that you know park county and at a system level because it needs to work through that otherwise we don't get we get lots of stuff happening here whereas we know that some decisions really to be made up here at a system level so we need to align it through the structure yeah certainly from a local government perspective that community setting will be hardwired into the unitary so we've obviously got from a local perspective existing town and parish councils that cover 32% of the county which is the same as the national coverage it is clear though that the government do not see the creation of a whole series of new town and parish councils they don't want to create a third tier of government but it is pulling in all of the partners and we've seen that as we've been out around the county particularly from a voluntary VCSE perspective that you've got some really very effective organisations working in a very tiny locality and it's how do we coordinate all of that and absolutely understand which is why I'm such a fan of Ruth's JSNA because that gives us a really good starting point in understanding what is happening in that community and where the gaps are and how we fill those so yeah I mean that's why it is all consuming because we have to get this right but we also have to address some of the longstanding issues around the remoteness of whether that's perhaps the health system or so on but also the GPs that are absolutely central to the lives and the livelihoods and health of our residents and so on so you know and I'm very clear on this the reorganization of local government is not it cannot be just about local government it has to be about a system system reorganization okay right I think that then brings us to the end of this agenda so the next public meeting will be on the 18th of June 2025 and the next informal meeting will be a deep dive we're going to Red Hill yep which is in East Surrey on the 23rd of April and we'll kind of share a program before then so thank you all very much a good meeting so thank you all