Transcript

Good afternoon, good evening everyone. We are going to start the meeting. Everyone should mute their microphone. when they're not speaking. For those joining remotely, handsets should be used if available. It makes a big difference to sound quality. Only use the chat function if you wish to speak or to bring an urgent matter to the chair's attention. The scrutiny officer will be monitoring the chat. Tonight's meeting will be recorded by the hosting authority which is us. The recording may also be used for quality and training purposes. It is important to bear this in mind and be aware of your surroundings if joining remotely. You may wish to use a backdrop or to blur your background. So, good evening and welcome to the Southeast London Joint Health and Overview Scrutiny Committee meeting. I am Councillor Christine Banton. I'm chair of this committee. We said the meeting will be, unfortunately, it's been recorded but it cannot be broadcast live. But the recording will be available tomorrow or Thursday. The council has a duty. I'm sorry, it's a bit difficult to hear at the back. I'll try and speak. Is that better? That's brilliant, thank you. Okay, I'll bring the pitch up. Okay. Please note the council has a duty to protect the sensitivity and personal data. To ensure such information is not inadvertently disclosed, please avoid using full names or any details that might reveal someone's identity. Help and safety housekeeping. The fire exits are over there and there to my left and to my right. There is an accessible toilet just outside on the right-hand side of the room. The committee... Sorry. So, I'm going to hand over to our officer, Roger Raymond. Hello. Hi. So, we're going to elect the chair and the vice chair. They were agreed by the committee in the year, but this is our first public meeting for the municipal year, so they have to be officially elected, even though we've been chair and vice chair since November. Do we have any nominations? Yeah. So, I'll nominate councillor Benton. I'm sickening. Agreed? Agreed. Agreed. And councillor Shaikh as the vice chair. I'm happy to be... Yeah, thank you, Minesh. Yes. So, we have our official chairs for the municipal year. Right. So, we've had apologies for absence from councillor Lisa Moore from... Bromley? Bromley? Bromley? Bromley? Bromley, sorry. Bromley. And councillor Mark Brook from Bromley, and councillor... Yeah, he's online. Yeah, but yeah, he's online. Is councillor Felicity Bain-Bridgesley online? Yeah, both of them... I'm not here in person, but I think he's online. Um, councillor Lauren Dinsdale from Greenwich, and councillor Annie Gallop from Lambeth. Those are the apologies that we have received to date. Is there any more apologies? I think, um, councillor Shaikh is late and should be here, and councillor from Greenwich, I think, is also in... Oh, no way. So, it'll be late. Sorry, it's still very difficult to hear most of the time, I'm afraid. Thank you. Do any members of the South East London Joint Health and Overview Board have, um, any pecuniary interest to declare? Thank you. Right, we will be, um, now moving on, um, to the minutes of the previous meeting of the committee held on the 1st of February 2024. These minutes are set out in the gender pack from pages 1 to 12. Um, no amendments have been received by democratic services. Are the minutes agreed? Agreed. Okay, can you note that the minutes are agreed by the board? Right, so our first, um, item is, um, tonight is the Sickle Cell Services to Support Better Care. It's item 4 in the published pack, pages 13 to 24. We will first hear from, um, Dr Sarah Stewart-Smith, um, Haematology Consultant at King's College Hospital and Chair of South East London. Um, if you'd like to put... Hi, it's a bit of a mouthful. So, I'm Sarah Stewart-Smith. I'm at King's looking after adults with haemoglobin disorders, including Sickle, but also I'm the Chair of the South East and South East London Haemoglobinopathy Coordinating Centre, which is a kind of network of specialist units and local units throughout the South East, including South East London. And we're just going to give an up, I'm going to give an update about some of our recent progress. So, there's a, um, the improvement programme for Sickle Cell has included a networked approach to community services. So, they've been historically very underserved. We haven't had community services in a lot of our boroughs. Um, and we've now, uh, with a lot of help from our ICB colleagues and some additional funding, we've managed to have a multidisciplinary team throughout the six boroughs, which includes physiotherapy, dietician, specialist nurses, specialist pharmacist. So, that's made, um, for adults and children, um, living with haemoglobin disorders. So, that's made a big difference. And there, all of the posts are now pointed to, and those, um, MDT even are functioning throughout the six boroughs. And there's been a lot of emphasis on having equitable access to all the six boroughs to make sure that, um, patients that are further from the centre of clinical guys that Thomas is who co-host the HCC are also served. Um, we've also been working on peer support and improving patient experience. So, particularly for our young people transitioning from children's services, where they're very much, um, handheld and, um, that helps navigate the complex system of the NHS. When they come to adult services, a big change, a big shock to the system, coming to an adult, mixing with adult patients. So, there's a process supported by the Sickle Cell Society, where patients who are transitioning, so that's generally the, sort of, 16 to 19 age group, are given a, well, offered the opportunity to have a peer mentor, who's a person with a lived experience of sickle cell disease, who's an adult and has already navigated that process, who, who can mentor them. Um, so that we've, we've referred lots of patients into that, and, and that's a sort of fairly new service that, uh, we don't have very much yet of, of how well that's being received by patients. Another prong of the work is this emergency and urgent care. So, um, throughout London, there was a decision that we would try, try having some pilot emergency department bypass units. So, some conditions such as cystic fibrosis, which share some similarities with sickle or that, um, such as being a genetic condition, have, they bypass ED. They don't, they go straight to a ward and they don't deal with the horrors of ED, which I'm sure we've all experienced. Our patients don't have that luxury, but there are now units throughout London, which are bypass units. So, for us in the southeast, it's Lewisham and that's just managed to get off the ground. At the moment, it's only working 12 hours a day, so it's not quite a complete bypass unit, but it's, um, early work and it's, it's, uh, functioning well and it's got good uptake by patients. It's a very positive feedback. Um, we're also looking at our sort of workforce awareness because, um, sickle cell disease, although it's very common in our southeast area, is actually not very well taught at medical school and nursing school. And, um, there's a certain amount of under awareness. So, there's been a really impressive, um, NHS England backed, uh, ACT NOW acronym. So, although it shares climate change acronym, it's actually a very good acronym. So, ACT NOW just spells out some of the steps that you take when you see a patient with sickle cell disease, like get that analgesia, show some compassion, get the appropriate tests, notify the specialist teams, give them oxygen and watch them carefully. Um, so there's, you know, part of a mnemonic. So, we rolled that out. We, we trialled it, um, at King's. So, um, the ACT NOW, so the ACT NOW is an awareness raising initiative, which was, um, co-produced with patients and staff and NHS England were the ones that helped, um, put it all together. Patients and staff had slightly different priorities, obviously, but we came together and formed an acronym ACT NOW, which covers all the sort of steps that need to be taken when a patient with sickle cell disease presents in an acute, uh, situation. So, um, ACT NOW just stands for A for analgesia, which is meant to be given within 30 minutes. C for compassion, because patients felt that they were quite brusquely treated and, and accusations of drug seeking and things. T for tests and triggers. So, what tests they need to send, what sort of triggered the crisis. N for notify. So, notify the specialist team. So, we can come and see them promptly and also notify their next of kin if that's the, uh, wish of the patient. O for oxygen, because oxygen is a really crucial part of sickle cell disease. When patients get low oxygen, that's when they can sickle and they can deteriorate very rapidly and, and it can become a fatal, um, disease quite quickly. And then W is for watch. So, that's just really pushing home the fact these patients can look quite young and fit externally, but they can deteriorate very quickly. So, there's quite a lot of, of detail on that. But, um, there's been very nice posters and lots of teaching in the emergency departments around the South East, um, to try and raise that awareness. And then we spent a lot of time on a co-produced e-learning module. So, we had some filming about a year and a half ago, maybe two years now. We got patients to come and give some very compelling stories of their experiences in the emergency department. And then staff, myself included, giving our, um, our experiences too. And it makes up an e-learning module, which has got a very simple quiz at the end and covers all the important steps that patients should be, uh, you know, to help manage patients safely in an emergency setting. So, that's now a straightforward, uh, module, which is mandated at King's and Guides St Thomas' for people working in ED, haematology and paediatrics. And we're trying to get it rolled out across the hospital. And we're also sharing with Croydon and Lewisham and Greenwich, uh, you know, so we're, we're hoping to spread that across the, um, across the local hospitals. And in fact, NHS England is hoping to, to use it nationally. And then the future service developments aspect are really, we've got this pilot funding for, um, two years, probably extended to three years for the community project. I think it's a really valid project. It will eventually run out of funding. And I suppose we, it's up to us to show lots of evaluation, show it's been a successful, useful thing, and that it's improved patient outcomes as well as patient experience. Um, but it's just a case of embedding that, um, appraising how helpful the, uh, community has access has been and, um, hopefully securing ongoing funding for the adults and children with sickle cell. And to put it into context, we have probably a third of the patients in the, in England are in the Southeast and Southeast London. So we have a really large cohort. We have to make it nice and loud. Um, questions, any questions? Go ahead. Yeah, I have one question. I want to seem to, to, to, to mention a piece of information. I start with the information. I think that, um, I don't know if, um, you have heard that in London, there is a lot of people from Latin American background have not sickle cell, but they have thalassemia, thalassemia trail. I am one of them. And a lot of people don't understand when you go to hospitals and I was diagnosed in London, but when you go to hospitals, the hospitals don't understand what you're talking about. Yes. A lot of people don't, don't know, don't have a clue of what's happening. So in my role at King's, I do cover thalassemia patients, but in the Southeast, we don't have such a big population. And the way that the NHS England has organized our services, we're an HCC for sickle, but actually the HCC for thalassemia is at Royal London Hospital and they reach out to the Southeast. So I'm not for their chair, but I go to their monthly, um, meetings and we have a number of patients who are transfusion dependent thalassemia cases throughout the Southeast. Um, but they are not so much, um, affected by things like the act now is not relevant to thalassemia. I'm afraid that's a separate issue. Did you know that for transfusions, you have to have a special blood? Yes. So, um, people with thalassemia who are transfusion dependent will be coming and having two or three units of blood every three or four, um, weeks. So they are well embedded into the systems. And I suppose the difference is that they don't tend to present acutely unwell to people that don't know how to manage them. So we all manage people with thalassemia on a daily basis. So we see them routinely in our hematology day units for their transfusions and in our clinics for their reviews, but they don't, by and large, come to acute services. So this is more looking at, um, a lot of what I've talked about is managing acute presentations. So sickle cell disease is unusual in that people can be very well for much of the time and then they can very rapidly, um, become very sick and be at high risk of, of death. So yeah, I do deal with thalassemia a lot and, um, now have the excitement of gene therapy for both thalassemia and sickle cell disease. So it's a, it's a very interesting field. But it can feel like you have a cold. You are very ill and you are very, you feel very cold. But you know, you say, what was wrong with me? I may have flu again. And no, it's not. It's the thalassemia reaction. So, um, we, um, acute presentations of thalassemia are much more unusual. And in this area, for instance, at the moment, I'm looking after a thousand patients with sickle cell disease, but maybe seven with thalassemia that are transfusion dependent thalassemia. And they are by and large, very, uh, well known to us. They attend every three to four weeks. They have their transfusions and their health is well maintained. So we don't see them in the emergency department generally. So much. I have a big question now if I may. Yes. Um, what measures are in place to ensure that the extended sickle cell community service is integrated consistently across the Southeast London and how will it be performance we monitor over time? So when the patient has their first contact with the community service, they complete a questionnaire that talks about, um, their experiences of community service so far and how they feel in terms of being in control of their disease and understanding their medications and other aspects of their health. And then they have their MDT input, which is generally as a multidisciplinary holistic clinic. So you'll, they'll be sitting in a room with the pharmacist and the dietitian and the physiotherapist and the specialist nurse. And that will be, um, a sort of wrap around care for them to deal with, you know, try and help them get their life a little bit more into where they would like to see it and achieve their goals. And then when it's felt that they're, um, on more of an even keel, they can be discharged by that MDT, but they'll always have the ability to flip up again with that team. In terms of psychology, that's being managed slightly differently. Um, there's psychology again throughout the six boroughs, but most of that is online. So they're doing a workshop once a month, which deals with different aspects that will be important to different patients. So, you know, one month it might be about men suffering from triapism and erectile dysfunction, and the next month it might be about complications of pregnancy. You know, it's different things being relevant to different patient groups and then more common themes, such as managing chronic pain or discussing your diagnosis with new partners, that sort of thing. So it's a rolling program that people can dial into. Um, at the same time, they are setting up local, there's a lot of local, um, support groups that are trying to make sure that everybody understands where the local support groups are and so that people can access them. And the specialist groups for parents of children with sickle cell disease, parents of newborns with sickle cell disease and thalassemia, um, teenagers, you know, there's, it's difficult because people don't all want to come and talk together about, I don't know, menopausal symptoms and sickle is to some extent we separate the patients into groups where they have similar themes that they want to discuss. Um, we do also have psychology provision throughout the, um, the network based in acute centers like the hospitals, but the community offering at the moment is not one-to-one psychology. It's all part of these groups and the patients have had a lot of, um, input into deciding what their group should be and where they will be centered. But it's a really good point and it's when we keep making that it must be equitable access across the six boroughs. You know, if somebody in Bexley should have the same ability to access this MDT group as somebody in, you know, Southwark that's, that's right next door to us. Yeah. Hi, I'm Martin Wilkinson. I'm, uh, supporting Sarah and the team. Um, I guess, I guess the other bit for me is this networked approach. So it's our community providers, uh, Oxleys, people like that, delivering some of these services and then with the support of the specialist MDT. Um, so it's been delivered within our places. And as you know, there's work going on in each of our places around integrated neighborhood working, um, more broadly. Now, this is a specialist area, but we, we are looking to integrate, and that's one of the ambitions of the ICB working, uh, collaboratively with our providers. Uh, so it's definitely on the, on the sort of forward plan. I guess the other bit, as Sarah said, this is the investment, I think is long overdue in terms of these services to raise equity. So I know the ICB is committed as far as possible to stay, sustain the funding, but it is going to, we have to prove that this model is correct. If the model's not correct, we might have an opportunity to change the model, um, and, and sort of make sure that support is still available for sickle cell patients, children and adults going forward beyond year three, but that, that's work in hand that we need to work on that together. That has been very helpful. Lots of other questions that I need, uh, the other people to ask for the questions. Yes, I don't know. Anyone else? Any other questions? Um, I think, thank you very much for the information, especially the act now. That sounds really interesting and very, um, very, um, usable in terms of the acronym meaning so much. Um, I think I, I also had a presentation for Lucia, where I'm from, and the only thing that I was a bit puzzled about was the relationship between the EDI, um, the EDI, um, and I didn't feel that it seemed to be attached in any way. And I, in terms of equity and equality and all of that, I think it's very important that we do that. And, you know, um, other, um, places in terms of, um, patients and carers and, um, there's a race equality framework that another hospital uses, not too far from where you are. And I just wondered if we could keep those lessons that we've learned to, to ensure that it is possible today. And, um, I'm very excited by, by this. It's a long time it's been coming. Um, so it's really a comment to say that I'm really pleased that you're doing this, but I do hope that we look at equality, diversity and inclusion and look after the carers as well, because you talked a lot about the users, it's very important to carry the carers along because they are important as well. Absolutely. So the e-learning module was sort of the EDI team were very much involved with that. So that was a really big aspect of it, the stigma and the inequalities. So that was in the e-learning that, that comes across very heavily, um, in terms of the carers. So there specifically are sort of parents groups and, um, people you've had babies. So there, there is a certain amount of carers, but I suppose it's difficult. It's quite a small amount spread fairly thinly, but you're right. We mustn't forget the carers. Do you have another question? I'm sorry. I'm sorry. Thank you. Um, so thank you very much for that. I echo that's due to you, I think obviously services have come on pace and so have there with the equality aspect of it. Um, you talk about an equitable access, which is great, but you can have equitable access to something that's really very good. So the question is, there's obviously been an awful lot of, um, research and advancement in services. Are you content with where we are now in terms of what challenges out there? What are there gaps to our gaps? Yes, I wouldn't say that we're content with where we are now. Um, there's one other facet that I didn't mention actually, which is these universal care plans. It's a slight misnomer because they're not quite universal. They're universal within the M25. And obviously our patients don't necessarily cut off at a exact border. So they are really good. And we've now got them for probably 95% of the population within the South East London who have sickle cell disease now have their, um, emergency care plan. And that's accessible by GPs, by London ambulance service, and also by all the hospitals across the patch. And that's made a really big difference because it means that when people turn up distressed and in pain, there's a certain amount of information that's immediately available, as in, yes, they have got sickle cell disease, more clean, 10 milligrams is their usual analgesia. You know, it's a certain amount of information is ready immediately, which, which has been really good. And patients have anecdotally been saying, you know, they've really seen a difference. You know, I mean, I'm not putting words into their mouth. It's always surprising and gratifying when people say, wow, it actually was different. The ambulance staff gave us the right medication on the way. We got to A&E, we were fast tracked through and, and it was all much better than usual. So I think that's good in terms of what we need to do. Still, we have an annual audit of our time to analgesia across the whole patch, and we're not achieving a hundred percent of patients receiving their analgesia within 30 minutes. And I know that's a really important milestone for patients in particular. So we're close to it. And so at King's, our last audit, the average time to analgesia was 37 minutes. So it's not that we're missing it by very much, but obviously we're still missing it. So we're trying to set up, it's frustrating to only do that once a year, and then kind of not see where we are for another year. So we're trying to set up a monthly, more automated audit so that we can have a bit more of a real time view of what's happening in the EDs across London. It's incredibly difficult because everybody's got different IT systems and, but when you don't want patient level data, it's slightly more than if you need patient level data, but it is difficult. So I would say that we haven't cracked this problem yet, but I think we've got a very big stride forwards over the last five years compared to previous things. Can I just get into that just a little bit more? Just a follow-on question from that. So that's your perspective. Do you do patient surveys and follow-ups? And what are the patients saying? Are they identifying any gaps? Yeah, so we have a system every three years, which is called PREMS, Patient Reported Experience Measures. And so we do them across the network and each unit has to make sure that they audit at least 10% of their patient group. And there's various different categories in terms of their emergency care, their clinic care, their inpatient care. So they tell us, we kind of have a fairly blunt way of saying, is it green, so it's acceptable, or is it red? So, you know, a bit of a problem. And it's certainly true that across the patch, it does vary a bit across different areas of Southeast, but the emergency department is usually not a good area. And they bypass it. So there's only a bypass unit operating in Lewisham, and it's only opened on something like the 13th of February, and it's only open 12 hours a day. So I wouldn't say that they can bypass ED, generally speaking. No, so all of the future, yes, the future would be that they 24-7 could come to a new bypass unit. The reality is that that's not yet available. So all of the big centres like King's and Guides of St Thomas also have day units that can be accessed by patients eight in the morning till kind of they're open too late in the evening. So, and we have ours open bank holidays and weekends. But if you're looking at Bexley, or Bromley, you know, places more further afield, that they they have less access to that. Just geographically, then they're probably not going to be there are, although they have access if they want to come to work. I'm Aaliyah, Aaliyah Sheikh from the Lewisham Councillor. I have missed most of your presentation. But based on what I read and the questions I had in is about the there's an emphasis that it makes a difference in the diet when dietitian and pharmacists see them together. So diet seems to be playing a major part in it, which seems very much coincide with the way health services are going into looking into more of the preventive and the proactive care, particularly with the 10 year. So have we got a special dietary plans and specially dietary educations for in general as such and the communities which there's a high prevalence of sickle cell? So interestingly, the dietetics was very much patient requested. So because this was a co-produced community project, and that's what they asked for. That's what we have provided. But if you to ask me, the most important thing, I mean, obviously, everybody should eat a healthy, balanced diet, but there's not a specific diet for patients with sickle cell disease. As such, they tend to be more at risk of vitamin D deficiency and folate deficiency. They tend to be more at risk of iron loading. And I suppose it's important to have a good protein intake and enough calories because when they make a red cell, it lasts two weeks rather than three months. So they have a slightly faster metabolic rate. But it's not that there's a specific unusual diet that they have to follow. And they have to keep very well hydrated, very well hydrated because dehydration causes sickling and patients can't concentrate their urine as much because of their relative anemia in the kidneys. So there are important things which we labor and put at the end of every clinic letter, but they're not particularly specialists, but they're very much what the patients wanted and also the parents of patients. So what we've asked the dietetics to do is to produce us a leaflet. I mean, they've only been a post for a couple of months because we also have lots of patients in the network that I'm chair of, you know, down in Brighton and Folkestone, and they're even less well served. So the idea is that we would have, as part of our network offering, would be at least very straightforward information sheets that could be shared across the patch and potentially nationally if we had agreements. So yeah, so dietetics, I think the patients are very interested in. So if I've understood correctly, it's primarily the nutritional part of it that as long as they have certain vitamins and part of the protein diet itself, not as such, but it's very much on the individual to decide which way they want to go. Yes. I mean, obviously there's lots of different ways of sourcing protein and lots of different ways of sourcing vitamin D. So it depends on their particular dietary preferences and, you know, there'll be sort of cultural differences in what people want to eat. So we're not really prescribing a diet as such. It's more answering questions and explaining to patients and carers what would constitute a healthy diet then. Thank you. Thank you. I have a question actually. The peer mentoring, how is that going? So it's a good question. So we have been referring lots of patients. My understanding is that in South East London, they have a lack of the mentors. So we've been referring lots of people to be mentored, but I think that people who will do the mentoring are less available. But when we've offered to sort of refer people that we think are suitable, I think the Sickle Cell Society has got its own sort of recruitment drive in their own way. I mean, it's obviously quite important that you select people to mentor young people who are going to be, you know, not misleading or not have any inappropriate relationships with the young people. So I can see that there's a certain amount of vetting required. And so I think that's that's something which is working. So there are quite a lot of networks out there of people who have lived experience of sickle cell that would be suitable to do this. It's just kind of everyone joining up and putting it out there, you know, like social media. And then you would probably have a big slew of people who were suitable to mentor. And the other thing, the e-learning, would that be rolled out? Because I think it would be something, a really good thing for like council workers, people that work in the various local authorities, because they have to make decisions that deal with people's health, like housing officers, when they're making assessments on people's health issues. This would be something good that could be rolled out to the six boroughs that you're working with currently. Yeah, we've got two e-learning modules. One is more the chronic complications and one is more the acute as in the rapid genetic complications. So I suppose that they all could be carried out by people who don't have medical training. So we've we've had receptionists and porters and everyone. The idea is that everyone within A&E, haematology and paediatrics have have are on the list to complete those. And they've been it's been a good uptake. And we've been giving little enamel sickle shaped badges for people to wear on their uniforms so they become sickle champions. So we invested about 300 badges and that that's been good. And we've been spreading them across to Geist and Thomas and Lewis and Croydon. So yes, I haven't looked at it with the thought of them of it being for people that are not involved in a healthcare setting, I must say. It might be that we have to think of a another one for that. But it's a good idea. And the other thing with parents of young children that have crisis and they're in hospital, you don't want to leave your child's side. So I think outside of London, I know someone whose child had a crisis, they had somewhere for them to stay, they were fed. But in London, it's kind of you have to vent for yourself. So your child has sickle soul, they're in crisis. If you have a partner is at home with other children, what do you do? So it's about facilities for the parents, for carers that are with that child that has sickle soul. And even actually with adults. So we had somebody transferred urgently from Medway who had a pregnant wife who came in the ambulance and then was kind of stuck in the middle of London with nowhere to really go that night. So it is, I think it is very difficult. I suppose the community setting doesn't, you know, that doesn't tackle that particular issue. I know that there's lots of informal arrangements between some of our women with sickle cell disease that when one of them is unwell, another one who's a very good friend will help with child care while they're admitted, you know, people form informal arrangements with each other. But I agree, it's a problem. And it's particularly a problem for people who are relatively isolated or new to the area and just don't have that network to fall back on or family that's nearby. I think that's something that could be looked into if there's like a pot of money. So people who have come here, English isn't their first language, they don't have any ties to the community. It's like, how are they gonna, how are they going to manage? So something, even if it's, I don't know, a little cot beside the bed, something that there should be, I think that there should be something, you know, there could be exceptions to the rule, like a small pot that people could access. Do you mean for a patient who's unwell, so their baby can be with them? Yeah, if it's a baby or a mother being with their, with their child or a father carer being with, especially like with young children. So certainly when they're on a paediatric ward, there's always the facility for a patient to stay over with them. And on our teenage unit, and teenage units throughout our southeast network, there are earmarm teenage rooms which have a pull down bed so mum or dad can stay. Yeah, that's fine, you've answered my question. So you can, parents can always, a parent can always stay with a child at the hospital, and equally, usually with a young person, unless there's situations where that, those beds aren't available, but still the nurse is very flexible on the ward, if it's a young person, particularly with a learning disability, if they're not quite so young, but you know, they could be 21, but we'd accommodate that to have a parent with them. That would certainly always happen. I have a question. Apologies, I spent 20 minutes trying to look for a place to pack. Coming from Greenwich, my name is Councillor Dominic Mbang, and I chair the scrutiny in Royal Bar of Greenwich. I think this is a very important subject, which of course, public health should take it and run with it as well. But what I wanted to find out is, how do we deal with young people who want to enter into marriage? And they, for instance, if someone knows his AS, and he just wants to know the partner, what the partner is before they enter into marriage, do we have some kind of assistance there? Because what we have heard from a lot of clients or people who are in this category is, the GPs wouldn't just do it for them. And some of them have to go private. I know some churches, especially some African churches, will make it obligatory for the young people to go and then test to see whether they are AS or SS or not at all, just as one of the criteria to see, so that they will know before they get into the marriage. I'm just asking, with this, with sickle cells and what you do, how do you look at that part of it? Because it's a very important area where these people really need to know before they get into marriage. It's a good point. So if people are UK born, there's universal testing, you know, with the Guthrie Hill prick test, and that screens for a number of disorders, including sickle cell disease. And then parents are told that they're, you know, the result to their child. If you've entered the country after birth, or if for some reason your parents can't remember what your result was, generally speaking, it's a very straightforward test for the GP to carry out. I was not aware that GPs were not carrying that out. There's a very nice South East London Sickle and Thalassemia Centre based at Elephant and Castle, where they have counsellors, and you can go there for genetic screening. And that's what we would suggest to patients when they've got partners. That's more for patients who have the disease and know they have a problem. I suppose it's less transparent what you do if you didn't know that this was even an issue. But they can do partner screening and partner testing, even for people who don't have sickle cell disease, but people who have trait. But because that would be flooded if they just did everybody, I think they would probably mostly divert them back to their GP if it wasn't known that the partner also had sickle trait. They're more interested in seeing affected, you know, potentially affected couples to give them counselling, rather than de novo testing all comers. I think that service would get quite saturated. So I don't want to say that everybody could be referred there, but you can self-refer. So you can you can go online, South East Sickle and Thalassemia Centre, Wooden Spoon House it's called, and there's a self-referral telephone number and email for patients and members of society. But I would say most people should get it through their GP. Very simple test. I think I think that's that's where I mean, I met a group of a group that was actually advocating for it. And this was some of the challenges that they face. And some GPs wouldn't necessarily even ask for to be screened on it. So it's just something to look at. The other area I was also looking at is the cultural part of it. And in most cases, it's difficult to penetrate people when they even have the condition and for them to even say it. And I don't know how you deal with that, because it's also another way of also, you know, trying to prevent things that possibly can if if I know I'm AS, I will definitely be making sure that I don't go with a partner with SS. So in that circumstance, what do you do on the part of the quarter side of this? So I think I think every human is valid. So I don't think that we push people towards not marrying somebody if they've got sickle cell disease, but more letting them see the options which are on the table. So they I mean, I say to patients that when they're choosing their partner, they may say that they to have a child with sickle cell disease is acceptable to the partnership. I mean, they have sickle cell disease. So that's, you know, it's an acceptable part of the range of humanity, or they may feel that it's important to avoid having a child with sickle cell disease. And there's lots of options. So they could choose a partner that had AA, we offer them obviously screening for their partners, there's pre implantation diagnosis. So in that scenario where you have somebody with sickle cell disease and a partner who has AS, they can create embryos which are screened prior to implantation. And that's funded by the NHS up to the age of 40, if they don't have a healthy child existing. And so there's options, I don't think we can be didactic about what people have to do. I think so long as they're able to understand the options, I think that's that's acceptable. Thank you. And then I think finally, it was about treatment. This bone marrow and stem kind of cell treatment, how effective is this? And how accessible is it for people who are in that category? So it's been a very exciting development since December 2021, we had fully matched sibling stem cell transplants available. But then obviously, pandemic meant that we couldn't do much about it for a bit, we weren't allowed to do non malignant transplants. But we got going with the programme in the southeast in sort of late 2022. And we've probably transplanted about, I will not know exactly how many, about 15 or 17 people so far. And by and large, it's been a very successful technique. We have three options on the table at the moment, the fully funded NHS commissioned is a fully matched sibling, and it's a reduced intensity stem cell transplant, which means they don't have any chemo, they get immunomodulatory treatment and total body irradiation low dose. It's still a big deal, they're in hospital for six weeks, they lose their hair, it can impact on their fertility, so it's not for everybody. And only about one in 10, sorry, only 10% will have a suitably matched sibling. So each sibling with the same mum and dad will have a one in four chance of matching you. So it's a minority that that's available for. And obviously, you have to have severe enough disease to want to have that. And yet you're fit and well enough in terms of your end organ function to be able to withstand it. The other option, if you don't have a fully matched brother or sister, would be to have a half matched brother or sister. So that's got more harsh conditioning, and that's only available at the moment as a trial. But we've got the trial ongoing in the southeast, and we've done seven patients on that trial. And we've had two successfully engraft and go home, and that's the they don't have sickle anymore. That's stronger chemo and a good sort of six or eight weeks in hospital, but that's still where we've been secured. And then the last option has just been, I think it was, I can't remember the date, but you know, last month, gene therapy has come on as a possibility. And yesterday evening, we have a, once a month, we have a national panel, so national hemoglobinopathy panel. If you've got a patient that you want a cellular therapy for, like that, they have to be discussed locally. So I've discussed them at King's Network. So that'd be the southeast, the southeast London and southeast England hemoglobinopathy center. So we discuss it, and then we have to discuss them at the national meeting. And if there are no concerns, then they can be agreed, and then they can go ahead and have that treatment. So it's quite a long pathway. Before you do these things to people, they have to, you know, either scan their brain, you want to know how well their lung function is, their renal function, their liver function. Sometimes we're going as far as having to do liver biopsies on people to make sure there's no surprises. Gene therapies, busulfan conditioning, that's high-dose chemotherapy, will render them permanently infertile. And it doesn't actually cure you, it still leaves you with about 60% sickle, but it seems to very much turn off the pain type issues. So again, it's not for everyone. I expect out of, you know, we expect to have fewer than 50 in a year, of course, all of our people have gene therapy, and probably quite a lot fewer. Patients are keen until they hear about exactly what has to happen, and then they are less keen. So we have other ways of managing people with hydroxycarbamide is a once-a-day capsule, which for many patients will lead them living very close to normal lives. And then we have a significant cohort on transfusions. So at King's, we have about nearly 200 patients now who just turn up every month or two. We remove their sickle blood and replace it with AA blood. They get on with their life, but obviously their marrow then produces more sickle, and the whole thing is repeated every month or two, depending on their age and how low we want to keep their sickle percentage. And that goes along across the southeast. So Garden St Thomas has a big service. Lewisham has got a significant service. Croydon is looking to set those up. So that's another way of managing sickle. So for patients, there are lots of choices now, but it's now a bit difficult for them to balance what would be best for them at which point in their life they want to do which type of treatment. Okay, thank you. Thank you so much. This has been a really fascinating presentation, very insightful, because I've learned, I think we've all learned a lot more than we knew previously. If there is any questions, can we come back to you, reach out to you? Thank you. Thank you. All right, so do members have any suggestions, members, anything that you've got to follow up on? Email address, or do we have any further questions? I don't need follow-on questions about the sickle cell. Yeah, email to me and I'll forward them all. Okay. So, basically what we will be doing, any follow-on questions, we put them on to Raymond, but I would I'd actually really like to follow up for this later today. I don't know what the committee thinks, because there is, there's so much. Right, so So, we are now going to item five, the reconfederation of cancer treatment services for children in South London. And this is in the agenda pages 2542. And we will hear first from, is, are they online? So, we have Alicia Willans, Programme Director, NHS, and if you introduce your colleagues, please? Well, can you introduce yourselves? Yeah. Good evening. Well, thank you very much for having us this evening. And we're here to talk about children's cancer reconfiguration. And just to do introductions briefly, I've met a good number of you before. Mr. Willans, I'm the Programme Director at NHS England, and I've led this work for the last couple of years, working across both London and the South East regions of NHS England. Hi, I'm sorry, I know I am this work for the Evelina London, and I'm Clinical Lead for the Programme for Guise and St. Thomas's, doing the federal work to bring the children's cancer service to the Evelina. Good evening, everyone. My name's Abhi Bhattia. I'm the Chief Nurse at Guise and St. Thomas's, I'm also the Senior Officer for the Safe Transfer Office Service. And I came, I was asked to take charge of the Safe Transfer of this programme once the decision was made, but it would come to Guise and St. Thomas's. So, almost a year now I've been leading the programme. Hi, good evening. My name's Trish Gray. I am the programme manager and lead for patient and family involvement in the programme. I've struggled to hear you. Just by way of a brief recap then, this is about the Children's Cancer Service, which we call the Principal Treatment Centre, and that's a service that leads on the diagnosis, the treatment and the coordination of care for children who are unfortunately diagnosed with cancer. And it's a service that looks after children who live in South London, but we'll say after the South East. And several years ago, I think we can, we can talk to the slide. A few years ago, we started a process driven by the need to provide best quality care for children with cancer, and that was to identify a future location for the service, which is currently provided by the Royal Marsden and St George's, but to identify a future location where children with cancer could be treated in the same location as a paediatric intensive care unit, and ideally a range of other children's services that very poorly children with cancer very often need. NHS England led that process over a number of years, and thank you very much for the contribution that this just provided to the public consultation, and throughout that engagement process, all the feedback that we had through that process contributed to the decision that NHS England leaders for both London and South East took back in March of last year, where we looked at all the information that people had shared with us about what would be really important for the future location of the service. And having taken that into account, took a decision that the service should move to Evelina London, part of Guides and Sciences, and that the conventional radiotherapy, which is needed for children with cancer, should move to University College London, to be provided there alongside other radiotherapy for children with cancer. As I say, that was a year ago, and the benefits really around service change are about the opportunity to provide care in line with national standards by ensuring that children can access intensive care on the same site when they do deteriorate and become very poorly very quickly, and also to benefit from having access to more coordinated care on the same site because the clinical teams can work more closely together with the other services that patients need. Some of the cutting edge treatments that are becoming available for children with cancer also require intensive care to be available on site, and because of some of the risks associated with those, and by moving this service we're helping to future-proof it for the future. The service change itself, whilst there are really strong benefits, does come with risks and things that we need to manage really carefully, so NHS England took those into account and gave us lots of thoughts, part of our decision-making process, and that was prompted by feedback that we got from people who gave us feedback through the process about what was important to them, but also things that we knew to be really important with a cancer service. And all of that has helped drive the work that Thais are now taking forward, and as part of that, to manage those risks of moving what is a really, really good service at the moment, but to a location where it can be provided with intensive care. NHS England are overseeing that, we're working very closely also with the integrated care boards who are responsible for commissioning services for their patients, and that will continue into the future to oversee the service change, but guys are doing much of the work, working very closely with partners to make the change of reality. And I'll stop there. In the pack, you've got a very high level, high line, and what we are working through is how to help the patient in the new cancer treatment centre, Evelina Lando, October 2026, and so I've been working on this, the decision was made in March last year, so this is a complex programme, and that Elsa has alluded to, there's lots of risks and planning and fielding and business case approvals, so there's a huge infrastructure that we've set up in terms of governance to do this well, and to do it safely. In this timeline, we've just added in some key constituent parts of the constituent parts of the programme, so you know, at the moment we've got the outline business case approved, and we're working on the full business case, which needs to be approved by the Guise and St Thomas' board, which we will do just before the summer when the construction, the very first construction work will start in the Children's Day Treatment Centre, and then we'll do some work in the Evelina Hospital as well, because this new treatment centre will be on the third floor of the Evelina Children's Hospital. We're going to go into a bit more detail in terms of the other vital parts of this programme, course engagement with patients and their families and various stakeholders, there's the workforce plan that sits beneath this, which is absolutely crucial to the success and safe transfer, so Sarah will talk to that as well, and we've been doing lots of engagement throughout the programme. And there's obviously other key dependencies for us at Guise and St Thomas' but also the radiotherapy part of this, which will be delivered by the CNH colleagues at University Hospital London, so we're working very closely with them. And then not to forget the digital pathway, so the electronic patient record, and actually at the Royal Marsden and Guise and St Thomas' we have the epic system that we have different versions of, so there's enormous amounts of work to be done there. So what we have done is set up very, very robust governments to make sure that we do this as well. The roles and responsibilities that we have to do this as well. So the basic guidance that St Thomas' NHS England and the relevant ICBs hold us to accounts but also provide support and oversight to the programme which I need. It is absolutely essential that the service we put in place complies with the national service specification, that is the minimum requirement requirement. Then it builds on the many strengths of the current service that is provided by the Royal Marsden. So everything that we do is at least at that standard, but in the past we've got, it builds on the service that we've currently got. And of course, you know, all the world-class services that we can to our patients. At Guise and St Thomas', we've been very clear from the outset that at every level of this programme, we involve patients and we involve their parents and we involve stakeholders throughout the programme. That is a crucial part. And obviously partner organisations working very closely with St George's, Royal Marsden and UCLH Codden Sleeping, doing that. So, you know, the planning and delivery period is a two and a half year period that we're aiming to deliver this programme. I've thought about the robust governance. You have got a governance overview in terms of how we've actually set up this programme to deliver it successfully. You've also got a partnership advisory firm who is chaired by the Chief Executive at Guise and St Thomas', just to make sure that we are doing that well and getting really good advice that a programme such as this needs. And we've been very, very focused that this is a partnership. This isn't just Guise and St Thomas' directing what the new service is going to be like. It's very much a partnership between Royal Marsden and St George's, St George's, the current service providers and what it will look like. And through this programme, you know, I also chair the partnership, the delivery board, which we have got the partners from all the other organisations. So very collaborative. I think the key word here is collaboration. And also there's a number of, when the decision was made, there was a number of recommendations that were made. There's also the London Mayor's tests that were done and recommendations from that. So it's also our duty to make sure that we do deliver against all the recommendations that were made. So huge amounts of responsibility here, huge amounts of risk. But we are working through that. I'll hand over to Trish now to talk a bit more about some of the aspects of the programme and so on. So one of the really key themes that NHS England heard throughout the consultation was around the importance of those support services that sit just outside the kind of clinical care, particularly around travel and access and accommodation. And so there has been a significant amount of patient and family involvement since the decision was made. As I've alluded to, we have patient representatives and a previous patient that sit on throughout our governance structures. And we have expanded those governance structures to include a specific steering group and advisory group around this travel and access and accommodation. And we have also expanded beneath that steering group. We are the work is sort of in in different working groups and work streams because we can't cover everything at once. There is a lot to think about under this umbrella. And since we've done some further involvement around the design of the future treatment centre, patient families have also highlighted things like catering and store and place. We've included that as well. So we're really responding to what they're telling us is a priority outside of their clinical care. So the advisory group is led by patient family representatives and it sits in parallel to our clearing group. And then out of these different groups and the working groups, all of which have partner representation sitting on them will come really focused, involved opportunities, because we're very aware that, you know, we can we can have representation throughout a governance structure, which is brilliant in the way that it should be. But we also need to consider the wider populations. This is quite a large catchment area. We want to make sure that we reach everybody across that catchment area, particularly on the outskirts when it comes to travel access. So the key piece of work that we've been focusing on, and we will continue to over the next few months, is around travel and transport and parking in particular. And we're doing a piece of work with our partners at the moment where we're collating data from the current service in order to build up a really good picture of what is required in future. Transport for London are working very closely with us, I'm very pleased today, and the Greater London Authority. Transport for London will actually sit on the working group around the travel and access and support us and support the families to kind of navigate this as we work through. And the GLA have actually said, as I've mentioned, they are responsible for the MERS-6 test as well, are very involved in that. They would like to use some of the outcomes of all of this involvement to use as a case study for the MERS-6 test, which will be really positive. And so there's lots of progress being made in this area. Thank you. Yeah, I just wanted to draw your attention to a piece of work that NHS of England are leading on, which is very much complementary to the work that Trish and her team are leading on travel and access. And that is work about improving the care that is provided in what we call shared care units. And those are the hospitals which work very closely with the principal treatment centre to provide care for children with cancer. And at the moment, there are 15 units across the containment area for this principal treatment centre. That's not going to change. What we want to do through the work that we're doing is bring the care, increase the amount of care that can be provided in order to provide more care closely to home. And so we're specifically looking at opportunities for chemotherapy, certain types of chemotherapy, which are clinically safe to do so, to be provided in those settings. And that piece of work is running in parallel with this. So that will directly benefit patients who access that care at King's and Denmark Hill and also at QEH in Woolwich for this part of London. But we'll be doing that across the attachment area. And I think it's a really positive way to improve access to care, which will in turn have the benefit of reducing the amount of travel that patients have to do in order to go to Evelina for the most expert input to their care. So I think we are pretty quite well placed to help our colleagues to deliver the cancer care currently, working with the POSCUs to deliver the cancer care currently, working with the POSCUs to deliver more work and it's something that we heard from parents throughout the actual process. So Avi's already alluded to the fact that it's a very complex programme. And it's also a quite plight, fine life. And so principally, to start with, we've been working very closely with staff that are currently providing the service at Marsden and St Chorges and the families to work on the changes that we need to make in our estate in the children's hospital. So we do need to convert an inpatient ward to be appropriate for these children who have some specific needs. You heard our colleague talking about bone marrow transplants. That is part of the children's cancer service that's currently provided at the Marsden. We also need to provide a day unit for the clinical care physician and some of the investigations and procedures that are required to be done under general analysis. And we have also to provide outpatients. Somewhat fortuitously, our day treatment centre that we opened not so long ago has two floors that are empty. We are able to convert one of those floors to be the day unit for the cancer service. And then the other floor is actually being used to create space within the actual children's hospital to give over one of our inpatient floors to this service. We are working with, as I said, colleagues from both Marsden and St Chorges who have been incredibly engaged. All of us want the same thing, which is to do this as safely and as well as possible. And we're going through the various stages of the architectural designs. We're currently going from stage three to stage four, which is a little bit more detailed in terms of the technical aspects of the plans that we need. And we're hoping that we're able to, the business case has been written and approved, and we're hoping we're currently on our time scale in order to start the first works in the sort of early spring of this year. But it is a lot of work. It's a very complex program and it involves change, not just for the children's cancer service, but also for the services within the Evelina themselves and the patients and the families that are currently looked after by the Evelina. And actually, again, gratifyingly, a number of those families who don't have children with cancer or have not been looked after at the Marsden or St George's are actually involved in this work too. And because we have to make sure that we're not creating something sort of incredibly, you know, gold-plated and forgetting all the other children that we have and the lessons that we can learn around the accommodation and transport equally pertain to a number of our children that access our services from really quite far away. Workforce is a massive program of work and you can imagine a lot of the work we've been doing with our relationship building with teams from across the Marsden and St George's. We've been there, they've visited us on numerous occasions and they are heavily involved in planning. But there are sort of technical aspects of the workplace, so we'll be working through the training process for those people who are employed and have the right to be transferred with the service. We've been with really like everybody that's currently delivering service to come. It's not as straightforward as you might imagine. There are certain personal reasons of life who do not want to relocate from where they are to the Adelina, but there are lots of things that we are, you know, communicating with colleagues around some of the some of the things that they will have access to that that they don't currently have. And I think we're hoping that at least the majority of all of the staff groups do come across. At some point we will know for sure who is and isn't coming and we will have a program of recruitment in order to fill those gaps and also upskilling within the Children's Hospital. But just to be clear, the service is moving. We're not creating a new service from scratch. The clinical work streams, we've set them out along a time scale, sort of starting with those that we think have the greatest lead in time because they might require the sort of greatest input. And those are things like demand capacity around imaging vehicles, because it's increased children that have in their surgical, their tumours removed by surgeries and surgeries. The bone marrow transplant service, there was there's so much specific governance around being able to provide that service on a new site. So that is certainly one of our first programs of work. And as Abby has also mentioned, currently the children at the Marston have some of their radiotherapy at the Marston. Some of it is provided already at UCLH because you're probably aware UCLH is one of the few places that is able to provide protein beam therapy. And so there are really, I think, very valuable reasons why it is better and would probably happen anyway, but with radiotherapy clinically needed. And that's around sub-specialisation, these small, very small teams providing very skilled and very, um, sub-sharpets and care. And certainly we're working very closely with UCLH to ensure that they are our patients who do that and that the pathway that we develop together is good. They currently provide radiotherapy for Great Ormond Street, and not that far away from UCLH in Paris to Great Ormond Street. And they certainly, um, will be delivering us the clinical service that they deliver for Great Ormond Street, which would include clinicians coming to the other unit to speak to parents, particularly if, if, if, if, if, there's a, a, a very difficult decision like radiotherapy isn't actually what we can offer, but they would come, um, in person to be able to, um, have that conversation with the patient and, uh, if appropriate, and their family. Clinical research, you probably are aware, is crucial in heartland in cancer care and no more than in children in cancer care. And pretty much, the majority of children would be on a clinical trial and it's imperative that we are able to sustain that up to the point of transitioning over to Evelina and as soon as the first patient is within the door. So that's one of our, um, key areas of focus. Um, and I think we, we, we're very confident that we will be able to do this. We do do similar sorts of trials already within the Evelina, not for children with cancer, but with other, other conditions. Um, and we have a, you know, really, uh, robust and, and established, um, research, work groups, um, and I've seen that those are people in the Evelina and football. Um, although most of the children will have their, um, their actual, uh, the clinical research that they're involved in will actually just be part of their everyday care. So wherever they are, they will, they will, that's where they will be treated. Um, and then I think, um, um, I guess the, the sort of last thing that I like to say, say is because you're probably sitting there standing and saying, which this sounds really, really complicated and difficult. Yeah. Why on earth are you doing all of this? And, you know, is it, is it going to be a problem for the children of, of, of, of Southeast London that we're doing? Really important for the children because there isn't anywhere else in the UK or to be honest around the world that doesn't have a children's cancer service within the children's hospital and future proofing aside, it is really, really important. I've worked in this region for 20 years and I work for the intensive care service and I have moved these sick children. And, um, I, I, so I, I obviously have a passion in health believes that this is the right thing to do. I think it's the right thing to do for the Evelina as well, because we've been on a journey for a number of years, but to create a proper children's hospital within our region, everywhere else in the country has one, we should have one too. And so it, um, it, it, it, it, it means that other services will, although they may think it's going to be very difficult to have to look after all these children with cancer, actually they will all, it will also help their development and it will create even more comprehensive children's hospitals for the children of South East London to access and all the other things that stem from that, like the opportunities around clinical research, um, and some of the advanced therapies that perhaps wouldn't be available if we didn't have that kind of infrastructure. Did you want to come in at the end? Yeah. I mean, just to note, NHS England and commissioners at ICBs are really committed to this. The change isn't straightforward and, you know, there are potential impacts at George's and Marsden as we disentangle the PTC from the services they provide otherwise. So, um, alongside the work with those guys, commissioners are supporting for George's and Marsden to make sure that those risks are managed and, um, they, they can also continue to provide really good services, um, for their local populations too. I will stop there. And, um, of course we welcome any questions. Thank you very much. That was very, um, for an informative presentation. Thank you. We actually have a question online, uh, first, um, Councillor, um, Zan Abakor from Southwark is waiting. If you are mute, ask your question. I'm traveling. I can't talk. I'm on a public transport. That's why I wrote it down. Um, you said there are risks. What is the process of identifying and escalating risks and how will competing priorities between partner organizations be married, uh, managed, sorry? Could you speak up a bit? I've missed quite a lot. Yeah, so I'll start with risk management, which is a potential part of the development structure for this, for this program. So, you know, there are, as you can imagine, a number of high risks, finances, workforce, will the workforce come, will they not come, will they have the skills, what training do we need to do? Can we deliver the, the infrastructure, the building that we need to build in line with all the discussions as a specification that we want to deliver within the financial envelope that we've got? Can we deliver this program within the timeline that's been set out, which is October 2026? So they're from the high level risks that we're managing. Can we deliver everything that Sarah has just talked about in terms of clinical trials, making sure there's this really smooth transition of that? Can we meet the expectations around travel, access, accommodation? So there's a vast amount of risks that a complex program like this will, you know, come to the fore. But at each stage of the program, through the governance that I've just talked about, we're managing these risks as we, as we go through the program. They will change as the program evolves and moves forward, the risks will, will change. But we have got a very comprehensive process by which we manage them. And also as my duty as the, the SRO for this program, I have to escalate the risks to the, the board of guys and sit on this and obviously flag them with our commissioners and NHS England as well. So, you know, we do work in partnership to resolve them as well. But we have got a good program in management. All the questions? Yes. First of all, I would like to say thank you very much for the fantastic information and presentation. Because since the last time that we asked, I saw you, you have addressed the magnificent way. All the questions and concerns that I had before. And the only thing, especially caring about the transition between now and going into the Belina for families and children, I think it's very important that you have addressed all the issues. The only question that I have is that if if 2026, October 2026 is going to be delayed, what, how, what have you, what the structures have you put together? If it is that there are delays, 2026. So governance structures. Firstly, if there is a delay to the program, we've got to be very clear. What is the delay? Yeah. So why, why is the program delayed? Is it something to do with the building? Is it the contractors that can't deliver the building on time? You know, what, what is the reason? And obviously, you know, this is a very, we've been very clear from the outset, this is a very tight timeline. We've talked you through the enormous amount of work that we do. So there is, there is risk to this timeline, I'm going to be completely honest and transparent, there is a risk to this timeline. If we do go over the timeline, I want to be very clear on why have we gone over the timeline, then what is it we need to do to address that issue to get the program back on track? It does say in the pack that October 2026 is the earliest. Yeah, so we have been very clear about that. And then it depends on, on what is the delay? Is it the delay that is end of October, beginning of November, which is very different from if it's January 2027 or later. In terms of, you know, the, I think the, what we do in that situation is going to be very dependent on what the reason for the delay is. I think that's the key issue there. I have had, you know, even my own board challenge me, you know, Abby, you talk about a lot of the risks, you know, there's so much risk here with, with this delivery, are we going to do it by October 2026. But there's also a risk if we don't do it. We've got a workforce for Marsden in particular, who are nervous about this in the first place, they're losing a service, they're very proud of, they've delivered for many, many years, been heavily invested in. And, you know, it's been really very difficult for them. So there's a risk of not doing it by October 26, leaving staff with the uncertainty about their future now, versus the risk of doing this safely. And that's what we'll kind of manage, help them manage. So I think there's, there's risk is a way. Just, I'd just say the, what's fundamentally important is, you know, the level of trust that exists between the leadership across those, the three departments, and particularly rural Marsden and just, you know, my counterparts, they're coming with the service. They really care that this works. And I, I suspect that if there is, you know, we will get to a sort of, I guess, a fundamental transition phase, where people are, you know, almost like partly working for the Evelina and the Marsden, you know, and we will be appointing people into the service who start their, their role at the Marsden, but will be coming across to the Evelina. And I, because it, it, I think it would be rather naive to think that it will, we can say now it will happen on the 4th of October. I think that's something to happen. And we are going to have to have a, a period where we're almost like double running the service. And people, and the leadership are a part of our structure already, maybe not even in a formal way, but as far as we see it. And that, I think that's practically, like, pragmatically how we are going to run this. And I have total confidence in the people at the bathroom who are treating it from a nursing and medical perspective, from a material perspective, they are 100% in this, to do this properly. And I would echo that from a commissioner standpoint, our priority has always been to, well, there's progress in a way that we get the best outcome at the end and that service moves when it's safe and sustainable to do so. So we will continue to oversee and support the process and manage the risks collectively as we go. The overall principle will always be safe. If we can do it by October 26, so be it, if it's November 26 or later, so be it. It has to be, it has to be safe. And as Sarah said, there will be an element of transition where the service is in transition to a period. Thank you very much. Yes, I'd like to say thank you as well, same as my colleagues here. I'm Councillor Walker Wilson, I'm from Bexley, and previously on the JOSC was Councillor Chris Taylor. Councillor Lisa Moore is still on, so she would have been doing that consultation period and now, but she can't be with us this evening. But Councillor Taylor did very much inform the councillors back at the base of the progress and what they were doing. And I was able also to join online, so I've heard much of the conversations and the consultation. And it's really heartening to hear progress. So to speak about Walker. And particularly what I do remember are some of the questions that came up from councillors ourselves regarding the councillors. The problem is that we all know if we've got somebody in hospital, even for a very short time, it's very instructing and disrupting and very expensive. Well, so for people with children with cancer, it's very poignant, very difficult and very expensive. So it's really, really heartening to hear, and particularly, sorry, I won't try to remember names, but the ladies are speaking about transportation for transport for London and all of those things. And I just wonder whether there might be some reduction in costs of travel or re-travel. That might be, if you could answer that one, that would be really good. And I've got three questions. That's all right. I do thank you. I do recognise very much in what you've been saying this evening, you've taken on board an awful lot when concerns were, and that's really heartening. In terms of transporting children when they're for the radiotherapy, I've understood that that's going to continue. And I'll just like to hear a little bit about how it's been managed safely. I'm sure it will be, but very, very briefly, if that's okay. And then just lastly, the lady on the end, the risks at the moment, and I've got no doubt whatsoever that this will be fine and it'll be worked out. But for my lack of knowledge, I am aware that there are changes to NHS England, to ICB, planning regulations. And it's a bit political, but it's a bit of finance as well. And I've just wondered about how old measuring and managing that risk as well. So it's flexible, flexible. Thank you. Shall I kick off then? So the real kind of ethos around what we're trying to do with the travel and the other support services is that what the families are going through is stressful enough. Let's see how we can take away all of that added stress that they don't, hopefully don't need to think about because we're trying to support them with that. Transport for London have been clear, and we're working together in the early phases around setting up the possibility of setting up a scheme whereby they don't need to kind of, I guess, pay and then be reimbursed. How can we do it? So we reimburse them, but can we take away that kind of middle part so that they're not out of pocket, even if it's for a day? So we're working to see if that's possible. And involving families and talking to families a lot about this. There's lots of different choices, I think is one of the key things. So it might not be that they need to drive. Do we have patient transport available for the patients, or we will do. And so can they be picked up, dropped off and taken back? You know, being flexible around the fact that things change, appointments can be longer, you know, other things happen. And so we're working to kind of provide a range of different ways of support and doing it in line with families based on what they need. And the plan is that they will support us with the criteria for these kind of these things. But the idea behind all of this is to take away any additional stress from what they're already going through. I spend a lot of time at the Royal Marsden now, I see it first hand, and how important some of the things that are not small, but you may consider small in the in the in the, you know, grand scheme of what it is we're trying to do here are often the most important things. And so say yes, thank you. And then around the clinical pathway between Evelina and UCLH, there will be different ones for different children, some children will stay at UCLH, some children will commute between the Evelina and UCLH on a daily basis. As I referenced, that currently happens at Great Ormond Street and UCLH. And so we are working with them about, do we have a similar kind of approach or are there changes that need to be made? There's a question whether the children should be going through and throw twice in a day, that's quite important to me. So can we make changes to that? So that's what we're working through with them at the minute. I don't think the actual transport poses a risk. I think where the risk really comes in is whenever you've got some transfers of care. And so we're also looking at how we use the, because we all share the same, we do strangely all share the same electronic patient records, UCLH, GOS, Evelina and Marsden. So we're hoping that they can make, we and them can make some changes to the system. So that becomes a tool for safety to ensure that everyone at each end knows exactly what's happening with the child and can be the same records. So that's part of the work that we're doing. So Abby's described the sort of governance structures we have. UCLH have a whole governance too. So they have a board that I sit on and colleagues from Marsden also sit on there. And then they have work streams below it, which and Trish is involved in the access, the accommodation and access work stream as well. So we are working through it. I can't tell you exactly what that will look like yet. It was really important. That use, as well as providing care for Great Ormond Street, UCLH also provides radiotherapy for children from Oxford and Southampton as well. So it's got lots of experience in supporting children through the radiotherapy and also working with at least four other PTCs to coordinate care. So that's a real asset to all the planning work that's happening right now. In terms of the question around organisational changes, yes, you may well be aware of the recent announcements which are going to have an impact on both NHS England and integrated care boards across the country undoubtedly. But this is a service change which is all about improving the quality of care for patients with cancer, which as hopefully you can see today has already got a real head of steam behind it in terms of the momentum for change. So I guess I can't deny that the organisational changes perhaps aren't going to be disruptive, but we will do what we can to keep this service change on track. And a lot of that really good groundwork is already in place, including around managing the finances of the service transition as well. So it will be a risk that we'll continue to manage, but this is a priority that commissioners have really stood behind and I believe that will continue. If you want to watch. Thank you for your holistic presentation. I think you've actually enlightened us a lot about the process and what you do and how you want this to improve upon the quality and accessibility. I just wanted to find out definitely if you have a centre within the Guise of St. Thomas Society, it's a great, it's good news for people in the area and also extending it to other places is also something that is great. I do know that when it comes to adults, there are challenges when it comes to people who have cancer and they are undocumented or they have no recourse to public funds. In the case of children, how do you normally manage that? Because with the adult side, I mean, especially the child is for your hospital for over two to five years. So I know of those challenges on daily basis. But in the case of children, are there any routes in which they can be treated in a compassionate basis? And then the other aspect also I wanted to know is how is the diagnosis? I mean, on the part of accessibility, how are children able to be more or less diagnosed in the early stage? So that at least it doesn't, what are the processes that you've put in place? And I know, lastly, so you just spoke about the NHS England, not being political, as the colleagues said here, but the announcement was made. So without the NHS England, what is going to happen for the work that they've been doing to support this process? If you can touch on those ones. Thank you. So the diagnosis. So, yeah, I mean, most, the issue is generally in children, once it's been recognised, they may have cancer. The pathways are very clear. There's not a problem in terms of accessing the service. I think what you allude to is the period of time between the first symptoms that I might have, and a healthcare professional realising that maybe they might have cancer. And that, how do we impact on that? Well, I guess the main way that currently the cancer services provided at the Martin, how they impact on that is through the cancer network, which does have representation from all of the different areas that the cancer service looks after. And also the specialist children's network, the STPA, which is the South Terms Pediatric Network, which again has representations from all the health providers, but also the ICBs. And they obviously have a responsibility also in terms of primary care within their areas because most children will initially present to their GEP. So education at that level is probably the most important thing. And we would certainly be very much wanting to support the cancer service, do more in the way of local care, as I referenced earlier, but also continue to support that network education, which is a diagnosis to children. Certainly my understanding is that brain tumours in children certainly does lag behind some other countries in terms of that recognition as early as possible. But we do, I think things have improved probably over the last 10 or 15 years in terms of the education, the guidance that's available, various websites for the STPM, the Adelina also has King's College Hospital, etc. has all of these educational things available. So that will continue. I don't think there's a problem once a child is recognised, say in Lewisham or Margate, the pathways are clear. Yeah, yeah. And on the part of the undocumented and people with no recourse? Yeah, so it's unusual. But yes, children do receive compassionate care. I mean, if a child presents with an acute problem, they will obviously be with a child, so if that was kind of so therapy, they will get as a therapy. We do occasionally have children that arrive in the country and they don't have the course, they have maybe a chronic condition that we can't, it's very difficult to start a therapy, but they won't be able to when they go home. But otherwise, yes, we do get an infection of heart surgery, but certainly if you care for child prevention. Yeah, still on the treatment side, if parents are with their children, you know, in some cases, we see that a lot also in the hospital where, you know, they end up possibly losing their jobs. So do you have a system in place that supports them or directs them to like social care or social services where they can be looked at and assess in a way of making sure that they don't just finally end up going home without not even getting a place to go back to? Yeah, I mean, we obviously do work closely with social care around a lot of very different circumstances. Specifically around Cancer Fair, a number of the Cancer Charities actually fund social workers to be associated with the Cancer Service and that's the same for the Marsden. So we would anticipate and we were planning for a little bit of space for those people to come with the Cancer Service. So they are a service that is quite heavily endowed in terms of charities that support them, which is, which is excellent. But yeah, but we certainly do, you know, we escalate, we signpost because it's not, it's not that unusual what you describe. Thank you. All that's left me to say, because my colleagues have covered everything that I was going to ask, is just to really sort of convene you all because you have come back with all the things that we want to know and answer them. And particularly for me, you've talked about patient involvement, the engagement and participation. And I loved the fact that you're really working with the workforce because that really did worry me in a time when, you know, particularly with the nurse, you know, it's very, very difficult. But I feel that, like you said, everybody's going to come with the same heart, the same song sheet and all the rest of it. And yes, it is difficult. It's changing well, but I think you're managing it really, really well. And so I'm really grateful to what you've said and what you've thought. Well, I have nothing to say other than I'm really pleased, really, really excited about this. It's hard work, but it's worth it for our children. Thank you so much, because like everyone said, all the questions that we asked before, they have been answered and you've gone beyond what we asked as well. So I think the only thing really would be to take you up on your offer to visit the Evelina Centre. We'll lose you. All right. Obviously, we also have to return to the committee's speech today as we get closer to the transition date, and I'm sure the team will be able to keep you updated on all their hard work. Thank you so much. Thank you. Thank you. Thank you. Okay. Standing orders. Can we extend to 8.15? That's what's really good here, promise. Thank you very much. Thank you. So our next item is dentistry. And we have Sam Heffelworth, Director of Prevention and Partnership and she is online, so she will introduce us to your colleagues. So it's just me this evening. So my name is Sam Heffelworth. I'm from South East London, ICB. I do appreciate that we've got probably a limited amount of time, so I will take the pack as read, as Roger gave me those instructions at the beginning. My brief really was to provide you with a sort of a high-level overview of dental services across South East London, but I appreciate there might be some areas that you might want to give us as an indicator of future conversations if you want a deep dive into any particular area. I just was going to just note a few things from the pack, if that's okay. So you'll see that responsibility for commissioning dental services is sort of split into two. So the local authorities have the responsibility around health promotion and prevention, and we now have that delegated responsibility from NHS England to commission and contract treatment. So we have sort of got a dual responsibility around dental services. As you see from the pack, we've got 193 primary care dental providers and so far this year we have had no dental contractors have given back their NHS contracts. You probably have seen in the news that that is one of the issues across the country. We haven't had that situation in South East London. The sorts of contracts that our dental providers have are NHS contracts. So they are standard. We have very little room for manoeuvre of adapting those contracts and they have no end date. So they go on until there's either a breach of that contract or the contractor decides to give it back. And they are made up of historical activity, which had been agreed probably around eight to 10 years ago. And the units of dental activity have got a standard rate aligned to them. So there's a level of activity and a level of resource that's aligned to each contract. You also probably picked up from the pack that patients are no longer technically registered with a dentist. So once you have finished your treatment, that's the end of that part of the relationship. You then start another treatment, but you are not actually registered with a dentist anymore. In this year, the ICB was required to ring fence all of the budgets for pharmacy, dental and optometry. So the pack also outlines for you how the budgets outside of those core contracts was utilised, including commissioning additional units of dental activity from our primary dental services, investment in advice and treatment from secondary care into clinicians into primary care and additional investment to reduce waiting lists, especially for children and young people. It's clear that NHS dental services are still not able to meet the needs of residents and there continues to be concerns raised around access workforce shortages and the current NHS contract format. You probably read Lord Darcy's independent review where he highlighted the need for reform to balance activity and prevention and attract more people into more workforce into dental services. Slide four does give you a sort of an overview of the number of primary care dental contracts, their value and the amounts of UDAs because I thought you might find that helpful broken down into boroughs. And the PAC also provides detail on the services we commission around community, secondary care, acute based services and the associated finance to that. We've also done a little summary of all the investment that we have done this year around dental services, which I thought might be helpful for you. In the PAC, obviously we are slightly out of date now, but there was a month 10 position with regards to how our dental contracts were performing this year. We won't have an end of year position until sort of March, sorry, May, June time, because dentists have a little bit of leeway to get their claims in. But at the moment we are looking towards that 94, 95% of all activity delivered in year. Then at the end of the PAC, I just put in some of the challenges that we were experiencing at the moment, both from a contracting perspective, but also from a public health perspective, just to give you some ideas of maybe things that you might want to deep dive on in the future. So obviously, what happens when you pull a PAC together from a South East London perspective, you lose some of the detail at borough level. So I will certainly try and answer as many of your questions as possible. But there might be some opportunity in the future, JOSC, if you would like for us to do a sort of a deep dive on a particular area, if that would be helpful. Thank you. So questions? Thank you very much. What are the specific measures we'll be taking to address workforce shortage with dental services? And how will this be monitored to ensure sustained improvement in the service delivery? So each contractor for primary care services, for dental primary care services, has a certain level of units of dental activity that they have to deliver. And that is monitored on a monthly basis. So in order, we would know very quickly whether we have got practices that are under delivering on their units of dental activity. We also have a quality assurance process to make sure that they've got the right workforce. So we're making sure that they've got the right sort of balance of workforce in their dentist practice. We are experiencing, and this is across the country, many dentists are making the decision to do more private work than they are NHS work. That's a decision that they can make. However, we are not seeing so much of that in South East London. As I said earlier, we're not seeing that the contracts are being given back. We're maintaining the amount of activity, NHS activity. We have actually, this year, seen a slight increase in that because of the additional units of dental activity that we have commissioned. But it is a national issue around workforce. They are looking very much to increase the numbers of training places at the dental schools. But that does take, obviously you appreciate that takes time to get people trained and then into dentists. They're also looking at a national scheme to increase the sort of the different roles within dental surgeries so that there's more of a blended workforce. But again, that will take some time to go through training. So we do monitor it on a regular basis through different routes. However, there is a, as I say, there is a national shortage of dentists across the country. Because I knew you were presenting today, I did a bit of homework as well as reading the papers. And what I found from my residents is that they're very unhappy with the services they have because it takes time to get an appointment. When you do get an appointment, very often the dentist that you've had all your life or most of your life haven't got the skills to do whatever needs to be done. So they pass you to somewhere else. You pay for that piece of work. You don't get anything because what you do is have an appointment that fills in a referral to somewhere else because they can't do it. So you don't actually have anything done when you're there because you want something done. And then I'm talking about two cases that, you know, I can hear them telling me all what happened. And then they go to the other place and they say, well, we did that before, but we don't do it now. And yet they've had a referral. So weeks, months go by and all the rest of it. So I think in my parents' time, the dentist worked on how many things they could do in your mouth because they got paid for everything they did in your mouth. So they would do as many things as they could because that meant they got more money. Now, it seems they do as little as they can. You pay for that treatment, but you don't get it. And then you go and you pay again and you might get the treatment. So there's a lot of unhappiness. And when I looked at Lewisham, the price, the amount of money that's spent is quite high. And I remember when I had to go to the dentist when I was a child with school, they said that people like me, pain patients, whatever you want to call us, have more suicide decay than all the rest of it. So I don't know if that is based on historical things where, you know, the population is more and therefore there's more dental decay. But I would hope that we look after our teeth better. But what I'm saying is the services has just gone downhill. And I don't know. I think it's time that we looked at services in terms of value for money, because if I look at my own family, my children have gone from a local dentist to all sorts of places because they're not happy with what we've had for a long time. So sorry, I don't know if that's a question. But I had to share my homework and my little research with you. Oh, well, thank you for preparing for this evening. But I think that's what really has come through in Lord Darcy's independent review that actually the current NHS dental contract is not fit for purpose. So I think it must have been at least 15, 16 years ago that the dental contract changed. It has then found that it hasn't worked so well for residents, especially since the pandemic, when there was such a delay in many people being able to be seen as a dentist. So I recognise exactly what you're saying. The way that the structure is now in place means that dentists obviously have a certain amount of units of dental activity, as you said, that was based on historical activity that went into this new contract. And they then get paid according to the amount of units of dental activity that they provide. So, you know, as you probably know from the research that you've done, they get paid one unit of dental activity for sort of a checkup and then three units of dental activity for something like a filling. So there are some practices that choose what activity they do based on the funding that they have available. And I think what Lord Darcy has said in his independent review is it's not really working for dentists and it's really not working for residents and families. So I think the government has committed to doing a review of the contract, but it gives us very little because it's an NHS standard contract. It gives us very little opportunity to in any way vary the service that we are commissioning from our dentists. So I do recognise what you're saying. Thank you. Thanks for your presentation. I think I want to agree with my colleague that a lot of residents are not really very happy when it comes to dental service. Of course, when you pay, you definitely get the service. But then the problem is the cost of dental care has gone up. And I just wondered how you look at people who are on low income, they are on benefits, children with disability, whether there is any programme or there's anything that really takes care or covers those category of people. Because at the end of the day, I have seen myself that something that you paid for something like £29 last two, three years has gone up to £45 to £50 now. So it's almost doubled within the past two, three years. And I think that that's definitely something that people need to more or less monitor and someone needs to possibly be monitoring these things. Thank you. Yeah, so there is certainly so again, there's very little scope for us to vary this. There is a national arrangement for people on low incomes and for children on how much they pay for NHS services, dental services. You're right, there is a standard payment structure for depending on which band of treatment that you have. So it ranges from sort of £26, right up to sort of over £300, depending on the treatment that you're having. But it certainly does exclude those where there is a national guidance for people who are on low incomes and for children. Children should not be charged for NHS dental services. I'm very happy to send through the guidance if that would be helpful for you or you then you can signpost any residents that have got any queries about that. But there is a very clear guidance for who does not have to pay and who does have to pay for NHS dental services. Yeah, it'll be nice to have that information. I will send it through. Absolutely. I sent it through to Roger. Yeah, thank you. It's just from what I hear from different people, the standard, the uniformity of the standard, it varies even with the fillings or whatever dental procedure is done. And it's very difficult for a lay person to know which surgery to choose or which dental practice to choose. And then there is not that much of a guidance on that. And then again, the complaint procedure or if you're unhappy or unsatisfied, where to go for it. And partially that was brought to my attention. Then when we're talking about a contractual, the contract is given to the person who owns the surgery. So it doesn't have to be dentist. Then they employ the dentist to do that. And a lot of it is becoming more of a business module than actual the caregiving. So how is the quality control or is it getting any better in that? And that goes across. That's not only for those who are lucky to get the NHS dentist and have those standards. The charges are standardized, but the quality of work isn't. And it's the same with the private dentist as well. Yeah, so you're absolutely right. Sometimes the contract holder will not be the person that actually is in the surgery or in the dental practice. We inherited, as you know, all of these contracts a couple of years ago. And it was all based on historical arrangements. So you're absolutely right. Right. Most dentists, whether they provide NHS services or not, are private businesses. And that is the model that has developed over the last couple of years, that there is the proportion of NHS services compared with private services is changing within practices because they are having to do what they need to do to be able to stay solvent. So you're absolutely right. There is a process in place. It's a national process and it's written into the contract about the requirements for us as commissioners to undertake quality assurance. We have now taken on as an ICB the complaints. So if people, again, I can send all of the details through to Roger, but if people are unhappy about the response that they have got from their dental practice, if they've made a complaint, then they can certainly make the complaint through to us as the ICB, which is exactly the same as we do with general practice. So I can certainly send that detail through to you. And if we are seeing that there is, again, if there are trends coming through. So if there are trends coming through on a complaints on a particular practice that are, you know, a little bit more than other practices, then we would certainly do some visits. We have a dental advisor who would go into the practice to see what's going on, have a look at some of the records, have a look at some of the treatment that's going on. So we certainly undertake that quality assurance, but there will be and there will continue to be that quality assurance under being undertaken from an ICB perspective. But getting people, residents experience is always very, very helpful. So I will certainly send that link through to you. Just to come back. We're running out. Can this be added to it? There's so much discrepancy even in the diagnostic stage. So if at all possible, a procedure of having a second opinion, should the patient's men should not be charged as to the confirm, confirming the initial diagnosis? And so the problem with that is that, as I said, this is a, I don't want to use this as an excuse, but this is a national contract of which we have very, very little opportunity to vary. However, if there are examples where people are finding that they are needing that second opinion, then I certainly will send you through the details of how those patients can contact us and we can have that dialogue directly with them. But there will not be, we won't be in an opportunity to change that a national contract. I am sorry. And I know that it's not really working for dentists or residents, but that is the position that we've got. Very little opportunity to vary. Can I ask a yes, no question? Is there a system similar to the Care Quality Commission inspection of dentists or is there nothing like that? Yes, there is. And again, I can provide you with some details of what that looks like. Yeah. Thank you very much. It's been very informative. And if we have any more questions, questions, we will send them through to you. So is that okay? Absolutely. And if after discussion, there's a particular bit that you want to deep dive into in a future meeting, then please let us know and we can get that detail together for you. Okay, thank you very much. Thank you. Thank you. Thank you. Thank you. Right. So I just wanted to know because we were going to look into the terms of reference and how much delivery we have or how much room we have of changing it or introducing it. And then again, there was these questions which we which came up in the previous meetings were that the term for the job starts from what month? It doesn't. It's October. October, October, what month the JOSC year runs? I thought it was municipal. No, it wasn't. You remember, this is the conversations we had. And that's why I wanted a pre-meet, but I just was going round and round here. And every time being sent a different. So it's a JOSC doesn't run with the Linsfield year, it runs differently. That was the first thing. And then we were also going to ask because when is based on that, you remember, we had that conversation online when we were discussing whether to have this meeting or just to have the next meeting in May or sometime. So that was the questions. And we were hoping to have some answers in this. Yeah, I know, because we had a long time. It was a long discussion. Yeah, there was a long discussion in it and there were going to be answers. That's why I asked about this thing, the first item that chair, because we had agreed that we will delay the final election of the chair and the wife chair until we have the answers. So Nidhi is not back till 27th. She is on holiday. So we were hoping we will have some answers today here, or we would have delayed it till the next meeting. Because it was also said that this in two months time, we still need to have another meeting, which will be the formal meeting in which we'll adopt the chair and the vice chair. Because the terms of reference says... It was changed afterwards. It was decided that the chair and vice chair were going to be elected and today they were going to be approved. That was because we were having this meeting. And what we were saying is that the first meeting in which is a current meeting has to be done. And that's why we wanted that meeting in May. So we were going to look into it, that how does it affect, but we haven't done any of that. Okay, can I just come in? Yeah, please. Then obviously it's up to the members then. But so the chair for this meeting was elected for this municipal year. And then the reference states that the chair and vice chair should be elected in the first meeting of the first meeting of the new municipal year. So chairing for this meeting is basically formed from last year to finishing in April. And then we'll have a new set of members starting from April, May. And then it should be a new meeting after that to elect a new chair and vice chair. So if you if you look at the terms of reference, terms of reference clearly state that the meeting in which the chair and the vice chair are elected, it has to be in person and great. So up till now, you remember the first meeting we had and I suggested because that meeting was not to happen. So I suggested that it's a JOSC is a good thing. And if you keep on delaying it, we might lose it because initially JOSC is when there's a business of NHS England, when they have something in which they want the six boroughs to be consulted, they send it and that's when the meeting is held. So the first meeting that happened, that was on my request when I became the chair of the Healthier Communities within Lusham. So I asked that it's a it's a very good opportunity for all the six boroughs to discuss different health issues which affect each other. So why don't we meet? And that's when I was when I was trying to encourage and thank you very much for agreeing to become the chair. But so the idea was those one will be the informal meetings. You don't really need to have a chair or a vice chair for informal meetings. Only the formal meetings, which is in person meeting and curate, which is the four members to be present, which we have today, you need to have a chair and vice chair. But actual fact, the chair and vice chair need to be there when we have somebody like if they are to contact, who will they contact? That is the purpose. So for this meeting, we were continuously saying not to have it in March, but have it in May or in whatever is the way to do it. That was from May or later. That's why we had our meeting in October. There was no meeting between that time, because this year. This year doesn't go with that. And then again, it chairs and different boroughs host it every year. So this is the whole confusion and the answers were going to be. So if I remember correctly, that was that was brought on by the hosting borough that they will find the answers for it. If not, then I can ask Nidhi if she can do that, which she was going to do that, but she is not back till 27th. All I can say is the reference states that the chair should be elected for the municipal year. That is when we had this year is that the chair didn't get selected until the year progressed. So what we needed to do was make sure that the chair and vice chair for this municipal year was an official appointment and we did that today. So we had a chair operating, but it was only formalized today. So you don't even know you've been chair and vice chair since November. We formalized it today. So what we'll have to do is in June or July, whenever it is, hold a formal meeting and then elect a new chair for that municipal year. But the chair and vice chair, that's how we, that's what we agreed with. We discussed this before. Yes, I'm right, but that's how I understood it. But the chair and vice chair can only be elected for JOSC in an in-person meeting. Which is today. We weren't it today. Hey. Okay, but I was, okay. We did it, we did it at the beginning. So, so, so basically we went back to front because of the, because of the fact we didn't have a formal meeting, but so now we can state officially that you, but you were chair for the full year and we formalized it today, but we'll need to have another meeting, maybe in June or July to agree the chair running forward um, for the next municipal year. I know, I know, sorry, we, we agreed to um 850 and we've now, we're now going over, so I'm really sorry. Can I just ask, are, are members of the public allowed to attend informal meetings? So, not only the public ones? No. And so, but also before we close, um, the changes in the terms of reference which we put, are everyone, is everyone happy with those changes as they are? Changes? In the papers, the, at the end, back of the papers in terms of reference, the officers sent around both changes and asked members if they have any issues with the changes and if the members are happy. Are they available to the public? Yes, we are. Yeah, they're in the papers and you should be able to find those online, yeah. The current to new terms of reference are in the agenda paper. Yes, thank you. Thank you everyone for coming and good night. Safe journey home. Thank you very much. It was very good value, thank you. Thank you.