Transcript

[inaudible] So it's been recorded that he meant the more than they were shown to be the inverse, because they were shown at the moment, on this and the inverse on the most of the problem, the new universe and that sort of thing. They would not be able to remove all the segments of the moment from the boat, and it's not that sort of reaching of it. [inaudible] The chat function will not be monitored, not monitored. Apologies perhaps. I've received apologies perhaps from the following members of the board, and they are. So I've got apologies, but I'm not sure if they're from the board or not, so just bear with me. Ashley, is it okay if we come back after I go through? Right. Well, definitely Roxanne is not able to behave on other issues, she'll just say apologies. So I'm standing inside, so it's definitely apologies. And Laura will be with the focus on the inspection. [inaudible] Apologies from Simon, he's on annual leave. Yeah, and you're standing in in a most great fashion. Thank you. So, shall we do introductions anywhere? My name's Neil Wilson, I'm the cabinet lead for health and I'm the vice-chair of this board and I'll be sharing tonight's meeting. Shall we go round this way? Thank you, evening everyone, I'm Charlotte Pommie, I'm the chief participation place officer for the integrated care board. Hi there everyone, I'm the assistant director of public health for London Borough, I'm a leader on health equity and so I can't relate to disease. Judith Powell, chief executive health portioner. I'm Pauline Harrison, the head of major 3 and lead nurse at Queen's Hospital, I'm also the head of the major 3 chair. Sorry, can you, sorry, I've got hearing aids, I might need to try and catch that. I'm Pauline, I'm the head of major 3 from Queen's Hospital in London, in Mumford and I'm also the major 3 chair for the LMNS. The local rotating network. Yes, yes, yes. Oh, you're right, yes, yes. [inaudible] [inaudible] Children's and education, environment and sustainable transport. It's nice to have each other. No connection to either. You just said something in the wrong place. Right. We should be joined by a few others. Oh, and Tom, sorry. Strategy for Newham Hospital. Okay, so again, Tom, the only person online. [inaudible] [inaudible] Is there anyone else online? Hello, yes, can you hear me? Hello, hi. Can you introduce yourself please? We know you Lorraine. Yes, I'm Lorraine Sandhuza, I'm the CEO of ALFT. Thank you for joining us. Anybody else? [inaudible] Yes, for some reason, my name hasn't come up. [inaudible] [inaudible] [inaudible] Right, so on page 13, it's the gender item minutes. You're asked to approve them as a correct record of proceedings, which was on the 1st of August. And it was so hard for me to remember. [inaudible] [inaudible] Anything on page 13, any corrections? Anything that you've seen that's glaringly? 14, just stop me and buy one as it worked. Anything you didn't see at the time? [inaudible] That's it. Thanks, Christina, for doing those. I assume we can all agree that they were accurate records, am I right? Yes. Thank you. So what we're moving on to now, it's the ICS, Strategic Approach to Meeting Population Need. The tropic ist, North East London, paternity and neonatal demarring capacity. Joanna? It's okay, it's you instead, and your name, sorry. Pauline. Pauline. So Joanna was not able to be here, she was the Assistant Director of Big Bird's Room, and Pauline is going to be presenting very briefly about the board. If anything else needs to be considered, then be followed by questions on the paper. This is the general item format. Would you like to just show what I do? Yeah, basically, it's been recognized within the North East London that there needs to be a case for twinning. When it comes to leaving maternity and neonatal services. So we know that the population of North East London is growing, and we need to be able to make the service of the population. What we have currently, when we meet daily as part of our daily hold, is that the capacity of what we have will not meet the demands of the service in the next 10 years. So what do we do? Do we just wait until 10 years time and say, well, actually, we don't have enough data to evaluate women, so then what? So there needs to be a case for change, and what does that look like? So we've done a little bit of background work, we've spoken to the five hospitals within the North East London, to try and identify where the pressure points are, and the complexity of the women. The first field work of that came back to prove is that there is a need to change what we're doing now, to be able to meet the demands in the next five, 10 years. And what does that demand look like? So daily, we have what we call the daily hold to do, and we're not able to meet the iron adoption, which we're not, because my guidance, which we induce, we may have 40 plus seven. And I can tell you now, of all the five hospitals in North East London, BH charity is the only one who's able to meet that. The others try to meet it, but we're not. Our still-veterate is high because most of our babies will die because we're just not able to meet the demands when it comes to inducing them, and unless we do things differently, in the next 10 years, it's going to get worse. It's not so much the number of birth, it's the complexity of the women. So diabetes is on the rise, comorbidities. Women who wouldn't have babies 10 years ago now have babies, tumours, kidney problems, endocrine problems. You would normally advise them, you know, that they don't have a baby, but now they want a baby. And then more and more, women are going outside of the country to do IVF, and then they come back, and the egg don't know it could be anybody, the sperm don't know it could be anybody. So you don't have that family history of where that scene is coming from, so that pregnancy automatically is high risk to start with. And women from black background, Asian women, and African-American men are five times more likely to die, we know that, that hasn't changed. Reports being reported as M-Race, Francis, Five Times More, East Kent reports, the current K-Cop reports, all the multiple reports out there have come back to say these women are at risk. And how do we manage these women? You can't take the services away from them, the best thing to do is take it to them. So if we do a case for change and kind of move women who are high risk to real London, I can assure you, a black or Asian woman is more thrilled that you don't have to worry about being wrongful. It's not going to drag her through that you're going to real London to go and have an antenatal game. So that just puts that pregnancy more and more at risk. And then you have the African women who arrive in the country, don't quite understand how the service work. So they don't have sex care on time, but when they get to us, it's sometimes too late to capture that pregnancy. So we need to do a lot of things different. How do you do this? So we need to let the you guys and the public of North East London know that we need to do things differently. And that's where this case of change comes. I'm not going to bore you with 19 slides. It's in the pack. Yeah. And at your free time, make it a bedside read and just have it put together. But what we are saying is we need to do something differently and we need everyone to hear it and see why we need to do things differently. And the grand future is to start to design the service to meet the needs of the North East London. That might mean moving services around, including staff, which we know is, you know, there are no midwives out there. You need to grow your own now, you know, that's able to have to be able to recruit because people don't just leave. They just stay where they are unless they leave for promotional purposes. So in order to be able to provide a safe service, we need to look at skill mix, staff wellbeing. There's a lot that needs to be involved. It's just mostly it's not enough to sell your books in Newham, giving the induction. There's no capacity in Newham. We need to get to Queen's for vomiting. It's beyond that. It's the capacity of the labour world is the staff on the labour world. There's a lot of things that need to go into that. And when it comes to neonatal transplant, when you have a premature baby that needs to be delivered, for example, from HIV to vomiting, for example. So the HR team might say, OK, I've got a cost to transfer this strength for a week to be delivered. The labour world might say, I have the capacity on the world to take it. So how do we optimise care and get it safe for women, taking into account that capacity is a big issue and the demand is increasing. So that's where this case of change comes from. So the message is for you guys to take note of what is going on and the need for this change to happen. Thank you. Can I start off with page numbers. Where is the neonatal care pathway summary? Can you just inform me what NIC, UNL and U is? So neonatal care units. They're both intensive care units, the most intensive level one, then how do we step down, depending on the level you're at. My other question was, it says on the spec 1, 2, 3, 4, 45 on the paperboard, page 30 and out, I thought, to provide the full range of choice. Now we would like to provide a standard, page 30 and out, it says to provide a full range of choices. Now we'd like to provide a standalone respiratory leg unit as an option if feasible. But it is important to be using a sustainable electricity policy to deliver high quality safe care. So are we talking about a geographical space for units that are connected to respiratory units behind hospitals or are blamed? We're talking about a standalone unit where you have your doctors at a home from home experience. We recommend you go on birth with the same concerns and then you transfer them in. So that, in turn, is not one. So we don't want those standalone units to close, we want people to draw staff into the hospital to maintain skill mix and safety. But we also know more and more of our women want a better side of guidance. If you don't want me to have a home birth and I can't come to the standalone unit, I don't want to come to hospital because of previous experience or just because I don't want any unnecessary intervention. You're not able to offer me those services I want, I'm going to free birth. And we don't want women to free birth, we know the complication that comes with that. So rather than allowing men to free birth at home, it's best to encourage them to come to a lower risk setting than allow them to free birth. So we need to start to, again, think about what that looks like. And more and more of our women are saying, you need to listen to me. Sorry to interrupt, but is it a geographical space or is it? Yes, it's a physical center. But there are other places, there's one in Barkham Community Hospital and then there's the Barkham Charlestown bar, but then there are physical spaces, but that's what Pauline said about complexity of women as well, that makes sense. Thanks for coming to this, it's quite some challenging stuff in there. And I feel like I believe to see some of my data on things like stillbirth rates and understand what the comparative picture is, both the New and Northeast London. I'd like to see mortality as well and maternal mortality, that's very low. I guess what I'm wondering is about what the overall kind of governance is for this work and to what extent there is, for example, public health representation within that governance. We're thinking about the role, you know, when I used to work a lot on this issue in North London, and we did a lot of work with children's centres, with the maternity pathway, with high risk women, preparation for parenthood, high risk antenatal class, you know, a lot of other things linking public health with maternity, and I've just given the scale of the challenge that we're talking about and the quite worrying data that sits behind a lot of this. Yes, how, what the governance is for it and how we're evolving the wider partnership beyond maternity, beyond the kind of fairly narrow demand and capacity work within maternity services. So, after this was all put together, they asked from ICB, Northeast London was to, for each hospital to go and present it to each person, to kind of understand the needs and to buy into this and then to bring it to different forums to come and present it. I think it's been discussed a lot within hospitals, I'm not sure how much the community knows about this, there's been a lot of work in the background, there's data to back this up, there's a lot of slides done there. But I think the ask is for the concern and the challenges that we in disabled come up with is, how is it going to work for many women with many children who can't travel? The idea is that the women don't follow us, we follow the women. We're now going to reshuffle the services and start to move things around for other hospitals. How do you meet the needs of the women who we know are more likely to have poor outcomes, who will not go further away from home to offer the services? I think that's the challenge for me. And what's the interaction with things like the desire to move some care out of hospitals as well, so there's no reason why quite a lot of antenatal care could be happening in the community. It's happening already. I think that's already happening. I don't think we have many, unless you're having a baby, we try and push the service away from the hospital and then we've kind of increased the pathway now to give women the opportunity to have a patient induction, so they don't need a bed. So you come into your induction or if you go see a 12-hour stand, as opposed to before, you have your induction and then you're in the hospital, in the confined space. So there is a lot of push to push things out of the community, but the external drivers and the national drivers are also asking a lot of the hospital, asking to induce women at 14 plus seven. It's a lot of women. It's just on the government. Don't check whether the public health is directly involved, but there is a group, it will be a board, ICP board decision, but each has someone going forward, so no one is allowed. Can we just say under the culture of collaboration, that would be really useful. It is significant and we know that North Central London have just, so the ICB and the North East have just consulted on a major, they were a step ahead of us in terms of what's changing and they're looking at some changes. So there's quite a lot of movement, which is why it's sort of further complicated looking out for one population, but also what the capacity is. So we rely on other services outside. Right, I've got Lorraine first and then Sarah. Lorraine, can you hear me? Yes, I can. Thank you. So I agree that I suppose we could look at the demand and capacity at the hospital end, but actually some of the issues that increase the risks are in the community, particularly we keep hearing about women from the global majority, actually the first time that they're meeting a lot of maternity units is when the baby's about to be born. And some of them would have been high risk pregnancy. So there is something about what we all can collectively do to make sure A, there's the identification, triaging and support, and in particularly where people may be worried about immigration and other things as well. So there's something I think to think there because it's almost like at the point of giving birth in the hospital, it's already too late for a lot of the populations and sadly, these stats have been around for quite a while in relation to the mortality, for mum and for baby as well. So for me, there was something about just how do we think how we can do that. The second thing I did wonder, because interestingly, when we've also I think there was another report done, led by Gloria Rowland, who used to work at Bart's hospital called Turning the Tide, I think, which also looked at some of the experiences of midwives, in particular, as well. And we know that can have an impact in terms of whether people stay, the morale, but also just the interactions of the multidisciplinary team, because, you know, good teamwork, particularly working with high risk clinical presentations, actually really helpful. So I just wondered if that is also something that we take into account and if there's something else that we can think about also the experience of the midwives while working within these really high risk situations. Thank you. Can I take, before you come back, the other two, is that alright? Three, I think. Two, two, is that alright? Mine is actually very quick, so I've never heard of this rebirth until tonight, really, and that's, for me, really concerning. Second, in Newham we do have some really good support for women, refugees and asylum seekers through the alternatives, but I know that they would certainly want to have some input into this. And the other is, what is the time scale for this? Because some of us have been around a long time and we seem to have been here many times. I just wondered if this is actually going to happen and what is the time scale? Yeah, it's a good question because I can't answer that, but I think there's a time scale attached to it in terms of the intensive free birth. And why do they do that? Because they don't want it. They don't want to come into the hospital and if you haven't got anything community-based for them to meet their needs, then you're free birth. And they're free birth for different reasons. So you could say, you know, the VMI is raised, you've got diabetes, it's comorbidities. This is what the guidelines says you should do. Ideally, you should come into the hospital and monitor your baby or your blood pressure is raised. We will advise you to have a home birth, it's against that policy. So this is what we want you to do. We would rather you come into the hospital and do this. And then women might say, well, it's my body, it's my baby, I choose to do it the way I want. And which means life wants to go into a woman's house knowing that there's a lot of risk involved in this birth and she's not listening to me. And more and more women are wanting to say, I do it my way, it's my way or not my way. So they just go, you know, don't worry, I'm free birth. How often are we talking women? Not many. Not many. Most women are sensitive. That ties up with Jason's request for more statistics around this, because it would be helpful. Any points arising on what Lorraine said? Yeah, so what she said, Lorraine, I agree with you. So part of this work is to look into preconception. So we want to capture the women before they come. So for example, a woman who has diabetes in her first pregnancy, we know she had diabetes, she's gone home. We don't want her to come back the second time for us. So we actually have diabetes the first time, so what do we do now? It's about managing that woman and putting that, so it's prevention and not treatment, if that makes sense. So manage that woman and support her with the services in the community before she comes to us. And that also takes us to postnatal care. When you think she's now on baby number four, we're talking about fourth caesarean section, we start to talk about contraception, right on the postnatal one before she goes home. As we know, every time she gets a GP appointment, she might be pregnant again. And we seem to be finding that more and more women are struggling to get a GP appointment when they go home. So the commitment of her complaining that we're discharging women who still haven't had a GP appointment, not seen the GP, just an appointment, because every time the ring receptionist, they say there's no appointment until about four weeks time or so. And you think, well, she's on a blood pressure tablet, I would really wish that her GPCs had sooner or later, but that's not happening. So again, how do we manage all of that in the community? Because I know what will happen to that woman is the midwife will go back and say her blood pressure will be raised, she'll have a PC back in hospital for weeks and weeks. And then we're trying to separate mothers and babies, or in that case, we will have to separate mother and baby. And Tamara will join as well. Tamara has come to speak to the supplementary piece. So yeah, echoing everything that is quite striking, it would be good to see the data and to understand with a little bit more detail the pinch points and the pathway in terms of population cohorts. And also, what are the potential allies in sports and community? So it's not just that you're relying on community midwives, or GPs, or the community partners who are there as part of the sense making journey around people's health conditions and prevention. So we have for example Newham Nature, working with high-risk women, and also with wanting to put in place something more preventative around gestational identities and rise and wade, even though we recognise the conversations are difficult because they're not super salient to women and they often feel culturally weird. But I think one of the other pieces of work that we want to do in the diabetes pathway is there's an academic piece that's going on somewhere else, jumping ahead to something, it's coming down to pipeline this meeting. But in that sense, we know that GPs have difficulty having those conversations with people, we know it's an issue around health literacy. So it's about taking what we know about our population and their challenges, health literacy, literacy, agency, agency particularly for women, you're describing quite clearly, and issues of having a negative experience in services and a lack of trusted services. And so how do you work with the as-is to start to, as a whole system, including your partners and allies, think about what are the parts of the pathway that need to change for the woman or the resident so that they can start to make sense of the information, they can start to do the things, so it's not an oppositional relationship. We're looking to see if we can do some of that in primary care, so that if there was any it would be helpful to you. At some point, I mean not for that 18 months time, but we could think about having that conversation. Just that you must come in, but so does Tamara. My initial reaction to your zygotic disorder, which is GP, I don't put it on, I'm a patient, or GP surgery that comes the same day five months, the scrapbook list waiting to rewind. So I think that might be helpful. You have to get on the phone, you know, and do then fill out forms and things, but there's no winner to wait, you build energy to avoid them at the same time. I think that might be helpful. Also to know that we are a borough sanctuary, so these issues that Lorraine said are still there and the fears are still there, but people aren't being reported to home office and all of those sort of issues around. Yes, they are in a very chronic condition. They've got a baby that has come from all sorts of areas that are really in difficulty. They're pregnant and then you've got to worry about are you going to, if you go to officials, you're going to be on some sort of problem with your, not just the birth, but also the registration. You went to the wrong town, huh? I must admit, I did double check. Yeah, it's not really easy. So, really, really interesting, slightly terrifying. So, so through Healthwatch we do a couple of things. One is that we support local and volunteer new neonatal voices, so we do, you know, work with the program. So I think there's a piece that maybe we could be picking up through, through talking to some of the women who, about their experiences a little bit more. And in Healthwatch, of course, we've done quite a lot of work across all, on example, Healthwatch across North East London where we actually gathered to turn into experiences, but I think one of the things that's really interesting for me is, is actually there's a little bit about changing hearts and minds. And whether we could be thinking about some sort of information campaign that can be done as a collaboration with, say, voluntary charitable sector, you know, because we're trusted voices and actually being able to have some of those difficult conversations so when women and people who birth are worried about the status of themselves or their child, then to reduce risk at the end of the day, this is, this is still more, how can we reduce risk whilst we're waiting for all of these changes to be agreed and paid for and built and things like that. So I don't know, is that something we could think about? We could think about tomorrow waiting, can I just bring that in and it will? Yeah. I don't know, how do I bring her in? Oh my goodness me, the clock's gone now. Hello. Can you hear me? I can hear you perfectly fine, can you hear me? Oh there you go. Go ahead with your question. More to do with a comment, I think it's really important about the language that we're using so I think fear is a really big driver as to why, you know, sort of people do not come for appointments, and they present late for maternity care. So part of some research that we did a few years ago was we were speaking to women who had had gestational diabetes and the language in clinics about the stillbirth rates or the complications of pregnancies quite, you know, causes a lot of fear. So I think it's really important for us to, you know, look at, you know, how can we portray these messages, how can we get the message across and, and also make sure that the hospital is a safe space. So that's one thing. The other issue is that we do have a campaign certainly in primary care where if a woman does have diabetes we're really clear about, you know, the HbA1c, those levels that we would be saying, you know, really don't get pregnant please be taking your folic acid, and we're looking at those sort of high risk pregnancies and helping so I think, you know, it's important for the, for the board to know that that's a piece of work that is going on in Newham already and that's I think a real success and we're seeing, you know, more and more GP practices and the data is including that five milligram dose of folic acid being prescribed as opposed to what we would generally recommend over the counter. And then I think the last thing is around the MDT approach. So I think it's really important that we're not waiting, as, as we said for women to leave the hospital before having those conversations about contraception and planning, you know your next pregnancy and we do have for diabetes a preconception clinic that we encourage referrals into, but I think it's about not making this GP access because our practice nurses, our clinical pharmacists, lots of other members of the team. So for me it's about, can you book an appointment at your GP surgery, not necessarily with your GP, because that is one of the things that's causing a block to access. We have, you know, reasonable amount of access and actually they probably have much more of a, an elongated conversation around contraception and probably feel a lot safer doing that with our practice nurses. So I think it's important to make sure that we're encouraging them to book with a clinician at the surgery and not focusing so much on the GP and it's an MDT approach. Thank you. Oh mate, thank you. I mean, the team at this area I'm at is about six or seven now, at least, you know, that's without the GP. It's interesting though, the last point from me is that of the 500 people who are consulting, 94% of those understood why services need to change. And I think Sarah, how many times has it come up to scrutiny or around, since we've been around about the services in this area, 94% of the responders also agreed with the need to change. I think there's an appetite for change in how best we do it and we can do it together with not just the, you know, culturally sensitive, the whole issue around being both aware of our people, have pride in front of various things, or have a, I don't know, pride may be such trouble, but you know what I mean, a peer abusing services generally. I don't know how we overcome that. Is that, have you got enough notes? You're out for a while. Anxiety, maybe. Is that what you meant, anxiety? Any last word? I guess just the wider context, the wider population, the piece of work we're doing across the place, partnership. This is a sort of contributory strand and we're contributing to it, so I think it's important that we don't see these pieces of work as separate, they are more interlinked. Because of the increased population, increased environmental services, and the increase in complexity. And we look forward to seeing the changes. Yeah, we're very happy to come back. We don't have to lie. You don't see how informal we are. We are a nice group. Don't feel you have to stay unless you feel you want to. I do want to. Okay, that's fine. Do you think there will be anything, do you think there will be anything? There will be a 10-year-old. Yeah, there will be a 10-year-old. It's not healthy though. It's natural sugar. Yeah, me too. I was in a bit of a hurry. This will come out on your watchbook. Is this why we're not on an ice cream? Shall we segue nicely into the help watch on Monday? Yes. Do you need to introduce? Yes, thank you. So, apologies that the title of the report doesn't actually tell you what it's about. That was my fault. So, apologies. So, what we've done is we've been really concerned in Newham about its health literacy rates. And so, I think currently Newham has the second lowest health literacy rates in the UK according to the University of Southampton's Health Literacy Assessment. So, we've been having different conversations with residents over time and there's lots of changes that are going on. And we've been concerned that sometimes people feel quite bewildered about what decisions to make, how to choose their pathways, seeking information. And actually, just what you've been sharing with today, it just kind of strikes a chord really with how the wilderness people find this. So, what we did was we thought it would be helpful to produce something called the Patient Information Systems Leaf Alert to add. We think that it supports some of the wider policy framework that the borough operates, particularly in terms of supporting public health, 50 Steps and Step 2. And so, what we did was we designed a leaf alert, which really is quite a bright... So, the idea is that we can print it and put it into the GP surgery, we can put it into pharmacies. So, it just helps residents, waiting rooms, hospital waiting rooms and stuff, and just be able to have a look and see how they can make decisions about who to contact. And I guess what we're really promoting is the one-on-one light, because that's really trying to manage the 999 calls. And really, to just present this back to health and well-being board. And the idea is that if you as board are happy with it, I'm sure that you'll have to comment about some tweaks that might be needed, which is fine. And then, what we'd like to be able to do is distribute it around the borough. So, that's really what I wanted to bring to the board for information and happy to take any comments or suggestions for improvement. So, yes, I think it's great, really colourful, very noticeable. I would say that, and I'm only going by my own GP or surgery, that you need to really make sure that it's prominent on the NHS board and not mixed up with all the deadly hits that are there. I would really ask whether it could go into libraries and, if possible, into schools, because they are the catch-and-audience in schools. And actually, once you're at the GP surgery, you're there, you know where you're going, but the significant number of people who have no idea, which is why they go to A&E, they go to A&E with everything. I like the fact that the first choice is the pharmacy, because actually they really up their game. And I don't know how possible this is, because when it says here, write your GP's phone number here, well, the individual will want something a little smaller than this. And I don't know how you reduce it, some of the bits and cards that can be given out. I know that sounds impossible, but I'm just thinking that it may be that we just, or you just include the pharmacy, GP, walk-in, A&E, just that. I just think that the people need something that they can refer to. Yeah, so libraries and primary schools would be a suggestion, because I think a lot of primary schools now see a lot of parents. I think it's a really helpful suggestion actually, thank you. It's really good to see, I guess, given the low health literacy rates, this still seems quite complex to me. So we're using words like obtains, sinua, we're using quite a lot of, you know, terms that I use. And there are a lot of words on there, if you're not literate, thank you. I think you'd be put off, you might not even go into it. So I just wonder if there's something you can do that I'm not quite aware of. Because most people wouldn't go to the pharmacy, they would call it a chemist. Yeah, and that's really helpful. So those are some of the things that I was further, because, you know, we did, we developed it initially for, in another London borough, which we tested by Prowell. But that has very, very high levels of health literacy. So, and one of the things, you know, but sometimes you just, so my approach is always, people are always really clear about what they don't like. And that's what this allows us to do is start a conversation about how do you support residents in terms of making choices so I think you're quite right, because the thing that I'm really into is pictures. So I thought, once I brought it here, but I'm going to try and talk to my health team about turning this all into pictures. They already don't love me so I'm going to just take this and give them another reason but you know those are the sorts of things we need to be thinking about. So there's more and more picture ways to do it. Yeah, completely. So it kind of builds on what Charlotte was saying, and I think a really important aspect of health literacy is, doesn't quite capture it because it's actually about, you know, cultural difference. So what does urgent mean? Urgent is a very, what does urgent mean to someone in their health context? Well that varies a lot according to your perception. What does complex mean? What does, you know, so there's something about, you know, you're not going to solve all of this with a leaflet. I mean I think it's, I think it's actually really helpful for this conversation to bring health literacy explicitly into our discussions and I know Izzy and our team is doing a bit of a piece of work at the needs assessment around health literacy. But I think it just in some senses it just demonstrates how complicated a lot of this stuff is in a place like Newham where there is such diversity we know about. I was just going to say that even for those of us who think we aren't health literate, we aren't. We don't necessarily know the system. And this is, to be honest, this is health service literacy, not health literacy. This is trying to help people navigate the system, this isn't trying to help people navigate their health. And I think that those are really important points because, because also, the thing is as residents, we're constantly bombarded with some of this jargon, so in a sense, things like complex, urgent, it's what you hear all the time here in the media, you see it published on posters, and that's the bit that's also quite hard and I think for many of our communities, you know, for whom the UK health services and systems is different to what they might have made back home. This is a little bit, so I think it's been really helpful about how we reframe it around health service literacy as opposed to health literacy. For people, I've got Lorraine, I think, and Tom. Should we do it in that order? Lorraine first. Thank you. Mine's really quick. On there, we can put 111 Press 2, which is the mental health support and it goes through to the Northeast London crisis team as well so if we can just make that adjustment happy to talk outside to make sure that's represented well in terms of where they can, but I agree with what everyone was saying. I think it's helpful if it's on a page that people can link in, but there is probably something that we can do. Yes, about how accessible it is, as we're also trying to promote the the different ways in which people can access, particularly mental health support outside of having to go to the emergency department but thank you. Thank you. So what I will do is take all the suggestion course should be captured in the minutes and then my team will work with it and potentially just rewrite it so it feels a little bit more nuanced, and then maybe what we could do is. I guess what I'm getting, did we get a say, yes, yes, I mean obviously I'll bring in a version of this to be bought but if you wanted something into it, I'm happy to be advised how you'd like to see the next iteration of this. I think it would be helpful to come back. I think we want to get it right, you know, really helpful suggestions are being made, and how much of all of this is going to reflect. The equivalent of one in two of our population is going to A&E. That's not all because they're emergency. So I'm thinking, I'm in helpful mode, not taking on extra work, but so there's a couple of things that link this in the previous item. So I'm really happy to share any helpful learning that we have in public health team from our time, looking, working with infographics and thinking about, because we've thought about this since 2019, and iterated different aspects of it and the healthcare to see working with is the latest one, thinking about how we think about reading age, thinking about how we think about translation, thinking about the QR code, the language shop so people can get things translated. We and our commissioners have explored all sorts of different ways, and with different sets of feedback and success which I'll have to share with you, it's similar and quite simple. And also, I think that I'm speaking as a behavioural scientist and thinking about some of the issues that we have around prevention and around the advice and guidance people get, which I know my own personal journey, but for the most part, as a system, this isn't individual, the system, our professionals, we tend to give advice that's a little bit non-specific, whether people are going to make change or do something, they need quite specific, quite specific, quite tangible information, so there may be a step with this, where if there's that piece that Natasha from NELFT has got a whole hack about health literacy, but something about the language reading age, and then there is the bit about the kind of conceptual understanding, so the type of, the type of things that people, that will be relevant to people, resonant to people in describing what we mean by, you know, what is an A, what is an A in E-Corps, what is a 999-Corps, which is, you know, and actually probably describing the actual symptoms that people expect it to be, urgent, important, worrying, people haven't worked in any, people are very fine, they're very worried, they think that their symptoms are killing them, even when it's panic, they are absolutely convinced that that's where they should be, so there's that sense of what it actually is. There may be a piece around that, and then there's a longer term piece about, as Jason helpfully mentioned, that is around prevention, that is around health literacy, how my body works, what I do, don't do, what happens to me, influences whether I'm well or not. And I think that we've got some, so that's on my to-do list, but anything in terms of community insight that we can collaborate on. Thank you. Yeah, thank you. Problem with going last is everyone said all the good stuff. So, so a couple of points, obviously just picking up the fact that ED is where people end up, when the other bits don't work or when people don't know the other bits and we had a, I was on call last week and we had a day where we had 565 people go through our ED. 500 days used to be incredibly rare and then not anymore and it's not even winter yet, so anything that we can do that helps grow the understanding of the populations about where the alternatives are really welcome. So I think it's a really good thing and I'd echo the point about the complexity of the language on there, and I think anything we can do to address that would be helpful and I'm very happy if it's useful, Julie, to share this or put you in touch with our patient participation leads and our working together group so they could take a look at it and take a view and offer some suggestions for how it works for them and therefore some of the things you might be able to change. And finally, it might have been picked up by Adi, I'm not sure, but I'm conscious that this is in English, and actually people who understand our system less sometimes speak other community languages. So is the intention to convert this into other community languages as well? I think eventually but, you know, my first language is English so it's like, let's get this bit right and then we can start to look at trying to make it improve this accessibility and obviously if we can get pictures for everything, that would just help a lot of it. I think one of the issues around infographics in truth is that we don't almost have a sort of infographic directory of not what different sciences are, that is actually, you know, some of that basic stuff we haven't, we haven't got coherency around in terms of a lot of institutions, but yeah, thank you. It's all been really, really helpful to think about. And we've captured that in onwards on a recording. Now I'm afraid I'll have to come back to your eyes, but we're going to do it on purpose with the chairs. The recommendation on this one is that the 1000 wellbeing board is asked to note the production of the patient information system to leave it as one of the articles of help for the current work process, this year, and to agree that the leave that's subject to any amendments suggested by we just should reach into community with all those caveats primary and hospital settings. But I think you know there are primary colleagues who are patient reference groups as well. I know it's a big task, but they would represent some of the negativity as well when they've had the bad experience. So it's all right. Now, back to the previous item. Well, if I've got to do, which is for note you but it's recommended that the board review the case the chain, and the approach, and any how ICB is taking to engage in the public estate order. Obviously, there'll be a health scrutiny is another process that you may get on this one, I think it's on their work program. What does that mean, so the outer northeast London and the inner northeast London joint health over you. Yes, we have a complex sort of structure is a pretty well those two recommendations, right, so we're making progress, yes, we're making progress, and the general support wants to see once they see how they have the equity program on date, and you have to see that. So, first of all, colleagues and board apologies, we had plans, a joint presentation with the safeguarding adults board we're doing a deep dive project with them. So the companion piece and when their report was withdrawn. We withdrew our companion piece, and we'll bring it in January. But what I propose to do is give you a verbal report so this is the last minute replacement, a verbal report on two of the key items that we have been working on over the summer, a two year report. So the progress of the program. For the first two years. And I've got a high level summary of that, and also to let you know about the gateway reviews. So the gateway reviews was a process that we put in place around the projects that were funded from the northeast London ICB inequalities distribution. That's a Newman's allocation for that, their aim projects were funded, and we asked all of them to report on their progress, with a view to seeing accountability and progress, seeing where they needed some help. And I'm happy Christine to share the slide back to circulate so that you can look at some of the details because it is money numbers and some, some details. We will also have, we have some quite detailed report packs that if members are interested, I can make available on our SharePoint site, we want to read the individual gateway reviews. They've been through the boards governance but they haven't been through the health and care partnership yet. So just as it so that's that that's what and then the next the next steps that we'll be taking will be completing a will starting a process around the support package for teams and services who are carrying out deep dive projects or QI projects. So we're not QI experts but what we have done through the TRID board relationship that we have with the TRID board and through our relationship with the commissioners and the 50 step strategy is that the strategy, the 50 step strategy has an equity golden thread, which is an active thread. It's, it's linked to every step has an active equity objective and an outcome measure. So there'll be a piece to support those step leads to deliver on that with what process they need, what support they need, what timelines they need. Every commissioner in the council has as part of their personal development plan annual appraisal process, a mandatory objective, a mandatory equity objective. It's a completely free choice what they do we're not being super controlling about it, quite rightly. But what we do want to do is ensure that those objectives progress during the course of the year. Some of them are 12 month objectives, some of them are two to three year objectives so they could have a look at some pathway in more detail. And the proposal is that we, we continue to develop the equity programme tools which I didn't mention in our first introduction, things like the R framework, does it look like new room 420 code wall finder, roadmap etc. To support people to navigate their way through their, their objective challenges and to take some of the heavy lifting out of it. What we're also planning to do is to find a process to support these project leads and teams to progress and to share learning from each other so the plan is to create action learning sets to theme, to look at the themes within the different sets of objectives and to group people by linked themes or linked sets of progress. What we've done in the two year report is create a four step process, so that we can benchmark all the different projects by whether they're in stage one, two, three or four. Stage one is effectively discovery and scoping. Stage two is effectively evidence synthesis and visioning. Stage three is co-design, co-production. Stage four is evaluation and implementation. We want to put those two together so that the evaluation is designed and thought about at the time of implementation, not as an add on when it's too late to do baseline data. The other two things that we have happening are the adoption of the roadmap and engagement with the programme and the council. We have three bigger people directorates, housing, children and adults. Housing has its own set of programmes and challenges but children and adults each agree to do an example of our deep dive project. So children looking at family hubs and the equity baseline and the patterns and variation distribution around the children's hubs has to be in change and for adults, we are working on the safety planning adults board, which is where we come a little bit circular on the question of whether referrals to the board don't quite reflect the demographic of the borough, they skew older and whiter and while our older population are obviously older, obviously more whiter and more female, it's not, we still need a bit of significance testing but it looks as though there is still a, it's not quite representative. And so we have that question and are working, really good steering group but also really good work with the Safeguarding Adults Chair. Safeguarding Adults Week is coming up in November so there are plans between all of those involved in this to ensure that the work of that deep dive that you'll hear about in January is reflected in the community engagement that's been planned for that. With, with, with, I mean everyone is into itemator. I was on the phone to Claire Schoelen, the Chair of the Safeguarding Adults Board, there is some delays around process, but seriously, I mean, even if it's not the end of report that doesn't stop the work going on. And then Yoda is reporting, hoping Safeguarding Adults Board on this very crucial topic. Sarah did you just want to come around the family hubs? Only then, I mean, you know, I'm very interested in the outcome of it, because I think we've sold, we've almost, we've sold the dream, but actually I'll be delivering. And I, you know, I would question in some areas, I think that a lot of the fans would see it as like housing or a council one stop shop. And I know a certain year needs to come, we've had to rethink around the advice that our people can give around housing, because actually a lot of people come in and that's what they want. And sometimes, of course, it is totally connected to their family's open front door. But, you know, I'm not sure sure that the shipment is as developed. And I think that's probably around where it is, there is very little other infrastructure around custom house, you know, East Ham's got plenty, custom house has got hardly anything. And then we've got a new one opening at the end of the month in Manor Park. But again, that is going to be set in a children's centre, so that it, they're not all going to be the same but I do feel that sometimes setting it in a youth zone actually takes away some of the stuff. So I will be imposing the outcomes of that because we all want to make it work, but there's quite a lot of things that need that. So that's very helpful. Thank you. I'll make sure that we can report back. So that was the safeguarding of this portrait and portrait alongside the safeguarding of the children's board. So we could do a companion piece of both of them to look at it. So gateway reviews, I mean, my understanding is we might have a half way, but we also have a gateway, so you may have to do something like that. So it's one of those things that, essentially, we came up with the funding formula, we came up with the process, we wanted to empower the Joint Planning Group to help get a balance sheet to decide what had to put on the budget, and then keep some money aside to deal with things that would be overlooked, and to support the programme, and to think about keeping some in reserve for the last year to do an evaluation, so it didn't feel like they needed to pop-slice their budgets to pay for evaluations. So we invented a thing called a gateway review. Now, I'm a bit of a tangent. I ought to know what the cabinet is. Well, exactly. But I thought I said it before you did, sir. Are these projects that we've been talking about when we were down at the hospital? No, these are, and that's the well-known challenge. That's another one. It's a much more economical type and focused set of projects, and a really, really good project. And I think you can name all the stuff that's going on. Well, it's all got to be linked, hasn't it? Yes, exactly. It is. So this is money that, this is money that the NHS in England's inequalities team won from governments by gathering perpetuity, but that piece isn't always, that phrase isn't always widely circulated. No. And North East London ICB have wisely chosen to allocate the money from 24 to 27 in a sort of three-year tranche. And it's not just Charlotte's, isn't it? No, not at all. I think there's something... Highly influential. I would just say, so one of the, in the two-year report and the Gateway, actually the Gateway reviewed, one of the sort of high-level recommendations, and one of the things we consistently get back from our leadership group or programme leadership group or programme board, is that sense that some of the projects are involving community involvement, some of the projects are involving recruitment of a role. There's a timeline to get something done at the beginning of any project and actually we need to think about medium, medium-long time horizons for things. So that having some, expecting something to complete within 12 months, if it's going to be substantial, is often unrealistic. And the idea that projects, what we can often do, one of the reflections was that the system can often pilot, but doesn't always sustain. And one of the hopes of doing it this way and twinning it with the programme of the people would explore a pathway and then come up with a solution. So that was using the deep dive process and then move the solution into business as usual within three to four-year timeline. What we're finding is that actually that move to business as usual, 10 is not to happen, is still quite strong. Quite a strong thinking that equity projects need to be funded by special money and sit somehow slightly to one side of a full pathway. And was actually our argument, and for Newham in particular, given our demographics, is that equity is in everything. If we don't think about the demographic representation of our population, if we don't think about our literacy and literacy needs, their social determinants of health, their deprivation levels, the barriers that they will face in accessing services, if we don't consider those at the get-go in design and in planning, delivery and offers, then we won't get the outcomes that we want for those residents or from our pathways. We'll have people in the wrong place, we'll have mis-prevention and we'll have uncontrolled activity. Thank you. Now we're going to ask to note that, Adeja, but you're a standing item. Yes, I'm a standing item. So can we come back this morning, Tal? Yes. I'm happy to send round the high-level summary pack of that review process and the snapshot of the eight projects, benchmarking roughly where they all are in their progress. I don't think we've done that with these ones. No, we have got where they all are. We did a different way of benchmarking them, where we asked them to complete quite a few surveys. Learning about how we should be more mainstream within all the partners around the health and welfare United States. About the global majority of the population as well. 73%. 73%, you know. Sorry, Sarah, did you want to cover that? No, not at all. I was just nodding in interest. Oh, right. Anybody else? I didn't want to cut those eyes for sure. Looking forward also to the overall report on the program. And that's January. Yeah, I can do that. It's pretty much written. I have to say the bit that I need to add in is slowing us down. So is that all we're noting is? We agree to note. And now we're on diet related diseases program. I'm going to put Adeola again. Tamara, who's GP and technical lead for diabetes, she's still waiting for the patient leader. Yes. Co-produce, as it were, co-design, co-order and advanced diabetes specialist, dietitian. So Tom Ellis will be speaking to Gary's slide. OK, so we're on the pages. This was the one that came in the supplementary. So it's on supplementary pages three to whatever, three to twenty eight. Yeah. So we just are very briefly. You've got a slide. I won't speak to all the slides, but we've got a classic public health snapshot with some data and some hotspots. It sets out that what we all know, type two diabetes is probably the most prevalent long term condition in the borough. And not only that, but it's part of the course pathway of heart disease and heart failure. And so that and its significant drivers are the same as heart disease and cancer. So there's an opportunity in this pathway to think about through the lens of diet and food and from the food landscape and food security, all the way through to secondary tertiary prevention in the NHS and points in between the commission services and weight management with health promotion and with how we plan advice as a connected set of pathways and processes. On this occasion, we're going to focus towards the secondary end of the pathway. We're looking at some of the challenges and opportunities of our NHS partners and the next steps for this. I'm very keen still to get our NHS commission providers. So this is a snapshot landscape of what is happening in the pathways. And I've just, in the data, I've just highlighted some of the challenges for you around. Before we go on, I'm just curious. Yes, yes, yes. D2F, D2F. Oh, I'm sorry. Abbreviation, it's an abbreviation for type two diabetes. See, everybody else may be all right. Terry, do you know? I just thought we are going to introduce a bell to everything, that when people use acronyms that we don't know, we're going to read that back. I think it's a really good thing and I apologise. I've used an out-of-date abbreviation as well, so I apologise. Now, moving quickly on, we don't know what you're teaching. The diet related to these, now this is a prevention pathway. It says that North East London long-term conditions, that's LTC, steering and TNF groups. The North East EP and the LTC JPGs, so they're all feeding into this. But the very important thing, whether we get through it or not, is a very good lecture. And we've said this probably, I mean, you know, I won't ask myself and Sarah, I'm trying to move our accounts into less siloed thinking because there's a clear correlation between air quality, the high rates of COPD, asthma, you know, those issues. So there's air quality on there, but there's also food because there's quite a clear need to educate our population about the right sort of food, without being a paternalistic approach, health promotion, more upstream, as we say, prevention. Do you have enough of that? I don't know. Do you know as well? I'm dying. A dying computer. There's a laptop oscillator in there. There's a laptop A and E. There's a plug in there. Well, you do have to borrow my charge. They do go on. Sorry, should we wait for... Oh, I see. So I was thinking, because, you know, we've got the focus on type 2 diabetes and relationships between food, air quality, air commission services, but also commission services across the health hardship as well. Well-known, well-known in the community, primary care and secondary care. You know, we could expand it too, what is the buy-in so far? Across the public health team. Yeah, we know what the answer is, that you're marvellous and you're all signed up for that. Yes, I think that we've got some reasonably good working relationships with our NHS commission providers. And I would say across the public health strategies, the public health team, we are solid. We're looking to enrol our NHS colleagues, but there are many, many more providers in that space. There's a lot of opportunity for variation, but we have Tammy and Gavin and Tom tonight. We have done some work with Thrive Tribe and Aviva for the NHS commission services. And in some ways it's not, they don't necessarily need to see themselves as part of this because they are already giving out the type of advice. But there is a sense that some of the big levers that we want to pull are in that food strategy space, around making sure that we are actively granting in the food that we provide. So our free school meals are not at least genic, not diabetic, genic, et cetera. I think we've come a long way on our school meals. Yes, I think we have too. I think there's a lot to celebrate. That's the thing that I was told off today, to remember how far we've come with the TRID programme. There's a lot to celebrate. We've done a lot of really good work. But it's, as Tom said earlier, all of this is like painting the fourth bridge. When you finally get to the end, you have to start again. So it's a fairly never-ending thing. So there's always something to do. But these percentages of the risk of developing Q diabetes among Princeton, Pakistani, Bangladeshi and another, they've been in the male population very high, 61, 75%. So I think that one of the things that's really important about this… That's an old smoke, that's a bit of a complication. Yeah, so the point showing this heat map is the big takeaway from this is that they're using BMI, and sometimes you get BMI calculated with some standard risk cut-offs of 30 being high risk. We need to change that. We are commissioners, we routinely do it, many of our partners with Diabetes UK do it, but we need lower cut-off for people of South Asian and African and Caribbean heritages. The risk for them happens to lower BMI, and the risk is quite substantially genetically driven. It's about 40%. It's good news. That means it's 60% other things. So that means that people are more likely to get their diabetes younger. So you can see if you look at the next slide, that we've got in Bangladeshi category, particularly in the mixed group, much, much lower average of age and onset of their diagnosis of type 2 diabetes. And then the other page, this doesn't quite show the blood test marker that's used, but one of these I'm coming to the photos later, but often our residents have quite high levels of that when they are first diagnosed, which means that they can't automatically go to the remission program, which means they need to have quite a lot of control, so often means that they've been living with it for quite a long time. And this is the average age we AIC, right? AIC, yeah. Anything to pause at that point, while we're just dissecting the information, anything at the moment from anybody? Okay, when do you want to bring the others in? So this is all about the services and the next thing is just a summary of who commissions what and what they do. I don't think it's worth doing the detail. There's one piece in the glucose lane medications which is taken from another pack. These are the medications that are likely to be stopped when someone joins the remission program, so that when it says that they're, is it safe in the remission program, various of them would be stopped. Which page are you on? Page 15. Sorry, I was just about mapping the services. Sorry, I wasn't doing that very quickly. But it's a high-level summary, so essentially what we have just back there, the point is to show that NHS England directly provides some services. Council commissions some services and some services are commissioned by the ICS. But understand that we don't have all the leaders, but we have a lot of influence and assurance. So EMI is still the supreme device of this literature? Is it still useful? Yeah, it's the only way you can standardise. It has strengths and weaknesses. But it's the only way you can standardise it. I hope you are moving away from that being. There are other indicators, but it is useful. OK, so we're not disposing of it, we're just saying that it's more holistic. Last one, I'm dominating this. Where it says, under eligibility, attends the last bullet book. The last one can ultimately, I suppose, I should say, attends diabetes monitoring reviews, including personal screening. If you read that, you do not need to have an identity screen. What's the purpose of the monitoring? Is it with the individual or is it a standard sort of timescale? That I can't speak to. Tammy may be able to say that when we bring her in in a moment. You know, this has been around the block as well, Sarah. Delivering of diabetes services at the Agnes Elspeth's commission for doing this. They are still, they have the diabetes specialist nurses. And it's going to be a contract to deliver structured education. Anything on this? There's a lot of detail here. I don't want us to get bogged down in the detail. I put it there for something to read, you know, bedtime reading for later. When you want to come back to it, there is a sense of what's actually happening at the coalface, but not for today. I think it's important that we don't get stuck into the detail. Then you go to the challenges. Let's hit quickly to the challenges and opportunities and I'll bring in Tammy. So one of the challenges is just to think about, and this is an equity programme related project. The colleagues in the NHS carried out some quality improvement, QI led. Explorations of diabetes, secondary prevention pathways, including structured education. Which is often the, it's very simple to our training to help teach people how to manage their diet. It's evidence based and is held in reasonably high regard. So we have an 80% referral rate and 20% uptake rate, which isn't great. But when you speak to other colleagues in different parts of the country, they have things like 90% referral rates and 10% uptake rates. So there's something about this programme that doesn't really have traction with its intended audience. We did do some deep dives to understand the place-based partnerships to our local ICB, commissioned some research to understand better what the drivers were. And the focus groups came back with the time between the diagnosis and the first appointment is too long. Could it be reduced from six weeks to something maybe like four? And the referral conversation around understanding an impact doesn't quite land. And for two reasons, some of the reasons were health literacy and some of the reasons why people have just had a life changing diagnosis. They're not really in a position to take in information. So we're really keen to look at that second piece to see where there might be some adjuncts that we can support. So there are some areas to improve that came from that. There are challenges, capacity in the system, that the service informs us that they actually don't have any capacity to make any changes. And that there is a level of broad, other what would be described as complexity, but factoring people with different languages, factoring people with learning difficulties, is something that, again, we need to think about different and enhanced pathways, which, again, we don't have capacity for. So I will leave those. There are these and the next quote, I'm going to hand over to Tammy now. Yeah. Yeah. Anything else we've got any other questions? I've got some stuff to come back to you, but I think, yeah, it might be. Yeah. Let's say my brother. Sorry, it's just on some of the. Noted and I promise I will move the next time. So. Hi, I think I think it's pretty standard that we, and we're naughty, that we do sort of abbreviate. It just takes a lot of saying type two diabetes, type one diabetes. So apologies if if it has caused some issues. But you wanted to talk about the care processes and you were asking about the retinal screening. Did you want me to answer that first and then carry on? Just say that. You understood that. So in in primary care and GP surgeries, we will do sort of the eight care processes and generally we will do those annually. Retinal screening has slightly changed that if patients have had two consecutive reasons where there's been no changes in their eyes, they've got no retinopathy, that they're now going to be moved to a two year programme. And I think it speaks to the research has been going on for quite a while, but it speaks to a way of us risk assessing and then trying to make sure that we are seeing those people with more need. So if they have got retinal changes and they may need to be screened more frequently. And then obviously, if we have patients who are on medication and there's quite a dramatic reduction in their in their HbA1c, in that their sugars really improve on treatment, then sometimes that can cause some complications with having sufficient sort of glucose to various sort of structures within the eye. And so they may need to be screened a little bit sooner as well. So it's a little bit more complicated. But generally, if people have had two consecutive retinal screenings, which have drove no problems, they'll now be moved to a two year programme. Does that answer that question for you? Yes, that's fine. I think we've got to just question what what what does it mean by review, you know, how often? Over to you about the challenges for the system capacity at GP level. Yeah. So I think in the slide pack, I've actually I did this talk for some nursing students actually at City of London. And I think it's really important to sort of understand just the context of what we are dealing with in a primary care, but also community care setting. So if I talk to my slides, first of all, I think it's it's important to understand that our workforce has changed. I think traditionally we talk about doctors and we talk about nurses and people understand those roles. But we have many new roles. And traditionally within the diabetes space, I think we know about diabetes specialist nurses. We know about podiatrists for the foot care. We have a concept of dietitians and our health care assistants and our administrators and our retinal screeners. And all of these people are really important for us to make this organisation work and to have that really robust call and recall service. But as time has gone on, we've got newer roles. So we have our clinical pharmacists, we've got physicians associates, we've got physiotherapists, psychiatrists, care coordinators, social prescribers, health and wellbeing coaches, as well as sort of working with our partners in charity sectors like Diabetes UK or some of our local programmes like the group in Manor Park. So what what we know now is that there are lots of voices within the system. And it's about really having a consistent message about how we inform those that need an extra support, where to signpost them to. But also it may be that, you know, how we build those relationships moving forward is really important because it's a very different model to a traditional one. So there's been a kind of health care for London diabetes model for many years. And if you look at it, it definitely is a pyramid. And what we're trying to do is to risk assess so that we can put the resources in to the various levels. And we can also look at, you know, if we've got patients who are well controlled or managing their diabetes very well, that they're also aware of dietary advice, they're taking their medication, they don't have any complications, they know how to navigate the system, that we can have a much more of a light approach and just making sure that we can almost do that what we call patient initiated follow up. And then as we get to more complex care, that that's when we're going to need more and more of that MDT approach and much more around wrapping those services around the patients who need that additional support. And it's really important to understand that people can move up and down the pyramid. And so we need to have, you know, services that really meet our needs. And, you know, looking at our data allows us to say, well, do we need, if we've got a high level of complexity, how can we upskill our workforce? How can we maybe put in some extra support so that we can really make sure that our service is sustainable and safe? And then just moving on, I think the other issue here is that diabetes is a constantly changing picture. We are constantly doing research, there are constantly new medications, there's constantly new interventions and trying to keep up to date with all the eligibility criteria, trying to make sure that we're keeping, you know, you know, that patient in the centre can be very, can be very challenging at times. So we need a structured approach. And so that really involves us having a robust training programme and that we are, you know, sort of introducing levels of competencies with lots of updates, not only for, you know, sort of information sharing with patients, but also for our workforce. And I think it's also about, you know, if we look at what we do in primary care in Newham compared to in other areas, we will have some things like insulin initiation in the GP surgery, whereas in other areas that would be, you know, a community, but even a hospital based service. So one of the things that we looked at, you know, over the over time in Newham is the fact that we have increasing rates, so we want to make sure that we're upskilling our workforce so that we can deliver some of this care closer to home. But with that, it's also about making sure that if we have a high churn or high turnover of staff that, again, we've got a good training programme in place so that we can constantly replenish the stock of clinicians that are able to support that and encourage patients to self-manage and to self-care and so that we can have more patients in that. Patient initiated follow up because they're aware of the complications and they touch bases with us so that we can pick up any complications outside of our routine call and recall system. And then, you know, sort of the other thing that's a challenge for us is that if we've got a patient that is moving around the service, so whether in secondary care, they go to community care, they come back to primary, it's that sort of accurate record keeping and coding. And we really need an effective IT system if our system goes down or it's not able to communicate. It's really hard for us to know where the patient is on the journey, how to make sure that that messaging is consistent and trying to make sure that we're individualising care plans. You know, there's bespoke that they are tailored to what that individual needs. It's not that sort of just light touch messaging. And all of that takes a lot of time, trust and relationship building. So part of the issue for me is that we do have this, we focus on access and we lose the message of continuity of care. If I've known a patient from, you know, pregnancy, the gestational diabetes and tracking them over years and inviting them for reviews, you have an idea about what that person's life is like. You know, you've built a relationship. It's a lot easier to have a conversation and explain to them about what the next steps are because they already trust you. And you understand that maybe they can't go because they've got children at home and it needs to be, you know, we need to look at a system that supports them outside of the routine care. So can I signpost them to something that's online? Can I signpost them to Diabetes UK? Those kind of things are really important. And I think the access to technology and to apps and patients knowing their numbers, knowing what their trends are, it's one of the things that's a challenge in you because of, as we said before about our health literacy, but also the fact that, you know, we have, we have a, it's not even just health literacy, there's digital, you know, sort of inequity. There's also an inequity in how patients are called and recalled because obviously if patients know that they should be coming, and we're seeing them once a year, we've got relatively good numbers compared to other areas over the years in Newham. Yes, we had a bit of a dip in the pandemic that those numbers are improving, but we still have about 30 to 40% of people that we're still missing. And it's understanding how we need to engage with that group differently, but sometimes for us it's, you know, it is difficult in a system where there's so many constraints to be able to adjust in a way that is sustainable. So what it can't be is that we can have a pop-up clinic today because we have the staff, but we can't do that consistently moving forward. And that's really, you know, sort of one of the things I'd miss you. That's it. And I apologize there, Jason, you've been patient. Sorry, Jason. So I guess, no, that's fine. It's really interesting. I guess it's a reflection both to you and Adam, which is tons of thought-provoking, interesting insight. It's in the nicest way, it's to kind of say what, like what is it as a board that we, you know, it's a very, very complex system. It's one of the most significant health challenges for our population. We can't, there are lots of different dimensions of it, but in this space, and there's a lot around the wider determinants that we need to work on and we are in other spaces. I guess from a board point of view, are there one, two, three things in this part of the system, the kind of treatment prevention bit of the system. Are there one, two, three things where it would benefit us to have a real focus, focus on the data, you know, really trying to understand how we can support and push the system to make improvements. We have Tom who's speaking for Gavit that's speaking to another challenge about community dietitians, and I think there's potentially a, there's potentially a case to focus on what dietetic capacity there is between our two trusts, between health and NUH, and are we thinking of deploying them in the right areas to deal with complexity and should we be thinking about sort of specialising and sharing that dietetic workforce, expanding and sharing it. There is another, and perhaps you could bring Tom in in the middle, I'll just ask you a couple more. The other thing is from the feedback we've got, we have a clear need to focus on the highest genetic risk and also the highest level of deprivation in terms of how we can reach them. And we need to focus, from my perspective, the bit that I might do with thinking about how we focus on supporting ourselves and the rest of the system around health promotion, this kind of referral conversation about health promotion, health literacy and culturally competent advice. So to be able to land some of these things simply and clearly at that key point of diagnosis. So that's all, that's all to do, but to be mindful, as Tammy says that it's against a noisy background or very stretched capacity and very low bandwidth for anything additional. So we're looking to those things that are not using the overstretched workforce. Tom, do you want to come in? I'm happy to, Tammy's got her hand up so I don't know if she wants to come in first. I do because I think part of the why we're here is because we want to hear from Tom, but it's also around the fact that, you know, yes, we have blocks in our system and we're trying to overcome those so there's the what, that's what if, and so what sort of question. But I think, you know, for us it's around understanding what our workforce needs to be doing, and to make sure that underlying, that we have the support from you as a board to make sure that if we're saying that this is a health inequality we have no dietitian, or not a sufficient dietitian support in Newham, that what can you as a board help us in doing so I'm going to hand over to Tom so that you can talk about what we've been talking about. Okay, thank you. So, unfortunately, Gabby shared a slide which I don't think managed to make its way into the pack. But I will talk to it and I think Christine's got it and is going to circulate it with an updated version of the pack. But essentially, this came out of a discussion between ourselves and NHC about the potential for there to be some rotational dietitian roles between NHC and the hospital, and that conversation developed and then ended for various reasons. But what it did do is to bring into focus the fact that we, Newham Hospital, which provides community dietetics in Newham, is only funded to provide 2.5 whole time equivalent dieticians for the whole body. is only funded to provide 2.5 whole time equivalent dieticians for the whole borough of Newham. And we have, Gabby has, and I've tried to help her navigate the system a bit. Gabby has drawn up a proposition for a significantly expanded community dietetic service in Newham, going from 2.5 to 9 in the first instance. And I think the issues that we've found, we've taken this through the diabetes partnership group, we've taken it through the long-term condition joint planning group, and everyone's very supportive. But the problem is the hardy perennial that no one can actually identify any money that we can potentially use to start to implement this because I think everyone would agree, even a layman, including myself in that, would accept that 2.5 community dieticians for a borough the size of Newham with the complexity that's in play and with the diabetic workload that there is there is insufficient. And Gabby in her paper, which you will see after this meeting, has listed some of the issues that the current risks and impacts. But, you know, there is a high number of new referrals and we're breaching KPIs for waiting times. We've got increased waiting time for routine patients. So there's 115 patients in August waiting for nutrition support. We've got no service provision for patients with BMI below 35. So they're focusing at everyone above 40, but obviously 35 is a significantly high BMI. Currently that dietetics, those 2.5 full-time equivalents, visit six nursing homes on a monthly basis. There's over 100 patients there. They do clinics at East Ham Care Center. They do home visits for the housebound. They do clinic applying therapies in Newham Hospital. But they are stretched to breaking point. And I think it's one of those, another example, in some respects, a bit like the community heart failure service that we didn't have in Newham and the ICP has helpfully stepped in to fund after a business case and the same with the home oxygen service that Newham didn't have. And again, the ICP has stepped in to fund is an example, seems to me, where Newham has subpar, I'm being diplomatic there, subpar provision and everyone's just got used to it and worked around it and not necessarily challenged it. So we have a proposition. I think people accept the model and are supportive of the model that Gabby's proposed. But we are stuck with the hardy NHS and council perennial at the moment, as it has been for a large number of years. There being no obvious funding source for this. So at the moment that work is on hold, subject to us identifying a potential funding source for it. So to be absolutely clear, there's a health contract, which is at the East Ham Centre in terms of clinical individualising. This would be meeting people where they're at, for instance, you know, care homes and all the rest of it. And, you know, 2.5 for a population, doesn't seem to be a huge team to me. I suppose one of the asks is, you know, this, I mean, the official thing that we've got to just say on the recommendation, to note the areas of activity and members are asked to enrol their organisation, network leaders or people to address the challenges and the approach and resources being developed to support this. So it's about not to share the approach, but also I think campaigning on behalf of the borough in terms of where we're actually still having all these gaps, because the figures are quite frightening. Can anybody explain to me, what is Central One Doctors, Newham Central, North East One North East? Well, they do. They are not exactly coterminous, but there is a significance, well there isn't reasonably enough overlap. It's important to note that. Plasto is a random question. Good question. Plasto is funny. You've got a bit of Central and I've got a map I can share. I think one of the things is they don't do, because of the way that practices are owned, that some of the relationships are through ownership or through shared interests. So that when there's a group like 18 Medics, they will put all of their practices in one group and that might not be geographical. And we have said, Charlotte, in our place, it's a very immature system. We have definitely said that our integrated negative teams will be geographically based. So the integrated negative teams, it should be a structural response. You've heard what's being said, I mean, Jason is a neutral officer, but I think we do need to, with the Mayor and Sarah and Montez and the politicians, carry on doing the campaign. But that's because two point five is not very well made. Well, I'm just looking at a report from a few years ago now that says that poor diabetes control won't necessarily cost the NHS three billion pounds a year. And I guess my question to Tom was how easy stroke hard is it to put a figure on something like unplanned admissions due to the diabetics in the hospital? Something where we could actually identify the cost of doing this badly to help make the case for... I think that's going to be a really good idea. I think the sense of questions around this prevention for different long term conditions and how much it's costing the NHS in a queue. Tom's got the answer. I wish I did. I mean, I'm just conscious in a conversation with Anne Clayton, who's our very good diabetic nurse consultant, that I'm sure she said circa 50% of every inpatient in the hospital has diabetes. And so therefore, it's a massive issue for us. But if people better at health analytics than me want to send me the question that they want to ask, I can get our business intelligence unit to run some numbers about what the current model means in terms of cost to the hospital. Yes, that would be very helpful. This is all part isn't it, of the shift or the West Streeting shift or whatever to prevention in health, but against... We've got the virus listed for a percentage greater than 12 years in care. It's on the slide. That's my family. Even my youngest brother who was diagnosed when he was about 30. It is within the population. I just wondered what that meant. That's all this locality. The figures vary from barking them down to about 54%. Does anybody know what I'm about to tell you? You've got the slide, you know what that means. I think that means they have diabetes longer than 12 years. So it's not eligible for admission that they're long term diabetics. So the NHS has eight, nine care processes every time three diabetics should have. Some of them annually, some of them more frequently. We're good at process and we're good at secondary prevention. We're good at secondary care. We've done really nice things happening at the hospital. We're good at some of this later stage management. What we're not so great at is bringing prevention together and it's a boring time earlier. It is as I kind of look at it and think, why is this so difficult? It is a complex landscape. So we're looking to pick two or three key areas to do something slightly differently and not necessarily have to rely on the as is system, which doesn't always hang together well, but something that's going to make those differences. But I think there's this point about the financial cost of not doing it well as is is definitely worth articulating. I guess not forgetting that this is at a point where people have already developed diabetes, then what is our primary prevention model that sits underneath that? Because they're all in the world. So how did we get to that wider, and I think it was the report out today. I just saw it on my phone earlier about actually this, are we the baby boomers? I'm not sure I'm a baby boomer. We are living longer years in poor property health and greater levels of obesity. So it's not something we can just start by adding dietitians into. No, I think that is an important dimension, though, because it's about how we can do this outreach for our populations. We don't, it's back to the circular art what we keep having, where it's how do people access and how do we get them earlier? It's taking us back to conversations that we've been having for a number of years, we still have significant food deserts. I was in a conversation today where there are people living in North Woodwich who actually their nearest food place is WH Smiths in the airport. They've got their travel to Galley and sing it to the co-op. Well, you know, or they actually, it's quicker for them to go across on the Woodwich ferry than it is to go to the supermarket. And we still sounded the A13 on real issues of food deprivation, not, they can't afford to have it, there is actually nowhere to buy it. You know, Nisa now in Freemasons Road has upped its game and had relatively fresh fruit and vegetables. But, you know, if you look around our whole area we've littered with fast food places. And if we could, you know, I think we'd go back, I would suggest, this is not necessarily for today, but if we look at the number of outlets that are asking for extension of their hours at licensing, so they can have up to 11 o'clock, after 11 o'clock they have to apply. It's a legal place if you want to have food available on the wretched. Chicken chops. Yeah, chips, whatever, until 5 o'clock in the morning. And all this delivery will start. Yeah, but we've got very, very few, I mean that's, we want to add, let's remember we had Andy last time. I'm sure. So talking, so we're trying, this is very complex, so we did talk about food environment, which is the Andy piece. Yeah, and there's a very limited, you know, we've been lobbying government to extend our planning and licensing powers because actually we are very toothless. Yes, you can't do science about this, there's a change of using under the law. And licensing, you know, we are, you know, we can't use health as a factor, it has to be around social behaviour, so it's, you know, we are very innovative. And the point Jason is, is that actually, until we improve the quality of the people on licensing, all right, and I say this, you know, because actually they just say yes to all these extensions, and really and truly they should be really far more circumspect. And there's this sort of view that all well leads to struggling businesses and they need this and they need that. But I think we can exercise more power there. We can also take away the financial modelling. Yeah, that would be great. Yeah, that would be helpful, and we're going to come back to this issue, but I think that this, we're really asked to know areas of activity, enrolled organisations, and we've got not everybody present, but we'll try and get that message through. Networks need little inferences to address challenges, share the approach more, and resources being developed, because it is like everything the state so far, we need to be equitable and have some impactful delivery, it's not just four people. When learning people realise what a complex subject it is, you know me. So I just wanted about the, about what we're looking at data wise and I think that we're making, we're only making this about hospital admissions and complications and if you think about 90% of the care happens in primary care. I think it's also important to look at our medication usage, so that if we were to have less people on medication that's an area that we can save. And I suppose the other thing you brought here is around workforce, and people attending work who can't go to appointments because of that so is there something about a local campaign with businesses to release staff, so that they can come to their appointments when invited, because that's one of the things that patients say that they can't attend, because they can't take time off work. Thank you. Which actually gives me an idea Tanny and Adi and others, which is, we just got some money to pilot health checks related to employment, and I wonder whether we could do something, use that as an opportunity to have a diabetes dimension to that work. Because it's more about where people are at, including their place of work, possibly. Yes, that reminds me there is a second ask, which is we need to think, and this is a mask for each other, we need to think about having more accessible HBO and Seaport for testing, what we're doing with all of our health promotion outreach or our health festivals, whatever we're calling them. If we're doing heart disease we're doing diabetes as well, if we're doing diabetes we're doing heart disease as well, so if it hasn't landed in these checks because of the way that it's being funded I think it would be really good if we could, but one of the things that's really helpful is if we can do people's blood pressure, have a chat with them, and also do an HBO and Seaport test. I mean it was amazing, I have to say yesterday, Saturday, at the Ageing World Festival, the constant, constant demand of people for the health checks, for the opportunistic health checks, that room, the NHC room at the Ageing World Festival was always packed. For vaccines, vaccination and for health checks, it was amazing Tammy, like really busy, busy, busy. We need to do more, I know that Councilor Ferdie and I've been to Seaport do some really good work through there with Laura and it's a multi-agency thing, we're GPs giving up their time and all the rest of it, and it is important because the community dimension is where people are at. I would say that if you do a GP surgery that is primarily focused on the community, then people will come. If you have GP surgeries that aren't, then actually they don't care whether they see you or not. I mean my GP hasn't been actually physically present since Lutka. It does everything by boat. But it's not that you go. No, no. If I may have one more ask, so thinking about how we get capacity to support Councilor Verdi and Ramgaria and sites like that more proactive and they're running their own community mini health checks, we set them up, we started off with, they've got blood pressure means, they've got machines, they've got scales, but actually it would be really helpful if we could give them some HVAC testing. One of the issues we have is that the most affordable you can get is at weekend when people are doing various aspects of worship, but the services that have the HVAC machines don't regularly work at weekends. So to be able to find another capacity where we can find a machine that's useful for community usage. Yes, so it's a blood test. It's a little fingerprint. It's a little fingerprint blood test and it's got slightly expensive display. We can't teach them how to do that blood test. Yes we can, but they need a machine. All right. You've got a spare machine there. You're democratising your access to testing and stuff. The last word I need to share. Fair enough. I think there's two aspects here. There are, you know, picking up the unknown, so there are going to be some people who we don't know about, but there's another conversation about those patients who have already been diagnosed and how we make sure that we keep them healthy and part of that is enabling them to attend appointments. Exactly. Excellent. We've all got homework, we've all got challenges and you know how to make a check. Oh no, that item which I must talk about. The date of the next meeting is not known by certain. Have we got a date? Thank you for sharing. I'm sorry I didn't hear you.

• Yeah. - Yeah.