Apologies were received from: Cllr Ange Tyler, Mandy Appleby, and Simon Trickett.

To receive details of any member nominated to attend the meeting in place of a member of the board.

Gillian Pearson acted as a substitute for Mike Hearne (Taurus Healthcare).

To receive any declarations of interests of interest in respect of schedule 1, schedule 2 or other interests from members of the board in respect of items on the agenda.

There were no declarations of interest.

To approve and sign the minutes of the meeting held on 26 September 2022.

The board requested that the minutes of the meeting held on 26th September 2022 be updated to reflect that board members were present for voting, with the exception of Superintendent Edd Williams who attended remotely.

David Mehaffey (Executive Director of Strategy and Integration) also noted that job titles, in the list of participants, needed to be updated to reflect some changes from the CCG to the ICB.

Following these amendments, the board approved the minutes of the meeting of the 26th September 2022.

To receive any written questions from members of the public.

For details of how to ask a question at a public meeting, please see:

www.herefordshire.gov.uk/getinvolved

The deadline for the receipt of a question from a member of the public is 8^th March at 9:30 am.

To submit a question, please email councillorservices@herefordshire.gov.uk

No questions received.

To receive any written questions from councillors.

The deadline for the receipt of a question from a councillor is 8^th March at 9.30 am, unless the question relates to an urgent matter.

To submit a question, please email councillorservices@herefordshire.gov.uk

No questions received.

A presentation welcoming feedback on the draft version of the Herefordshire Health and Wellbeing Strategy ahead of the final version sign-off later in the year.

Matt Pearce (Director of Public Health) provided an overview of the draft Health and Wellbeing Strategy in order to invite comments from the board on the draft strategy. The principal points included:

1. The strategy focuses on a prevention-first approach; community empowerment; reducing inequalities; workforce and integrated ways of working; and outcomes of the strategy.
2. In addition to primary priorities (good mental health and wellbeing), there are a number of secondary/supporting priorities which emphasise the important role that is played in people’s overall health and wellbeing.
3. There are four identified goals that also reflect the wider factors that determine people’s health and wellbeing. These include:
   1. Thriving communities
   2. Healthy and Sustainable Places
   3. Opportunities for all
   4. Healthy People
4. The strategy also talks about what does a priority mean and there still needs to be further discussions as to how these are reported including the potential of the HWBB holding dedicated sessions to explore the priorities in more detail, in addition to reports being brought back to the board to report on whether these priorities are being delivered.
5. The two main priorities of the strategy are:
   1. Best start in life for children
   2. Good mental wellbeing throughout life
6. The two priorities reflect the ten-year period of the strategy and thus underline high-level outcomes.
7. The next step, once the strategy has been ratified, is to delegate to partnerships beneath the board to align existing work within the integrated care system and primary care networks. Ultimately, the intention of the strategy, in its current form, is to therefore emphasise the key-level outcomes going forward.
8. Against those two primary priorities and the six supporting priorities, there is consideration about how delivery of these priorities sit across the system (p20 of strategy).
9. There are high-level outcomes included within the strategy alongside the strategic outcomes, primary outcomes, and secondary outcomes. There needs to be some refinement in the coming weeks to fully understand what the impact will be.
10. In terms of governance, there has been discussion with partnerships regarding who owns the strategy and there have been early conversations with One Herefordshire Partnership potentially having oversight and holds the delivery groups to account.
11. The next steps of the strategy are ongoing consultations with partners and sign-off of the strategy on 27^th April. There are scheduled feedback sessions with the public on the 28^th and 30^th April, in addition to continuous engagement with the public going forward.

Councillor Pauline Crockett (Chair of the board) thanked the Director of Public Health and Mary Knower for the engagement consultation. The Chair then proceeded to ask members for comments and questions on the strategy.

Councillor David Hitchiner asked the director for clarification regarding ‘prevention and early intervention’ on page 10 of the draft strategy. The Director of Public Health explained that primary, secondary, and tertiary prevention are primarily associated with health and focused on preventing disease. The intention was to frame the three tiers of prevention across the wider sense of health including housing, the environment, lifestyle etc. and therefore encapsulate  ...  view the full minutes text for item 72.

A presentation of the Herefordshire Safeguarding Adults Board Thematic Review: Premature Deaths.

Ivan Powell (Chair of the Herefordshire Safeguarding Adult Board (SAB)) provided an overview of the premature deaths – thematic review. The review considered the deaths of six individuals in Herefordshire between January 2019 and August 2022, and was jointly commissioned between Herefordshire Safeguarding Adult Board and Herefordshire Council. The principal points included:

1. The review focused on six individuals – five men and one woman – who died between the ages of 24 and 54.
2. In the review, there has been some overlap in which individuals have experienced multiple complex vulnerabilities including:
   1. Criminal justice - six individuals had contact with the criminal justice system, either as perpetrators or victims of crime.
   2. Poor mental health - six individuals had poor mental health.
   3. Substance use – all six individuals used substances
   4. Homelessness – all six individuals had experienced homelessness at some point in their lives, although they were not homeless at the time of their death
3. The over-arching recommendation from the report is clarifying where the overall governance of all the supporting/enabling parts of the system sit between the Health and Wellbeing board and the Safeguarding Adult Board. 

Christine Price asked about recommendation 11.1.3 from the report with regard to the leadership from the different boards involved in the review and enquired about how this is best achieved.

The Chair of the Herefordshire SAB clarified that the Health and Wellbeing board as co-commissioner of the review, in effect, owns the recommendations and action plan resulting in a governance responsibility to make the review land effectively. Additionally, the Safeguarding Adult Board does not have the same level of influence and therefore there is a need to discuss where over-arching governance sits in response to delivering the review.

The Director of Public Health acknowledged the need to discuss governance and how to knit together the work, in dealing with people with more complex needs, between the existing partnerships.

Councillor Diana Toynbee asked who was responsible for investigating non attendance/disengagement at arranged appointments.

The Chair of the Herefordshire SAB noted that the role of the safeguarding board is to seek assurance from the agencies about how they deal with non-attendance.

The Managing Director of Wye Valley NHS Trust recognised the complex area of non-attendance and how this is confronted.

Ewen Archibald (Assistant Director, All Ages Commissioning) noted that on the issue of non-attendance, the thematic review, in addition to Project Brave, emphasises a new, assertive way of approaching the challenge of non-attendance of vulnerable individuals from a range of services and represents a critical risk factor in preventing deaths and its critical in the wider work of supporting people in their journey through homelessness and complex vulnerability.

The Chair of the Herefordshire SAB added that as part of learning from the review, a workshop was held which included managers and practitioners whereby there was frustration in which support was given to an individual through treatment and detoxification and knew that on discharge, there would be a risk they would become homeless. When considering who to put  ...  view the full minutes text for item 73.

A presentation of the draft version of the Project Brave Strategic approach.

Ewen Archibald provided an overview of the strategic approach to Project Brave. Project Brave emerged during the Covid pandemic emergency in March 2020 through cooperation between the local authority and key partners to protect vulnerable people including those who are homeless and have wider multiple complex vulnerabilities, seeking to improve outcomes for people at risk in communities. The principal points included:

1. The strategic approach proposal has gone to Cabinet and was approved in February 2023 along with the council’s Homelessness prevention and rough sleeping strategy which is the wider strategic context of this work.
2. The core principles of Project Brave are aligned with the objectives of MEAM (Making Every Adult Matter), a national programme led by Homeless Link and sponsored by the Department for Levelling Up, Housing and Communities (DLUHC), which significantly focuses on homelessness and encompasses multiple complex vulnerabilities.
3. The key element of Project Brave is ‘Homes for Homeless People’ which focuses on long-term and transitional homes and accommodation that vulnerable people can live in.
4. There has also been an increasing focus on what can be done long term to prevent vulnerability including the use of Talk Community and wider partnerships to emphasise upstream prevention. Across the whole Project Brave cohort, the prevention of substance use is a key long term consideration and work is being done, across partners, to identify the most effective interventions and approaches to prevention.
5. Through Project Brave there has been engagement with a wide range of stakeholders and partners, in addition to people with lived experience.
6. Overall, since the inception of Project Brave, a number of achievements have been reached, including the council having accommodated 252 households at risk of homelessness or rough sleeping – and successfully moved 157 households into transitional or long-term accommodation.

The Chair thanked Ewen Archibald for the report and stressed the importance of noting the many personal experiences at Herefordshire Council who are of most need.

The Managing Director of Wye Valley NHS Trust also thanked Ewen Archibald for the report and asked firstly, whether the name ‘Project Brave’ should be changed in order to emphasise the long-term nature of the initiative, and secondly, where the long-term funding exists with regard to the initiative.

Ewen Archibald acknowledged the term ‘project’ does imply the initiative is temporary and that there should be some reflection on all aspects of its identity and how it is understood by stakeholders and individuals who are part of it. With regard to the funding of Project Brave, the core funding that supports the current work that focuses on homelessness, is secure until April 2025. There are now opportunities to apply for funding, some of which overlaps with the period and some that goes beyond April 2025. DLUHC, however, is focusing on other areas it regards as priority areas of need, and that there should be consideration about dependency can be reduced on some of the existing streams of funding while making best use of further funding opportunities.

The Chair of Herefordshire SAB noted the difficulty  ...  view the full minutes text for item 74.

A report outlining the Herefordshire Inequalities Strategy for 2023-2026.

Alan Dawson provided an overview of the Herefordshire Inequalities Strategy 2023-2026. The strategy was developed by a sub-group of the One Herefordshire Partnership and has engaged with a number of partners including, in particular, the clinician and practitioner forum and the One Herefordshire Partnership, itself. The principal points included:

1. The strategy attempts to link the national approach to reducing health inequalities to the local proposed approach.
2. The national approach, ‘Core20PLUS5’, contains three main elements:
   1. ‘Core20’ deals with the 20% most deprived wards in each area in England. Herefordshire has 9 in that category.
   2. ‘PLUS’ are the areas that are specific to the local population and there are three groups that are focused upon in the strategy. First are those who are not registered with a general practice. Second, those who fall within the most rurally dispersed of the population, which is another area that particularly affects Herefordshire. Finally, the strategy focuses on the Gypsy Roma and traveller community.
   3. ‘5’ relates to the five nationally mandated clinical areas that are focused upon regarding health inequalities:

                                               i.     Maternity

                                              ii.     Mental health

                                             iii.     Respiratory

                                            iv.     Cancer

                                              v.     Hypertension

3. The strategy aims to create a framework that can address health inequalities in the county.
4. There are three over-arching objectives that the strategy seeks to confront:
   1. 1. Digital and health literacy:

                                               i.     There is a lack of digital and health literacy in which accessibility to services has become increasingly digitalised.

                                              ii.     A key aim of the strategy is to help staff to improve their digital and health literacy so that they can assist patients and the public and in turn, reduce inequalities.

                                               i.     This objective seeks to ensure that staff understand what is meant by health inequalities, how they approach them, and ultimately reduce health inequalities amongst the workforce.

                                               i.     There is already a lot of work being done in the county, a lot of which is reflected in the plan at the end of the strategy.

                                              ii.     The work of the Community Partnership, led by Herefordshire Healthwatch, who have looked at the factors driving health inequalities and consider what can be done by partners in the statutory and voluntary sectors, respectively, together around that.

                                             iii.     The work of primary care networks of general practice, community staff, and social care workers is also important to understand the needs of their population, in addition to dealing with those needs in defined areas and in defined ways.

5. The plan at the end of the strategy is not exhaustive but covers the main strategic elements of the approach and highlights the approach being taken to meet the three over-arching objectives, stated above.

David Mehaffey asked if there could be direct reference to the Integrated Care Strategy in the context of the health and wellbeing strategy.

The Chair asked how and when an evaluation of the three over-arching objectives would be delivered to the board in the future.

Alan Dawson confirmed that he would bring back a report to the board  ...  view the full minutes text for item 75.

A presentation of the Herefordshire and Worcestershire Child Death Overview Panel’s (CDOP) Annual Report for 2021-2022.

Elizabeth Altay provided an overview of the Child Death Overview Panel Annual Report 2021-22. The report was written by Herefordshire and Worcestershire Child Death Overview Panel (CDOP) and notes any thematic learning and actions that can be utilised to prevent future child deaths. The principal points included:

1. In the year 2021-22, there was a total of 43 child death notifications and 28 were reviewed by the panel.
2. Of those 28 cases, 67% were ‘expected’ deaths whereas 33% were ‘unexpected’ and triggered a joint agency response.
3. The purpose of the panel is to look at any modifiable factors and CDOP identified modifiable factors in 57% of the cases reviewed.
4. The most commonly modifiable factors identified were smoking and neonatal care.
5. There are four themes that presented more frequently than others during child death reviews. These are:
   1. 1. Prematurity

                                               i.     10 of the 28 deaths reviewed were children who were born prematurely.

                                               i.     7 of the 28 deaths reviewed identified smoking as a modifiable factor.

                                               i.     5 of the 28 deaths reviewed identified neonatal care as a modifiable factor.

                                               i.     8 of the 28 deaths reviewed identified families with complex social factors as a modifiable factor.

6. Page 14 of the report focuses on the recommendations from the previous annual report and highlights the progress against those recommendations.

The Managing Director of Wye Valley NHS Trust asked whether lack of access to higher levels of neonatal care (level 2 and 3) was an issue regarding child deaths, which is not provided in Herefordshire, or whether it was a deficit of level 1 neonatal care, which is provided in the county.

Elizabeth Altay noted that the quality of neonatal care, whether provided in Herefordshire or Worcestershire, is not drawn out in terms of geography in the report and instead is more general. Each individual case would have looked at access to care and any recommendations about access to care would have come out of the individual child death review which would then have been taken forward to the Local Maternity and Neonatal System (LMNS).

The Director of Public Health asked whether data could be combined from previous years to see if there are any trends/commonalties in terms of any themes that may be present.

Elizabeth Altay accepted that this was a useful recommendation and the CDOP would look to take this forward.

The board therefore agreed to the suggested recommendation to combine data from previous years going forward in order to identify new trends and emerging issues.

The recommendations were proposed, seconded, and approved unanimously.

Resolved:

a)    That the Board consider and note the report.

b)    That data is combined from previous years going forward in order to identify new trends and emerging issues.

A slide presentation introducing the Community Paradigm approach.

Hilary Hall provided an overview of the Community Paradigm. The Community Paradigm emerged from a report from New Local, an independent think tank, and takes initial thinking around community development, involvement, and empowerment onto the next level. The principal points included:

1. Community Paradigm considers how work with communities is done on an equal shared basis of power and how different models of funding are explored to support people with different multiple complex vulnerabilities.
2. Community Paradigm focuses particularly at prevention and the outcomes that are intended.
3. That there are challenges regarding evaluation due to not having a rigid set of performance indicators and these need to be overcome.
4. That there needs to be more of a balance in terms of governance in ensuring that there is a balance between ‘top-down’ and ‘bottom-up’ mind-sets which can better reflect solutions found in communities as well as institutions.

Christine Price noted that from the community’s perspective, there is a desire to work in partnership with statutory functions, but that there is not the right approaching mechanism to do that well. The fundamental idea of the Community Paradigm is that there is a shift in how funding is delivered, in addition to the need to collectively come together to arrive at shared solutions.

David Mehaffey expressed his support from an ICB perspective to work and develop the Community Paradigm.

Resolved:

a)    That the Board considers and comments on the Community Paradigm Presentation.

b)    That an update on the Community Paradigm is brought back to the board in the first meeting of the municipal year.

A presentation and update from the Health Protection team.

Rob Davies provided an overview of the Re-establishing the Health Protection Assurance Forum report. The principal points included:

1. The forum has a role to assure that a wide range of health protection functions across Herefordshire are working as they should.
2. These functions extend beyond flu and Covid-19 to also include screening and immunisations; environmental health; control of chemical, biological and radiological hazards; risk management and project planning; hospital infectious diseases and hospital acquired infections; and activity in care homes.
3. The breadth of functions thus reflect the range of organisations involved including public health and environmental health in the local authority; UKHSA; NHS partners and others.
4. The forum seeks to understand the risks associated with the range and complexity of the functions across the system and looks to ensure that what is currently in place is robust.
5. The formal meetings of the forum were paused in 2020 during the Covid-19 pandemic. As a result, less was done around the broader health protection work including preventative activity like screening and child immunisation.
6. Since the summer of 2022, there has been work to re-establish the forum and the underline the broader focus on health protection functions. This has required:
   1. Re-establishing relevant terms of reference.
   2. Updating members of key organisations.
   3. Re-establishing data flows and information.
   4. Reviewing performance against range of measures and comparing Herefordshire to other local authorities.  

Rob Davies proposed that an annual report come to the Health and Wellbeing Board to provide a more systematic and rigorous assessment of where the forum is at. This report will help emphasise what key priorities need more attention in addressing.

The Director of Public Health agreed that an annual report would be useful to address system issues to help identify which priorities need particular focus and attention in order to improve performance, particularly as these issues correspond with health inequalities and functions such as the Community Paradigm.

Councillor Diana Toynbee asked why the forum is needed in addition to the other work being done by the HWBB and other agencies including the UKHSA.

The Director of Public Health noted the statutory function that he has as director of public health to ensure that plans are in place to effectively deliver screenings and immunisation. The UKHSA operate at the regional and national levels and are part of the overall forum, however, at the local level there needs to be assurance and coordination that the forum would help to provide. For instance, there have been conversations regarding screenings and immunisation which will be delegated through to the Integrated Care Board from 2024. These conversations with the ICB aim to clarify how screenings and immunisation will be delivered at the local level.

The Chair noted table 2 on page 13 of the report which shows that performance is better in Herefordshire than the national average.

The Managing Director of Wye Valley NHS Trust asked if the health protection function – ‘emergency preparedness, resilience and response’ (EPRR) – was specifically in relation to infection prevention.

Rob Davies said that  ...  view the full minutes text for item 78.

An opportunity for the board to review and populate the work programme for 2023-2024.

The Chair noted the upcoming meetings as listed under the work programme 2023-24.

The Director of Public Health suggested the use of a workshop in May 2023 for the development of the Health and Wellbeing delivery plans, and welcomed the board for further thoughts.

David Mehaffey noted the Joint Forward Plan (JFP) which the HWBB has a defined role in giving its opinion on the extent to which the JFP addresses the HWBB’s priorities. It was suggested that the use of a development session to discuss this before sign off.

Any other business.

No other business noted.

The next scheduled meeting is 27 April 2023, 14:00-17:00

Date of next meeting: Thursday 27^th April 2023.