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incredibly honored. Very please to have Mr David Jones with us. David is working part time as a medical kilometer with ensure or throw in Manchester. He retired is a consultant general. Correct the surgeon in 2020 on has extensive experience and search for education on professional affairs and healthcare. He was the TPD in general surgery on develop cataracts, simulation course surgical trainees in the Manchester Surgical Skills and Simulation Center. He's been drink course, a rectal for the fire fighting Manchester Me to Trauma Skills course, which he helped develop following the monster Arena attacks for the local major trauma network. He developed an interest in sustainable healthcare towards the end of its surgery Korea. And that was the theme for his years. President of the Montecito Medical Society in 2021 David is jointly for the Green or operations James Lind Alliance NIH. Our medical priority setting partnership, which aims has that research funding priorities through public and professional engagement to deliver green or operations eso to give his talk on changing green operations. Thank you very much for joining us, Mr David Jones. Thank you and confirm you can hear me and see my screen. We can definitely hear you. I can't see your screen in the moment. My Yep. There we go. We can see your screen. Now you see the presentation now? Yeah, well, thanks very much for that very kind introduction, Onda. So now I go to talk about changing to green or operations, and I just like to set the scene a little bit on, but I'm going to assume that everybody is on board with the concept of climate change in the need to do something about it on, I'm going to set the scene and then move on to the greener operations research, priority setting partnership that I've been involved with that came to a conclusion just the day before yesterday. So the data at the end is very hot off the press on, you've spoken quite a lot already about the need to make change and and changes quite difficult, isn't it? Another how many of you have sat outside of pubs such as this one on the left, next to a patio heater in April or May on with were addicted to travel. And yeah, we've got to start making changes to the way we live the way we work in the way we deliver surgery and perhaps challenge inmates that you shouldn't actually go and sit it outside the pub with the patio heater. But go somewhere else. Where? A coat. Oh, our sit inside. But these are discussions you need to start having with your friends family on contact. So heard the NHS is responsible for something like 4% of the UK. Is carbon dioxide equivalent emissions on? There's a commitment to get to Net zero in the NHS. Now that's going to mean a big change inclination. Your practice on that changing clinical practice needs to be evidence based. It needs to deliver the health care in your instance orthopedic surgery with a lower carbon footprint, but with the outcomes that all our patients were want and deserve. Now my own journey on sustainability just started with something very simple. And this is an example of what I called normalized deviance. And you might want to put or think about your own example in your own operating theaters, your own orthopedic practice of something that's become normalized part of your practice but perhaps shouldn't be so. My practice had a lot of inguinal hernia surgery on I noticed that there was two diet firm ease on the instrument tray. There was the conventional forceps die if their meet with the red lead, which came with the instrument pack. But for every case, they were opening a single use finger switch diet, same which everybody liked. So I started looking into that, and I was told, you know, don't be silly. It only costs 1 lbs 64 for the version with the 3 m cable, but but I started to pursue this in generator on interest in sustainability. It's just some simple little trigger like this that you need to think about your own practice that you can then use to start to make a difference on whilst the only cost 1 lbs 64. The procurement of this finger switch diet. Same. It would be responsible and have a significant carbon footprint on, I would say, for an angle hernia operation. There's nothing you can't do with the conventional reusable diet. Same the indeed the finger switch for I did a lot of laparoscopic. Cholecystectomy is a side was finishing my training. Laparoscopic surgery was just coming in, and I must have done probably possibly even 1/4 finger number of laparoscopic cholecystectomy is using reusable instruments only. I never saw a plastic court probably toe the last 10 to 15 years by operating practice on these started to creep in on Teo the fear to trace, um, because I was getting towards the end of my career. I I wanted to be seen to be down there with the kids. So I just normalized the use of plastic reusable laproscopic ports and got rid of the reusable drapes and started to use the single use drapes and the single use plastic kidney dishes. As we've heard on, I'm sure there's something that you can all think off in your environment. Where you working? That's approval into my diet firm in my laparoscopic ports that you've adopted but could be focused for change and perhaps put it in the chat box if you were know any. So I don't know whether you know your trust. Green plan yesterday was actually clean Air day on Green or an HS and out yesterday that every MHS trust in the country now has a green plan on. If you haven't seen the Green Plan for the organization. Where you working? I would go and look it out and perhaps go and talk to the sustainability team because you will have one on. But maybe something in your particular trust that you can get involved with straight away on this is the, uh, clean the big the The Green Plan. For my trust, it's Manchester University NHS Foundation Trust. We've got several hospitals and we're actually the biggest trust in the country on this is how our carbon footprint breaks down. So three quarters of our carbon footprint relates to the supply chain on procurement. And I know you have heard from a mood butter earlier on this afternoon on certainly in surgery, procurement of the equipment that we use, Have you heard today is a highly significant component of our carbon footprint. Travel for patients and visitors and staff is down at about 6%. Then is the in eight carbon footprint off your particular trust? Your particular hospital, at about 20% on waist, is in their waist. Itself isn't responsible for a large part of the carbon footprint. It is responsible for pollution. But the best management of waste is not to produce any waste, if you can in the first instance, with responsible procurement. So let's just have a look at a couple of operations, one that I know very well. I did lots of England or hernia repairs, and you can do in England hernia repair As an open technique, you can use a local anesthesia, spinal anesthesia, general anesthesia. You can do keyhole surgery, which is usually under general anesthesia on. For any of these options, you could use single use well, reusable equipment. When I was a training became a consultant. I did about a third of my hernias under local anesthesia. But then perhaps another example of normalized deviance. It was easier to do them under general anesthesia if I did them under local anesthesia. Everybody else left the operating theater and left me there on my own on. Do you start to adopt practices that perhaps there not best to the patient on for the environment? So just a simple operation, like an inguinal hernia repair as many variables that you're associating with different clinical outcomes on different carbon footprints, and I know in orthopedics and this is a bit technical. This, like you're very keen on measuring patient reported outcomes on these air The outcomes for inguinal hernia surgery. For some reason, we've stopped publishing these. We haven't done them since 2017. But the shocking thing about England or hernia surgery is that something like a half, depending on which lot of quality of life assessment you used either resulted in no change in the quality of the quality of health or worsened quality of health on the worsened quality of health, was probably because the hernia wasn't associated with that much in the way of symptoms, perhaps didn't need mending on the purpose and had chronic pain or growing pain after the operation. So this avoidable surgery, which is very contentious, is potentially a part of our carbon footprint that we could address. Now I know you're old orthopedic surgeons and coming from Manchester, we're very proud of professors to John Charlie, who did the first total hip replacement back in 1960 on day worked in various places but most noticeably, a writing the hospital near Wigan. Now you've seen ah graph of temperature change and climate change, and on this graph, you can see I put this set of bilateral hip replacements. They're in 1960 if you look above, you can see the global warming that's happened since the first hip replacement. So all the hip replacements that have ever been done in the world have been done in this last part off the rise in global temperatures. I'm not saying it's all due to hip replacements, but it just Redflex a change in the way we live, the way we work on the advances in medical care, surgical care, which company? Increasing carbon footprint on associative emissions. Now I know in orthopedics you're very good monitoring your outcomes on. As a general surgeon, I have to pay homage to you because most people who have a hip replacement on it and the latest data that was published earlier this year, I think 97.2% of patients having a hip replacement reported in improvement in health. So it's a fantastic operation. So is one we want to you to carry on delivering. But can we do that within a lower carbon budget? Now I know. Get it right? First time is a bit of ah Marmite topic, but get it right. First time I started in orthopedics on. I think the first report forget it, right? First I'm related to orthopedics was back in 2015 on this showed a very significant variation in practice and outcomes, uh, across the country, on dingy if rinse hospitals. Onda. I'm no expert, and I know there are various ways that you could do. A hip replacement, I don't know, really should cement it in or don't cement it in which one's easier to do. Which one's more likely to need revision. Need revision. Which one's going to be easier on give the better outcome to the patient. But there is a significant variation in the clinical environmental impact from the operations that you're doing now it gets it right. First time in orthopedics They they've gone back on had another look at it on. This was from the first study in Manchester on the blue part of the grafts of those having a cemented hip replacement on. You may know some of these centers that if you see there's such a huge variation between the sort of hip replacement you get in stop oars compared to bolt um, which is probably at the most 20 miles apart on My trust is somewhere in the middle between those two organizations. So if you look at the get it right first time follow up study, they did actually in a very small part, look at the environmental impact and there was something like nearly 50,000 procedures avoided by adopting the principles of guess it, right, first time on reducing the variables. It's a very contentious topic, but the word used in the get it right first time report is undesirable activity. And getting rid of what was perceived is undesirable. Activity was associated in something like 18 million lbs of procurement savings on a significant reduction and the CEO, to be equivalent emissions, associate it with orthopedic practice so well, don't. So I'm gonna move on now to the initiative that I've been involved with, which is the James Linda Lions Greener operations, priority setting partnership. And James Lend, if you've never heard of him, was the Scottish naval physician who is credited with doing one of the first clinical trials back in the 18th century who showed in a trial giving all sorts of strange substances that you could reduce scurvy on there by mortality in sailors by giving Citrus fruits on James Linda's name is attached to something called the James Wind Alliance, which is allied to a National Institute for Health Research on the James Lind Alliance. Does priority setting partnerships to raise awareness of research questions on one of the keys is this. The involved patients Carers, A. Z well, as clinicians, all working together under James Lynn. Priority Setting Partnership agrees which uncertainties about treatments matter most on deserve the priority on attention for research funding. And the unique thing about this is that it gives a voice to patients, and care is not just the clinician's. So the outcome isn't just that of, ah, researcher. You may be biased towards a particular technique, a particular implant or whatever, but it's a it's an open process on, hopefully delivers the research that is important for patients. Uh, we started a project I I'll tell you a couple of years ago. But the NIH are actually announced quite large streams of funding at the time of Cop 26 in Glasgow last year on they still have many funding streams open, uh, which would be applicable for people wanting to do research, wants him to make operations greener. So it's food for thought, and I think this is an area for research funding. This is only likely to get bigger. So the Green or Operations James Linda Lights priority setting partnership. The aim was to set a top 10 research priorities to deliver more sustainable operations on every PSP comes up with a top 10, and this actually concluded only two days ago in London on Wednesday, So the results are hot off the press. So we started on this journey back at the end of 2019, when we got approval for it. Covic came along on inevitably delayed everything. So it's hosted in my trust. Manchester University Foundation Trust and it's funded from monies are how, within the charity that came from a philanthropic patient, what we hosted in Manchester, it's very much a national partnership on We've got many, many major national partners in medical and allied health care professionals, including the Road College of Surgeons of England, the Role College of Surgeons of Edinburgh, the role college of any statistic association of any statistics and many professional body's associated with Hal. I happy with with allied health professionals that help us deliver operations on. It's also supported by Center Sustainable Healthcare. UK Health Alliance for Climate Change. This week was actually the first time I've ever met because we did everything on the zoom up until this Wednesday. So the process involves two keys, surveys and initial survey on an interim survey. The initial survey ran last year on it asked a very open questions about what your thoughts were around delivering more sustainable operations. Um, we have almost 300 responses. Almost 80% of those were healthcare professionals on about 20% from the patient care on public, and we got 1600 suggestions. We then had to distill that into something called the interim survey, which was open until this spring on. I know some of you completed that survey and thank you very much for helping us with this project. We had to include every suggestion that had been raised to be seen, to be given an equal voice to everything. Convince resulted in 60 questions in the interim survey. All the questions in the interim survey open subject to a verification of evidence. So we've done on up to date state of the art literature search around the topic of greener operations on that will be published shortly, along with the rest of the project. And we got more responses in the interim survey on a similar split between health care workers on the patient in public. So 25 of those 60 questions were taken to the final beating on Wednesday. So if you completed the survey, you out to identify your own 10 priorities, I'm pleased to say that it was actually very good concordant. So despite having a much farm or healthcare workers and patient in public, there was a lot of concordant between the two groups of healthcare and patient in public groups. We identified 25 questions to be considered at the meeting on Wednesday. On the concordant spent, there were 15 of each group stopped, 20 included in the top 25. So we had the meeting, which was hosted by the Association of Any Statistics Can do, made their facility in London available, and again it was mix of participants with laypeople, professional people, people from allied health care. They were recruited openly on the nature of the procedure to get to a top 10 out of these 25 is by independent small group working using facilitators from the James, then the alliance to make sure that everybody got an equal voice and nobody dominated. So this is just a sample of some of the workings, and you might see mood butter in the picture on the left who was involved on the small groups changed throughout the day. Eso that we get a consensus and there's no strong voice in any particular group, so that you come out with a top 10 that we think is valid. So this was the end of the day. On Wednesday, we was all gathered together, having agreed a top 10 on our going to show you a short video which just announced the top 10. We're here today to send the top 10 priorities for research funding to deliver greener operations to help the NHS achieve that zero. Today we were joined by diverse group of people patients. Care is conditions members of the public on they've worked really hard to help us to robustly develop these top 10 research priorities. What's the most sustainable forms of effective infection prevention and control used around the time of a non operation for example, ppd. Drapes cleaner in ventilation. How can environmental sustainability be incorporated into the organizational manage of operation? How should the environmental impact in operation we weighed against its clinical outcomes? FINANCIAL. What is the environmental impact? Different anesthetic techniques. For example, different types of general regional local anesthesia used for the same operation? How do we measure and compare the short, long term environmental impacts of surgical and non surgical treatments that the same condition? How come the amounts of waste generate it during it around the time of the operation? Be minimized. Can more efficient use of operating theaters associative practices reduce the environmental impact off for a shins? How can have care professionals who deliver care, joining and arrived type of operation encouraged to adults sustainable actions in practice? How can help care organizations will sustainably prop your medicines, equipment and I Tums used during and around the time of operation. How come more sustainable reusable equipment safely be used during and around the time of a non operation so that that's the top 10? It's probably difficult to take on board just looking at it like that, but I'll show the top 10 and there's probably something for everybody in there. It's always possible to debate the questions. But as I say, there's a very detail literature reviewed to check the all of these questions that were included, uh, not been answered by research or if they're partially answered. There's identified need for more research in this area. And if you're going to get involved in doing some research in this area, or just making some changes in the environment in which you work, the priorities which were a James Linda Lions Top 10, um, or likely to be received favorably and more likely to attract funding. Whilst we published the top 10, we're going to publish all of the project, so none off the questions that were raised will will be lost. But you can see there are questions around, uh, the the use of reusable equipment, and the cow cannot be safely use. There's a lot about procurement, and you've heard already today about procurement on. That's still a very difficult areas. How we procure with an appropriate Calvin budget. They're behavioral questions. How do we actually get ourselves? T change on deliver more sustainable operations? It's difficult enough not to be enticed and sit outside that hub with the patio heater. So there's a huge area of research relations about behavior, and I'm sure they're. You'll recognize there are ways that we can use the operating theaters more efficiently, and we need to do research to see how we can show that safe within a lower carbon budget. There's a lot of discussion about waist on down. It's really about minimizing or waste the questions around, minimizing waste rather than what you do with it. Did the a miserable enough to generate waste because waste itself is a so were they fairly low proportion of our carbon budget but minimizing that wasting the procurement is important. Measuring our outcomes, which you've been very good at an orthopedic surgery on a short term, the long term basis is important to do. We need to operate how the outcomes for operative and non operative treatments comparing You've heard about anesthesia, Really, you're on, and there's still a lot of questions. There are some assumptions around inhaled and intravenous forms of anesthesia, but it's still a area that's right for research. And there's this big factor about how do we weigh up the environmental impact of an operation with that against its clinical and financial costs on day, perhaps we should be talking about carbon budgets rather than financial budgets. Or perhaps we should be talking about both. How do we get really get in behavioral term sustainability embedded in our daily practice on what are the most suitable forms off infection prevention? Which compass is many of the things that we've discussed today? So what I would encourage you to to do, we've This's we We've just published the results on the James Linda Lions website. So if you go and visit the James Lind Alliance website, your see there's links to the green or operations sustainable peri operative practice Top 10. Uh, we only got to the conclusion on Wednesday, so we're going to publish the results in full, including the priorities that we're not in. The top 10 will be publishing the literature review but really want to encourage research around these themes. Um, to get engaged around these things as you've discussed on disseminating this and we're the team that I'm involved with a very happy to come and talked to groups that may be interested in doing research in that area, so I'll conclude there. I'm very happy. Teo, take any questions or look to see what your evidence of normalized deviance in your operating theaters. A Z being do. What's this space? Is Mork coming out very quickly. Visit James Lind. Alliance Website. Thank you, David. Thanks so much. That was absolutely brilliant. Talk on Thank you very much. Well, for a lot of hard work you're doing with the James Lind Alliance program setting partnership because I think, you know, without that kind of engage in our national level, you know, we wouldn't, you know, make a much prove us is we would like. So thank you ever so much for that. Um, thank you very much for joining us. And I'm now gonna hand over to all over for some closing remarks from our conference today. Thank you very much. You know, and I just wanted to pass the thank you for your work on today's conference and bringing together a fantastic array of speakers. Thank you, Mr Jones for you. The Aquino speak speech today on. I just want to thank all of you for attending today and making our first on my naugle sustainability in Orthopedic Surgery Conference of Success. It really has been a journey to get this far, but But by you being here today, we hope that we can continue to develop, develop and deliver this event in the years to come on. The hopefully become bigger and better. I want to thank all our speaker's who have shared fantastic initiatives, ideas and ways for us. Ultram aspire to and used to improve our sustainability quality improvement within the NHS. I'm really make a difference. What is clear is that the world is more where the challenge with regards to sustainability, climate change, inefficiency and I think it's vital the surgeons. We continue to contribute to sustainable healthcare and it's triple bottom line to give the NHS the best possible chance to improve patient's lives on. I leave you wanting to highlight that our Congress the boat annual Congress is in November 21st, the 25th on go. We will be offering a prior to the best of stand a beauty projects admitted submitted for presentation. So a lot of you there today who keen on stent ability we encourage you to Teo get your projects admitted on. We look forward to seeing you in November, which will also be on the metal platform. Please. Do you feel that the feedback for me at the end of today on But that's just know what you thought of the event on. Remember that this event will be available under manned on the metal platform that anyone Teo review to watch with the sessions on, even collect a certificate at the end of attendance. Please do that. Your friends know if you thought that this was a good event, let them there they can Still, it's union and still get a comfort. A course certificate for for it. So thank you all for coming on, but hopefully we'll see you. Our Congress. Oh, last week. Sorry. Before I go, I want to say a big thank you to meddle at Phil and sue for their amazing work and making this happen without it could be possible. So I just want to say thank you to them as well. Much appreciated for their support. So without further ado, enjoy, enjoy the sunshine. And like I said, see our congress