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So um welcome everyone. Good afternoon and welcome to our webinar. So I'd like to just thank you all for coming along. I can see that people are joining slowly but surely we had over 200 registrations were sitting at 60 for people at the minute. Um And hopefully that's going to continue to increase. Um My name's Steven Fryer. I'm a critical care consultant up in N H S Grampian and I have been working on treatment escalation plan implementation along with Robin and others up in Aberdeen. Uh This is the second webinar that we have done the second one in our series and it is going to explore the practicality of looking at treatment escalation plans a little bit about advanced care planning. So A CPS, we're going to look at the doubts and concerns about their use um or previous webinar, I suppose, discuss the Y and the lot of treatment escalation planning and this webinar looks a little bit more at the, how we're going to um look at how this fits in with the deteriorating patient. So the deteriorating patient um identifying the deteriorating patient is a key element of patient safety. But the response we due to the deterioration patient is also very important. So this means managing the clinical uncertainty that goes for this um identifying ahead of time when treatment escalation is appropriate and when it's not in the patient's best interests. So the webinar looks at implementation of Tepes, looks at A CPS and we'll look at DNA CPR including um identifying the situations where this is appropriate. It'll identify the appropriate tool that delivers the best information in that situation to the clinicians. So, a CPS potentially in primary care and kept in acute emissions and secretary care. Um It look a little bit about delivering the training and education that is there to enhance their use. Looking at Tepes and a CPS and combination and interface between the two. Um and then looking at how we can make these tools digital to enhance their use. Um And finally, Robbins going to touch a little bit on how we um and corporate um tips and A CPS into uh the clinical governance processes and the merger morbidity and mortality process as well. When Robin and I first discussed the idea of using um putting together this webinar about the use of tepes, I think we always thought that maybe uh by 30 people would register. Our previous webinar had 200 people. And again, we're sitting at like 240. The last time I looked uh there are 79 people currently watching at the minute Um And I think whilst it continues to be a continued surprise us about the number of you that are joining. I think it's testament to the feeling that we all have that we need to change how you manage patient's who are deteriorating. Um I think this needs to be a system where the discussion has had earlier where management is not just timely but it's appropriate and where the plan has been considered in the context of the patient's um wider, the wider trajectory of the patient's journey. Um It needs to be a system where it's open to all and there's consistency, quality of care and those concepts of realistic medicine with the discussion of the patient, their families and their carers is maintained. I think the main function of tepes is to notice commissions to identify the goals of care rather than just the technical aspects of care. And moving away from that fixes medicine that I'm sure Robyn will mention to having a conversation with the patient, their families and carers about what we're aiming to achieve. Um So that fulfills the goals of realistic medicine and planning for the future as busy conditions, we all know that communication can get lost on call, staff, hospital night, rapid response teams, etcetera can be on familiar with the patient's and this can lead to overtreatment and nonofficial interventions. Um And I think tips in general A CPS and tips, empower the whole team to act to achieve the goals of care of that patient. It supports decision making, reduces that moral distress that arises when there's ambiguity in management plans. And when the team do um what the I think is right, rather than what they think is expected, I think that um does best for the patient and the conditions. So the webinar explores all of these questions will heal from. Experts have been working in energies, Grampian NHS borders N H X N H S, Lanarkshire and NHS Lothian. So it's, it's gotten wild, widespread. Um We will look at the national digital platform. Um and we will look at respect, we will look at a CPS, we will look at tests and we'll look at how you uh navigate um all these together. Um We aim to exchange ideas with you. So there is a chat um uh button on the on the right hand side and feel peace, feel free to put questions into the chat. Um And I will work my way through them. Um We have created a lot of the questions you submitted whenever you registered. Um uh There is a frequently asked question document that we've added to the catch up content that you can access through the landing page. So feel free to go and look at that and Sue has put the landing page. They're in the chat for you to click on if you want to go. Have a look. Um We will take questions at the end of each talk and we will have a panel at the end if everybody presenting. Um, so that we can have more of a discussion. Um There will be a break halfway through comfort break and you go and have coffee for about 10 minutes. We have a number of breakout rooms um that you can go in and chat to your fellow delegates there and um some of the speakers will be in there as well. Um That is more or less the housekeeping. Um I just want to finish by saying one of the reasons we choose Metal um as the host of the webinar is not just they're excellent support that they always give, but there's a mission behind Metal to provide healthcare training for all. So that means that we are providing this catch up content freely accessible to help train um every healthcare professional everywhere that wants to come in and look at it and it's all limited by where they are, who they know or the resources they have. So it's there. Um Our first speaker who's maybe popped up in your screen already is Professor Robin Taylor. Um Robin is a consultant RisperDAL position um currently working in Lothian Grampian Borders and he's been implementing text in all those areas. He's previously initiated the tech program in N H S Lanarkshire way back in 2016 and onwards. And he's authored a number of paper, respond tep implementation um including papers on reduction and harm for interesting tepes, reducing moral distress amongst medical staff and and recent. Excellent Riff you article on the subject as well. So Robyn is going to be looking at the challenges to implementation and I shall pass over to robin 2%. Thank you very much um Stephen and thank thank you to you all for participating and joining in. Um uh This is a simple concept but an amazingly complex underlying uh foundation and what I'm going to do, I'm going to try and take the questions and issues that are opposed to me in the training and education exercises that I've been undertaking in various hospitals over these last 23 years and just explore them. This won't be comprehensive. But at the, at the bottom of all this, the concept can be agreed by many, like we can all agree on the need for carbon reduction in uh different ing further climate change. But actually driving it forward, it means behavioral change on the part of individuals. And uh at its core, there's a whole shift in the paradigm of what actually is good medicine and good medicine. By that, I mean, good medicine in particularly a deteriorating patient because you know, and I know that urgency or a sense of unfamiliarity with the patient and so on and so forth. There are the things that make us act and react in a way which drives protocol driven medicine which may not be appropriate for the patient. And we have shown that the use of tepes reduces harms in that territory. But that's all very well. But when we're actually trying to encourage one another to adopt and attempts the tep process into medical decision making, there are sincere and genuine challenges along the way and I want to address them. So the first is the whole issue of medical uncertainty. Now, uncertainty never goes away. And as clinicians at whatever level you're functioning at will be the your you may maybe think well, there's the issue of the limitations of my competencies. And then when you come to a bedside for a deteriorating patient, there may be inadequate information, what an inadequate detail about their background or what's been done by other clinicians in the two or three days prior to your your arrival to deal with the emergency. And then there are these elements that are actually unspoken, their subliminal often that are we we bring our own temperament to our decision making. And the way I illustrate this is when we turn up at the airport to get, get check in and go for a flight, some of you will turn up 15 minutes before the closing, the gate closes and some of you will turn up to an hour and a half before that and some will be comfortable turning up early. And some say what a waste of time. There's a whole variety of things within us as persons that gen generate differences in how we handle uncertainty. We're never going to change that. When there's uncertainty in the clinical setting, we tend to say, right, uh will not, will not, we'll deal with the present problems, get on top of the present situation. And if things get worse later on, we'll deal with that, we'll cross that bridge when we come to it. And I want to emphasize that there are two planks to the, to the two elements, particularly conversations with patient's, um, uh, that, but from the foundation for a tet, the first is what are we trying to achieve? And the second is what should we be doing if things get, don't, we don't get on top of the situation and things get worse and that's usually not thought about or it's not sufficiently thought about. And there's no plan in place. If you don't think about it, there can't be a plan. And if there's no plan, then there's the uncertainty of what is going to happen when that patient gets worse. So there's not just in a deteriorating patient responsibility to recognize it, there's the responsibility to respond appropriately. Some people say to me, well, things are uncertain. Therefore, I must do this or I must do that and we'll give the patient the benefit of the doubt even although the intervention is unlikely to be helpful. Well, that's one way of dealing with uncertainty, but it gets us into difficulties. Then there are people say, well, we're very uncertain. We can't possibly put a step in place, the treatment escalation plan in place because we can't fill in the detailed bits of a tip. But I'm going to say to you the absence of a plan, whether you're going on holiday or whether you're attending to a deteriorated patient, the the absence of a plan multiplies uncertainty rather than diminishes it. So if we feel okay, filling in a tep or completing a tep process with a patient being admitted, I can't think ahead. I'm uncertain about it. I want to say we need to change that. We need to change that even we need to live with uncertainty. And at the same time, try to put in place a reasonable plan. That means that when the deterioration occurs, they will be, the patient will be treated appropriately rather than in a reactive knee jerk fashion. The knock on effects are significant not in staff as well as patient's if we are paralyzed by uncertainty. Um And I've just done a study among the Fy one Fy twos in Edinburgh and they were given five cases to study. And then amazingly on 57% of, of the, of the occasions that they had to make a decision, there was a difference in their minds between what was, what was the right thing to do and what was the expected thing to do now, if they had a plan. If they had a tip, then an F Y two or a hospital at night nurse at 11 o'clock at night would be guided and their insecurity wouldn't be driving them to go for a protocol driven interventions which may be inappropriate and internal leading to harms. Um Here's a study looking at what happened to a hospital at night. Team are rapid response, team decision, the decision making dilemmas and they had 351 call outs, uh sorry, 351 patient's and it more than one call out to some of the patient's 456 decision making events. And you see here that the consultations that resulted in a change to palliative goals of treatment occurred in 28.5% of these. Now it may differ from hospital to hospital, but there's a message there. It shouldn't be the hospital at night team who are deciding on the goals of treatment. It should be the daytime team and they should that who are on the ward round or at an MD tea or admitting the patient. And at that point in time, there's a plan for what happens or may happen or may need to happen during the night. It shouldn't be out of our staff who are making strategic decisions about a patient's management. Then we come to clinicians, you say to me, I've always done this sort of thing. Well, I can accept that I can accept that many of us as senior clinicians have thought the right thoughts. But I want to say the problem is that we haven't communicated it down the line. Um uh senior clinicians, we have a responsibility not just to the well being of patient's but to our trainees. And this continuity of care is a major issue in the provision of uh in the provision of out of our services. So we may always have done it. But I'm going to suggest we need also not to think the thoughts but put a plan in place so that our sense of uncertainty doesn't get visited on the on the encore staff or on the patient if they deteriorate out of hours, one of the consultants have chatted to in the western in Edinburgh says I really love tips on a Saturday morning because I come in, I'm on a one in eight roster with my colleagues and they help me to on a Saturday morning to get a feel for what my colleagues have considered to be appropriate in terms of goals of treatment. Um uh When I'm doing the weekend ward rounds. So it's, it's at every level that what we may have done maybe true. Our priorities for a patient, our engagement in conversations may be part of and parcel of our normal daily practice, but it needs to be communicated and that communication needs to be accessible. And then there's the big one I don't have time for this. Now, this is a difficult one because I recognize that it's not too long ago that I did acute medicine and you could admit 17 or 19 or 21 patient's in the night. But this is time well spent steps are associated with good outcomes. Admission's to I T you do go down non beneficial interventions and harms, go down, patient's and families complaints go down hospital costs go down. We've demonstrated that in a number of studies, the problem is I as a clinician do not experience the benefits of tips. I don't get a buzz out of it because to a significant extent, the tep prevents and constrains staff from overtreatment. Overtreatment is our problem. Overtreatment is our problem. And if you have a tape that's effective, then you're raining the system in such the overtreatment futile treatment is constrained. There's a different way of doing things, but the rewards are limited and we just have to accept that the reward is knowing that I've been ethically disposed to the well being of patient's, to their priorities, their preferences and to appropriate treatments and that should be reward in itself, but it's difficult to feel it. And I acknowledge that when it comes to conversations being lengthy, I just want to commend to you the issue of red map to develop by Kirsty Boyd. Um So the conversation in an acute patient doesn't last for half an hour. I've got, if I get a patient with acute respiratory failure, complicating uh COPD calm. The conversation can go through these steps. I can prepare the patient to say George, um your chest is your chest. You're in trouble with this chest of yours at the moment. And he says, I know doctor and then I get them to reflect a little bit on the way that their, their condition has been evolving over months, weeks or months. Then I come to the diagnosis and say, look, you've got pneumonia and that's got the potential to be life threatening if we don't get on top of it. And then I get into. So what is it you would like us to be doing? What do you think? I'll do my best to get you stabilized. But what are your thoughts if things take a turn for the worst, what, what would be your priorities? And then that sets the scene for what are the goals of treatment and what to do if things get worse now have robbed through it and it's not as fast as that, but it doesn't need to be so time consuming as to be burdensome. And there are certain patients for whom this is imperative in order to guarantee good management further down the track, I might get sued. This usually comes from junior staff and they frightened that by not adhering to the protocol and not intervening, they will be criticized perhaps on the ward round or the huddle at the huddle. But, um, sometimes it goes further than that, say there might be litigation or there might be complaints. So, a few months ago, I went to the Chief litigation officer for NHS Scotland and I spent an hour with him, Michael Stewart and I asked him to, I asked him to go through his sort of database. Is that where he wasn't a formal database? But he said there are almost no cases of litigation associated with conservative treatment. And he examined all the ins and outs of what was the treatment escalation plan on how it was applied. And he said, look, most cases of litigation relate to a deteriorating patient relating to a deterioration are about overtreatment, often futile treatment and families get upset if there are harms associated with an intervention that's over the top. That's when the trouble, the trouble arises. And so I want to encourage you to, I want to dismiss your fear of using tips or abandoning protocol driven interventions, as you say, well, I'm going to leave myself exposed from a medical legal point of view. And the answer is that is a very, very unlikely, far more likely is that you've taken into consideration the fact that treatment will be non beneficial. You've discussed it with the patient. George, putting you on that machine with the mask on your face. You know, I'm talking about non invasive ventilation. Uh It didn't do you, it didn't help last time you were in, um, what do you think about it now? And, and then he says, well, when we arrive at a consensus that we're not going to do certain things and then that's the territory where we need to feel a little bit more secure. And this is uh, information from the, the, the NHS law office to tell you your security should be assured assured in terms of the fear of litigation. No. Um I want to go into some elements of implementation and this is relatively recent. Should, when we encourage in training and education sessions, we encourage people to participate and to engage with the process and so on. You think, well, some people just won't engage and don't engage. Uh one of the ways that is being developed. Certainly an NHS Lothian at N H S Grampian is the idea that treatment escalation plans and particularly goals of treatment are woven into the morbidity and mortality review process. I think if we had the right questions asked at Eminem Eminem meetings with that and we'll come to that in a moment. I think a reflective process would reinforce the idea. Tips are a good thing, not so much. Well, there's, there's the communication to but the TEP process. So here, here are screenshots from what's now going onto the track system in NHS Lothian. You see was there a treatment plan in place? If no, was there evidence in there is that some degree of escalation planning took place. If no, did the absence of a written adversely affect communication. If yes, was the treat created in a timely fashion? And if yes, what level of treatment escalation was recorded? Active, full escalation, selected treatments or comfort care? That's the, that's the uh that you can re evaluate, you can look at these slides again later on your, you'll be, you'll have access to them. The more important Slade is this one and that's to do with, to do with goals of treatment. It's more subtle and you have to search and into the notes or into the, into the evaluation of the case more deeply. But it's to say we're their explicit or implicit goals of treatment at the time of admission did where the goals appropriate, did they change as things went along? If did they need to change or they were they timely in terms of changing? Often a patient's course and prognosis changes. But people keep bashing a way of doing the same thing and they ought to have changed, changed course. So here we're getting it down to the, the underlying thinking that drives a treatment escalation plan and drives the response to the deteriorating patient when they deteriorated. And when the team responded to the deterioration, did they have the right goals of treatment in mind? Should they have been embedded in the, in the tip a bit more completely and more fully and so on? And so m and M's are a mechanism whereby this the TEP process can be brought to the light into the, into the light as it were. If you're really keen, you can go for a thing called the structure judgment review method. I'm not going to deal with it in detail, but it's the Royal College of Physicians template for M and M's. And you see here, what in this one question, one, was there a problem in in assessment investigation or diagnosis was the problem associated with non beneficial interventions? And did the problem lead to harm? That's the bunch of questions. But there are eight domains and I'll just let you cast your eyes over that. But there are eight domains in which all of the questions on the previous slide are asked. So you might like to have a look if you were doing in depth M and M's, you might like to look at this template. There are other templates around. It's not, there's no one that's uh that's the best as it were, but just in case you don't have one, this is a really helpful way of assessing, where are we doing the right things from the very beginning for this patient? And did we respond to the deteriorations appropriately? Yeah. So just a note on some implementation strategies, some of you in your questions have we asked? Is it for all patient's or just patient's with a designated condition? For example, patient's with a fractured neck of femur. Should they all have a tip? That's a, that's a decision for your own locality. But if I just tell you that in Essex, in the Princess Alexandra hospital, they decided after a while that every patient being admitted acutely should have a tip. And in so doing, you avoid the question, who should have a tip and you move it automatically onto the question, what does the tip designate? What does it contain? So, uh I think in an ideal world, everyone should have attempt. Now that means the majority are for full escalation and not a great deal of, of uh work needs to be done arriving at consensus about the goals of treatment. But I do raise the question and that question was raised by many of you prior to the meeting in what you submitted in your registration. Should you have, who should be doing it well, in, in one locality I've been involved with, they're having advanced nurse practitioners who initiate the tips uh simply because they are admitting patient's in that particular unit. I think everyone in the team should be involved, but of course, it needs to be in the tent, needs to be involved. Usually by somebody with four or more years medical experience, you might include uh tips as part of your structured ward round where there's a checklist, you say has the patient got a temp? Have we reviewed it? Uh make sure that your ward clerks are stacking the paper copies into the same area as you've got D N A C P R forms. And that's regularly done. If you've got the opportunity to grow over the next two years to develop an electronic version, then I would encourage you to do so simply because the compliance goes up if it's on track or similar and you're, you're much easier to do audits. And then in one or two places we've run little campaigns. No, D N A C P R without a tep simply because D N A C P R s are not the best starting point for planning for what might, what might might be needed. If the patient deteriorates, I realize that you can't plan for, you can't discuss it with a patient if they've arrested. But the whole discussion about what are we going to, what are the goals of treatment? What to do if things go wrong shouldn't be started? You shouldn't start off with the issue of CPR. It just gets us into trouble. Patient's misunderstand it, families misunderstand it far better to have a discussion about the contents of attempt. So what are the challenges? Then there's uncertainty, giving the patient the benefit of the doubt doesn't solve it for the patient. It solves it only for me as an as an insecure person or decision maker. Tepes reduce uncertainty particularly for on call staff by setting goals of treatment. We give a framework whereby uncertainty is reduced. And this question, what should be done if things get worse? That's the, that's a key element in all of this. That historically, we haven't, we haven't been asking. We need to think ahead. We need to think has this patient got the potential for deterioration? And let's have a plan for that eventuality even although the plan needs to be flexible. Uh And uh and it may need to be changed at the time. Let's have a plan. We need to be aware of harms because harms avoidance is an integral part of tip creation. Uh And the harms come from well, meaning well motivated staff who want to do their best but do the wrong thing. And finally let's deal with the time pressure issues. I am giving something precious to my patient by giving them seven minutes in which I can arrive at a consensus about the goals of treatment and what to do. If things go wrong. That is, it's not just an ethical responsibility. It's at the heart of good care. You can call it shared decision making. Yes, you can call it realistic medicine. But if I'm in hospital, I'd like somebody to chat to me just for just for a short while and say, here's what's wrong. What are your, what are your thoughts about the situation and what are your thoughts about what we need to be doing? So this my mantra for all of these things, if it comes up is tips, make it easier to do the right thing, the expected thing to do and the right thing to do are often not the same. And that's been demonstrated to us by, by what the work we've done with junior doctors, let's improve the quality of life, not just for our patient's but for our staff as well by engaging in this process. Let's get feedback from them. We are engaged. There are a number of studies underway at the moment, including what do patient's think of all this? What do families think of all this and we're developing that as we speak. Um I, I hope some of you have had a good experience with tips. I can understand some of your hesitance is and you're there. I say your reluctance, but I would say there are rewards in this that are really worth having and even as a management level, if I tell you that complaints and, and problems fed back to management, which of course our time consuming and emotionally demanding they go down then if you're a quality improvement person, then you should be laying hold of the tapes process with, with, with eagerness. So thank you very much for listening and I'm open to questions now. Okay. Thank you very much, Robyn. Um There are no questions in the chat just yet if people want to add any. Um, please do. Um I might kick off with a question for you. Um Just I'm wondering if the chats working, I assume it is. What are the common barriers that you have um come up with, against, with implementation of um Tepes? What about the, the common, common things that come across and what have you uh done to overcome the barriers? What have your solutions been? Uh Well, the first of all, there's the practical value if you're doing with paper forms, are they always available? Let's make sure they're available. That's very practical. The second is uh I think a no non consultant staff feel a little bit as hesitant about engaging in the process. I think. Well, I, that's above my pay grade. I shouldn't be doing it. We're encouraging everyone to at least make a stab at it. Remember, it has to be endorsed before it's, it can be activated. It has to be endorsed in order for it to become a medical legally active document so you can encouraging uh younger stuff to feel secure in, in embarking on the process is part of it. And that I think we need consultants to be creating a permission giving environment and sure there were mistakes, sure they'll be in, in, in experience, but that's true of some of our practical procedures. I remember learning bronchoscopy and it took four or five months before you got up to running speed with the skills. Well, somebody had to be patient with me and therefore being patient with one another, creating a permission giving environment so that an F Y one or an F Y two knows that Doctor Taylor when he's on his ward round will commend the fact that the tape is in place rather than question, it is going to be a very, very soft but critically important dimension. And lastly, I think we probably the barrier, the greatest barriers, the time barrier. And at this point in the life of the NHS, I can understand that. But if we don't spend time, we get disasters. If we don't spend time, we get disasters and that's, and the disaster rate goes down if you have a plan in place. So, um let's, that's defensive medicine ought to mean not doing everything, defensive medicine, not to mean putting a plan, a plan in place and, and training ourselves as senior clinicians to think this way because it's not, it's not, it doesn't come naturally to us. So they are the barriers okay. Um There is, there's a question from Victoria who is asking vanishes grandma has a TEP template. Yes, we are rolling that out coming to an area near you. Um uh Paula has asked if um there would be, you know, who should be trained to do this, who should have the conversation. So I think this comes into communication. So training for nursing staff that could have the conversation. Um or do you have resources Robin, I suppose, would you recommend resources about having the discussion? Um And um you know, who, who, who should do that, who, who's open to doing that? You've kind of covered a wee bit in your talk. Right. Well, I, I only put up one slide, the red map tool because that's very helpful in the acute setting. If it's a bit more relaxed. In other words, you're not having, uh, you know, you're not in the middle of a ward round and you're not just admitting 17 patient's, then you can spend a little bit more time. Yes, I can provide guidance and, and resources. And a Sue Gibson from Medal will be happy to provide my email address and I'll be happy to give you directions. Um The thing about communication skills is a bit the communication skills I do need to be learned and they don't, they don't come naturally in a deteriorating patient. You and I want to be optimistic. We want to be hopeful. And yet if we're realistic, I have to say to some of our patient's, I'm not sure I can pull you through or we'll do our best, but we may not win. And you see, we need to be learned to be truth. A tuition in truthfulness is part of communication skills because communications is about empathetic engagement. But it's also about the substance of what we communicate to a seriously ill patient and truthfulness were shy of it were squeamish about a financial fact. If we're not truthful, the patient feels isolated, they will know, they have an instinct to know when we're not actually being up front with them. So there's all of that communication skills are just as important as clinical decision making skills. Um But you have to learn it and you have to practice it in order to get it right. You won't get it right first time and you won't get it right. Probably until you've done it 30 or 40 times. Another question around uh communication um would be, um, what about the patient or the family who don't want to discuss? Or it's Brian's question here. What if patient's um uh family's expectations are unsafe or who are not achievable? I either not a candidate or how do you have that difficult conversation? Well, I'll be honest, that's come that treatment escalation plans are not going to solve that problem. Um Maybe one in 20 or one in 25 patient's or patients', families will be in that category and it, and it is difficult. It's taxing, it wears, it wears you down. However, in terms of being a plan and you're the first of all having a plan that's offered to you by a senior staff and is contained in a temp. And then you're having to use as at 11 o'clock at night when you call the family in because of a deteriorating patient. It's easier the platform upon which you stand has made much more robust if there's a plan already there. Um for those of you who are juniors in all of this. Um I have to suggest to you that you have to say you have to pass it up the line if it's really, really challenging and difficult. And even those of us who have been around a long time find this an immensely problematic territory of life. And I don't need to say that in front of Stephen Fryer because he's in intensive, the intensive ists have this almost every week as part of their work. It's, it's in the territory of communication, skills development. But it, but there's no easy answer to that because we live in an environment where families feel they ought to be controlling the situation rather than the medics tips don't solve that. And I'm not setting out to solve it, but I have every sympathy with you in asking the question. I've got two more questions for you. The first question is about, I think hopefully answering Emma's question here, Joan's question in that. How do you engage your colleagues? How do you engage those senior decision makers um better um whether that's consultant level or even higher management. How do you, how do you say, look, we think this is good and useful. Well, uh I think I'll have to be honest, I've struggled with it myself. I've engaged when I was in Lanarkshire. I went after two years of trying to introduce tips. I felt as if I was up, up against the brick wall over that very reason. So I went around 100 and 69 of them over a period of a year and had a 1 to 1 conversation from a juniors point of view. I think you need to get up your loins and it's and politely but firmly say, look, I think we really need a tip for this patient. And what do you think should be the boundaries and goals of treatment? What are the boundaries? Is it for full escalation or selected appropriate treatments or comfort cares? The future belongs to you as juniors, the future belongs to you. There's a generation of my generation who find this really difficult. And I think if you learn, if you, if you learn to, to stand firm politely, then you'll do the, you'll do, you'll not just do your individual patient's a service, you'll do the NHS service. This is the future, this is the future. And uh and I look to you, I'm agonizing with you when you feel that you're unsupported. Uh but don't lose heart and don't lose your way in terms of your own career development, become the person that you want your consultant to be. When it comes to this type of work, this dimension of work and never give up, never give up. I didn't give up in Lanarkshire and I'm still not going to give up even although I have dearly beloved colleagues who give me a difficult time. That's the best I can say. And I have one last question because it's, it's happened. It'll, it'll come up later on. Um, what would you say? Um, the difference between treatment escalation plan uh form there? An A C P so an advanced care plan and uh and respect as an advanced care plan. What do you think the difference between them is and where, where, where do they sit? Um, we're going to hear a little bit about this from our next speakers anyway, but just your opinion on it. Well, uh uh first of all, the treatment escalation plan is designed specifically for the hospital environment for acute admission's. And it's about planning for the next few days and it's complementary to what you would find in a respect form or an advanced or anticipatory care plan. Um When a patient's out in the community or at an outpatient clinic, I would use respect because it's a good anticipatory care plan, advanced care plan. And I'm planning for weeks and months ahead and I'm getting the principles of select, selecting or versus not selecting certain ways forward with a patient's healthcare. I'm getting these principles woven into a conversation and I'm getting consensus with the patient in the less pressured setting of advanced my for me and respiration, advanced lung disease clinic. For example, when a patient comes into hospital, no matter what plan they have already there, you need to revise it. It needs to be up, the circumstances have changed other, otherwise they wouldn't come in. Sometimes the patient's thoughts about what they want for the best have changed. Or sometimes these thoughts changed during the course of an admission and the, the, uh, the treatment escalation plan compliments what's been done by way of advance care planning or, or providing a respect. The two will talk to each other when the patient's admitted or when the patient's discharged, but they're, they're different. I look, put it this way if I want to climb amount and I wear boots, if I want to walk on the beach, I wear sandals and they're all footwear, but they're designed for a different environment and a different concept. So, uh sadly, in the past, there's been this an idea that they're competitive, there's a, it's either or, but no, it's both and, and one complements the other. And we're going to talk about that. The team from Lanarkshire are going to talk about it and doctor Alistair Ewing is going to talk about it in a moment regarding the national Digital platform. So I think Steven I'll leave it at that. Great. That's been amazing. Robin, thank you very much and Robbins going to stick around for the panel discussion at the end. Um If you have a question for the panel discussion that you want to put everybody, if you just highlight that right panel discussion in your question, um Stick it in the chat box and the messages and I will come to that.