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And I think that we can move on to our first speaker today and it gives me great pleasure to be able to introduce to the stage. Professor mcnally, um invited Professor mcnally to come and talk with us a couple of months ago. And within almost half an hour of sending out an invitation, she said, yes, please. I really want to get involved. This sounds like a fantastic event. Um So I'm absolutely thrilled that she's able to join us here today. Um And I will hand over the stage to you, Professor mcnally. Thank you very much. Thank you. And it's lovely to see everybody. Um I'm just going to share some slides. Um uh huh. Mhm. Um Hang on or maybe I'm not um say, can you see my slides? Yes, we can. Perfect. So, um this is a whole load of different ideas on sustainability and orthopedic. So, I'm a consultant orthopaedic surgeon in East Sussex Healthcare NHS Trust on the South Coast, which is lovely. Um and deputy director for the Center for Productive Care. Um I'm also present the Medical Women's Federation, which is where I am today. Um I have no conflicts of, in a sense of productive care, pays my trust for half a day of my time. I do lots of other things or have done for fun and I'm going to talk about some of those um today because they're all quite connected. Um So this is also me. Um uh the left is me operating. Um That's about the only picture I've got, but it's me being very pregnant. That kid is now at university. I've done quite a lot with women in surgery. Um and um diversity issues. So, um and I've put up two links there from when I was on the Council of the Royal College of Surgeons of England for 10 years, 2011, 2021. So our CSE MG four slash career for is that study. Um uh So please go on that. It's all free resources. Thank you. Um So sustainability is reduce, reuse, recycle, but we don't really think about the reduce enough and reduces reducing waste. So things that didn't need to have happened. Um And that's not just waste of staff, like all the packets you have to open it. It's also a waste of staff's time or another human beings time when they could have been doing something else. So they're working very hard, but actually, that might not have been necessary. Um Okay. Um So this is my mother's been um in half a week, it's half full. Um And uh sure we can talk about I had, I've got four kids. We had disposable, we had non disposable. Nappies of territory. Napping is we did all that, you know. Um, but actually you can't get with carers and things, but what I'm going to say, literally what a waste. Um And it's not just that it's the people to whole time equivalents looking after somebody, that's all that stuff if dementia is preventable. So this is a slide from the Lancet Commission on dementia and right in the middle is exercise. Most people if you say, can you reduce your risk of dementia? They'd say yes, please. I'll take the tablet. So I'm just putting the context of what I've done most of my um non operating time thinking about. I've also got column in the BMJ saying this was uh something about road traffic, if we can actually reduce the number of people having accidents, not accidents, collisions, I should say that would reduce so many completely changed lives and bereavement, um that sort of thing. So, um yeah, do you look out for me in the BMJ? It's open access. Um But it's just a different way of thinking about it. Um I spent my sho years sometimes picking glass out of people's faces because that was before seatbelts were widely um used. Um So um on one of the earlier drafts of the agenda, it said I was talking about Q I methodology and lean system. So I've got two slides on that. Uh So I've got an MBA and my dissertation was about starting ambulation, traumatised. But basically, if you want to change something you can but do it small, ask everybody, keep asking people try and get it to fit their agenda. So I had um coffee and biscuits with the receptionist and the ward clerks and every to find out their agenda when I was trying to change a few things on the ward, Um Get lots of before data because it's much easier to present. You got after challenge each other listen to little create something. So actually, for my trying to do the ambulatory trauma list, we created a patient information leaflet to be given from the emergency department. So people didn't feel they were being flogged off by not being admitted. So it's that kind of thing. Um um And this is what Qatar says about the eighth for how to change. And it's basically, I think Tim Briggs called it a burning platform. You've got to show people how incredibly important it is to do this important thing, have your vision, but you can't just do it and walk away. You've got to get other people involved and enthused and then you've got to go back and keep on embedding it. Um So that's the, but I thought I was at one point supposed to be talking about what actually I think I was invited because I've got three papers now gave me on uh on sustainability. Um uh I know obviously we've all been doing webinars for uh ages. Uh But what I tend to do is I print screen and copy and paste into a word document as we go along for the interesting stuff. So if you feel free, that's my top tip to get maximize you obviously asking slides later, but you might want to do this. Um So I've written some stuff about sustainability and the middle one is what I'm really talking about reducing complications and surgical activity. If you can do preoperative care better and shared decision making and that will reduce the number of operations we do unnecessarily. Um I also um we started the Sustainability Committee at the Royal College of Surgeons of England. That's a draft of our strategy. Um You go on the website there. Um It was down when I tried to download the latest one with Victoria Pina uh being instrumental in starting this. Um uh Yeah. Uh So I'm going to say God, I feel like a vascular. So he's periodic care, patient centered nous prevention and pre debilitation. Those are the big wins for sustainability and surgery. So period, active care is from the moment surgery contemplated until full recovery. So you can imagine all those little steps that have to happen. You know, the GP has to think and the um they often go to an MXK practitioner or there's some decision to operate or um and then the assessment and they need to sit around being on a waiting list and we need to use that time better and we also need to use the POSTOP it. We need to get all that anything upfront. We can get up front. The problem is it's actually lots of silos and people wait and you get decisions made a bit late for people coming. I frequently get emails going. So and so's BP is this or they're HBA one C is that? And it's like, and they go, do you want to operate? It's like I'm a surgeon. Of course, I want to operate. You're asking the wrong question and what we need to do is get screening early when they go on the waiting list. Um And then if there are big problems identified um changing it but having all the little problems having the nurses deal with that. So the center of corruptly care is amazingly credible. We've got great news that so do uh do go on our website CPAP dot org dot UK. Um All these big, big enormous organizations working together with patient's and health charities and policy workers to try and get it like this is how it's done. We don't have to have a discussion about how we treat anemia. This is how we treat anemia. Page 17, whatever. Um And we've got loads of guidance. They do look it up, see part of the UK. It is really good and it's largely funded by the Royal College of Iniesta's, which makes me feel very humble. It's like, it's like the Iniesta's buy me a coffee every single day. Um uh for my entire career. Um So we've got lovely stuff and it's about how to, how to do day surgery, all that stuff. So, do you do use it for everybody? We've got pages for patient's on there too. So this is how we can do the reduced, better preparation for surgeries, fewer complications, prevention, fragility fractures can be prevented. We need to get our older people. I'm going to do it now just because I don't know if this works. I haven't tried it in this room but basically sit to stand, you won't get your granny doing squats, but you can get your granny doing, sit to stand from a chair. How many of these can you do in a minute if you know, we can teach people to do that? Admittedly. Um uh that sort of thing we need to do. Um So this was a paper that we wrote um recently on Lean Pathways North Police. I just like to highlight ear a muscle who's organizing uh some of this meeting. Um And um I keep getting told how great you got two people called Scarlet who co authors on a paper because basically I asked on Twitter at Scarlett mcnally dot co dot UK. Uh no at Scarlett mcnally on Twitter. Um for people who would help, right? And we each read a little section and it was really lovely working together and talking about sustainability across all the bits of the pathway. So, thanks team. It's on my website as well if you want to download that. Um It's about because that's why you're here on this conference. Why it's important. Um Just the waist 10% of complication, 14% of patient's express regret, at least 11% of readmissions are preventable. Um So that's the waste a bit. So the preoctive phase needs to be used. Um So, and that's focusing the modifiable risk factors and empowering patient's and getting the pre assessment team empowered. So you don't just shout back at them. Oh That BP is not too bad. Of course, I'm gonna operate. You kind of get so that it's done early in the pathway so that they go, oh this person published with this, but I told them to go for a walk every day and to stop it, you know, eating so much junk food and it's like, oh well done, you've done a great job, you know. Um So it's what can you do earlier? So um crutches, discharge planning, you know, I've got in my patient information, leaflet, things, find a friend to stay with so that you can be a day case. So they find a friend. Um I don't want to admit people just cause they haven't got folk postop a human being that they can, um, stay with or stay with them, uh, and crutches. So, um, you know, so it's practiced in advance, um, uh, smoking cessation. This is the big, big thing. This is from the World Health Organization, January 2020. You can google it. Um, 50% reduction in complications and it kicks in about 19% reduction in complications within four weeks. Um, it's really worth doing and what I tell people in my clinic, I said I'm not going to do your skate way. Um, nonunion surgery. If you're still smoking, there's no point. It's going to fall apart in a sea of person. It could be horrible. So it just stops making the craving only last 90 seconds you can do it some do something. I'm just, you know, but luckily there's evidence behind that. So, um, and I get away with it because people think I'm nice even if I'm not. Um, the preop exercise is the best and most they've got the most evidence. Um, so I tell people go for a walk every day, use a static bike, go swimming. I've just helped, um, swim England with some new resources. So they've got a Pool Finder app. If you go to Swim England Pool finder, you can find the nearest pool. So I've sent people after that because, you know, if their legs hurt, they don't want to go for a jog or whatever and what you're trying to do with the exercise. You don't have to be an exercise, physiologist to tell people go for a walk every day or go swimming. You want the cardiovascular fitness, 100 and 50 minutes a week. You want the strength like squat so you can get out of bed and they're not stuck in hospital deep breathing. So they don't get pneumonia and things and then a bit about the practicing mobility aid. So balancing on, you know, so they don't dislocate their hit when they're trying to um plug in the charger. I had a hip replacement two years ago, which is working incredibly well. But I practiced before hand balancing on the good leg, like ballet exercises so that I didn't dislocate my hip kind of bending down to plug in my charger. But why should it just be me doing that? It should be everybody. Um So pre habilitating is the term for when it's a formal program individualized to you for exercise is making a bit of, you know, they talk about the other stuff and surgery schools put quite well as a kind of peer support thing that everybody's invited up on, you know, from 2 to 4 on Wednesday afternoon on this particular day. And you get 20 people in the room to talk about, you know, they're about to have a hip replacement or no replacement or something. They work incredibly well. You can't, online does work, but it needs to be local and personalized because otherwise people, um, people don't feel it applies to them, they think. Oh, yeah, that's very good. But it doesn't apply to me because, you know, um, maybe some people, everybody's a bit different but we need to hit everybody. Um, nutrition is really big. I've got a better slide on, on, on this, uh, anemias. I've got a better slide on. But this anemia we often diet detective eat new thing. The BNF changed last week because of some of this guidance we brought out from center productive care, we wrote to them and said it's ridiculous telling people to take these iron tablets three times a day because that stimulates hexedine which then stops the absorption of more iron and then you get diarrhea and then you don't take your iron tablets, then you're anemic. So once a day, the BNF has changed it. Um uh And uh or on alternate days if the symptoms of um um so uh IV I, and if there's less than four weeks to go when they are anemic, um it is something that modifiable and there's lots of stuff about diet and then the inter operative phase and there are lots of initiatives about trying to not waste. All those. You've got 10 highly trained individuals there and lots of kit not wasting that. Um So getting better start times golden patient, a trigger of when to send to the next patient. And what I'd like is someone to write the discharge letters and things for me. So I'm a bit quicker between, between patient's, for example and good team briefs and we've just brought out the national safety standards of invasive procedures from the center of palliative care. So you got to order it okay. Um And that says how to do a team briefing. Anyone can lead it, but it's also just identifying when there are going to be when you want all your personnel there. Like this bit's gonna be really tricky. Don't go on break or it's or it's like, oh no, I'll be doing a super chance. It'll take an air in 10 minutes. Please go away, just leave me with a knife and some saline, you know, do you know what I mean? It kind of, it's just actually needing to be honest rather than assuming what people know and then try to get patient information and empowerment. So patient's have leave and so patient's can go can, can really be involved in the decision making. What are the benefits with the risks? All the alternatives? What if they do nothing? Because for some people not operating is better, particularly if they're going to have a complication. And they also need to understand how to get the best possible um possible result, which is basically exercise, nutrition, stopping smoking, getting some sleep, that kind of thing. In fact, these are the seven things that are proven to reduce complications by 50%. Um And the exercise doesn't just work by getting you through the anesthetic. It has an effect on inflammation, um effect on a metabolic effect. It's very empowering for patient's and a really good effect on pain management. Um So, and some of these interventions might make people day capable. Um And I'm gonna got far too many slides. Um So I'm just gonna plow on through them. And do you tell me when the wind stop? Um, it ought to be better and there are some places that some, uh, it systems a lot have been developed individually, some, it systems that save appointments and get people really feeling like they've got their own personal app and their own personal trainer. Um, and so it's reducing complications and that kind of thing, but it's difficult because it's kind of, lots of different companies doing their thing. Um, Anesthesia. Um, Desflurane is a greenhouse gas, essentially total interveners. Anesthesia is probably better. Um, but uses consumables and regional anesthesia is probably better. Um, anyway, you can read about that section in our paper. Um, we've just, this is the East Born New kit on the left was the hand tray. Um, that, uh, we, we did have many sets but there was one time I was just, was Indian carpal tunnel operation, in fact, and they were trying to count the nibblers and things and it's like, why have you open that set? And it's like someone was off sick and someone else was covering, it's like get I just want 20 of these mini sets. So they've got them. Um And it's lovely and it's much quicker to count as much, you know, less washing and all that business. Um And postdoc mobilization, we can do this anybody, any train member of the team can mobilize the patient. And this is from our patient information leaflet from East Sussex for hip fracture. So it's got how to use crutches. And we've got a little bit that if it's in the patient information, anyone can give that information to the patient, including the receptionist or they can hand the information leaflet out um or to a relative and it's very empowering for people's relatives. So there, it's got to get someone an ordinary car, put a plastic sheet, plastic bag on the seat on the passenger seat because it helps you slide in. So you're not then waiting for the ambulance following week if somebody's granddaughter can come collect at the weekend. So it's a bit of empowering and supporting everybody. Um And then we actually wrote something on enhanced care. Um So these are levels of care, defining intensive care society and level one is when you need a bit more than the ward, but you don't need that one organ support. Um But for that, you need the nurses to have a little bit more training and confidence. So it might be a um an enhanced care bay or award or you might get um of the things together, but it kind of um increases your capacity to look after more difficult patient's without relying on about cancelling patient's because of lack of intensive care bet. Um And trauma similarly, you can put people a little bit. So it shouldn't be oh surprised, given it to me, this thing's this person's arrive with this injury when you know, you get certain of these kind of injuries. And the biggest example of that for me was when Fascitelli aka blocks came in for people with hip fractures. Um So, and people have had training in that technique so that people aren't suffering horrible pain or being given opiates that make them go all funny when they got a hip fracture there waiting for our, you know, uh and also the pathways mean that yeah, as I say, hip fracture is a brilliant example and that's coming in my lifetime. I'm a lot older than I look, but it's coming in my, in my career. Um and it means people when they get to the, I'll have a cup of tea, we never operate on these after eight o'clock at night. You are right, you know, getting the receptionist and all that stuff to be part of the team. Um And um and day case we can do day case ambulatory surgery using the fracture clinic, but it needs a patient information, leaflets start given early, come back to the fracture clinic that proper discussion. Oh, your risk going to be a bit wonky if we leave it, I'll be all right with a bit wonky of. Oh, no. Do you know what I mean? Rather than people trying to make those decisions? Um, but when the person is really stressed, um, yeah. Uh, this is something about anyone on Twitter follow Helen Bevan. She's fantastic about change management. Um, J Curve. That things actually get worse when you try and change the, you know. Um, um, and actually we don't understand risk. Now again, I've got 40 minutes like I'm just gonna plow them. The biggest risk that many people have to. Their health is sitting down sedentary lifestyle is absolutely lethal. Um, genetics is any responsible for 20% of ill health and 10% of cancer and lots of people get bad luck. Um This is from the Marmot review and actually what are we doing in the end of trying to fix the thick fix things? But we should be out there trying to improve, um, reduce health inequalities because you're 2.5 times more like to get heart disease or cancer. Um Its dose dependent curved if you live in the least deprived, most deprived areas. So what actually causes ill health with the same kind of species? Um And we can talk about big things that people think are too difficult to fix. Like um social class, poverty, parenting, pollution accidents, things that shouldn't have happened that are six times more common in certain areas, the road traffic collision, but actually, the physical cause and those social causes play out through the physical causes. Um And I say I've been working quite a lot of physical in activity and I was lead author for this report called X Exercise, The Miracle Cure. And we gathered all the data, it came out in 2015. Um All the data about people doing the amount of exercise reduces their risk right at the bottom osteoporosis, up to 50% for 30 to 50%. If you've got strong muscles less likely to fall. Um and huge lifetime risk and it treats all these conditions, you know, type two diabetes, that sort of thing. Um So we need to get people environments to change and it's not just me saying all these other august uh bodies um saying that and people get all these multiple conditions. Um This is the number of conditions you have by age. The line is at age 65 and actually half the operations that require at least is in the UK are in people over the age of 65. So in that cohort, 72% have multiple comorbidities. And what we could do is flatten the curve a bit so that they can reduce from what zero conditions to one condition, you know, do you want? I mean, it just, it isn't inevitable and we know things go wrong in healthcare. And what I'm trying to do is to reduce the number of things going wrong because that reduces waste. Um, 10 to 15% of operations have a complication for five times more likely if you're frail, four times more likely if you're physically inactive. So we need to do this. Prevention is part of the surgeons job because no one else is doing it because not, no one else is doing. Everyone's really trying to do it, but it's done. Patchouli and people listen to their, to their doctors. They really, really do. They really, they've been waiting for you to come and see you 10% of operations of council, mostly due to lack of it's um um so look at see doctor or the UK and um we've got evidence reviews showing all that stuff about reduction in bed stay, better, team working, better patient satisfaction, um pages for patient's about fit a better sooner. It's a teachable moment when people will do stuff. If they really understand it's person, it's what they ought to do. Um This is about not, this is my mother again. Um So she had a proximal humerus fracture and it joined by itself. Six months later, it was very painful and she found it very difficult. But I'm just saying that, you know, um in the old days, we have definitely fixed it. Um um empowering patient's is about their expectations. Um rather than it's not being paternalistic, telling them what you expect, it's telling them, you know what the menu is almost and what the likelihood of stuff happening is. Um But we need the senior clinicians freed at the doctors, the surgeons freed up to have these conversations with people. Otherwise everyone's on that conveyor belt of thinking. I've been referred, I got a story, I've got to get it, you know, fixed. Um And the really honest decision about the benefit is the risk, the alternatives. What if we do nothing? Um uh And actually it's a nice guideline. MG 197 about doing shared decision making, who knew when it came out during the pandemic? So I'm sorry. Uh and basically it's about listening to the patient a bit and giving them advice. Um uh a bit about options. Uh And then another is if you're a team, it takes longer, my clinics take too long. Um And getting a whole team involved. There's papers and papers on that. Um, a few more minutes on primary prevention is never getting a problem. Tertiary prevention is when you've got something like diabetes, you're reducing your risk of the complications, like kidney failure, problems with the eyes, amputation. That kind of thing if you do something. And this is all about trying to get people to exercise and about nutrition and the World Health Organization talking about how to reduce ill health, how to reduce noncommunicable disease is the big winds of diet and physical activity. And they said active travel, space, walking inside the school, healthy communities objective. So this is, and I'm really keen that we get the NHS Estates to be a bit healthier so that people can cycle there. So there are lockers to put your bikes in cause I have one stolen in November. Um Changing behavior kind of you can change it quite quick. I think it's the right thing to do and if it manages to fit into their schedule, um um As I say, you just have a menu, you've got to do the exercise to what you do. Stick by electric bikes, swim, um or something, nutrition. Again, if you look up Jane mcnally nutrition or something, you might find that article rate. But it, I think we've got it wrong with, with a low calorie focus some people it really doesn't work for and low carbohydrate might be better um because it takes it. Um the carbohydrates are, if you can turn to sugar that which turned turns to fat and also you get an insulin spike. So you feel hungry two hours later, it's very, very difficult to diet on that with carbohydrates. Um But I don't have time to go to the detail of that and that's, and, and there are different sorts of carbohydrates wants to avoid. Avoid are the ones that give you that big sugar rush and the insulin brush and then make you feel hungry. Um And low carbohydrate diets are recommended by the Scientific Advisory Committee on Nutrition as something to be considered. So I think the well plate of getting 40% of your calories come I'm gonna move on. So it's fruit, vegetables and protein to get wound healing. That's the message we should be pushing out the anemia. As I said, that's just the picture for patient's. Um This is again, the the, this is the amount you can people we need to get the whole population fitter. Um But we can start with our patient's and then it will trickle down. It sounds hard, but that teachable moment could be used. And it's particularly, this is just to show them your risk for going from 12.8 as in a reduction to 80% risk of whatever it was. Um It happens very, very quickly. So the people who do least get the most benefit. Um This is from we it out in the BMJ showing those reduction along um the X axis is how much exercise you're doing with a little arrow and 100 and 50 minutes a week of moderate exercise. So just that little bit of getting up, going up and downstairs doing some squats doing that. Something's really, really worth doing to reduce your risk of breast cancer, colon cancer, throat, that kind of thing. Um And 25% of the UK population do no exercise at all. Um So Mylan's help with the pre habilitating with that's coached exercise, talk about alcohol, smoking, nutrition, psychological preparation. Um, and it really does work not just for operations but for cancer and there's some cancer treatment and there's some quite new evidence about reducing the recurrence of cancer with exercise because probably of its effect on inflammation probably. Um, and it, but it's when you're trying to get people to change, you've got to get chemicals. So dopamine, see, retaining oxidated endorphin. So you want, so again, if you're setting a project, you need little wins, we'll be going all right when I post all the uh but doing things together. So you feel like a team and then you discuss the little, you know, niggles that you have and it gets things better. So this is the uh East Born um hospital uh emergency department doing a park run. And just to highlight that on the eighth of July is the NHS park run. You think there are multiple, if you just Google part run, you can find something at 250 centers all over the country, the Medical Women's Federation, which is where I'm at now where I'm Presidente. We're trying, we're trying to everyone to wear purple to take a selfie, put in the app Medical Events Federation on social media, but you can do it any Saturday. Um If you get your um barcode, um it's five K run or five K walk, they've just introduced a park walk so that people don't feel have to get fit to go, but it's encouraging, we're trying to get the population fit as it's swimming transport. Um, I've got three electric bikes now. They're absolutely fantastic. And you get just as fit as using ordinary bike and anyone who says they're cheating needs to come and talk to me. Um, and if you lend people electric bike, they do more. Um, they never want to give it back. So anyone here who has a really good system with an NHS trust because we just, we got 1.4 million employees. Why is everyone driving to their cars and getting all annoyed because they can't park? It's just crazy. Should be um anchor employer and the benefits weigh the risks by 10 to 1. Um We've talked about that and this is the Chief medical officers of the four nations, the United Kingdom. Um on everyone should be getting 100 and 50 minutes a week of um exercise, including people with disabilities, they're not excluded. They've got to find something that can do, which might again be swimming or static bite or something. Um And for frail people stair climbing, so take your granny for a walk rather than well her to the restaurant for a meal, it's much cheaper. Um But we need to embed that into everyday life. The Japanese do it better. Um And this is moving metal. Okay. Fantastic about motivational interviewing. So, so you're telling people asking people how they could change and you're linking in with their change talk rather than what's holding them back. Um And they've got some on corruptive care. So, Juliette Movie medicine dot s dot UK and the conditions gave paresthetica. Um And there's a consensus statement is always, not always, it's almost always safer to do exercise than to be sedentary. Um And we've got stuff on or not, we um property active hospitals, various, the Royal College of GPS is really on board with this and they're linking with part running. So this is what we need to do. We need to sign post people to get fitter so that they don't waste the resources and use the whole team, um trans disciplinary working across the team so that people, we share skills. We don't, you don't have to be so and so to make this decision or to teach someone how to use quickly, we kind of share the skills so that people aren't stuck waiting for the expert because we're so short of workforce. This is just a quick plug for. Um We've got doctor's assistants in East Sussex. So that was minus two. We train them up from band to healthcare assistance. Uh to ban three. We've now got apprenticeship for them. It's on my website. But um and they basically uh draft a discharge letter put in drips, allow doctors to get to education um and that kind of thing. Um And we've won awards for that, but in my view, it's uh it's better than having a physician associates who are doing the more exciting things. These doctors are absolutely fantastic. We've got 15 any so character cares, better, patient, better patient's better cost, better stuff, better for money. And just, this is a slide from about gray blobs or 1% of patient's and basically 3% of patient's are responsible for the area of graph, 45% of the costs. So this is try, try, I'm trying to use this kind of stuff to get the the people that have the decision making power to change. So to put in the prevention but not lose what we got already with the excellent surgical care. Um And this was an article about if we put the prevention in place, we won't need so much social care. Um And the the need for social care is preventable because each um on average going to need 10 years of social care. Um And we simply can't afford it. There's a number of people and people who get active can reduce their requirements for social care because they can get themselves to the lavatory by themselves, for example. Um So we there's stuff on pre emptive assessment and optimization on our website. I also wrote a paper on that productive assessment and optimization. And the key point is that it's the standard pathway that they protocal eyes, they optimize they, but they also identify the people that the geriatrician or the anesthetist or the surgeon need to see again to really work out. We're doing the right thing by operating or is there anything we can optimize? Um So there's a kind of that's the same flow chart but the with the two steps, high risk, low risk, um I know you got to get this slide data so you can go through. Uh but I think we need to do sit to stand in clinic. We need to tell people to go for a walk and do we need to tell them. Um And so this initiative like prep, well, uh this is they have got sustained reduction in animals with doing this pre habilitating in um and sustained reduction in alcohol use, for example. Um This is in part for people with lung cancer. Um This is, uh again, that's lung cancer. This one's Saint Thomas is, and this is quite, quite interesting. They've got a geriatrician to see patient's elective and emergency. 14% decided against surgery. 50% given lifestyle 5 75% medications changed. And we haven't got enough general titian's in the world. We should be training more, but they've got uh nurse practitioners in geriatrics that can do such a brilliant job, but we almost need to think like them as well. Um And this is just a few minutes about me, I've got myeloma, I'm in remission, which is great, quite a keratosis. Um And I was at me with cyanosis. You can't really see. I couldn't walk up a flight of stairs, which is why I got so good on Twitter. Um, and, um, I was told I was too unfit for a stem cell transplant. So I do, I looked it all up and I worked out, I just had to get fitter and go have a hot test and prove that was fit enough. So I got my lecture bike. I went out every day, rain or shine even if it was because I knew that's the one thing I had to do and I have myself some chance part in this brilliant. So that's my cardiac amyloidosis. That's not my heart obviously. But the the abnormal plasma cells produce antibody light chains that go all around your body and they stick in your heart and they make it rigid. So it's a restrictive cardiomyopathy, which is why I was so sick. So I had chemotherapy and also heart medication. Um But actually that's improved over the four years. Um I had um uh well, you know, um and it's quite interesting being disabled. I'm not, I don't feel disabled or, but that radar key so you can use the toilets and who is nice to you and who just sneers at you because you've got neighbors um electric bikes we talked about. Um And I'm doing very well. So that's my new hip. Um not my new hip. That's me in, in waiting for my new hip wearing a wig. Actually, weeks are fantastic people then don't just treat you like a patient. Uh It's not, it's real now. Um And this is one of my final slides for trying to get the population fitter and the NHS staff fitter. Please give 1.5 m when overtaking a cycle because it might be that person on their first wobble to try and get fit and save us all paying taxes on pay for their social care later. Uh That's what I say when I'm I'm talking to radio groups and things. So primary prevention, they're getting it turkey prevent Asians part of treatment, reducing complications. This is sustainability. This is how to reduce and we'll never see it will never count it. Um So it's perative care patient, Centeno's prevention and rehabilitation is sustainability and those seven things reduce, reduce complications and every surgeon hates complications. And um and that's just the link for my website for the central care. Um and do look at moving medicine dot s don't care because there's stuff that we can do we, but the problem is we'll never see the will never count the numbers because um that's not how that's not accounted that what gets counted. Um Thank you. That's fantastic. Thank you so much. Um We've, we've seen a huge amount of information there and that's absolutely brilliant. We've got some questions from the room, Mr sofa, please. Sorry. Um So someone was asking about Um Are there any patient information style resources that could be used to give to patients in fracture clinic in a sustainable manner? Are there any methods that we could use? I'm glad to ask that. So, what we've done at the Celtic Healthcare NHS Trust is um close shielding during the pandemic. So I wrote or rewrote, we've got 100 patient information leaflets. So we've got the fifth metacarpal fracture, you know, all sorts of things. Um And they're all on our website which you can get TSH T dot NHS dot UK. I can probably put the link in the chat if that goes to everyone, but you can use your own. But what we've done is we've made QR codes for each of them. Um And you can do that on if you Google QR Code monkey, you then get the free and you can just put in the thing 20 seconds. You get QR Code. Um So we got a poster. We've got some in the emergency department waiting room. So the nurse says, um you've got this fracture, you need to come back to fracture clinic, point your phone at that, get the leaflet and then also when they come back Fracture clinic, um we also give them a leaflet because often that, you know, some they haven't, you know, you can't, you, the nurse wasn't the right nurse on duty, whatever. So we've got a menu and we just select, we got a proximal humerus fracture. Oh, you want this? We got, you know, and then, and if they haven't gone, we we've got we print one out. So yeah, that's low environmental cost. Thank you, Professor mcnally. I think that's given us a lot of food for thought. So there are some ideas for quality improvement projects from this. Um Some of you might be interested in trying to create processes that could be used in your own hospitals and then potentially submit them as abstracts to the orthopedic meetings around the country and or other places in the world. Okay, thank you, Francesca. Thank you very much. Um We'd like.