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make it start for the afternoon slots. Great to see that. Lots of do ST let's see if it happens after the next break with that online again. Sorry for the future. Just delay in getting back online. My name's McKayla a little. I'm a nurse on, but I'm sure Nick needs no introduction. Is you really already? But what I want to be able to do before we start is just talk about evaluation certificates at slides. Handouts had lots of comments about that on the chat online, and I'm sure you guys a clean, too, at the end of this session, and email will come out with exactly what to do. We're using a platform now called Medal that If I come across metal yet, no, you're going to learn to love It was moved by a cardiothoracic surgeon in Lock Down from Belfast. It's an open access platform to free for conizations. I'm not no condition just to let you know free, free, free for organizations free for healthcare professionals. And it is absolutely brilliant to use, so we will do your go through. Do you evaluation if you're not using the Net recognized No chest. Email address. If you just give, you have to verify it. But all your all the slides that are available get loaded up on there. You can pick them up whenever you want to. We might have to catch up. So you have to double catcher content. You create your certificate in there, I put in your name on it. It's just brilliant. And so if you ever do another session for medal, you've already got that set up and your certificates will always stay in the same place, which is awfully handy. It was designed by a doctor big for doing the validation and stuff. So brilliant. So I'm gonna hand over to Nick now, who's going to start with off with the session? I just wanted to make sure we did. Evaluation was before, so hopefully this is working so well. Welcome back from lunch. You are well fed and agreeably junk. Eso a pact afternoon on. But first, I'd like to introduce Harsher who is a GP in on D. And I've seen a chatting for quite a while because of long copay, because she has had the pleasure of running her local lung covitz service on. We've been writing both bits and pieces. A zoo? Well, so that's you could come up and give us your insights into the nightmare of running primary long everyone for my name's caution on. And I'm a duty need in the Eastern North heart chair hoping Rehab Clinic. And just to say like it's a sore sexual partnership is it's actually divide it up into three bits. And so we're one thing. Um, and I've been also talked a bit about Parkway and how it develops, uh, on. So I just want to start by saying our service we started developing our service really early on like a major went to 28. Originally, it was designed. So wait, we needed some sort of rehab part like of the patients coming in twice to you with copays and then very quickly we get that today it is it, you know, to manage some of the community based on on credit patients. Well, so our service we feet anyone and everyone with post complications where they've been annoying to you hospital all the community on our service works across the primary cast that convict care and community care in spite. So this is our team, and it just kind of gives you an idea that along cooperative, it's have been done differently. Everyone still have done them in different ways, and I'm just going to focus on ours today on that kind of gives you an idea between for a lot of the services be used with existing services already on sort of taps into those. But we did commissioner few other people's of the rehab court and eternal talk about her role bit later, that was commissioned. Okay, shingle therapy. We did commission and the psychologist that we thought lots of patients with the suffering from PTSD Post Cove it on a course. My role as well came into their way. Also worked very closely with colleagues and secondly care Social Kurt on the voluntary Fekter. And that's really evolved. You know, we could start that from the beginning, and it sort of growing and growing and growing, and it's been hugely important in the development apartment care that we offer on. The main aim that we always try to do is to provide coordinated holistic care involving both medical assessment on rehabilitation, and that is the key. I think he just do the medical side. They don't really patient will get better on if you just we have them. They don't get better either. So it really use, like, combination. Both that works much better. So these are just in stats from our service. Then I'll just give you a slip of general overview, but that's very clear. But you can see the referrals that we start. Stop about 40 to 50 referrals. The month is what we start with originally massive spike. In March 2021 word worlds tripled. That was after the Kents training thing, and then it came down and we kind of thought big, vaccinated and maybe a little go away. But that hasn't been the case on. Actually, we seem to have sort of stabilized around. About 64 was a month. So it still gets in that now, predominately in see 78.7, then off white British that we're seeing in peds instead of 22% of other ethnic groups, 66% female hurts, a vegetable percent mails and interestingly, 91.4% of our referrals are all coming from a primary care. So these are not coming most. It'll you know, majority of these are community states patients. Yeah, and just to give you an idea of kind of where some of these patients that going on. But if I you know, almost 46% I see so it doesn't really go to show how important that medical aspect in it is on. Then the rest we'll go down in order. 36% probably rehab 20% of chronic fatigue and then mental health and then other services. So just kind of gives you an idea of where some of those patients being seen. However, you know, I think it's really important stated there have been huge challenges. Like when we first set this up back in May. There was literally nothing was new illness, not cyst in terms. We had no idea. How are you going to manage it? We didn't know what to do. There was really limited guidance that also evidence really, really challenging. And we have to really kind of thinking of eight it. But wait to do this. And even now, I would say the optimum treatment and possibly designed still isn't clear. Lots of people doing very good things. Funding has been a really big issue, like up until now. We weren't really even now. Actually, we did the total funding till next year. We don't know what's happening after that. It's been really tricky because that master of the effects recruitment in cystic, um, two teens on we struggle. We struggled to recruit your patient therapist, probably rehab because nobody wants short term rolls on the vocational rehab, massive area. You know, I just was so sick that that that that was so many different symptoms. How do we get back to work? What's the best way? He still doesn't have some of those answers. So it has been really, really hard, little, little bit side. I think it's really important to say that that uncertainty has, you know, and actually hoping in itself has more about what's good changes as well That shared uncertainty has made us work in a really different way. We've had to work a bit more collaboratively it in a more integrated way. We've had to think creatively, innovatively, laterally, you know, I really think that's like the books in how trying how to manage some of these patients and I think that that particular place to park. So I think, you know, two years ago we didn't even know what what's words. You have no idea. And we had to learn that we've had to put that into a pathway, and it acts it accordingly. And I think it's really important on. I think it's a result of. That's what we have now it's a part of. It's quite dynamic. It's quite flexible. It's quite integrated, and it has adapted according to patient means. We're talking is really crucial. So what have we learned? As I said before, that multi disciplinary approach offering tailored medical assessment investigations, treatment and rehab is essential. You know, it isn't one size fits so I think lots of people have said that and I will read to break that. They do present patients present with similar symptoms, but actually the management can be quite different. They're quite important to remember that every half hour or so this is some of the condition really early on, and she had been absolutely critical to our pathway. So she's a specialized or professional therapist on what she does. Is she triage? Is all of those referrals coming in initially on develops almost like a personalized package of care for them. So, you know, refers because the parkway coordinates their care and keeps tabs on them. Essentially, my role actually have proved to be a quite able. So I know I do like medical assessment. I can offer a much more syphilis stick. You I can organize further investigation, and I'm that sort of link into secondary care of as well if they need further investigations. But like people have said, what you almost need is you need one either a few or a few people holding it. You need someone that haven't overall, you know, has over care of that patient who can cause a lot of them will go into a different specialty. They may have some guidance and t cardiology respiratory, and you need someone to hear. But oh, this thing, all of that and then put it all together again to kind of then decide on a pan off where to go next. So it's really been quite important. We use the question that we used you should screening questionnaire, but can you know this? This is a few out there and again because there was so many symptoms. It's just a good way of being able to document symptoms, their severity and sort of, you know, a document, their functional possibility of the results of it on one of the things that I do, which is what we will probably not offensive. Look at what they were like, pre k did it and what they like now what could they not do now that they do? But oh, that's hugely important because that's how you know that's what where you sort of measure that recovery, the multidisciplinary team mates thing. I can't really say how important it is. We have a weekly one with a lot of the things I have another separate one with some of the secondary care, My second taper. He's in critical care, and actually this is where we see lots of are learning. And I think that shared chemical decision because we don't have all the answers. We don't always know what to do on, I think, working together and sharing that is hugely important. It can help with learning with reflections on actually in hours. We use that time to also look at our service improvement and innovation what's working? What is it? What do we need to change? Have the symptoms change? Like, you know, we know that the different variants of cause different long term problems and we're gonna have to adapt or parkway according to that. And I think last the again This has been mentioned before, but, you know, considering the emotional, psychological, financial impact of coping 19, they have been huge. You know, people have lost their jobs, they have to work on. So there's quite a few people that I know got to bolster that have left home really struggling. So it isn't just the medical bits, it's all of it. And unless you address it all together, that recovery doesn't really happen. The other thing that we found with the sugar is the earlier, but a slow stream rehabilitation approach is better. Now, when we first went like we sent a nice to with exorcise that we could offer, you know, we have dieticians. That probably happened taken, you know, they came in with all these symptoms and, like, brilliant, we'll just start you here. Here, here, here, here. And we thought that would be the solution. You know, she wants down the line. We came to review them. Gosh, they were really you know, So they had no idea who they were talking. Teo. They were getting different conflicting advice, and it didn't really work. So there is this pressure to kind of get them in and get them out really quickly. But that is a work. You've got to slow it down. And you always want to do one thing at a time that we kind of do probably rehab on a medical review festival. Once they've had that, then I think about very carefully, and we've learned to streamline. Now what is that they really need? Is it more fatigue management? Is it more mental health? Is it more, you know, speech and language, for example, And it's really about toner in it, on giving the right care for the right problems. This is just a really brief summary of like how our team what's because obviously it's no the same in every area. I did want to mention in science fiction language, you know, I think they have a fish sandwich weren't in original Nice guy, isn't that they think it's It's a recommended apartment T, but they're really crucial in the first week. You know, it's not some people with a voice issues swallowing issues. We didn't really know how to manage that we have worked together on. Now we have a party and chase with anti as well, and that works really, really well. And it's together with the voice you get breathing and shoes. So actually palm rehab and speech language and are working more collaboratively as well to kind of treat the patients. We've got video with the occupational therapy. They're able to do cognitive assessments, manage fatigue and help with return to work. And we're really lucky time, according team that we can refer into. And they do that more sort of severe, but it management advice on pay, things, the issues and chronic pain with very much linked in the secondary. Careful, I worked really closely with my respiratory okay colleagues in their copay coverage in IQ, and we always have found that, you know, like I I will have a patient. I'll see them. I refer in. They get the test, they come back to me and then they complete every have journey. So it really benefits everyone. I think it benefits us of conditions and really benefits patients as well. I'm just going to give a really, You know, everything of a case of this will just demonstrate how our part works. So this was a 64 year old lady who came in really early. Actually, she with the healthcare on worker. She got coded in March 2020 previously Fairly fits of. Well, the only thing she really has was an unprovoked pa and shoot. That was back in 2016. She had lots of lots of investigations and they didn't really find the cause. We'll get it down the bottom. You can see some of her ongoing symptoms, lots of symptoms, which is really what we say. Breathlessness, cough, dizziness, palpitations, anxiety, fatigue, all of these things all together. So we discussed a really earlier r n g t on actually, our community spirit treating when out see her at home. She was so poorly on, found she was desaturating on exertion. So we managed to get her instant copay coverage. Then it really quickly she has a lung function test. The CT pa. They were normal because of her palpitations. Dizziness. We referred him to cardiology. They did some of their investigations, which all came back normal as well. So after that, she came back in. I mean, she's a little part of cough. Anyway, we were reviewing her regularly. What? We were sort of waiting for the medical components to be done. We discussed her again at the MG T and looked at some of her own going symptoms. The breathlessness. We referred into public rehab in a did note of those work about the breathing on. But the biggest thing for her was actually, um, anxiety. She was really stressed, was questioning times by everything she's been through. And she had something called some dynamic mind. Is there a Petri? I asked you Really helpful made a massive difference. And then towards the end, we referred into chronic fatigue. Um, I actually spoke to her about it on, but I wouldn't say she's really better on, but she knows better than what she has what she was before. She has gone back to work, but she's had to do a juice hours on. She has a considering early retirement, but you know, from the beginning where she literally couldn't leave the house you don't think she's come a really long way, and I think focusing even on those small positives is so, so, so important on what we try to do in our pathway. Patients tools, you get them back strategies and you know, ways to help themselves to recognize what's going on. We know that. You know, if they get cold it against the sample, it triggers all this instance to come back. And they just need to record everything they've learned, you know, just give them a bit more empowerment, control over their symptoms in terms of recovery. It's really, really slow that that I am seeing recovery, but it gets the date of this morning there in our clinic. I think we have discharged 300 patients, which is about 34%. It's Are they better? No, no, really, some of them are not lows of my better than what they were when they came in. But many are not really back to that sort of baseline and what we found, And I think it's what we've all found in your copay Tenex that yes, the medical part that really stops once they have been ruled out, it really is the nice damages that make the biggest difference in everything. So what? We know that you know, this is a remitting relaxing illness. Symptoms will come and go on. There will be unique triggers in each person which cause of the relax the sofa stomach might be. You're doing it on exercise brothers. It's 20. That's worked too soon. You they have to work how we have to work out water to That's their trigger on, then trying to get them to address it, express poor sleep. All of those things you know completely affect someone's level that make me feel very both of you being on the relax, the best invention. So dressing. This is really, really important. And if you've got someone with fatigue and brain fog, if they're not sleeping, that's huge. You know, you've got to address the sick first, and if they're not sleeping because they're in pain, you need to address that. You have to break that sort of cycle, which allows recovery. Um, the big thing that we noticed at the beginning with these sort of remitting relapsing symptoms was the fact that patients they always describe this. They have good days and I have bad days when they have a good day they would get and they wanted you more. You know, they want to push that. They want to go back to how they were. So they do a bit more and then a lot their symptoms come back and they feel really terrible on they relax them, crash. And that has significant impacts on the news on everything. So you know, some of the strategies that we do is about breaking out. And that's what paid Thing is all about. Is trying to break that cycle on different strategies, to silence their activity in their rest in order to avoid an exacerbation of their symptoms. Okay, so obviously a flexible patient sense to tape returns work. It's also really, really important. They're just a quick thing on future plans, I said some of the areas that we've struggled with, what we're trying to do now actually is working public health on. We're looking at working with sort of hot. We were quite posting parts. Help you deal with social prescribers. Vocational rehab is that we're looking at. We're working with the Health Protection Board on. We want what we're trying to do is give advice and guidance than education. So let's let's try in social describe those people who deliver physical physical activity. So let them help their patients because I think without their knowledge, they're not really gonna be able to do that. So that's and stuff that we're working on it the minute I think, just in summary. I hope that just gives you a real racist summary of how our part probably work on the real benefit of it. Integrated holistic pathway. I really hate that. We get to continue doing this where I think some of the things we've learned that it's been really good things that come out of it on. I hope that we can use what we learned to apply the other positions well.