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fantastic. Thank you very much. So what we're going to do is hear from Dr Heitman from the second week in perspective and then we'll take some questions. So, uh, Melissa is a consultant, respiratory physician at UCLA church, working with Toby here. We heard from earlier who has been leading on the lung? Copacetic, UCLA, which is. Obviously, it's not even aware the largest long copay clinic. But we'll give us the insights from secondary care side. Thanks very much on Horseshoe. That was brilliant. So everything whole shift says I I agree with I'm speaking today with two hats on. Partly, I worked with the interesting, the non created programs or Teo National National Specialty Advisers. So it's a little bit about the plans of foot there, and you'll mention are in journey at UCLA, which is really similar to what horses described. And actually, yeah, I don't think of us is a secondary care service. I hope we've become an integrated pathway. We know that cove it hasn't gone away, and we know that long. Kobe. It hasn't gone away, but we do need to know more about what's going to happen next, and we'll waiting for the next oh, in estates to release, which I think is due next week. What's been really difficult formal of this data is actually know which of these patients who have self reported long do you actually need access to an NHS uncoated service on. So the modeling continues to be quite challenging, but we know we have a big problem, and there has been linked fence funding in England since the end of 2020 and in some senses we've been ahead of the rest of the world in that regard. On the long copay plan that we were following up until March was very focused on establishing and setting up these assessment clinics and integrated rehabilitation offers. Um, I'm making sure we developed a self management support offer. There was a little bit of funding for primary care to try and help initiate about court with both way under a drive to collect a much as we can in terms of data about the patient's access in clinic, because this is a unique opportunity to learn about their needs. Funding was renewed for this financial year, and we are told that there will be funding for the next financial year. But the modeling is going to inform exactly how that looks. And obviously today is the day that we will transition of officially to integrate it. Care boards, which are the rules, sort of struggling to understand what that means and what that means for all of us is providers. But a lot was changing at the same time, which is really challenging for us on the ground. Torture, isn't it? So I think at least I can tell you in the end it testing than program. They are aware of that and I complained about it and awful lot so I hope will get clarity seen. And there are 90 clinics around the country, so every every person in England should be able to access referral to one in their local region. On there are 14 services for Children running more reserve husband spoke model as harsher explained we We've all been on a journey with these services. I know you've seen this band before, and I do find it very weird that three of the original band members are talking to you today, so obviously had a big impact on all of our careers that we started our clinic. Exactly. Asshole, she said, is an emergency response. Really? Our goal was to protect our emergency department from the very high readmission rate that we were seeing. Patients who left our own hospital. But because we have a background as integrated respiratory doctors, we know well, our local GPS. And from the first week we had two referrals from community managed patients. And extraordinarily, we have now seen 4000 people through our service on down where the leak provided the north Central London, which has a population of 1.6 million on we are very busy clinic with 100 and 20 appointments a week. So we really burning the cons of that? Both ends on weeks that we don't have any fun. Rebecca. Okay, now I started a Zaretski Eritrea position. I would say that I'm now a post CABG position because I've had to learn so much about this multi system disease. This is not risperidone and medicine, or only a little bit of it is respiratory medicine. But fortunately, most respiratory doctors a G. I am accredited as well, so we're not completely useless. But we had to do a lot of of learning on. I think the doctor functioning. This could easily be a GP and such a harsh with post covert expertise and d t has been essential from day one. And I. I thank my lucky stars that Rebecca turned dark. She's our lead busier. He's going to speak to you later on day one of the van with a clipboard, and I remember thinking, What are you doing here? You know you need to be on the Ward's, but actually, it was like, Oh my goodness, we really needed her. And she brought in a lot of other therapists that we've come to realize that was fortunate for patients on then multi specialty is that we've been lucky with cardiology, neurology feeding into our model particularly, and then the old other allergies as well. We are trying to coat design, are pathway with patients on be patient. Voice has always lead the way in the non payment space and they've seen an important driver. We will now had all personalized care training and that's being really very helpful and improving off insult a shin skills and identify what's important to that individual is harsher was describing, and we've been working closely with our GPS and our community providers, so that we really hope that we don't act as an ivory tower in off off way that were acting. I mean to face it'll the other providers who we work with so that the top is our Islington and borrow MG T and the same Still, the professionals that harsh mentioned well, we need all of their input on then. We also have a weekly multi specialty and DT at U C H. So we actually running five them DTs of weak, and it's helped us learn about the condition. Avoid siloed thinking really thinking about research that's required in this patient with because that's also extremely important in terms of the NHS England position, there is about to be published on update on the Long paper plan identifying the key areas of focus been improving long ago, but services going in to the next few years on these are some of the themes that will be covered in that. So really no understanding. What does it look like in non coated services? You know, what are the best outcomes we can achieve? What outcomes should we be monitoring on D. How are different models around the country achieving outcomes? You know, how can we drive a more consistent approach? And what should that consistent roach look like? Looking at patient experience in the different services with friends and family test? And there's more research going on about patient experience because we know it's been really challenging for many individuals improving the Your Cable recovery resource, which started off with a post hospital baker. So and there is a real need to make that more broadly useful and a huge amount of work being done. And it's being updated very often at the moment, So I hope you'll see that that's that contents more useful to you the the modeling I've talked about widening access, so lot of work going on in different regions about Proactiv case finding. We do not get referrals with patients with learning difficulties. I've never seen anybody from a prison, you know, on we have concerns that patients from deprived backgrounds and know accessing the pathway, so we need work on the ground to understand how we unblock that problem. I I think we put all the theory we need now, but we actually need to pace studies. Capacity has been a challenge from the star, and we're going to be encouraging a process of triage on received Superbowl so that you prioritize with bowels appropriately and direct into the white part, the pathway and maximize the capacity trying to get rid of those weights about 15 weeks, which are a real problem for many of us, were developing some resources for training postcode clinicians. Because we've done so much learning on, we now need to extract or expertise for more heads on our MG teas and share. It's somewhere in the skills. Transference in this field is being one of the really lovely things that on. But we do need to continue to support primary care who are under so much pressure at the moment, a long talk. It is being developed with the RC GP, but I think finding ways within all of our in pathways to really help primary care with this is remains very important. Lots of brilliant research is going on, I think. Well, a vintage postcode services the stimulator ICP study in the locomotion study of particularly of trust to us eso the former Rizza, including evaluation of diagnostics, medicines and digital of supported rehabilitation on the Locomotion study is trying to define what a gold standard pathway with, as harsh said referrals have been steady on. We've seen an increasing requirement to follow up that's looking at this. I don't know if my point is working, but the graph top left on. We just do see that people from least most deprived backgrounds or slightly under represented on for us we plant found the public health data looking borrowed by borrow really, really helpful. So, for example, I know in hiring gay that the people from deprived backgrounds or not as likely to be coded by their GP is having long coat bit well, Postcode syndrome is it should be known in the coating sense on I Can See That in Comes In, the referral weight by Primary Care Network is is unexpectedly varying, especially as some of these PC and literally overlook our hospital where we're based. So this is This is where we need to fix our attention on this unwarranted variation with moved in the last week really to a different referral process in your central London, where we now have a single point of access. We're trying to make it easier for GPS to know who to refer to and save too much for me care time and doing an assessment and increase the consistency and all approach to decision making about access to the pathway. We also use the self assessment tool, which is done by an online patient portal, which is being real useful. And the other good thing about the single point of access is it becomes some of the digital barriers we face in taking the pills from five hours, we've simplified our primary care template process mint on any ms on it. Auto populates a referral form Geeky has told us that what we developed to start with this part too complicated and it was very much a reflection of what we were doing with in the clinic. But no one else really understood long overdue at the time, and it was too hard for them on. We've now recruited a GP lead for each ora in north central London to advocate for the pathway attention community MG ts on outreach, two practices that aren't using the parkway populate, or I shouldn't say properly or optimally s so that we can really try and even up her that access were quite worried about that. And they were very jolly on this team meeting. So I think they're very happy. No work. Um, one of the key things we've been learning about over the last two years is how to match the offer to the patient. Need I? I don't think a lot Patients with in the owner survey, for example, need referral to a postcode service on. So with that lower complexity need, they can be well supported by the GP, with self management on support. Then there are others who need more input for their recovery but may not have read flags requiring a sort of increased doctor assessment. And they may be suitable for the therapy lead postcode rehab. And we've got four hour based teens delivering that multifaceted rehab offer. Um, but what has been surprising to us is that, like, Harsher said, a good proportion of people really do need to see a doctor with post coverted expertise on what we hope is that with this pathway, we flipped the pyramid horizontally to try and create this integrated model so that people can transition between the sword doctor overseen component on the therapy lead component, trying to reduce multiple appointments. Multiple on wood referrals, you know, trying to wrap the care around the patient as much as possible. And I know it's easy to say these words, and it's very hard to deliver them, but that's definitely what we're always trying to do on. But we drew the spend diagram probably some by year in we did a lot of blobs of the different components of a long presentation. You know, certainly, long coat is not the same as parts. It's not just parts one and five patients has exertion take ecology or inappropriate Sinus tachycardia. One in five of them were doing a whole strong. But there's the the other people we see where you don't have parts. And I think what's so challenging in this field is being able to identify a lot. The components you need to from that one assessment on our assessment is an hour long. So 30 minutes for the doctor and 30 minutes for the physio. There's a lot to do in that time. So this is Rachel, who is one of our oaties. As I said, you know, we have a sort in person. First assessment. One of the key jobs is to make sure we're comfortable with the diagnosis. We found that one in 20 people referred to us has another diagnosis which accounts for their symptoms and sometimes quite severe. Other other pathology identified. We're trying to think about bio markers all the time. We definitely not cracked that. We see things off interest. We're pursuing questions about the micro clotting, which I think has been very inflammatory. What's been published so far? We're trying to understand that we're asking questions about mitochondrion function about auto immunity, Um, on, but it's all very fascinating, but it remains, uh, incomplete. So I don't have any big announcement to make that we understand what long pope it is. And we find a simple exercise test on the active lean test. Very helpful. We try to do some simple same day diagnostics on, then decide on more advanced tests, just depending on clinical judgment. Um, on. Then we used the assessment tall Teo track that ongoing progress on many services of finding the Yorkshire we have screening tool useful for that. I think you know there's a few different tools and use around country, which I think is healthy so that we can compare and pick out the best best aspects of all of those. And then the multi faceted rehab has been a lot of healthy debate about the right approach to rehabilitation for this patient, Rupert, as harsh has said. The key thing is that it's that what your program remains completely spoke to that individual, because people are at different points in the trajectory of recovery, they're long it might be affecting them in a different way. We walked into lots of arguments about whether they should be doing exercise or whether the focus should be doing on paper the on pacing on. Of course, that really depends on where that individual is in their recovery and and how they're affected. So that's one of the real skills of the postcode. We have teams in the they're increasingly able to match the model toe what that individual needs. Um, Andi, Rebecca will talk to you a bit about how important is that? We measure the outcomes from rehabilitation with We reassure ourselves that we are actually seeing improvement and through the NHS England program We've been able to capture reports from many services around the country which are really proving that they are helping of patient recovery. And we need to, um, really speaks strongly. I think that message that proactive support improves the outcome of patients on that This is work that's worth doing and that is the end. So we've got time for a couple of questions. Is there anyone in the audience? I'm looking good a hand up there, So So I'm going to take that one right in the middle of the back. So if you want to have a chicken run the whilst we're doing that just to let you know, there's been a flurry of discussion on line, hardly to do with access to services, which actually your door used to on the variability. Almost. We're getting there. There was something There was a question that came in saying, Is everyone working to the same past May? And if so, where is it? Yes, So I think the best source of what we're trying to work, too, is the commissioning guidance. Yep, on that is being updated and due to be released in the next 1 to 2 weeks. So watch this space. It will speak strongly to that need to improve consistency, offer and of the core elements that pace cable service must include million millions. Chris is a lot of decisions. Oh, yeah, It's true. There is a unwarranted variation in access under approach. Brilliant. Thank you. So we've got time for one in the room as well. And that's that. You that you know, looks like thank you very much for the for the talks. I'm saying it might. Snow, there's a little button on the side. Make it degree yet. No Crestor side, No. Maybe try through the night. I can hear you. Yeah, Shout will uncomfortable repeated it online minority ethnic groups. So the last time I looked at the onus starts and that was admittedly a number of weeks ago, it seemed to suggest that people that Caucasian, it's a city we're more likely to self report long. Kobe's then people of minority ethnic groups, and I'm just interested to know. Is that is that still the case? And it's so what? What? My explain that Yeah, so I think I think that is the case, but it really Berries around the country. So in our own patch, for example, the ethnicity of patients referred to the clinic Exactly. Matches that about local population. But we had thoughts that Kobe Heather, high prevalence in ethnic minority groups so they may still be under represented on. I think that remains a really important focus. Um, we, you know, we would love to improve the quality of death misty data in the chest thing than registry. And I think one of the great things every service couldn't do is ensure there documenting that accurately. So I agree. It's one of the key areas of focus.