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So, uh, hello, everybody. And welcome to our first episodes in this brand new talk series, which is econometrics Directors cuts. We came to me. This is interactive in about it's possible on dicey. You guys have been introducing yourselves in the chatter righty, which is which is fantastic. And we've got people from from all over the place, the one in, uh, doctors from seven, a medical student from Ukraine, hardly in Pakistan, a couple of any chest directors and a physical from London in college, on holiday in Canada. So people from all over the place joining, which is probably the beauty of the Internet world we live in a a moment joining from all around the world. So so welcome. I'm on. This one has been a long time coming. There's a climate emergency, and as House Cup officials, we have both their duty to lead the way and to advocate for change. But of course, the health care industry itself is no exempt from this, especially given it contributes. More than 5% of the UK is common footprint on, given the NHS ability to influence industry with it's massive purchasing power and it's vast. Apply chain. I think it's really important that we could take the test is right on that zero very seriously and use that as a platform to almost guide how a lot of other industries within society might be able to make some changes. So in this talk series, we are going to aim to do about 34 of these a year away. Let's bring together frontline healthcare professionals that are working to create change from the bottom up on sustainability. Directors and team members that are working so hard to bring about change from the top down as well. And we hope this event will open the minds of everyone as to what is going on, both with them, their own hospitals, but also in hospitals around the country and taps around the world as well. So we hope this talks to use will facilitate some good ideas. Sharing on hopefully leave everyone feeling about hopeful at all that's been achieved so far. But ambitious teach driving towards net zero as fast as possible. So in this first episode, I'd like to welcome mat Molony dot from Bristol on Leak O'Shea from UCLA church James Dixon, who is the director at Newcastle was meant to be joining us. But unfortunately, he's come down with cave it on a sentence. Apologies in terms of the format of the events that will have to very short presentations. I'm starting with Leak with some questions after each one on, then we will move into a bit of a more of an open discussion. So Teo Citate feeling interactive and all of that when we get to that stage Or if you want the question feel free to, uh, make yourself come on camera. Um and, um, come on line. But if you're in your pajamas somewhere and you drive, not then feel free to tease the chap. Okay, So without further do like to introduce our first guest leeco she on. Luke is the director of innovation at UCLA. Choose your hearing just now on executive lead for sustainability. Aspartic issue leads on innovation, transformation on improvement on prides this He was director of clinical policy and programs at NHS, England on held senior rolls and six government departments large in policy and strategy. So leak over to you. Brilliant. Thank you so much, Nathan. Very excited that people are joining us from all over the world on depressed by your dedication, Hannah joining from being on holiday. That's absolutely amazing, Nathan. I don't think I could do screen showing until you get that terrible picture of me down. Thank you. Okay, So, uh, all right, let me just get my slides up. So, um, I will. Apologies just did it. Did it, um, so we'll get the slides. I just wanted to give you a bit of a a sense of our journey over at UCLA church over the last year. Really, as we've got about declaring climate emergency have tried to up our game really? On the move to net zero on what we've learned, Um, my car active on Twitter if you're interested in those things commission on. But we contract a zio, see how we do, or some of the time, But I'll let you know a few things that we have learned in the process of this give you a little bit of a flavor of why we've made some decisions that around the kind of the the timing in the areas that we've looked at, um, Onda bit about what we're going to do next. Um So as you all know, her joining 19 in the last 20 years have Bean the hottest on record. We will see a kind of continuing it smashing of temperatures affecting both our patients now on. But, um really, very significantly across the world, I'm thinking, particularly of the situation that we've seen in. Well, given the guess we've got, we have, ah, all time highs in of temperature in Canada last year in places like contempt. Er and I think that we had, of course, in, well, Pakistan, India have smashed records of sort of missed some of the really miss spring entirely received floods. And Bangladesh. I think it's the Indian subcontinent. Were some of my guests adjoining from this is, uh this is happening now, as you all know, in a very, very serious way. Um, so it feel it felt that you see, like it's like this was a sort of a pea decisive moment for our species as well as the planet and the, um, in the pants animals we share it with. So, um, one of things I wanted to explain is why we decided to declare a climate emergency last year and give us A. Give a 10 year time frame. And I think the clearest thing is that you know, we have daily data on atmospheric concentrations of Coatue, another greenhouse gases on. It's very obvious where the trajectory is going on. Do you know if you look at the kind of Paris agreement and the 22 temperate to degree temperature rise? If we hit 450 parts for a million Oh, two we could easily hit in 12 12 years may have the kind of current rate of 2.5 packs per million increase per year? Um, Onda. It means that this is absolutely the decisive decade we need to act on show the way as, ah, a CNA chest owners, healthcare providers across the world within a 10 year time for improved that it can be done. Um, it's very real. I think there's a lot of debate. I don't know what other people feel. There's a lot of debate about that kind of what happens at four degrees, a little bit of debate about what happens that one half in two degrees. But there is a lot of uncertainty, a huge amount of risk between the sort of to three and three and four degree temperature rise on D. You know, I particularly think about the some of the tipping point of the western untucked. It shelf goes and some of the sea level rises a part that which are, you know, go from very quickly from centimeters. 2 m, you know, this is London were already heavily affected by flooding. What that will mean for London and, you know, one billion people who lived in that kind of exposed parts of the world. Um and as I think we could really, we've made it very kind of clear that this is this is the problem of health systems across the world, not just because their part in contributing it to but we're seeing very, very significant health health problems. As a result, I won't go through all of these cause I'm sure you're well aware of thumb being. You know, the kind of group would join this kind of talk, but we should not stop saying that This is a This is a health emergency. A swell. So there are some positives. I wanted Teo pull out a few of these, and I think it's really, really important that we as the NHS, continue to inspire people to work differently, to be bold on. I just took a few headlines the last couple of months the you know, someone amazing, you know, sort of things that would seem completely crazy about five years ago in a band on petrol diesel cars. You know, you'll see we're seeing a shift of remarkable shift to renewables, including some of the areas that have been traditionally much more resistant in terms of some of those big polluting countries of biggest areas. You know, big moves from China. Big news from India Ah, Australia moving towards renewables from from coal on Um, it's on just the technology coming on a huge pace, really exciting changes even in our country, obviously in the in the UK, a dramatic change in the last 10 years to towards for noodles, you know Windows Cell was 4% 10 years ago. It's now 29% on average of our electricity. Things are changing in the NHS could absolutely accelerate this, um but I think it's easy to forget in some of the news that there is. There is a big opportunity, and there is still quite a lot of hope and that we can do quite a lot to make this move much, much faster. I'm not going to reiterate the obvious points, but I found this. The the, um right on the right. Quite useful. Which is a from the, um, in a chest, Um, s so sorry. Getting girls get rid of, um, from the intestine at zero report, which basically gives, you know, a footprint of the NHS in terms of its breakdown and carbon and the amount that is within scope one, including anesthetic gases, which will hear about which is about 5% of our our total footprint. One of things that we very definitely focused on Ah, UCL later will become a stronger, stronger Part of our strategy is that most of this we know what to do in scope. Want to We know we have to get up gas. You know, you have to build our renewals up, but on reduce our waste. But and I gas is, but we really, really need to tackle supply chains, the major league in time. And it is our biggest issue. Um, and it makes up the majority of most of us Tums, footprint and I talked to a very, very big system in the US recently, and it's more like 75% of their footprints. So it's, um it's a huge part of the problem, the supply chain issue, and that's something we've been looking at. One thing we did you sell a church in August last year was really pushed on. Um, developing are communications are bored support getting executive sponsor in place on building a dedicated teams that you have to get the infrastructure right and you have to focus on outward communications as much as in words communications to get get stuff really supporting you in the journey that were on toe net zero by 2031. I think you have to have a quite a clear vision. You have to give people hope and have a plan, and you have to bring people with you. Um, I was saying, I think there is, um, I using ability in the any chest when the urgency is there, too. Pull something out of the bag at the 11th hour and that is very definitely the position we're in now. You can also look to some really positive changes in other air, other industries and big, big businesses that are ambitious. I mentioned kind of like he is climate positive approached by 2030 is an example the move off gas where some countries of doing that in a significant way domestically, like Norway. Um, Andi, you know, individual Hammett that are changing meetings, State of electricity to the eating, less gas, less meat, even becoming more active on the individual moved things like electric vehicles last August. What we did was to agree a 10 point plan alongside declaring close emergency that included things like, You know, the getting to net zero within 10 years, being the first Met zero hospital, um, in one of our sights, which we we hope to do the to deliver a swell A some very practical things around, reducing our energy emissions through things like a massive investment in any D life. We and I would encourage all of you to think about this. Think about the areas where you can make a significant quicker win, and one of the big areas that we worked on was anesthesia won't talk about that because that's going to cover that. But we simply also got a bit of investment, a bit of support that are in in East Texas. Wanted, for example, into installing an offering 138 new IV pump so that see it has worked fighting over them. Very practical things, Trying to make things easy. Um, a swell a some ah, sort of, If you like high level leadership, we know what we have to do in scope wanna around buildings and energy efficiency on. But, um, I think there's some very good support that you can get from an HS England around this, and I know we've got the stakes colleague on the phone, but we know that it's going to take significant capital investment. We did a study of one of our hospitals of West Moreland Street, which showed that we need to invest about 4 million lbs to get to that zero on that site. And that was the sort of most detailed thing which makes the overall any testing done. Estimate 4.9 billion capital look a bit low to me, but actually, in this game of the kind of levels of investment were talking about even if it was 50 billion, that is absolutely double and in the long term is absolutely going to pay off. Um, we have it's iterated reiterated what we're already doing and continue to do more, so I won't go through all the things that we're working on Me. But, you know, we recently and out agreed on Capitol funding for 488. So panels on one of our hospitals All of these things are both visible and important signs that we are actually sort of putting our money where our mouth is. Um, Andi Azelas, um, kind of bottom up schemes that have been, you know, really interesting. Such as moving our default search engine into a cozy, which is a carbon negative search engine. Very easy to do. Um, on, um, you know, really interesting in terms of forcing, you know, changes in the market as well around behaviors with some of the sort of tech giants, a swell, so really important part of what we're going on. The big challenge, I think, is some of the reinjuring nearing around carbon, low carbon camels. But we have done some really interesting where there were some really obvious areas that we've really pushed. So about 40% of our outpatient appointments virtual have been last year. It's dropped a tiny bit. We've looked at, you know, different particular areas. For example, endoscopy. You know, to what extent when we replace traditional endoscopy with, you know, new forms off, um, things like a colon capsule camera technology, But also just screening fit, testing and things like that to go upstream to kind of try and reduce the amount of, um ah, sort of more intensive interventions. And then finally, so just a summary of what we really have done over the last year. We've got the team, the infrastructure of place. We've got the sort of senior sponsorship from the board down. We've looked to implement some big kind of quick wins. Um, communicated on awful lot about what we're doing on now. We're working on the kind of detailed strategy to sort of get us in place by 2031. So that's all for me. Thanks. That's that's actually fantastic. On thanks very much. It's actually really It's amazing how much you guys have achieved so so far on, um, hopefully off after hearing, actually, because it seems like from what you're saying, especially that I think that second slide, where you're saying about how you know China's I'm doing what it's doing is doing what it's doing. Australians sort of an eraser become a a super power of renewables, and then one detecting Now is this almost a sense of competition? Like a bit of a race. I'm, you know, a race to be no good, the richest. They're not the best, actually, the race, you know, between countries and the race between eating hospitals, even to be the greenest on, you know, the first two region at zero. And I think that is something that you know, we know that works well. You know, we know how people always strive to be the best day over the course of history. And actually, if that's know what's happening in terms of renewables in that zero, that that sounds like quite a hopeful situation to be in. And I know James isn't here in the moment, but I'm sure he'd be very proud to tell us that actually, that new Caster was the first healthcare organization in the world to declare that moment. But then I notice that you said that you want your hospital to be the first Teo getting that zero hospital. So it's interesting seeing he's like, it's a competition coming out. Well, what would you make that leap? Yeah, I'm I go from being very well, I don't naturally, very optimistic person. I, uh Do you think that we have a moment to make some big decisions about energy and that potentially things like security and other issues could reinforce this? But also, in the past, we have, you know, we've had opportunities. Lots of governments had opportunities to invest in, um uh, renewals, which for lots of good reasons, they haven't taken it. So I don't think there's any. I mean, we have to stay absolutely focused on continuing to kind of push for political change around this s Oh, I, um, I and I also know that, you know, shifting that we've got just a huge, huge way to go on. Go talk is cheap. So, you know, we've got got to kind of keep keep the pressure on. But I do think we know exactly what we need to do. And I do think we're in a definitely in a better position that we were even a year ago. But yeah, uh, you know, we've got to stay hopeful that way. And actually, if we the other thing is, you know, that is there's no point giving up This is the sliding spectrum is the how far we will go? You know, the temperature can keep going up and up on the faster and the more the more we push, the more we will mitigate that sort of the worst excesses of the you know, the potential catastrophic problems that we're facing. So, yeah, we just have I think you have to stay, stay focused and on optimistic, but know unrealistic and also continue to hold Hold those in authority to count on this. I think you make a good point in that. You know, actually, every little bit of effort we put it now will translate into less suffering. Last people coming to harm last damage being done, you know, you could sit. You could say Well, actually, because right, this tipping point today is pretty much as bad as it is as is going to get. And you know, we want to prevent getting worse every little bit we do will help in the right direction. Um, my I could see you got your your hand up there. Yeah, it's just gonna sound that competition side of things. I think you're absolutely right over here instead of ours. You know, most of us and hospitals have come through pretty aggressive exams through a latex combat. We're all competitive is your life and sticking some competition, they're just makes us do what we do best. Which is gonna go on. You know, you just go that little bit further so you'll see my talk Reduce competitive stuff is a definite and we were all just hard wired that way. Next in it. Yeah. So that way works well. Thanks, man. I've recorded interesting and question from Nicarico. I said, thanks, Leak. It's very, very hopeful. Talk on gout. Do you balance the positive environmental impact of virtual appointments with the potential negative impacts on patient experience and satisfaction with the service on? Is that taken into account? Little Yeah, I think it's a brilliant point. We are constantly improving the way that we do, um, on learning about the way that we do virtual appointments and of course, I mean, in the NHS, the majority of appointments are telephone and, um on that gives a different experience again from video appointments. They have to be selected incredibly carefully. You have to have patients bought in, and we're gonna get better and better at doing this. And we're also gonna be able to support that more and more with data that's behind provided ahead of clinic by patients. That gives a much richer information about whether of virtual appointment is appropriate and clinical at the moment. Because we don't have information ahead on we don't have way sort of manage some of the risk around. You know who's gonna walk, walk through the door and what problems they have by bringing lots and lots of people into into clinic and so on. Diesel Do UCLA First Appointment's almost Allfirst's to face for that reason, because we just don't even in a heavily diagnostic based area like, say, cardiology, we still don't don't want to just kind of rely on on virtual, but I think we get much, much more sophisticated at knowing exactly when ever chew Elizabet er balance and when you face to face is is is the right thing to do. I would say that most patients really love virtual, especially if they're routinely kind of being an easy LH gets has patients from. I'm sure Bristles is active saying from all over the country on when you're traveling free, I mean, I sat in clinics of traveling to someone trouble three hours, stayed overnight to get the result of some of the change into in on a kidney stone. And actually there was a much change. And so, you know, they been go back on their relieved because there's nothing to do and it is good news, but the same time that absolutely could have been done over the phone. So we just got a improve the way we do virtual. And I think, um uh, well, you know, we're gonna get better and better. I think it's a really good point. And, you know, you mentioned the hurricane there the potential negative impact on patient experience and satisfaction. And I think if if for chew a ploy, mints are sort of mandated, and the patient doesn't have that choice, and that's definitely a potential issue. And as you said, actually it concertante be it could lead to better satisfaction. You know, some people have to travel a very long way. I've got a person example that my mom broke her back a few years going based down in the country. But she's seen at the world National Speaker Customer been stand more so for the annual follow ups. You know, it's a case of taking a day off work for for both my parents. They can drive, you know, several hours up to north London. Um, for someone to essentially house, it'll going, she goes, Well, good on then drives all the back and ask to lose a day of work takes manually that cetera. And actually, since since covert and virtual follow ups have been introduced, you know is much, much, much easier. It is much, much better for them. And obviously that's for the environment to know, have to make that that long journey. And I think one thing that I definitely noticed, especially being in a knee doctor myself, is actually there are a lot of people who really don't like having virtual appointments on, you know, they you know, some people will be so frustrated that that the fact that can only get a telephone appointment with the GP, and so I end up coming into the emergency department on. I do wonder if you know better systems and data to know who suitable for which is one thing. But I think also putting patients in charge of Well, I think you know, a lot of the time patients will be able to tell if they're, you know, if they want the actual appointment. If they need a face to face appointment on, there will be some who you think. Okay, they could have a virtual point, but actually just for their own health anxiety in peace of mind, they think, actually, I really want to see someone face to face. And so I think it's I think, you know, the patient choice is really crucial element. And it will be trying to build a systems that allow allow a degree of automation, but also allow the patient to hold on to that, Um, that, uh, that was the words autonomy as well. When it comes, this is making. And I think, eh? So we'll come back to small conversation. I've got lots more questions here because Well, actually, I'm sure other people do as well. I I think in the interest of time. So we move onto mats, talk, and then, um and then we can come back and have a bit more of a discussion at the at the end. Excellent. Okay. Just before we move into mats that it's a very good point in terms of think about how we communicate with patients and that we don't want people to think we're putting environment above patient care. Actually, we need to It's gonna be interesting way of thinking about common strategies and what not to say. Well, actually, you know, we're trying to optimize your patient care, and it just happens that it makes it better for the environment. And that also happens to make you know, patient's health better a lot of the time. Anyway, without further day of the mouth. Yeah. Thanks for, um can you hear me? All right. There it was a not yet good. I'm glad I put the apostrophe in the correct place in director's cut there. So that's good. That's a good start, But yes, medicine. I'm in the system. Ishan on. I just thought I just went through, so my journey. How that's interacted on this slightly wider level after the knee. The test. You'll know. We're also see perspective of boots back constantly outdoors. That's that's what I look like an hour you got. People who run across the desert and we're all extremely clever is well and, you know, but they're not all of us. This is my main meal. He's not quite so there any way that that that's That's the anesthetic sided things. Patients don't often see a slightly differently where the last thing they see before, uh, they get a wonder, You know, they just see the mask and they some time to look at us like that. But actually, that's what we're like. Well, for the planet. And this was This has been over the last 567 years. It's really come to light, and this is the back bar of the anesthetic machine. And it's those two anesthetic vapors there that the real bad boys in the in the two requirements because the blues right, they're just being desperate. It's one model of that we typically lasts. About a day of anesthesia is the equivalent of 886 kg and see how it is. That's when I should have got into this done. Well, it's It's nonsense, you know? What should we do about this and the looking further into the data you go? Well, what can we do it about? A tough little cartoon shows See the floor in, which is a perfectly acceptable drugs, like Went driving 10 kilometers Nitrous oxide, which will come to slightly separately, is $106 and then best friend Boston up to 400 classes. So there's a big issue. Then you know what's the risk benefit balance and wave study. Okay, how we go about making this change, how we get our polyps on board. So we with myself and trainees and some other colleagues, we made all these little cards that sound. Top the anesthetic machines. Little nudges on them. Stove top one is vaporizing. One often is the same as 440 kg of coal. In one year, April forest will absorb comebacks, an improvement to produce vaporization. One bottle, it says. So we're doing a lease things throughout you talking terms of CO2. It's not that relevant, but if you put it in terms of passenger car miles or forests, that kind of has much more impact. Um, and again one. But it doesn't really saying is driving 2000 miles. And then we also had a little consider little numbers at the bottom. There's a little mystery word puzzle that result. And if you if you're one that yeah, you went up, submitted it through a website we put together for three of your t little website on there's a bottle of champagne without, you know, on this, then here comes the date of this was our best friend used to could see there 2017 years will be implemented. That change in the the years dropped tops very, very quickly. A same time is that we said okay. And this has been like Yuriko Medic stuff and working in teams season is several. And environmental anesthesia and Sustainability Network. It's a lot of training years ago because a lot the different hospitals feeding in, spreading the story, making sure that everybody understands driving, driving, driving. And so then we have three hospitals playing the desk brain game. And this was Gloucester, North Bristol on um, person. You can see that again Bit of competition. Unless the blue line was lost. The red, delighted because they were late into play, absolutely smashed it. So there there, please s o. You know that that's the kind of thing and that now, when you talk about the amount of 02, couldn't say that there's ulcer Hospital. You've gone from 80,000 tons of months down to less than 10,000 tons of my frequent so dramatic reductions. You can flip the date around and say, Well, what is this safe in that same in? In just two years, they've written 744 tons of oh two. That's what happens when you spread these things across. The number of hospitals on the money saved his That springs expensive with 54 grand in in a couple of years. So there's there's good data that so that's the anesthetic babies. And that's kind of it's got some quite a few places now what beyond death? You know what else is there? Because there's this kind of be done a bit, although I must say that he mails every other weekend we still use dance across outfitter me how you do it you know, it's It's about getting a few people on board, um, and just working it into the system and then leave those out liars to carry on using it. And they also become, you know, pariahs and you know they'll they'll get dropped soon. You know, they have to make the effort to get the desk brain off the shelf, put it onto the back bar, and that takes them a little bit of time. They get annoyed. It's assumed, you know, by the way, actually, I I'm quite a fan of 98% reduction is fine. And let me, uh, take percent. Don't find that too much gone to the next project. So the next one is nitrous. So this used to be a a co anesthetic agent for every single anesthetic week we give you know. But more commonly with these days, it seems, enter knocks, which is used, of course, in labor by Mom's on do quite a lot now in endoscopy and areas like that. So will you put that into context? This is a 2019 days you can see the top it they're up to about half past two type thing is estranged is a small slice with the largest is almost half of that whole I Chuck E 02 data is maternity, nitrous, emergency, nitrous, um, ambulance mattress. So they they're be beast that that are out there. You know, we chat a lot with our trainees that always a fancy stuff about nitrous member. Of course, it used to be no, his laughing gas, but it's no laughing matter anymore. Bit way, learn a list stuff is, um, it's just that there are side effects is in the seven Days inhibitor, which I'm glad there's no midwives president, but that's, you know, that's where they the the eye and made. It gets changed to a neighbor. That's because they expect exposed to too much of that stuff and then that it has been shown in cardiac anesthesia. It's no good. It makes you stiff. It's no good and gas builds basis. Like I said, so it's not really used anymore, but and it's an environmental group. Problem with it is, it's still piped into everything too complex through these kind of manifolds on. We have five of these manifolds and I trust, and they are huge systems provide a little nitrous and then to Knox into the hospital. And so we started making look at this with the guys from Lovea and Newcastle would be making a move to get rid of this stuff. Uh, it's difficult, okay, because it's a drug. So that's pharmacy. It's tapping through pipes for that's a stent. How it gets the anesthetic machines is memo on the gas out. Let guys who changes it. When it's the only piece of the anesthetic assistance that do that. Who uses it well, it's the initiative which people use it well, that's actually obstetrics. The's things are complex things to just undo. But pleased to say we have now taken down to about five minutes for tremendous results, and the reason is a wheeze gases enter, not on medical ass. These cylinders contain a huge amount and see the GI line. There is what yu 9000 liters and is enough to do a huge number inductions, which is what it's really useful now in pediatrics. But the main thing is, if you see a bunch of guys doing this in the park, you know, I thought my chaps blowing up balloons for an orphan party or something, and it turns out it's not the case. This is nitrous, and it's being abused. If you look at the same cylinders those ago festival, if you get a sort of posh festival about it, cost up to 10 lbs. One of these balloons, which means that the opportunity for 50 be cylinders is huge. Okay, so those juice, I still it is in sort of focus. I work, you know, to end user level of 11,000 lbs each. They cost very little, but they get stolen along. The analysis of our use of nitrous from one of our manifolds into night 2022 2021 showed that only 1% into the fish, only 1%. The rest was I stolen, always leaking on the probably difficult to know which is which. A huge amount. It's just through leaks, and also when it runs out of date, it has to be taken back on the O. C. And expected to the hospital because it's a drug that has to be about it. So, you know, we're not talking. About 1% is tiny amount, so we just thought, you know, get rid of it so disconnected all our anesthetic machines. No more nitrous again. You've got a couple of folks that are very keen on. It's like a one cylinder with an adaptive valve on top. That means you can just plug you out of Senate machine back in. If you want it with these kind of posters, then where's my nitrous? While the cylinder is located between theater for, you know, quite a lot of work to sort of sort all this out portrait and all this kind of stuff on a little QR code that the tests would just flash if they use nitrous on a course that was now 18 months ago. It's been used once across the whole manifolds area, so that's that's nitrous into theaters. But if you look them again, as always with this stuff to go down a bit, you know that wasn't the problem, that here it is so that mattresses enter knocks in labor is a big deal on. There aren't many alternatives, and I we use a team have gone into this a couple of times, and it's dangerous territory because you take away pain, control the labor you're know, you know, especially is a bloating is late forties, you know. You know you know, you don't go down to you. What? There is some good options. Now we have today being using this for the first time. This is a med class system. Any huge splits night nitrous into nitrogen and oxygen and blood flows it on two floors. It completely removes. Not just otherwise, go to the atmosphere. And I'm a night just in. The atmosphere is about three times bad is 300 times about it too. So this is But I just put in from this morning. That's us with the the rep there. We've got that one mg you unit then which will be used unfortunately, only on one patient at a time. That's what we could do. But this is a start, you know, And this takes This is the big leak into the world of nitrous. Used it. The maternity side of things on were very hopeful listing comfortable coming that unit, by the way. 10,000 lbs to rent it for the year. Huge amount of money. No, anything that could be done with across the whole of being a chest. But the way I look at it. This is bit like the first iPhone. You know it's out there. It's groovy. It'll soon drop in prices, you know. But when it gets stuck, the technology is spreading. Used across the area, it's power is only 100. What's but this is power by the solar panels on top of that very same roof that I'm in now so that that's pretty good. A lot of our buildings now covering the solar panels three guys in charge, a bit depressed because it's only 3% of the PAP power from hospital. That's brilliant 3% spirit, and it's, you know, it's forever. It's not Stop. Ah, so where next? I'm wiggling on a bit. But you know this. There's plenty more stuff to do. So remember, we're saying there's still a bit of death spray and be used. And the course There's a lot of the other anesthetic agent in years. Well, we now have a cross fitter. You look, there's a little canister back to the anesthetic machine that's called Contrave Flora, and that's full off charcoal. It's right back to that on. It essentially is a collection device for a little anesthetic agents that the vagus that use not the nitrous, just the vapors when it's full and then goes back. Teo Baxter who? Distillate out of that container on it can be reused. Sold again. So this is the kind of direction of trouble. These containers they cost about 17 lbs each, so there's a cost pressure. But this is very hopeful. This is the way forward, and, of course, none of it that ends up in the atmosphere that they're very excited about it. There's potential negative consequences. People move away from what we call total intravenous anesthesia. You're back to something. Using gas is you have to watch this. But now this is This is a good direction of trouble. Um, I would go to much on about that. And then so then, with all that, how does that fit in with the trust? This is absolutely insane, crucial that there's a wider trust level. You know, team, working on this and way have a huge team with all these different stream's. If you like it. The Boston man is the carbon neutral work stream. A time part off. The sustainable procurement, which is one of my colleagues, is works with again with sustainability managers, clean air works through communication engagements and then the waste management just quite a big deal. But these there's there's benefits, of course, the having the systems in place, which are very important, the M E if there's an issue with it, once you start coming into this level, when things can get what we want, I turn any chest if you like. You know things concern removed quite slowly from being a dynamic, flexible system. When you're doing a small project and then you enter, these things can concern down. But it has to be. It has to be the way for it has to have a top down. Yeah, with very senior leadership input. Which is why I do like stuff top to get stuff onto onto the local news in the evening, that kind of thing, because it's positively. And then when you go to him with an idea, I actually yeah, this is actually important because it's it's headlines stuff, you know. So that's why quite light. Yeah, pictures around the place and, for example, with that med Claire on nd you nitrous better. We will get the local pressing. We will show off about it because that that means it's more likely to get funding and less likely to get pulls. Now, you can't do any of this without waste on waist is the one that all of us since you know, first touch to the other chest. What on earth? So I'm just going to run through a little interesting journey with waste. Am I due for time? Maybe. We right? Yeah. You're getting it. Yeah. So weight is a big one. You know, we're all used to these time of posters and confusing multilevel, different types of bags. Aled Different. It costs etcetera slightly more. Kind of easier to see if you got the kind of recycle stuff down to black bags, Yellow bank, or, in fact, effective waste. What goes in it is we have these opposed to They were very useful. But, you know, the black existed ically domestic waist and orange bags should be infected west. Then we've got these new ones to the tiger bags. Which of these offensive waste being non infectious but infected waste on on the course that Trimex recycling and they all go on end up in our waste streams. And this this. This Siris is really just There was a medical student was getting to come and do a Q I project with me. So I said, Okay, follow the clear back on, follow it away all the way so that it's two days a great flow. You follow the clear bag and he followed it down. A way to be recycling sense from years and years. Uh, gene from the NHS and what happens is the way it works is a sort in company, like differ when the contract to take your waste away they take the waste away, ends up there sorting artists, and this is the first sorting office factory in even my near Bristol on. Then it all gets sorted into his various different bins on sent off a recycling, and this is just the recycling sign, which is fantastic, really. But a little plastic there then goes off to a different company to be dealt, and it requires those companies to need the plastic or to cook, put to draw on the plastic in order to take a class. And if no, that plastic pen goes landfill burn for energy, so it's a very complex area is very difficult to know in between amount of contamination in a clear bag, for example, in the drive, it's recycling very, very difficult to understand. I went back to the management. I said, Okay, if there's a 10% contamination rate in the clear backs, does that mean it'll get sent to a landfill? It's don't know. The answers are always very. It's a different one. You know. There's one solemn, blood soaked gauze inside the black bag. What happens then? You know it's difficult, but we went on the next step we went to This place is a team of about five minutes, and this is a giant new Vera door Wreath energy from waist recycling center and you just take a look at this picture. Doesn't make sure here is that this guy is driving a giant cross that lifts up tons and tons of weight and burns it from that. They make energy. So this is one of the guys we went to last a car own pictures. The leader from the website that wears a fascinating journey insiders these enormous burners that burn a ways, and this includes all the black beans from your hospital and all the tiger strike back the events of waist on down Fantastic. It makes you know, prove all these pipes exception. My pressure Steam on makes energy. And so this facility takes 320,000 tons per year of waste all sorts of ways, including that recycled waste that cannot be it is not needed by summa Be plastic resi class, unfortunately, but it does make 300 gigawatts electricity spray to 4000 homes, so these are It's a massive facility, and then next to it they just feel a polymer recycling acidity, which deals with 80,000 tons of plastic, which is quite a bit of a billion plus plastic bottles. It's great stuff, but and it's good because it avoids land of a waste is better than just sort of burning off right away. But course it all leads up a CEO to So when better say to us all your waist is not going to landfill and it is green, it is. The garden is net zero because it makes energy, but you can see from next is clearly making cm two. So it's not it's not. So watch this face with the waist I find it very confusing this development of fun with this spray we used test anesthetic blocks where is actually moving across to just use this 100% reusable colds feel little cool stickers. It's known instep Fantastic. Say it's easily done so to summary, from my side of being stairs just broadly with sustainability stuff you're pushing on open door. You're calling to pretty pleased to join you and get on with it. You know, as opposed to six. A lot of other things, like reducing SDA or, you know, increasing hours and stuff. Use your training and students make networks and they you I projects and is that brilliant July project, uh, does stopped. Even it pushed force push. This is the way to do it. Never give up, no matter what happens. So, uh and that's that's the end of I bet they're Thanks, guys. Thank you. Thank you so much. And I signed myself. Had so many discussion points a month throughout that have been in the morning or more, more. But it is fantastic to hear from you and everything you've ah, you achieved at critical so far. It's really interesting to hear this sort of the other side of the story about a week. You know what what you're doing is a clinician on the ground on time that somebody said that I thought was quite interesting. You know, he says, how Ah, there's all these people who are sort of trying to strive towards change, and then now they'll be like the laggards. You know that that late later doctors and remind me of that. You know, the graph of change makers. There's usually that innovators, the early adopters, early majority majority and etcetera on, you know when with focusing our efforts, you might as well focus on the people who are open to being converted. You know that early majority of people, because it's fantastic seeing from like clinicians during these sorts of changes. But it seems unrealistic to expect that across the entire wells, but you'll find in the States we're going to put in that level of effort in every single hops around the world. So the way, the way I often see the role of conditions such yourself in some of the comics team, doing these sort of quality improvement projects is really to say, Hey, this is this can be done on, you know, we've done it on. So it kind of sets a precedent for other hospitals to follow. And then soon, as there's, you know, five or 10 hospitals that have done it, then that gives the green lights of people you know, right at the very top to say, Well, actually, clearly it's durable less. Just shut it down across across the board on, then that's what. And that's really when the big changes happen. And it's only I heard Nick watchers giving the talking Our, um, you came in. It's conference recently is opening conference and he was saying how he's learned about all this desperate and stuff and the and you're saying the wrong question. Is this going back to him and say, Well, you know, let let's aim for you know, it's a 5% inside and he was like, Why? Like switching you turn it all off? Why do we need it? And so I think it's it's really interesting hearing. You know how many opportunities there are for for certain projects like that? Um, I have a question on that day. Um, is is that any time, Where does Marine really is the only option. And actually, you couldn't get say, you know, cva or nitro that's also not a or anti you, for example. You know it's other Any situations where you would say, actually really do need to have desperation's in the news test. Uh, the the short answer is probably notes. Unless you're Doctor actually thinks there is. You said, you know you're in the same same as before. So the last discussion I had on this way, one of the unique just use of it, is the absolute fantastic Neatest was just yet for some of we would have a heart institute where we induce this rhythm music patients and the best rate is pro arithmetic, which is one of its downfall. But actually, when you're trying to induce these dysrhythmias and PP studies and cardiology, then destinations, you know that his argument was that desperate is a good drug for that and, you know, wears off what you said. You know, this, this arguments like that which case you get from my 40 viewing, I get asked. Fine. Yeah, you keep you know it's gonna be rare enough. And then I lost the BBC completed the end of it. Let's to put it on the shelf and then slowly disappear. But you're you're right. This there's other hospitals near my glass there they just set up on, you know, so which which which is is equally good. Probably more balls. You know, I if you you know, I think it'll It'll disappear pretty quick that the new guys are using it. So, you know, I remember you know, the plastic bands came in and maybe the dentist of papers or news. New reports which follow a family with zero plastic and then go. I could meet my medicines because they in a little plastic blister pack, get really a nurse. Interesting television. But if you reduce your plastic by 95% that's pretty good. And then let's go with something else and then, you know, then maybe that last 5%. Maybe that's that's just a personal thing. You might be the wrong ask you, but that's the way I Well, I I suppose it's that sort of reduce reuse, recycle, and they just got over Jesus fires as far as possible. And you know that there are some muscles that are going bold as you say. Uh, I'm saying what? She just switch. Switch it off. Your sold it sooner if it's missed, I suppose. Yeah. Um Leak Leak. The other question was saying to mount, What do you think of total total intravenous anesthesia or TV? Um Ondas. Well, as that, we really need more innovation or nitrous reduction and capture. Be on Med Claire at 10. 10,000 again. Although I would add to that week and you may or may not remember when I spoke to you guys easy. L 10,000 is the exact number with the exact amount of money that the the UCL intensive care tea room on T three was spending or coffee cups in one financial year. It was actually is actually 9100 something 50 something pounds on. After I spoke to you, I think its name is Adrian On the waste money, he said he estimates it took to cost about 800 lbs to throw it all away is year. So So most of all of that is the amount of spend on coffee cups in that department. I agree. I mean, there are I mean, we've looked up. Um, we've looked at my Claire, and we've got I'm sure exactly like a big a very big labor ward on do, um, birth center on. And so the the ideal is actually to have it plummeted in rather than Teo. But I I think, you know, be really good. See that the prices come down, but I think it will come down faster if we can get some competitors on scene. But yeah, I was very interested in TV. Um and also, I do feel that that the rule college perhaps, could be more proactive on some of this stuff aside, Well, but including TV er and And there's even though I totally agree that if you get 95% of way of the way there, that's that is absolutely, you know, that's the That's the big battle on. Then you get diminishing returns. Yeah, well, I think so. On TV, yes. I mean, I think it's just becoming more and more normal lenders. I you know, this is practical aspects to TV, which means it's a bit of a fast, because it's separate to the anesthetic machine. Where is the first manufacturer who brings out the anesthetic machine where? Well, the typical Sinus. These bit more like the profiles in the back. More like the milk in a copy machine. And you just plug the next you know, thinking, and it gives you that order date yet that that would be the way. And if you want to use a gas, they have to plug in a completely separate trip stand and you're kind of disappear. So that's why I'm a little bit worried about this. Absorption technology for the gas is because it it even if it works well. Of course, stations exhale, you know, outside of the anesthetic really be end, you know, down. It could drive people back to a volatile agent on a statin, which you might be a negative consequence. Although, you know, hey could be ideal because more look at pro profile. Then they say, Well, what about its metabolites in the water systems exception? So nothing's perfect and the destroyer to make it and stuff, so I don't know. And indeed even that desperate and see Florida nitrous did that, and I, supporting that, is currently captured by the Baxter Systems, and other companies say checks another one. They can currently distillate in keeping in tanks. But it's not legal yet to sell back. It's the drug because they haven't got the license for it. So these things again during their infancy and guess where they're all that's done? Well, it's done in Germany. And how does it get a truck? And you know, So it's, uh, yet. But well, see right now, phenomenally complicated when you when he was looking into anything, really isn't It's even like, you know, in terms of everyday use for consumers, things like whether something's could possible or not. And then when you start reading into it, you know, is this really great? And then and then you say, Well, actually, we investing technologies and something that is kind of avoiding the actual solution. You know, saying, Well, the actual solution is to stop using the the volatiles and to move toward something like TV for a while. Is that going to slow things down attention by developing technologies like capture And, you know, it's interesting. It's so it's so new on still of this stuff, which is probably why it's s o interesting. I think on one other thing. I thought you know, obviously, if anyone's got any questions, wants to come on and say hello. Uh, please dio your hand up or type of the chat I'm But in the meantime, at one of the things that really stood out to me was around the nitrous since, and being in a a knee doctor, you know, we're trying to move away from night so much from count towards things like Pence rocks on. But it's not yet License and Children. So that scenario and that's still need some development on Biaxin. 44 examples of sub acute combined the generation of the court now and in my clinical practice on. But that's that's from nitrous abuse, usually. Or it can be just from nitrous use in people who are otherwise B 12 deficient. Such a people with permission anemia on MySpace because the body just stops being able to use it. It's better Men B 12. You get spinal cord degeneration, and I thought that that fatal was quite interesting because the last person I had's on just a few weeks ago, you had actually had managed to smash. They're 1000 balloons in a three day bender on Then came in being unable to walk from my staff. So it's It's only interesting to done See your chart, which showed only 1% of the nitrous was being used clinically. And actually 99% was either leakage or stolen. I mean, that's absolutely mind blowing on, then even the ones that doesn't even the the gas it doesn't leak or get stolen, then get back to money. Fracturing gets bent it anyway because it's out of date, you know, that is that's just incredible. And I hadn't really appreciated that the importance of switching off the manifolds before that either thought. Well, if no one's using the manifold, does it really make much difference in the selection off or no? Well, actually, you know, everyone's using it, and all that gas is leaking going to waste. But you still got the menopause being capped, talked opposite way that actually, that's a massive problem. So I think, you know, I really appreciate why it kind of manage phones and so, so important now. Yeah, fascinating. I had no idea when I think this is the messaging around the nitrous from abuse by folk up, you know, festivals and stuff is Well, it's interesting this the university guys here You were just behind the hospital university Bristol Bay Balsam on nitrous sniffer that sits on top of the hospital on top of the university. It looks of parts per trillion part familiar looking, a lot of pollution they were interested in okay, these sniffers in corridors in the hospital just to see maybe where there's accumulation but one of the bits of information they said if they have to big spikes in nitrous pollution from their past four trillion on. But of course it's Friday and Saturday night, and that's because it's abused. So So there's probably some work to be done in a while. It'll just saying, Hey, you groovy gave thinking your old being, you know, right on and modern. Actually, you're not too well much field when you, you know, on your own brain. Obviously, you know, s so maybe the best place for the med clear would be an attentive glass of room and really right on abusive nitrous. You know, I'm heading to glass. Every adds more. I should say maybe I should count my parents. I do need to need a medic to sort of find the machine next. Um, so I got a question from and that is I've been trying to reduce my colleagues ease of nitrous, uh, any sadness on have quite a few average users. Do you have any tests on house and encouragement to switch it off? It sounds like you've done a pretty good job about, you know, You think you're saying it's being used once in your hospital recently. So you have any tips on getting your colleagues reduce the use of nitrous? Yeah, well, I think, Hey, it's it's tricky. It's about China. Have a Friday morning meeting mentioning, you know, a lot of the stuff around. There's then pull up the nitrous bit, mention it to the anesthetic assistance. Make sure the anesthetic assistance or only peas, because they're the ones that can often challenge during your case. Go and I can see that some more encouraged indirect encouragement. So even if they're using my kids, they look pleased, and you make sure it's often the end of the case, because if it's left on a 0.1 liters for the weekend, please, if you have to really force the message to say you're using it but it's fat. I'm not telling you to stop. What you're doing is fat. Just this left on? It is bad, but you're not saying you are bad. You just take a look. So it's about trying a just nudge things along there and train. He's very, very, very good. But yeah, um, it's not easy if the department still is a wider culture, generally using it, and it's a difficult one to make those that first if you, um, few viewing wrote. But then it tends to get that. I mean, most of the arguments are always around speed of wake up, quality of wake up and stuff. It's it's not really it's. It genuinely is an ideal use these days. All the time and I've changed and they're of them really is a difference. Then I even rather half of my life is around efficiency and fear tea. It's Mike. That's my main focus. Is that this theater efficiency that is not the wake up, that it's inefficient. It's about skill of, um, if it is just turning it off a bit earlier. Most of the delays because there's no better on the war or no no, the the last. You know whether or not you can turn the gas off 30 seconds or a minute earlier, So no, you know that that will be the counter argument back. Okay, who's like, Cancel? You have it. It's not true. It's not true. I think I understand. Six is one a days, um, medicine Nizoral most definitely incredibly scientific, As you know, anyone who said the FARC, um example will tell you. But it's also very much an art, isn't it? You know, trying to get the sleep, the cleanest anesthetic going on underneath this. But I'm certainly that's what I have seen two here. You know, the every any sickness has very little cocktail concoction to get the cleanest wake up the most beautiful obstruct the end of that. So I think if someone's you know, you've got very used to using desperate and on the nitrous, and then they'll be washing. Stop. All that that are really learn another way to get really an anesthetic. Uh, that's interesting. And we've got it. You're gonna get question from from Hannah s. So do you think some of the communications that were used with clinicians in regards to the environmental impact, such as driving a car X number of miles, my abuse with patients and you could make choices about back here based on what impact that procedure is going to have. A lot of patients like they have no idea that. I think that's a really interesting question, because at some stage, in probably the near future, if not already we'll have patients saying to their doctors, You know, What about the climate crisis? You know, what about my inhaler? You know that that's not so Environments and friendly on, you know, people are made A conscious consumers are making choices in the environment based on things like, you know, oatmeal person's cow milk. You know, this is a lesson, a conference, so people might start doing the same thing with that can and say, What do you think of that much? Uh, yeah, well, we we asked, Well, John, Big Mood is one of our CEO trainings. And on the season stuff, we asked a bunch of moms to be in a bar from the antenatal clinic on that kind of thing. What do you have to be? Very careful? Questionnaire, actually about the impact environmental impact of their delivery processing them. And actually the majority kind of took me if the overall sense of it was, Look, I'm going through this once or twice. You need to sort out your sister's. I want the system to sort out. But I don't want to be denied anything because it's not great. And then the way I look at that, it's a bit like if your sister's getting married in New Zealand, you probably fly there because it's a one off in LA la land. Be delighted if the plane use our office, much fuel and all that sort of things. But you know, you're not gonna have that massive change in your life and miss stuff, you know? So that's kind of kind of to take about me the It probably will become one certainly more with something like me to dose inhalers way that you're using and front for major life event something folks, you know, they just go look, please do what you need to do, but I just need to be treated right. Yeah, I think it's good point. I'm trying to imagine scenario and anywhere summer comes in, say, is it with the desiccated Children and someone gives them the nitrous, the night no planet. Please, please give me something else. I can't imagine that happening, but I think it's something that, you know we will start to see. Certainly more of the patients try to be a part of that conversation. Potentially know in that like emergency setting or an anesthetic setting, but certainly around a lot of aspects of of medicine. I think so. You're right in the birth plan, for example, I leave that Claire unit here. Now I can see people in their birth plan. If it's advertised that the antenatal think I want that device, I will have that device. But there, when it comes to, it's a Okay, So you went down. One night is if it's not, if there's fuse is gone it, then that's not That's sort of unfair. I don't think so. Yeah, yeah, I know exactly. Um, I've got iPhone not sure who it is, but someone who's a niece test with an iPhone on, um, he or she always presents regional anesthetic. The day cases. There's a reasonable and safe political choice in the matter of iron mental choices. Well, on what you thought sudden on that? I'm probably the only I last question anesthetic say we can't be on after that, but yeah, yes. Far. No, no, no. This is really, really in kids. And so one of the time running on s so it would be really interesting conversations. I've really enjoyed it so far, but I just wanted, um Task it, I guess, given we have a clinician to be doing laser stuff and Luke use a direct You doing loads and raising stuff? Sort of maybe something to discuss between the two of you is ah, sort of racking up went would be What do you think is the role of the, uh, the other side, but some, you know? So what? What do you think the direct need to be doing to go to support year and loop? What do you think you want to hear from the front line traditions To make your job easier on? You know what's the best way and fostering that happened? Leak. Do you wanna go fasting? That's not Yeah, I think I think things work best when the when sort of conditions and management work very closely. Hand in hand there is the thing that I was able to do when I was working with a niece test was they said, you know, need 140 machines, and he just that on the other on. But, you know, I sat down with the managers we worked out plan, We got the money, salt it on and then they have kind of provided the kind of clinical leaderships they set up the kind of clinical group this morning. They were doing a session of the order meeting there. Really? Um uh, and if you can get that partnership relief working, well, then I think that's where the magic happens. But, you know, there's definitely, you know, more that could be done from both the kind of clinical leadership in a managerial leadership side. But I wouldn't necessarily say it's, um yeah, I mean, I think everyone just needs to. Everyone needs to be up there, Game on this, this, You know, time is running out. So, um, whoever is. But you just you do need that absolutely soft side by side partnership, different skills to make stuff happen because it's complex stuff requires money, process change, etcetera, and that needs both parties kind of come to the table mostly, and not any. Any thoughts on that? Yeah, I couldn't agree with that. You know, um, looks obviously straddles that between this of traditional management and clinical, if you said I mean, which is fantastic. But of the more manager types that always been fascinated, how sometimes people blame the managers to be on a sudden it alone managers I've ever worked with in any guy always be absolutely superb in a driven by the same things we are. And if there's usually that's stumbling blocks of colleagues, to be honest with you, so you know we'll world on the same page. It's just sometimes, you know, you just gotta be. It's just gonna be clear that arrangement for the same thing. Waste management. For examples, the Waist manager might have it a strong directive around on GDP. Our stuff of patient name's only back ending up somewhere. Where's yours is on a green thing, so it's just making sure that you both So let's work on. Let's make sure we're relying on this before we get it. But you know, the drivers there from both sides brilliant. So it sounds like a collaboration is key, Um, getting a stakeholders involved early on, but we will need to be doing as much You really can't because we're running out of time is he said. But, um, it's nice to know that if you have ideas there was a clinician that you know, I think now more than ever before, you're really gonna have that support bathe in terms of, um, you know, support that the concept but also support with finances as well and certainly recently was doing Project Kings and management were fantastic, saying, You know, great love this project. Let's know what you need and we'll help you build some the materials and comes around it. And I think that's another thing is clinicians. Sometimes we feel like we're doing all of this in our spare time. You know, we're not getting paid to do any of this. Um, and actually, I certainly felt when I speak with management at King's, they're really supportive and said, Well, I know you guys busy, so, you know, tell us what comes you need will will produce it for you. So I think having those conversations between the people on on the on the ground and people in the office is is really, really, really helpful on on that's kind of the purpose of this, this whole talk series. So I've really enjoyed the conversations we've had today on. Thank you so much to to matter, Leak for coming on. And so it will be for for joining from all over the place. So I'm Yeah, thank you very much. Any final words from matter leak? It'll no, just massive. Thank you for everyone joining. I really enjoyed the session. If we can help, you know, Just get in touch on deal, try and do what we can. But thanks to you to you know, You know, I've I've just got to put on a quick, uh, a quick feedback. You are code. So if any of you want certificates who are listening, please just scan that you are now taking two the feedback for more. Once you filled in the feedback form, you will get sent a certificate automatically on do. Yeah. Thank you very much for joining. We'll probably try and run another one of these events in about three or four months. Time on. Got some more direct small conditions on board. Hopefully have some more interesting conversations on See what other exciting progress has been made. Um, towards the end of 2022 on until then. Thanks very much on. Have a lovely day. Thanks very much. Bye.