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Okay, So, um, we'll press on to the next session, which is entitled leading recovery. Uh, and we're delighted that we are joined by Sir James Macky. Who's the national director of elective recovery. I'm not I I simply lack of charisma, don't I? You just You're just not listening, are you? What do I need to do? I could sing. I could I don't know. Oh, look, it just Oh, here it goes. There it goes. Uh, lovely. Right? So this session is leading recovery, and I'm delighted that we're joined by James Matthews, national director on elective recovery. Uh, gym is going to be laying out the strategy on elective recovery that he's developed. Uh, the NHS, uh, England, I think a lot that be fascinating. And then And then we're going to get two responses looking at that through the the Northern Irish lens from Maria McCool, Gormley's chief nursing officer, the Department of Health and Neil Gucky and who's chief executive of Western Trust. But first, please welcome Sir James Macky. Hi, everyone. It's great to be here. I'm going to speak with the jury accent throughout to apologize for that. Probably. Subtitles that appear at different points. So I'm going to talk largely in my role as national director for elective recovery. But I still part time roughly half time. I work in Northumbria Trust and half time in the national role in a bit of a sort of regional perspective as well. Im born and brought up in north East England family originally from Ireland hundreds of years ago. The Northeast very like Ireland as well and very like north. So the demographic mix up feels very similar. Uh, so you'll hopefully see things that you're recognizing in all of this. Um what? Some things will be specifically different just because of the different sort of systems that are working so just very briefly, that is Northumbria. We cover roughly 2.5 1000 square miles from the time to the Scottish border across the Cumbrian border. As an organization, we have about 11,000 staff. If you include our commercial incomes, we've got about 800 million turnover, really massive focus on staff experience and patient experience. We built our patient experience program in 2010, added staff experiencing in 2018 to really try and get very, very, very focused about that and that drives all of our key decisions in the national roll. Have to keep reminding yourself of those things and bring yourself back to them all the time as the politics kicks in and get sort of stuck with performance problems, etcetera, etcetera. I was asked to talk about elective recovery, and when I agreed to do this last year for Amanda and colleagues nationally, it did feel a bit weird just talking about elective recovery. So in England, we're doing that largely the massive focus on it, because that's what the spending review give us money for in the summer of 21 so that at that point it felt like covitz. Over here is a chunk of money. Recover the waiting list crack on. And we all know life's not being that simple. And I had a couple of months I started, I think, in October of last year, a couple of months of just trying to get agreement. What recovery meant is its size of list is that our tea tea is a long wait as a patient experience, you know, what do we all mean? Because everybody meant different things. Treasury bought more activity. So what the Treasury wanted us to do from all the models was do broadly 130% of 1920 volumes by the end of the plan March 25. I think ideally, we want to try and reduce waiting times, improve the lived experience of patients. And if we can do that with doing less work fantastic, we haven't quite managed to pull that off yet. We have a plan ready to go in November of last year as a macron broke, it was supposed to be published over the weekend when our macron broke in England, so got suspended. Well, then get it published in February. And we've been trying to work through ever since. And I'll show you a little bit of progress and all that so again, and I'll show you in a minute. It's very different in different parts of England how all this works and the last phase is very different than the next. The next phase and just before I start jumping in all the graphs and all that. The last couple of weeks I've spoken to people in the Middle East, in America, in mainland Europe, everywhere in the world in developed healthcare systems. People are feeling broadly what were feeling. It's really hard. Work force is a really big problem. Public attitudes are really changing. Money is getting tight. Governments are starting to feel the strain of it. It's pretty much the same everywhere. How different systems are building the constructs and that sort of slightly different. But generally we are all feeling the same pain. It's important to remember as well that we were struggling before coverted in any major exertion or event. Your recovery is driven by the shape you're in beforehand, and we mustn't forget that we were going backwards on most of the main metrics in the running, too coated. So these are the elective chart and show you what happened before, Covidien, cetera and similarly, in emergency care. So emergency care in England. Sure, it's the same here across the world is an absolute nightmare, and we had in the first part of covert that was, explained the colleagues earlier on that first part of Cove ID always sort of slightly embarrassed, going out of the house at eight o'clock in the first night and receiving the clap from people in the Street, mostly elderly people to retire GPS because we were empty, we had 50% occupancy. Roughly through that period, we're all worried and we didn't know what we're leaning into. We didn't have patients lying all over the corridors and stuff and then so I felt a bit odd and we kind of probably all new. The heartbeat was going to come later on, and we're absolutely in a very, very hard bit now and in urgent care, largely through the complexity that was struggling to describe. And I was also one of those people who are naive. We thought it would be a bit hard for a few months and then we'll rebuild and we'll crack on. It will be over. You know, we'll just get on with our lives. I think the bad news is I don't think we're actually at halftime yet. I think we're through probably a five or a six year cycle of complexity, and we just have to keep managing a bit by bit and buying it off into manageable chunks. So as well as those metrics there were, there were declines, inpatient and stuff experience. The broader health care system was starting to feel stretch. We were starting to see gaps in social care and big, you know, increases in delayed transfers of care. Primary care was starting to struggle. They were talking actively about workforce problems for the first time, you know, having had a few years of trying to work through and get everybody to. Except where the workforce problem money was getting tighter, blah, blah, blah and broadly were working a model that was our best built in the seventies and some of it built in the forties and trying to expect to withstand the massive shock and deliver public expectations in a very challenging environment in the last couple of years, just exposed and off an awful lot of that. And then we mustn't forget In my last board meeting in North and before lock down, we consider the market update again in very part of our population. Very deprived sort of collective sensor share. Mr. We're actually going backwards. And a lot of these things A lot of the key population health metrics. Um, in the previous 10 years, so we had a discussion about at some point we got to deal with that cove. It actually helped us embrace that more in the trust where we had to. We created a PP factory in the first couple of weeks of lock down because of the panic around gowns, massive community response, business response, university response, volunteer and etcetera. And we build that into a bunch of commercial businesses that are aimed at finding education opportunities for kids in schools, creating employment opportunities, really challenging whether we need to buy things from other parts of the world, can create jobs locally. And remember that if we do that well, 2030 years time, people will be better off in. Some of these things will actually start going the right way. So one positive of covert and that first impact was it reminded us of our role in society. Another challenge we had when we when I first sort of turned up and the team were already started on pack. What is this? All looks like across the country is it looks very different in different parts of England, partly because people went in the cove, it and different shape in terms of performance. The impact that cove it was very, very different in different parts. They couldn't so part of England. We're locked down for very long periods of time. Other parts had short, sharp lockdowns were very in the Northeast, very allergic to London narrative. So I keep hearing about, you know, London had it's third or fourth wave or whatever colleagues in Manchester. Or so we've had seven. I think we've had six or seven, you know, etcetera. It's just really different everywhere. But when you look at the impact on the waiting list just purely the impact on the waiting list and long waits the Midlands in the Northwest have huge problems. Um, so initially on the two year problem, those two areas covered roughly 40% of our long weight problem to trust actually covered a massive proportion of our very long weight problems. So we needed a national plan, some national principles, but able to reflect local nuance and differences as people recovered a different different rates. Explaining that to a population is really hard. Um, and also there's a lot of misunderstanding about what the waiting list is and and how it's made up. I'll come back to that in a minute. We managed to agree with political colleagues that will bite this off over a period of time, but it's manageable. Chunks really start with the long waits, originally two years, then 18 months, then a year. You know, we'll just try and work through it methodically over time, try to change the system, engage patients more, change the outpatient model, you know, etcetera, etcetera. And the good news is, we've managed to make a lot of progress on the on the first bit. So some key themes in the plan and if you had a chance to read the plan those of you that have been involved in national processes when you set off these things, you have really hard, really naive ideas that actually recognize a lot of it at the end. Often you don't recognize much of what you wanted by the time it's actually published. And you do you know, you lose a lot in the political discussion and the attrition of agreeing with people, different things, etcetera. So the key principles from my point of view and many of these are there. That may be not emphasizing the way I would have like them to be, but key thing. For the first time ever, try and separate, urgent and elective care and build resilience and both streams. In my Northumbria life, we've been structurally separated in urgent and elective case since 2015. So all of the hot emergency work happens in one site, including emergency diagnostics. All of elective care happens on other sites, so you never have a situation where a surgeon or a diagnostician is having a juggle. I want to do this plan thing now because this person has been waiting a long time. But I've got three emergencies. Just come in the front door, try and build resilience in the system in huge investment across the country to make some of that happen recognition that were being under resourced from a diagnostic perspective and some of the investments being targeted. And that and that's you know, that's an ongoing process there. I really wanted to invert the outpatient model, um, as part of all this, and I'll show you some of the maths later on on this, but basically move away from this. This is driven by personal and family experience. Move away from a model that says Clinician sees you, put you on a treatment path, books you in every six months for the rest of your life, whether you need to see them or not or says you're alright, started your treatment. Tell us when you want to see us again and this is what you do if you need to see us. And this huge resource tied up in that followup system that I think increasingly find it hard to justify to a population when we're not on top of our work load, and we'll talk about that again in the middle in a minute. Part of that activate patients give them more control through technology eventually. So the public in England trust the APP because the coated vaccine and you know those sorts of things make the NHS AP a portal into the NHS and enable patients to put their outpatients tests, change appointments, have an interaction with the clinical team, uh, etcetera, etcetera. There are portals in use now, and over time that will get embedded properly into the up as a gateway into the NHS, and choice can help facilitate that as well. Focus on long waits continue to try and deal with productivity and variation, and we're being challenged a lot in recent weeks from political colleagues on the extent of variation. Why is one organization seven miles from another still only doing 90% of it's 1920 volumes? The one next door is doing 100 and 4% of 1920 volumes? Why? Why is one got 85% theater utilization? The one next door has got 60%. Why? Why is one thing that can do inpatient operating? They've got the same occupancy as the place next door. Usually we can't explain that, so that whole variation things are really big issue for us all to get get around in the productivity. The flexibility thing is a really big issue. So the beginning of cove it We had massive flexibility driven by extremists. And we all celebrated, uh, specialists, surgeons working as generalists at the front door, marking in people who weren't trained in intensive care, mucking in working together. We all said we wouldn't go back to normal, and we've all gone back to normal with knobs on were more rigid, more siloed, more protected now than we were pre covert, and it's a really big enemy for us as well. And then we've got the specter of the the requirements of the spending review in the background and in England in all of our models. For the it is to support the spending review and the plan. There were 11 million patients missing from pathways in our system. So if Cove it hadn't happened, there would have been 11 million more people in elective pathways than we could say. One would develop the plan of 60 odd million people who live in the country, so that was a huge risk and blue every other number in the plan. Almost every other number in the model was irrelevant because if 11 million people turned up, we were finished. So it was always my instinct that a lot of those people would be an urgent care being managed at home, community and primary care. They're being mental health pathways that being cancer pathways. We have seen a big increase in our cancer bounced back, um, as well, and some of them have died and, um, it was still trying to work through now whether we still got much of it to see or whether they're actually all in the system, and it's part of that, we'll have to go searching for people in different parts of society. You, for some reason, are now unable to access access the service. Um so I think we've probably seen a lot of it, most of it, but we're not going to know for a while yet, so we need to not get to get distracted from it. But 11 million people, we actually had the benefit of huge investment, as I said earlier on, to start supporting the separation of urgent elective care, development of surgical hubs, etcetera, etcetera and a lot of diagnostic investment as as, well, just quickly I'll counter through the next bit a little bit quicker, just to just to try and get the messages across. And this is roughly seven million people on our waiting list in in England. And we all think the media think colleagues think that they're all waiting for surgery. 80% of that seven million will end there episode in outpatients or diagnostics, 80%. Only 3% has an inpatient surgical state. So you have to understand the numbers in the maths and all this. If we're actually going to make an impact on it, we have an exchange overnight I don't know whether this is true or not yet we're still trying to get underneath it. But of the seven million just over that, we think there's only just over five million people. So you got people who are on the list more than once. Some of that's legitimate. Some of it's not, so we'll be double counts and all of that. It's pretty powerful if you can actually understand that. Probably it's very differential around the country. As I said earlier on, um, so we need a bit of recognize all of this. And the first the two year weight problem was largely surgical. The 78 week bit that we're in now. It's largely outpatients. So you know we're watching. We're moving that really quite dramatically now. So there's been throughout a really strong focus on our patients in trying to shift the model. Some of our most try challenge to Trust on 78 weeks can deliver comfortably. What they're 78 week challenge is if they're just reviews by 2 to 3% not 50% which looks possible in the model. Two or 3% can go from looking impossible to look uncomfortable in terms of delivery, and we're really just trying to get into all of that. All of that. Now. We're broadly at the point we wanted to be or hoping to be in October on the 18 month challenges. 78 week challenge. We needed to be 45,000 or something, you know, sort of number to go into the next half of the year and be able to deliver 1 to 12 at the end of the end of financial year with just about just about there to work out how we supported organizations and held to account to split them into four segments. Tearing approach, which was using the regulatory system in different ways over the years. So the idea would be in tier one year under national scrutiny and support. Tier four. You're fine. Just crack or no one's going to bother you. Just just keep going, etcetera. And all of the organizations that are that have been in Tier one and Tier two done a fantastic job, So the rate of progress across the country has been absolutely incredible. You'd never believe it if you read our papers and you know you looked at the media. You think you know we're still an absolute mess. But on two year weights, this time last year we were we were heading towards having 40,000 people waiting. Two years at the end of March, we got through a terrible winter. Resurgent coverted, massive covert occupancy loads of sickness absence throughout through different, different waves, especially in the spring. As of today, we've got about 2000 people waiting, um, of that you've waited two years. About half of them have refused options to have their treatment somewhere else or in a different way. So it's about 1000 of the NHS you could argue should have been able to treat and hasn't managed to yet. We're trying to get that to know as quickly as we can in the way people have gone about. It's been absolutely fantastic as well. So a lot of a lot of it's been sort of traditional performance management, getting a hold of the data, you know, all those sorts of things. But the way people have embraced technology, the forms chatbots, the chatbots stuff had a fantastic impact in Lancashire very challenged system, basic SMS communication to patients when people have been on the list for a long time. A couple of certainties. One is we probably haven't spoken to him for a long time. Probably the lives have changed that might be less interested in having what they originally uh listed for. And usually the data is crap. So when you when you start getting to it, you'll find very quickly the date is actually useless. And you can make a massive impact just by validation and getting the clinician's to work through what's on the list and whether they are still people who need to be treated. Almost nobody. This time last year, no clinician understood what was on their list. Almost no practice in primary care. Understood what was on the list from their perspective with with different providers. So just working through all that and I just trying to share the day to get people to validate and work through what impact could be made. Their we've had Super September September, which was a, um, just just trying to stimulate innovation and sharing ideas of fantastic effort with pretty much every organization in the country. My organization sort of grudgingly accepted. It was a lot of grumpiness to really have to do this. These crackers, You know, if you just ignore them long enough, we don't have to do it, you know, etcetera, etcetera. But when you get into it, there's lots of things sort of come out. Maybe we should every few weeks, just have a focus on news. Maybe we can do something about reviews. Maybe we will try virtual group consultations. You know all those sorts of things, different ways of trying to get back on top of the workload and give patients what they need for a long period. One of our most valuable, if not the most valuable clinical activity is being clinical Validation sounds really hard to explain, but often a clinician is better spending a session tidying up the waiting list, talking to patients, working out whether they still need what originally intended to have versus actually seeing patients because the list. So you know, that becomes so out of date et cetera, and especially with long waists, so an awful lot of effort going into clinical validation around the country. There's a couple of slides in here that I've been using different things in in recent weeks, but one of the really strong things in all this, and you can really feel the pressure trying to make us all do when we're all under pressure in urgent care. Got no headspace. Etcetera is to just rebuild what we used to have. What we used to have wasn't working, and it didn't withstand the shock fully. Let's remember, we've got a lot of benefit out of the innovation and flexibility, etcetera through the first waves. Let's try and reassemble new bricks, not the old ones. We've absolutely got to try and facilitate clinician, patient dialogue and all this. This isn't just the management system. Feeling about with numbers and lists and stuff will enable people have proper conversations about what they need. If you're listed for a gall bladder up three years ago and coated like you allowed you to lose a lot of weight, you probably don't need it now. So let's have a conversation about whether you actually need that. Whether it's right for you, you know, etcetera, etcetera. What else is going on in your life? Be driven by the data and fax, and I do. If you access HSG. I'm getting slaughtered in HSG today about all this, but it's really frustrating how few people actually understand the data and understand their data. Have had arguments with people about whether they can do what they need to do because they've got no beds because they're full from an urgent care perspective. But the long wait problem is all dermatology. They're not going to go into medical beds, you know, really understand what actually, what is actually driving their problem. The problem is all out patients, you know, etcetera, etcetera and really try and get people to take ownership of that. There's a lot of appetite going on. There is a lot of innovation going on around and let's, you know, learn from each other and really understand how the lists is made, made up etcetera as well. So these are some challenges were putting out in the system now organizations in Tier One and Tier two. We'll have to have you aboard self certification in the next few weeks to confirm they're doing all the basics. The board saying the data, they've got a plan. They've actually considered how they're going to get through winter rather than just assume they're going to get through winter. You know it's a lot of sensible stuff and we are now under much, much, much more challenge on value for money, given the state of the economy. And you can feel that pressure now from other parts of the public service and the economy generally. So just before we wrap up, there's a lot of challenges in all this and you can really convince yourself it's not possible. The NHS has done a fantastic job. You've done a fantastic job through your version of this in the last few years. The NHS as well has done an incredible job on the long way challenge. Whilst we've been going through all this additional complexity and that was navigating just the last few months, even and now we're you know, we're looking into a tough winter. We should do that with confidence in the way that everybody has managed to deal with it so far. There's a lot of innovation going on about. We've got virtual access to our patients now that we didn't have pre coated, so theoretically we can level the load. We can give people who are going to wait a long time in Devon, access to a physician in Newcastle now completely, practically, that's totally possible. Theoretically can do it across the world and to embrace some of these things. But let's be driven by the day. Let's not forget the public who are really stressed about what's going on and access, etcetera. Try and look whole system as much as we can. Primary, secondary care, community services, etcetera. And let's not let the defeatism and negativity get to us and remember patients and stuff throughout all this. It's really easy to get driven by the numbers and the performance management and all those sorts of things that would actually get driven to. And then finally, this isn't just something we're experiencing. It's the same across the world. There's a lot of learning across the world. A lot of people can learn from you and the things that you've done, and I'm pretty sure we'll we'll we'll get through this next phase as well. So just some final thoughts they're on disruption and getting people to take local control. Handing back the cases a local thing with my trust about trying to enable people to take control again of their teams. Their departments were in a level for incident for a long time and not really disabled people. Let's not forget urgent care and primary care and social care and mental health services. That's what it's well as well through all this. One of the big things that's thrown back on the all the time and I have had this problem myself and I've got it with the local management team is headspace. No one's going to give us headspace. We have to carve it out ourselves somehow. That's the bit that's going to get us free from all of this. Just expecting everybody to work harder isn't the way out of it. But I think we've got enough innovation. Will agility, flexibility and performance over the last few years to be able to deliver what we need to for patients and stuff. So stop their math. You happy to have a discussion? Uh, thanks, Jim. That was really inspiring. Um, so, Maria, it's up to you. Yeah, correct. Thank you, Jim. That was very inspiring. And I think one of the important things for me from coming to Northern Ireland I have a 92 year old mother, um, is the number of appointments that she's been actually sent out. Since I've arrived here, she's probably had about 10. Um, she's 92 probably doesn't need any of them and probably in the last 1000 days of her life. So I think we really do need to learn from this. It's really, really important, and particularly for older people. So just a bit for me. New C n over Northern Ireland, eight months and post first Nikon Conference. So thank you very much for inviting me. Um, my job in the Department of Health is really the professional policy lead for nursing mid free and a HP es, um and I do believe that are professional groups are part of the golden thread for actually recovery. Working with our pharmacists are medics and the wider social care family. So that's really important for me that we do this and we do it on the whole system place. I actually did my presentation around the view, my view from Stormont because in Northern Ireland is very new to me. Having come from Scotland, I've spent I started in the Republic of Ireland, moved to England, then moved to Scotland, where I spent the largest proportion of my career and I'm now back in Northern Ireland, some very privileged to be here and one of the things that struck me about Northern Ireland when I came as a population size of 1.9 million. And when I put that into context, that's probably not much bigger than Greater Glasgow and Clyde or indeed greater Manchester's. But what? I have no distance coming to Northern Ireland. There's a lot of hospital based infrastructure. The challenges that we face in Northern Ireland are those faced elsewhere in the UK and globally and away. That's probably quite reassuring and we've just emerged from the pandemic and that has had significant impact. I know in our communities, our staff and our services. We've seen an increase demand and actually I spent 12 hours in a and he recently with my mother and it was really, really interesting to see how busy and what a demand is in our services, particularly, we've seen demands and mental health, Children's services, elective any primary care. It just goes on importantly, I think similar to the rest of the world. We have an increasing older population which is in itself something that I know we should be celebrating. But there's a global recognition that this is place increasing demands on our health and social care services, and many of the people who care for older people like me, also a part of the working population. We have a widening health inequalities which has been compounded by the pandemic and will be further impacted by our economic crisis in Northern Ireland and across the globe. We are reporting rises and complexity, comorbidity, frailty and a significant proportion within our older population. When I was in a and he recently, the biggest number of people in and they were actually older people and I did ask myself should they all actually be there? Securing and retaining are responsive workforce. To deliver safe and effective care is also a significant challenge that we're facing when I add in the political instability, proposed reductions in public spending, the legacy of the trauma which is quite unique to Northern Ireland to the to the troubles. It gives us a lot of wicked issues that we need to handle and solve, and I know we can't do this individually or by one service, but I do believe we can do it collectively my slides are going on, but it doesn't matter. I just talked to um I do believe they haven't come from Scotland and with previous experience that Northern Ireland has all the ingredients for success. And the reason I think this is because one you have a integrated, a fully integrated health and social care system and having worked in Scotland, where they try to integrate health and social care now they moved to a new model. There was lots of difficulties with that, and the main one was that there wasn't one joint budget which you do have in Northern Ireland. We've also got implementing encompass, which I think will be really exciting. And I know that my colleagues who've had demonstrations in Scotland are very envious of that, and I'm sure that that will help us as we move forward. Since coming here, I've been apparently struck with the collective willingness of all our staff working in health and social care in the Department of Health, the independence and the voluntary sectors in wanting to do the right thing, working together to improve outcomes for people in Northern Ireland. And I know this Echoes administers talk this morning it is long recognized that our workforce is by far our strongest asset and this was evidenced in our responses to the pandemic. I believe that we have to harness that innovation and gym has touched on that and we must learn from the pandemic and not move back to where we were before because we weren't doing things right. However, I also recognize that the pandemic has had a significant impact on our front life staff, resulting in exhaustion, demoralization and some contemplating leaving our careers. What's this is crucial to address those concerns, also acutely aware that coming to Northern Ireland there's been a lot of investment over the last couple of years, both in the workforce and a new service model designs. I know also that we have to actually ensure that going forward are investments in health and social care are really targeted wisely. And I know the minister talked about off contract agency. I can say to you today in this audience that Northern Ireland has got the biggest spend per population across all of the four countries on agents and of contract agency spend. So how do we drive recovery first? I think we need to get through what I think might meet them, one of our most challenging winters. We have an individual and collective responsibility to protect ourselves. Our families are patients, are communities and our health care services. So I'm just making employees because every contact counts and for everybody to get their vaccines to help with that, I think it would be really important. We need to recognize that getting it right for older people must be a key priority within our recovery plans. We need to develop clear whole system pathways, and this requires a collective and collaborative response involving all those who use and provide our services. Our workforce is key to delivering a high quality health and social care experience. It is widely acknowledge that our workforce cannot deliver an excellent experience without having a positive working experience themselves. We need to offer solids support to our staff, making the health and social care service in Northern Ireland a great place to work. We recognize that there are many wicked issues we need to address to lead recovery. To address these as leaders, we need to create the conditions to allow creativity and empower are frontline staff and service leaders to lead recovery. Of course, we must rightly focus on responding to ill health, but our future goal must be to move to a model of prevention and early intervention for prevention. We must make every contact count. This will require both a cultural and paradigm shift in all our thinking, the ways we work across health and social care, and we must recognize that hospital should only be for acute episodes of care and for the shortest period of time. This is vitally important for our older and frailer people. We know that the transformation of primary care when I use the term primary care include community health and social care is a key ministerial and World Health Organization priority. So this has to be a focus of our recovery Changes and improvements are being made across the UK as we plan to rebuild and recover. Some of this may require long term planning and investment. However, we must learn from others and share and scale practice, and I think we're really, really good at innovation. What we're not good at is actually scaling it. Finally, in an increasingly digital world, we need to ensure that recovery is data driven, evidence informed and outcome focused. Key to this will be improving data linkages across our systems. So finally, I believe here's eight months and I hope you all believe that our health and social care can deliver the seemingly impossible. We have the people, we have the skills. So we need to demonstrate collective leadership working together to achieve. Like Jim has said, together we can harness at the innovation and the learning from what we did in the pandemic. I think that here today we have a room full of such folks. And I look forward to working with you to fight the fight to achieve a world class service in Northern Ireland. Thank you. Yeah. Hello, folks. I've been asked to give a Northern Ireland trust perspective and thank you, Jim. Your troubles are our troubles. We have the same issues in terms of rebuild. So I'm not going to be delighted here in terms of the time scales, I'm not going to repeat gyms presentation. Those who know me will not be surprised if I start with the financial challenge. The financial turbulence, I would call it, and I was very taken by quite a few of the comments already today. Firstly, we've heard that funding cut backs are coming, and it's almost this drip drip feed of fear that we have of what's imminent. But we have to set that behind us, and I'll come back to that. There is the potential we keep hearing of losing any overspend next year. So that's again more doom, uh, very taken by grannies comment. But we're not just, you know, an acute trust. We're health and social care. We have to be so mindful of the financial stress in our population, and it manifests in so many ways. But we need to get back to focus. We spend billions of pounds, so this is an opportunity for us to look at what we do, how we do it and how we spend our money. This will be, however, the first winter, probably in my career, where there isn't extra resources being presented for a winter plan. So we need to start getting innovative in terms, then going back. I make no apology of talking about work force, and I know Maria and Jim have talked about that. We are losing staff for a variety of reasons, and we are. We cannot be judgmental on those reasons. People, we all make a career decisions. It's because of workload and stress. It's because of Push Cove. It changes in life choices, and so many of us have done made those sort of decisions. The cost of living crisis has made people decide to change their employment work, life balance, flex the route of flexibility which is close to my heart, and also the opportunity or lack of risk in terms of agency working as as Maria has has hinted at. But without the workforce, we have no service. If you can't talk about elective, as Jim has said without thinking about unscheduled care beds and flow on on schedule care versus elective access, they almost are competing. At the moment, our hospitals are really struggling to maintain flow due to discharge delays linked, in my view, to work force issues and domiciliary care and other factors and care homes, so our winter will be tougher than ever before, but we will have to stand together and we will get through it. So how will we address it all? Well, today and tomorrow we were continuing to hear all so many examples of improvements and good practice we must scale and spread them by working together as a system. We will get through this winter by driving improvement. We'll get through this winter by learning from each other. We'll get through this winter, but also being flexible with our staff. And I was one of the events at lunchtime. Milton Canes is allowing all their staff to choose their hours, and they're building their service around that something we can look at because certainly our staff are telling us they need things need to change. Productivity has been discussed this morning at quite some length. Uh, talking to the right person. They're definitely, uh, but basically, what can we do in terms of what's within our own gift? Theater utilization just referred to, uh in the Western Trust. We've done an awful lot of work in this before, coated and we made great progress, albeit from a very low base. But we will be fantastic progress on this, but we've lost the games during coated. We've lost staff again. It's a vicious circle. We need to We are rebuilding that work. We will get that back and we already started our journey. We need to separate emergency from elective, and that is extremely times difficult conversation to have. And I'll come back to the conversations. It's no coincidence for my organization that we are over delivering against against baselines for for decades work because we have, um, a hospital which does not have a link to unscheduled care by separating out elective were able to focus on our day casework. That is something we must do. We must focus on our day casework if our beds are so pressure and we need to bank these improvements during coated and improve further. So rebuild isn't just about acute hospitals. Daycare is an issue very close to our population. Down ancillary care. Also HPV. We will all need sustained improvement to make our systems improve. I'm very conscious. Uh, we've been talking about society and gyms, talked about social deprivation, where you've come to the capital of social deprivations gym that northern Northern Ireland. Not only have we historically had the most social deprivation, but Office of National Statistics this week have announced, in terms of the movement in the nation's Northern Ireland have a greater reduction than any other area in the region in the UK in terms of reduction in, uh, income for households, we already lowest, and we've fallen by more than everywhere else. So remember, with levels of social deprivation already worst, the current cost of living crisis will inevitably increase. Demand for a range of our services, including mental health, just discussed family and childcare and across our hospital services. We have a lot of strategies and a lot of change. But our corps service needs focus and support a few issues. If I get a soapbox. I'm very predictable about a couple of issues, folks, and I'm not going to apologize. Equity of Work Force. I come from the Wild West, folks. I lived in dairy all my life. We need senior and junior medical workforce equitably spread across Northern Ireland. Otherwise, system capacity won't be sustained. This shouldn't be a threat to anyone and any organization in Northern Ireland. It will make a full system work better. Rural communities subject very close to my heart in recent days. They need respect. How do we bring them with us? We need to change, but we also need to convince all of society that the outcomes will improve. My feedback is why feedback from my local community is why should rural communities always be the perceived losers? So to finish, I'm going to finish with some positive spokes, Uh, as I as I wander around my organization, sometimes that's what it feels like. Every day I see innovations. And yesterday, for example, Peter came up to visit the West, and he came in to see Trick our research organization. I was absolutely flabbergasted by by the innovation going on in just two rooms. We happened to wander into David Gibson's Here from the University of Bolster. He was presenting on the research into the impact of coated and the analysis of covert patients who have mild symptoms, severe symptoms and then six months after and trying to get behind the whole concept of long coded. It was absolutely fascinating to listen to all the clinician's around the room, their analysis of that scenario, and then we wander down the corridor, and John McGauran, one of our consultants, came out and described linking innovation to our problems. We have massive waiting list for endoscopic services, so they were testing across the U. K. He was one of the test sites to test a mechanism whereby you swallow like, almost like a vitamin pill that dissolves. And then it turns into a sponge or a Brillo pad. They take it out of you and they don't. You don't need any real major intervention, so they can then use that as a A biopsy. Fantastic, uh, innovation. By doing that, that can be nursed, lead and not doctor led, and we can split the witness into the future. So my other play a couple of final please. Let's go for two or three priorities. There's an awful lot of moving parts at the moment and half in social care and where they're moving parts. Then you don't hit the target. Going to targets were working as a system with more regional waiting list and work. Uh, let's really focus also on community services. Measure them, measure the impact and prioritize the impact. Let's use the digital gains made during coated. Uh, I never thought I'd say this, but as a provider of GP services, which doesn't quite come out of my my lips, naturally, uh, 60% of the patients have more, uh, practice are quite happy to take a telephone contact, so 40% need to visit the face to face. So going back to the conversation earlier from from our Royal College of GPS, that's that's absolutely right. We have the evidence to support that. Let's bring that into hospitals more and, uh, the final comment to final statements. Let's make it a doable ask for all our staff. And finally, we have dark winter ahead. It's important that we all pulled together during that period. Thank you. Uh, thank you, Neil. So we have a very distinguished guest to wrap up the day, and I don't want to leave him, uh, waiting much longer. Um and so therefore, I'm just going to completely take advantage of the fact that I'm the chair and and only ask one question, which I'm going to direct to gym, if that's okay. And, uh, Jim, I know you have an answer to this question, but I'm I'm really interested in the nature of the answer. So there's a lot of talk and there's been a lot of talk here as well about the need for us to think about fundamental shifts in the health service in relation to more system working in relation to prevention in relation to health inequalities, population, health. And we've been talking in the health service for decades about the need for this kind of shift, and yet the the precision and the positivity that you give to an account of change, which is a much more traditional model of change. In many ways, it's acute lead. It's quite centralized. It's target driven. And yet all the kind of contributions we've heard over the last day, yours is, in a way, the most positive. And I suppose the question I've got to ask you is, you know, I say, this is someone who worked for Tony Blair in the years of Michael Barber and that kind of target driven approach, which had big outcomes. And again the investment generated the results, but but in a way that stuck with that traditional, acute dominated health model. So I guess my question is, and I know it's a long question is how do we How do we combine the kind of brilliant work that you've described, which could in some ways seem to reinforce an acute central, target driven model with the kind of aspirations for more system working more preventative work and that kind of left worship. Sorry, such a long question. But I'm deeply fascinated by your I'll give you a long answer then. So, uh, I think first of all, we shouldn't fall into the trap of seeing them as binary in either of those. So my trust life, they're not. Either of those were putting as much effort in the community services R E s G and CS CSR work. You know, the support and communities. All those things are, uh, a public health infrastructure within the trust for which we received no income. We decided to do that ourselves. All of those things are getting effort. So first of all, beyond either or they have to both happen will fall into the trap of them feeling very either or all the time we've got to avoid it. Um, this is the second point is we'll have to probably, I think in our colleagues have said this as well. Bring some of the precision of measurement and improvement science to community services, mental health, social care, longer term, determine and set several things that work because the science works and everything and often what what was struggled with in community services, the absence of data, the absence of impact And so, you know, very live issue across the world is the people who were in hospital beds for one of the domiciliary care package. My instinct is, and we're trying to prove this now that we've got roughly 3.5 million quit tied up and running award. About a million pounds worth of the maxillary care gets those people home. So let's start measuring those sorts of things and looking at the impact and making good decisions about it all. And the final thing? I'm an accountant as well, so I'm got numbers in the heart, the financial impact of investing in community services, primary care, longer term determined and certainly public health is absolutely tiny in the scheme of things. So in a hospital you get nothing for three or four million quid. You can get a hell of a lot for three or four million quid in terms of primary care and certainly community support, support and vulnerable communities. We probably couldn't spend that in my population, So let's help some of that drive. Our discussions about decisions and investment decisions and, you know, to take responsibility ourselves. We've got a terrible addiction in our system to look for permission, wait for instruction in all those. I'm completely built to reject that. You know, let's all grab a hold of this and work out what our version of that is. Frankly, even our local systems will spend a half a percent in some of those longer term determinants or whatever. Frankly, we probably wouldn't notice. It probably have a huge impact, but we need to prove it. We need to measure it. We need to have confidence that I'm sure it's worth it. Yeah, Thanksgiving. I think that critical to that is, is how can we can talk about prevention with faster feedback loops. Often we talk about prevention as if it's a kind of heroic intergenerational challenge. But actually stopping people having medical interventions. They don't need a secondary prevention to stop people who've got one condition getting a second or third or fourth. There are fast feedback loop possibilities, preventative work, but we need the data, and we need to demonstrate that, and then once you got those feedback loops working, you can start to move to a bigger and more ambitious objective. Absolutely, absolutely. And I think we're also in a position where, and this is really counterintuitive course. We spent our lives trying to manage demand, restrict demand, given what's going on and what's happened to the most vulnerable in society. We probably need to be trying to find people and catch them before it's too late. And that really feels odd because it feels more expensive. It's probably not, but, you know, let's not just wait for them to hit the system later on, and I think you're absolutely right. I think a lot of this stuff will actually see more immediate and short term impact than we think we'll have. We'll definitely not. If we don't try and in your points on the vulnerable elderly, it's just we've got a model that's putting people in the wrong place, treating them inhumane inhumanely, not like people probably exacerbated the short of their lives, and we've got to stop that. Only you can stop That government won't stop that. We have to take responsibility for that. Well, I think that's a great message on which to end. Uh, this session, Uh, and the day apart from what was going to be a fantastic final session. I'll hand over to Heather for that. But please, can you join me in thanking Gym Macky Maria and Meal?