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Um So hello and welcome to our next session. So this is looking at sustainability in surgery. We've got three fantastic speakers lined up for you. Two are joining us virtually in one in person. So my name's Helen Skinner and I'm general surgery registrar and I'm also Asset's current Webmaster and Bursary liaison and I'll be one of your chairs. My name's Rose. I'm a neurosurgery registrar in London and the current BTA. So neurosurgery trainees association rep for as I'm doing program this year, working full time as a sustainability fellow with Green. So it's topic very close to my heart and if anyone wants to talk a little bit about sustainability fellowships after the session, more than happy to have that conversation. So as you mentioned, the first two speakers are both virtual. So we'll introduce our first speaker then be online. So to set up, we've got Professor Mahmood B professor is the inaugural chair in Ent Surgery and the professor of sustainable healthcare at Brighton and Sussex Medical School and an honorary consultant and clinical lead green lead for University Hospital, Sussex. He has a long standing interest in environmental and labor rights harms caused by medical supply chains. He chaired the recent Greens surgery report in collaboration with the UK Health Alliance on Climate Change and the Center for Sustainable Health Care. So we'll pass over to Professor Booter. No, sorry Ro Rose. Um So I understand I've got 15 minutes so I'll try and er run through everything and I, and I apologies that I can't be there in person today. So this is a report that was released in November. It's freely available online. If you just Google Green Surgery and UK hack UK, health on climate change, you'll be able to find it. It's basically an evidence based approach to how we should be making surgical care greener. Um, and it's certainly the first stage of what I hope is, er, a, a journey that we're on. I've been involved in this for the last, um, er, well, nearly 20 years now when I first came across issues with, er, labor rights in our supply chains and I'll talk to you a bit about that later on, but just to give you the context, um, green surgery, this is this report that's come out, like I say, you can download it. And when we're talking about green surgery, I mean, II will be focusing later on, on the products that we use, but in particular, we should think about the whole care pathway. So the surgical pathway includes the development of surgical disease, preoperative care and I put it as preoperative of course, uh, the v, well, certainly a large number of patients. I see. I don't operate on and they'll exit the pathway at that point. Then there's the operating theater where we may operate and all the things that go around with that to provide us with the equipment and the facilities we need and then postoperative care as well. So, what's the best approach to this pathway is doing no surgery at all? If you do no surgery, we save the whole carbon footprint. And we need to be honest about this, um, where surgery does and does not have a role because there are balances here. So public health approaches are part of the solution and that may include things like, um, you know, sort of a better, er, speeds for cars so that we reduce the number of road traffic accidents or better, no cars at all. And we move to sort of, er, more, er, cycling, public transport, walking, oncological surgery with low probabilities of cure. I mean, I certainly have had experience where we feel like we need to be heroes and we're going to save these patients when the truth is we know that we wouldn't put our c through some of the surgery that we put our patients through because we, we seem to have this failure to be able to be honest with our patients. That's not always the case, but I've certainly seen that and, and that is not helping our patients. I'm not suggesting anywhere that we compromise clinical care, it's about good care and perhaps green care comes with good care. So from my, my advanced or recurrent head and neck cancer has a very, very low rate of cure and has significant morbidity associated with treatment, cosmetic procedures. Is one thing that I have also highlighted, we seem to have a cultural phenomenon where cosmetic surgery has become a norm. And uh we could debate about whether that's a medical condition or not. And non surgical management of it emergencies is increasing in moving towards things like small abscesses. In my specialty is ent small neck abscesses can now be treated successfully with antibiotics. I'm not suggesting that's always the case, but it's just things that we should think about not having surgery because surgery is very carbon intensive. So that's the public health approaches. I've already mentioned preoperative care. We need to embrace remote consultation and streamline pre op assessments. There's some work that's gone on locally where we found that some patients are having up to 13 in person appointments as part of their preoperative check. And if we digitize that process, you hugely streamline all of that and that obviously reduces the carbon because the main contributor to the carbon of a consultation is the patient's journey to get to us. There's a systematic review showing the carbon footprint of er, an of, of an outpatient appointment and you can see it's almost linear with the distance of the patient traveling to reach that consultation. What else? Um Anesthesia, we should be preferencing local or regional anesthesia where it is equivalent. So for me, I can think of gromit and repairing some eardrums and even superficial neck lesions can all be done under local anesthetic, much less material intensive. Also better patient care. They go home postoperative care, day care, short stay surgery, streamlined, POSTOP investigations virtual where patients can report their, their um sort of POSTOP care as it were POSTOP concerns. That's also been shown through digital pathways to be helpful. But I'm also going to concentrate really on the operating in the operating theater. I think one particular area of interest of mine for a long time has been our reliance on single use equipment and the amount of materialization we have in the theater which all of us see of course in our daily lives. So carbon hotspots in the operating theater include anesthetic gasses. And there is now a mandated reduction. In fact, elimination of des fluoran a very toxic greenhouse gas that are on anesthetic scholars historically used 3000 times the global warming potential of carbon dioxide that will stop in the UK this year, we should be very proud of that. There's Decommissioning of nitrous oxide manifolds as well. Cos nitrous oxide leaks out of pi nitrous oxide and it has 300 times the global warming potential um of carbon dioxide energy use, we should turn off equipment when it's not in use. Operating theaters are the most energy intensive part of the hospital. And we leave things running for no purpose and then consumable equipment, my particular interest. So I'm gonna talk to you. Um If that's ok, some of you may have heard this talk before, but for those who haven't, I'm going to talk about the linear economy of our medical goods. And there's different approaches we may take, for example, to surgical care. Here's some data looking at different approaches of vaginal abdominal laparoscopic and robotic approach to a hysterectomy. The carbon footprint varies depending on which technique you use. The a there is the anesthetic gasses that was actually historic data when desflurane was being used, that's now hugely reduced. And then the single biggest contributor after that is our use of single use equipment. As we've gone to laparoscopic approaches, we just started to throw things away as we've gone to robotic approaches, even more stuff thrown away. For those of you who are the newer, you probably think this has always been this way. It certainly has not back in the fifties and sixties. Almost every single piece of equipment was reused. It's a cultural phenomenon. There is nothing that says we cannot reuse all of this equipment except of course our linear models that support convenience and support caps models of continual consumption and continual planetary destruction. Here's some data from er India where they performed cataract operations en masse at one of the leading centers. They use highly efficient systems. They re reuse almost all of their equipment and they've got low rate of infection than we report in the UK and a 30 fold lower carbon footprint. So it can be done. And here's some of our data of the carbon footprint of products used in the operating theater. And we found that red part of that pie chart is the production and use of single use equipment. Two thirds of the carbon of the product used in our operating theaters is due to single use products and the scale of it is huge. 1.7 billion gloves were used per year in the NHS in England prior to the pandemic, people with this er, sort of cultural phenomenon where they were put on gloves for no reason. So if there's one thing you can please take away, do not wear gloves where they are not required, you only need to wear gloves when you're in contact with potentially infected bodily fluids. It's widespread misconception. It's a widespread cultural phenomenon and we know that over two thirds of drug use is inappropriate. 52 million metal instruments including 2.9 million laryngoscope blade that we just throw away. 93 million drapes and gowns because we throw them away. We have, uh, again a preference for single use 48 million electrosurgical products that we throw away. And I'll show you some of the examples of those. So what should we be doing? We should be reducing, of course, where we can because reducer saves 100% of the carbon reuse also stays between 38 and 56% of the carbon. Um And that accounts for sterilization and decontamination recycling, which we all get passionate about has a very small carbon footprint recovery if done optimally. So we are not going to recycle our way out of the climate crisis. We find huge amounts of microplastics and other toxic compounds such as DE HP used in plastics in our operating theaters, in our hospitals. Much higher than we find anywhere else because we use so much material, we find problems with resilience. So we have unprecedented problems in getting hold of products. It's getting better, but at one point there was over nearly 2000 products. We could not get into the NHS um because we just throw everything away so we can't get it again. Free market. Economics also operates when we produce things, we want them produced in the lowest possible way. And so here's some bandages coming off a production line, they're going into different boxes. Um and they're all different brands. A brand on the right is selling to America. The brand on the left is a local Mexican brand. It's exactly the same product. The is when we do that, we have problems with er, labor rights abuses and when we've tried to survey this, it was very difficult to get data. But when we did, we found half of our medical products are manufactured in countries with known risk of labor rights, serious labor rights abuses and those manifest as realities. So all of the incentives and barriers to us throwing things away is that perceived risk of infection. It's the economic drivers where we think it's cheaper to throw things away. We have a human and physical resource for use. It's not easy to reuse things. I'll show you some of that example. So as I've said, 1.7 billion gloves almost enough to stretch the moon prior to the pandemic and the pandemic just made things worse. I have no idea why we were told to wear all this pp We needed to wear some masks. We didn't need anything else. We just needed to wash our hands. What we find is those gloves are manufactured using outsourced labor. This is a glove factory in Malaysia, the world's largest and the they use immigrant workers. These immigrant workers are from Nepal and Bangladesh. They pay illegal recruitment fees of up to 2000, typically $2000 sometimes up to $5000. You can read our report on it. What we find is that they also live in terrible conditions. Here's some shipping containers that these workers are living in on the right. We just throw things away and nobody cares about these workers. These workers live in shipping containers for three years and work in this factory. This is a sub company also supplying the UK NHS. It's endemic in Malaysia, the production of gloves, but you just put them on and throw them away for no good reason. I'm afraid the majority of the time metal instruments, it used to be that we reused everything. But in the 19 nineties, we had problems with this thing called mad cow disease that led to inconsistent or adequate sterilization. And because of this potential risk to us, we start to throw things away rather than deal with the problems with inconsistent adequate sterilization. Every hospital more or less used to have their own sterilization department, that's what used to happen. That has all now been thrown away because we just throw away the instruments instead in many cases, certainly in our accident, emergency departments, our laryngoscope blades, it's horrendous. We don't need that because now we have robust decontamination and sterilization and the highest standards in the world. And here's how your metal instruments they're thrown away and this is how they're produced in Pakistan using sweatshop labor, using child labor. Here's a child working g making grinding on a grinding machine. I've seen seven year olds working to make this stuff cheap as possible because we just want to throw it away. We throw away human dignity, we throw away our planet and we throw away money, textiles. This is some misconceptions that reusable textiles have some sort of problem, cotton drapes and gowns. Uh, we have to throw them away because of infection risk. This is not dated with thin cotton drapes and gowns have no place in orthopedic surgery. That is absolutely true. We have not used cotton as a material for our drapes and gowns for nearly three decades. Now, this is hopelessly out of date. This is people making decisions without knowledge of what's going underneath. We have European standards that mean these products must meet these standards throughout their life cycle. You need to have no concern about infection because it's all monitored. And if you reuse textiles, drapes and gowns, they're typically used 55 to 75 times and have one third of the carbon footprint of that throwaway stuff. But there are companies that will tell you you have to use single use because it's better for infection risk. It's utter nonsense. There's no evidence for it whatsoever. We have the best sterilization and laundry standards in the world. But if you make your gowns and throw them away, maybe they were manufactured in this um factory which was supplying the NHS with forced labor of North Korean workers over the border in China where between 70 100% of their salaries were sent to the North Korean State electrosurgical products. Hey, we can get on this bandwagon of infection risk and say here's a paper saying, oh, rhinoscopes, yeah, eliminates a serious potential risk of prion transmission. Yet the Department of Health has says there is no known cases of a prion ever been transmitted by S Orosco. But let's just throw them away and let's give you some marketing that tells you that throwing it away is better. It's simply not use is better. Here's another company and they know that I put this slide up. Here's a, something called a harmonic scalpel. Perhaps you've used it, but it's single use. It doesn't need to be that just needs some pads replacing because this organization, the association of medical device reprocessors does do that. But inside there's a chip, the chip has to be taken out and a new chip put in because the chip they've put in only allows this product to be used once that's simply planned, programmed obsolescence to make money. 48 million of these. Let's just throw them away solutions that we're working towards on. This is perceived risk of infection and working with the infection prevention society to try and bring some sense and sensibility to this and they're completely on board with this. What else? We've got economic drivers. We're looking at whole system finance because actually it's false to think that throwing away things is cheaper, usually almost always. It's, it's cheap, it's cheaper to reuse and we're expanding natural infrastructure point of care for reuse. So that includes new methods such as UV D contamination. But it must also include expansion of our sterilization capacity. To make this reuse phenomenon er easier. So I'll stop there. You can look at our website for more information and uh thanks for your time. Thank you so much, Professor. That was very interesting and very eye opening to be truthful. I think that we can't keep professor for too long. But if we wanted to ask a couple of questions while he's here, if anyone has anything, they'd like to ask. Yeah, I can see someone with the hand. I'm just saying if we got a mic in the audience that we could potentially um Yes, we'll just get that over to you now one moment, sorry. It just, it's quite difficult for the speakers to hear virtually if you don't use the microphone. So just one moment. Thank you. Thank you. Um Professor Butter. That was brilliant. Um My name is Christopher G. I'm an orthopedic surgeon in Scotland and I sit on the National Green Theaters Group in Scotland and run our hospitals, uh Green Theaters program as well. Um You talk about the need for reusable over single use. And one of the things we've uh looked at is that we don't necessarily have the sterilization services to cope with that massive expansion of reusable over single use. And it's the same with the laundry services for reusable gowns and drapes. So I'm just interested to know what, what's kind of happening behind the scenes in terms of how they're going to fund that expansion because I understand in Scotland it's several, several billion pounds worth of investment required to make the sterilization services have that capacity. Yeah, sure. It's um thank you for the question. It's, it's, it's a difficult problem. I think we need also to link up with government. Uh And I'm glad you've got government next, but they are England. So Scotland also needs to come aboard. We need to have an open and honest conversation about what this is going to cost. But I think equally if Scotland was to, for example, pass policy to say we will be transitioning to all drapes and gowns to be reusable by say 2026 or something like that. You know, that will send a clear signal to the market for those who want to come in to build that capacity because it's a big chicken and egg. The people who are trying to build the capacity may say hang on. We don't know if this is gonna be worth us actually investing, er and equally on the other side to saying, well, we can't do it, but if you put out a clear mandate that this is what we're going to do going forward. Um I'm actually at the moment doing a systematic review on the evidence for reasonable DRS and gowns. I'm pretty sure I know what it's gonna show and then I think we need the policy leaders um and the er to, to say this is what we're gonna invest in, um, whether the government pays for it or through a private model. I'm not sure. Thank you. And we've probably got time for one more question if anybody else would like to ask anything. Yeah, just over there. Hi. Thanks very much. Thanks for your talk. There's a lot of mention and sustainability and it's kind of the new hot topic. But what are your thoughts on companies, green washing? And how can you tell these companies apart from the ones that are actually doing a good job and trying to be more sustainable? Yeah, it's very difficult. Um So we, we, we I'm trying to put out a clear message and we've actually just been commissioned to write some policy for the Green Rs which will come out later this year. But in essence, I've said to, I mean, I say, be careful. Um you know, people say, oh, I've made my product disposable, but I've made it of a biodegradable plastic. Well, actually biodegradable plastics actually release methane. They're far more harmful to the planet than actually normal things and also the disposal. We're just gonna incinerate it. So be careful of what people are telling you. What I always say is why did you not make your product reusable? That is the one question I would ask every single company. And I think if you send that mantra out, then that's what they're going to listen to. Companies are listening. Perhaps not to me but they're, they're seeing some market shift and we now got staplers, for example, I've seen one that's been released uh just last year that can be reused several 100 times. Um There are now mask airways that have been released that can be reused 40 times. Surprisingly, the first ever laryngeal mask airway that was made was actually made to be reused 40 times. We're just going back to what we used to do. So I think it's up to us to say no, I want our products to be reusable. Why did you not make that product reusable? Um And that should be the simple message I think. Thank you so much. So I think we'll probably in the interest of time move on to the next talk. Now, obviously, professor, if you're available to say you're very welcome to, but I understand that you do have some other commitments. So if not, thank you so much for joining us this morning. And so our next talk will be by Mr Peter May. So Peter currently leads on workforce leadership and training in the Greener NHS National Program. He has over a decade of experience working in the NHS starting his journey as a clinician before transitioning to clinical research and finally joining the National Greener NHS Program where he's worked across a variety of areas including the Net zero Clinical Transformation, travel and trans book and communications. He cares passionately about the health of people and our planet and believes that NHS staff, the key to delivering a low carbon healthcare system for all. So hopefully I'll be able to join us virtually now. Hi, everyone. Uh Thanks for having me. Nice to meet you all. Um Always enjoy listening to Mood speak. I think his um his lines on the justice around or injustice around supply chains are really powerful and always land really well. So, thanks Mood. I was inspired by your talk. Um I think for me, I'm gonna zoom out a little bit which is maybe an odd order to do these two talks in. Um I'm not a surgeon, er and so not an expert in the surgical area. Um but maybe I can provide a bit of an overview of what's happening in health care in relation to er net zero decarbonisation, climate change, et cetera. Um So yeah, hopefully I can take you through that in the next sort of 10 to 15 minutes and then leave some time for questions. My slides will move the other version. So why, why does the er why does the NHS care about Net Zero? And um climate change? Well, the answer to that is is pretty simple really um climate change impacts directly on health um and it impacts directly on our ability to deliver health care in the UK worldwide both now and in the future. So what does that mean? Well, um climate change directly impacts health, for example, through heat waves increased heatwaves. So, in 2022 we saw 2.5 1000 excess deaths caused by the heat wave in the UK. Um, also indirectly through things like air pollution. So, air pollution is the cause of, um, one in 20 deaths in the UK. Um, and it's estimated over 13 million avoidable deaths occur each year worldwide through environmental um causes. So it's a pretty big issue. Um, and I think lots of you will have seen in the news as well. Um Things like, er, extreme flooding in the UK, disrupting er, the services in Ed departments and other hospital services in recent years. Um and it's only getting worse. Um in the last 10 years, nine have been the hottest on record. So, uh we need to take a note of this and, er, pay attention right now. It's on our doorsteps. Um We need to make some change but hopefully that's most of the depressing stuff out of the way. We have a big opportunity. So the NHS um is accounts for about 40% of UK emission, er, of, of public sector emissions in the UK and about 4% of total emissions that's massive um bigger than aviation in a lot of countries. Um So with that large problem and the fact that we're con contributing to those health issues comes that massive opportunity, an opportunity for all staff to be involved in something quite meaningful, we can reduce that carbon footprint, we can reduce that impact on health now and in the future, you might not have heard about it, but, but the NHS has been thinking about er net net zero and sustainable health care for quite a long time. So, since about 2008, when the Climate Change Act er came out from the UK, which set an 80% nationwide U er emissions reduction target. Um We had a small team working in the NHS. Um looking at starting to kind kind of try and um carbon footprint, the whole NHS er and work with willing partners. Now, what you'll see on the bottom left here is is when things started really to accelerate. So the delivering a net zero report came out in 2020. Um and that was the most comprehensive common footprint of a healthcare system to date but importantly, sent set the um pace and trajectory of change required to reach net zero for the healthcare system. And it was the first net zero target set by the national healthcare system. We're pretty ambitious. We went for net zero by 2040 for the emissions we control directly. So that's things like our buildings, energy, a few of our different medicines um but also 2045 for all the emissions that the NHS can influence. So a massive um organization with 80,000 suppliers, um we can influence our international supply chains. Um We can influence patient and visitor travel hidden away. In recent years, you may have seen another target around reducing air pollution, our, our contribution to air pollution by 50%. Um by the end of the decade and you'll probably see from the, the health stats that I talked about on the first slide um that this could be really critical in improving health. So another world first um the NHS was the first er country to put er this into law. So, the Health and Care Act 2022 now includes that delivering a net zero report as statutory guidance for Trusts and I CBS. So each trust and ICB has an obligation to deliver against the net zero targets. Um and each trust and ICB has to have a net zero lead um and a green plan. Um So that's pretty exciting stuff we appreciate. There's a huge amount more progress needed. Um but it really is a sea change um in the system. And mo most recently of all er the regulator for Health and Social Care, the Care Quality Commission um is now regulating against um sustainability as one of its um core assessment frameworks in the well led section of their, of their new assessment framework. Um So you can check that on their website that is gonna become more comprehensive and more rigorous in years to come. So something to keep an eye out for and to uh tell your trust about when you go back to work. So where does the carbon come from? Um, I guess the answer to that question is pretty simple. It's, it's everywhere. Um, and that's, that's really powerful message because it means that there's a role for everyone in solving this problem. Um Just looking at this pie chart, I'm not gonna go into it in detail, but just so that you have an idea, a lot of our emissions come from supply chains and medicines, which sort of highlights the power of mood's talk. Um and, and his focus on, on er, devices and medicines. Um but a lot comes from travel from inhalers, certain anesthetic gasses which again, mood mentioned. Um and er other areas as well, acute care is the biggest emitter irrelevant to lots of surgeons in the room, I'm sure. Um but there are big chunks in um primary care as well and community care in the areas you'd probably imagine. So, medicines, travel, et cetera. So what are we doing? We're not a massive team. Um but we are doing our best. So we have areas of, of greener NHS working um on all of those different chunks of the carbon footprint. So we've got a team looking at travel and transport um decarbonisation. So looking at zero emissions, ambulances, um an emergency vehicle call amongst er sort of transitioning staff commuting to, to travel, et cetera. We've got team looking at how we green our state. Um looking at er, research and innovation. And because some of the stuff we know how we're gonna get to net zero, some of the things we need to do, we don't know. Um So we need a lot of research and innovation. It's a really um right emerging area which I'll um I'll talk about a little bit later, which I think if anyone's thinking about doing research, it's a great place to be um workforce, which is obviously my area. So developing people, training people, making sure we have the right leaders to drive forward net zero supply chain. I think mood's kind of covered that. So I'm not gonna run into that in too much detail, but we do have a national team working on that. Um We have a data analysts function who've done a lot of the wonderful work around carbon footprint in the NHS um and tracking our progress as well, which is even more important. Uh We have a team looking at lower carbon, food, nutrition and diets, um medicines and er the area focus today given the audience um I thought I'd zoom in a little bit on next area of clinical transformation. So what is er net zero clinical transformation? Well, basically in my view, it's looking at care pathways and looking for opportunities um to reduce the carbon footprint of each one. So we need to do a few things to do that. Um We need to obviously engage with you the clinical community and other clinical communities to understand where their priorities pressures are, where the carbon hotspots are, assess those pathways in detail, understand where the carbon is and where we can take the most effective action and then really embed change. So it becomes part of business as usual functions on the previous slide. Um I mentioned in text there about a principle based approach and this is something that's quite hot off the press. Um We plan to publish this in the coming weeks if we can navigate the um tricky NHS England publication processes. Um but this is a, a way of framing and looking at clinical transformation that's hopefully helpful and allows um the user to easily enact change. And the basis for this, these principles are that every part of clinical care as I've discussed earlier and I think probably moods slides really nicely demonstrate as well is every part of care has a carbon footprint, but there are areas of care that have greater carbon footprint than others. So those are when care needs are high and complex ie in an operating theater in an itu bed. Um if care delivery is inefficient and appropriate. So mood mentioned, you know, people come in might come in for 13 appointments before they have their surgery. It's crazy, right? That causes so much um additional carbon, but also it's worse for patients and it costs the NHS much more money as well, making sure that our care settings and treatments are lower carbon, um, which I'll go through in a bit more detail, er, in incoming slides. Um, and um making sure that the system in which we work, um, is, er, sorry, I've lost my place in the slide now. Um failed to embed. Oh, the system in which we work to fail to embed in that zero is called as usual. So, yeah, sorry. Just coming back to that, it's kind of that failure to embed that systemic approach um in from an A zero perspective. So what are these principles? Um we call them the low carbon steps and what that stands for is settings, treatments, efficiency, prevention, and system change. You can see that in that nice little puzzle at the top. Um Apologies by the way for a few trips in these slides, I'm not able to look at my slides whilst presenting, I'm having to wave my head back and forth. So, apologies for that. Um Let's go into these er, in a bit more depth. So, settings, what does that mean? The objectives of lower carbon settings is to reduce the carbon and resource intensity of care settings. How do we do that? Well, we need to make more efficient use of energy. So that's like things like making sure um we're efficiently using automation in, in surgery is to turn off equipment when we're not using it, things like that, reducing travel and transport emissions, um reducing food waste treatments. I think mood cover this really nicely. Um We've got lower carbon effective treatment options that we're not using at the moment, things like different anesthetic options, different equipment options. So we need to be using those effectively efficiency. This is all about avoiding unwarranted variation, duplication, not getting people to come in when they don't need to making sure that we deliver the best care possible, which is best for patients and also cheaper and better for the environment as well. Prevention. There is the obviously the the silver bullet that no one quite gets to. Um but that is definitely a core part of what we want to see as mood mentioned. Um The lowest carbon er form of treatment is the one that doesn't need to happen. And that again, that's better for patients if you're not having to come into hospital because you've not got the condition in the first place, saves carbon, um saves money better for patients. Um And then we need to embed all of these in, in our system. So people need to be trained in the right way. We need to have the right governance and support around that. So that's your kind of system change piece. Appreciate. There's probably a whole talk on each of those areas that we could do and dive into lots of detail, but I just want to give you the overview and the framing. So what could the steps look like in um in process? Well, Um I've taken a hypothetical scenario here for uh a fictional person called Gary Green. Um Apologies for the unimaginative title for his name. Um Gary's got low back pain. He's got lots of sensation in his groin around his back passage. Um He calls the ambulance um and they realize that he has got, um he has got an acute onset of chroni syndrome, so he needs to be rushed into hospital. Now, as we discussed in earlier slides, well, this is gonna be a high carbon intense um procedure. But fortunately, Gary's local hospital has implemented an excellent green plan and as part of the green plan, er they've really looked at steps in detail and implemented them across the hospital. So Gary's ambulance is actually a zero emission vehicle like the ones operating in Birmingham in London at the moment, taking patients to hospitals. It's faster, no tailpipe emissions, not causing any health problems for the population on the way in, saves saves money um and saved carbon when he arrives, he needs an urgent scan. But fortunately, the ed department has um got involved with the Eded framework. They're a gold standard on there, which you can, you can Google now if you want to have a look at it. Um So they've implemented er local on site renewables and the MRI scan, which would usually cost a lot of energy. Um in this case, is powered by solar panels. So no carbon. Um and that energy supply is also extra resilient as well. Now we go on to treatments. Um uh huh there we go. Nice picture of the ambulance um for you all there. Um We go on to treatment. So he goes into theater. Um And fortunately the theater staff have, have engaged with the green theater checklist. Um And that means that not only is his, he not given Des Forane um as we mentioned, that's being phased out this year. Um But he's also given a, a total venous intra er intravenous anesthetic. Um His surgical tray is rationalized to reduce waste. Um He's using res reusable surgical drapes and gowns. Um So again, less carbon, less money, all good. We like it going onto the efficiency part of steps. Um He's discharged in line with um clinical guidelines as quick as possible, no delay, meaning that the extra day in hospital is saved better for him, better for the environment. And when he goes home, um he then has his follow up appointment where the um his scans and his first physiotherapy appointment are in a community hub all at the same time, saving those additional travel, travel requirements and saving money as well. Moving on to the prevention element of steps. Um He's given a comprehensive er rehabilitation program by his physiotherapist um biased as a physio, I'm sure that that will help him. Um And it'll mean he doesn't get readmitted again, better for him, saving money saving the environment. And finally just looking at that system change piece, I think across this whole journey, um the whole system change, system change piece would happen to be in place to ensure um the effective er journey that he's seen. So we need to have staff that are trained um in order to implement the different interventions we've talked about. Um we need to have overall governance and the trust um and understanding from leadership that the need and value of installing things like onto renewables. So that whole system change underlines the whole journey nearly down. You'll be pleased to know. Um But the just a couple of examples of some initiatives that are going on in surgery at the moment. Um So we're working really closely with GFT and there's some really exciting aca er academic pieces coming out of that, er, as mood mentioned, there is a report that's just come out. I really highly recommend you read that um you could implement locally the green surgery checklist, which you can see here on the right. Um Decommissioning DESRA, as we mentioned has happened this year really harmful anesthetic gas in terms of the environment. Um and the James Lind Alliance in orthopedics has also come up with the top 30 perioperative priorities for um green research. So um check all of those out, get involved. Er, it's all really interesting stuff. Um and this is a really exciting emerging area in surgery and finally, as I mentioned, it's a good time to get involved. So if you want to come and work um on this kind of stuff. Um Rose is one of our current fellows, er, who's in the room with you now, but we've got applications open for um the Chief Sustainability Officers Clinical Fellowship Scheme at the moment that stays open until the 27th. So you could apply to join, er, do an op um and come and join us for a year. Um There's loads of different research calls so there's funding out there if, and innovation calls as well if you wanted to, to take the academic route. Um and we've got a couple of national clinical weeks, not surgeons at the moment, but we've got um a greener nursing and midwifery week, greener HP week coming up in, in on the 22nd of April. Um and perhaps there should be a green surgery week as well at some point. Finally, er, get learning on this stuff. So go on to the Greener NHS, Future NHS site. Um There's a knowledge hub on there. You can go on, there's loads of different training and education around Net zero and climate change. Um It's lots of, it's free. Um So get involved and er, yeah, that hopefully that's, that's everything from my side. I'll stop sharing and apologies for the tech difficulties there. Thank you so much, Peter. Yeah, I'm trying to speak on behalf of all the audience when I think it's really useful for surgeons and clinicians to understand what's going on with the national team behind the scenes. I think on the ground on the front line, sometimes it's hard to know about the big policy changes that are happening and also to see what net zero clinical transformation could look like for us in future. I think we've probably got time for maybe one or two questions if there's anyone in the audience and if you've got Time Peter. Sure. Just to be clear, II don't count myself as government. We're somewhere in between anyone in the audience with a question. Oh, it's one in 11 over here on the other side. Thanks. So I'm Simon. I'm one of the course surgical trainees, Barry ST Edmunds. And we're quite lucky that um we've been selected as one of the sites for building a new hospital. Um So I just wondered if you knew what the government and um sort of wider approach has been towards building new hospital buildings in terms of ensuring their energy efficient and build towards that system change of sustainability. 11, excellent question. Um I mean the new hospital program is a tricky one. I think it it in a way that might need to be seen in its own separate light um because it's so highly politicized. But um in terms of in terms of building new hospitals, we have um quite recently released um a net zero building standard um which sets out the specification for the building of new hospitals. Um Both the actual build and also the lifetime kind of carbon cycle. Um It's really detailed really excellent report with technical annexes designed to really help shape that process. Um There's also an e-learning on that. You can find it on the e-learning for health and then you have um I think there's five modules um you can go and have a look. Um And so there is a real mandate um nationally from greener NHS around that there's also lots of funding opportunities as well. Um So there's er local net zero building hubs um set up by the government, but the key one that we've seen and the NHS has really taken advantage of is the, the public sector decarbonisation scheme. So it's called P SDS. Um I think the NHS has, has leveraged somewhere in the region of around 800 million um from that scheme, which is a government scheme, er designed to decarbonise buildings, so that's powered. Um getting rid of oil boilers, um solar panels on site, improved insulation, um all sorts which, which obviously saves money sometimes immediately, always, pretty much, always in the long run. Um but is also er makes buildings much more resilient and makes them um more comfortable for staff, more comfortable for patients. So I appreciate I've gone off off just new hospitals there. Um but there's lots and lots that going on there in the estates world. Um and certainly the the building standard provides that framework for new hospitals. Um and new new builds should all be adhering to that. I think one of my old trusts in, in East London, um Whipps Cross is doing a new building and their goal certainly is to um align with that sort of necessary build. So, um yeah, exciting times the resources are out there. Um We'll probably need a bit more time to see how those actually land and how they're implemented. Um But yeah, hopefully that answers your question. Thank you, Peter. I think in the interest of time we'll probably move on to our last speaker. But thank you so much and thank you for giving up your Sunday morning to talk to us. We really appreciate it. Thanks everyone. Thanks Rose. So our final speaker, we've got Emily Mills, which is our own treasurer. Emily is part of the sustainability working group and she's a course surgical trainee working in the east of England and she's going to give a little bit of an insight into assets approach to sustainability. So, firstly, I'd like to say thank you for having me and also thank you to my, the previous speakers in the session. I think they set the scene beautifully for asset in terms of what we're going to do for our sustainability strategy and deliver on behalf of our members. So as we've said, this is a global issue. There's 3.6 billion people on the planet currently living in areas that are susceptible to climate change. These people will die, they'll be displaced, they'll lose their homes. And if we don't do something about it from a position of responsibility, we're allowing this to happen effectively. And as we've already said, this specific statistic, the NS is responsible for nearly five per cent of the Uk's total carbon footprint. So we have a mission, we have a mandate as surgical trainees to move this forward. So operating theaters are really resource intensive, we produce most of the hospital waste and there are initiatives ongoing that you've heard about. But actually, what we've got to think about is what can we do as trainees and what can we do as at it to move this forward? I'm really happy. Someone said earlier about the concept of greenwashing and that's what we want to address really is we want to address the elephant in the room because we need advice from our members in terms of our sustainability strategy and actually a survey that we made and the survey that we created that I'll present to you in a minute does reinforce the interest and importance in this topic. We have a moral responsibility and as trainees, we can deliver on the ground changes, we rotate from hospital to hospital. And if we took our learnings about sustainability and brought this forward, we really could be the people pushing these changes. We need to be reflective of our members. And we also need to have a think about what we do in terms of conference in terms of travel policy. But we need to make sure this is evidence based and it isn't one person dictating what we think our sustainability policy should look like it should involve everyone that's interested and all of you in the room effectively. So in terms of the methods for this survey, it was a scoping survey. So it was pan grade pan speciality. We used track IP addresses to ensure we weren't getting multiple responses. And we included 22 simple questions in there, looking at basic demographics, then priority statements and local issues to be raised. We wanted to gain an understanding of members, priority areas within sustainability, but also to formulate our strategy and what's important to trainees. So we received 100 and 30 complete responses and thank you to everyone that filled that out demographics. Interestingly, the majority of responses were specialty trainees and core trainees. We had some a couple of medical students, a couple of consultants, but this was really mainly t three and above, there was an even distribution across the UK and there was also a reflexive distribution of surgical specialities. So I think these statements speak for themselves. So 92 per cent of people agree that sustainability is important to them as an individual. Sustainability and surgery should be a high priority for the surgical colleges, but also sustainability and surgery should be important for the community in tons of local results. A lot of people, their department, they don't even know if we have a sustainability strategy. Most people are unsure, followed by no and only 8.5 per cent of people knew about their sustainability policies in their department. Despite a lot of talking about the Green Theater checklist, which is a brilliant initiative. Actually, nearly half of people weren't aware of it that responded to the survey. And I think this is really important results. When we're looking at tangible changes, we need to deliver that on the ground aspect to it, that asset can provide. Most hospitals do not use the green theater checklist. And most people that responded to this survey have never been involved in their trust sustainability group. And the most important thing is that members that reply to the survey think that should have a sustainability policy regarding events and we need to be how to account on that as it should also prioritize sustainable practices at conference. So we're going to build that into our strategy, looking at travel policies. So in conclusion, and thank you to everyone that responded to that survey. Otherwise we wouldn't have this data. It's important to our members and it really really should be, there's poor awareness of current initiatives that are ongoing trainees aren't integrated into local strategies. And I really believe and asset believe that we could really be the people pushing this agenda. We need to translate these opinions into a strategy and we can create trainee sustainability networks. We need to engage with key stakeholders, looking at our previous speakers, looking at a wider, looking at Royal Colleges and it's really important that we get this right. We don't do greenwashing and we are held to account on this. I'd like to welcome many questions about our sustainability policy and thank you for listening. Yeah. So we probably have time for one or two questions. So has anybody got anything they'd like to ask? Yeah, so you gents money with that. Thank you, Emily. I'm Olly, I'm an orthopedic reg and I'm the boat rep for sustainability and workforce so very much a fan of this and hope to do some similar work on what we can do on a similar vein. I just wondered how you think we can get surgical trainees and surgeons more broadly to take this more seriously. So I appreciate your results with it. There were very strong agreement with sustainability as a priority but it was II, look at that and go, you had 100 and 30 responses compared to 2000 for your pa survey. So that as a headline statistic tells you the relative importance amongst your membership, even if the people that answered the survey were all very strongly positive about it. How do you think you get more people you know, the other 1800 people that replied to the PA survey that didn't reply to this to care more about sustainability. So I think that's a really important question. We also always need to address when we look at when we're presenting evidence in terms of our methodology. So we're all in the room, we're all purely academic background. So we need to think about things about survey by us. So when you're touching the pa survey, when you're touching sustainability, that's really important to note as well. I think in terms of what we can do that that's tangible. I think these on the ground changes. So I personally didn't really think about sustainability until I'd been to talks on this. And it's mad that we go into work every day. These operations, I talk about five things in the bin, you put gloves on to move a patient and, and it is, it's that awareness and the translation and I think or a or both are potentially able to deliver that. And I think it's going to be about raising awareness of why it's an important issue in the first place. And then we've got to think about how we integrate that, how we make sustainable long term change, that doesn't disappear as soon as we change departments and it just, we need a culture shift effectively. Thank you. You have one more question II think um Mister Bre, just that. Thank you. Great, great talk um from, from the ground point of view, as you said, we we're there. What, what message, what message of awareness can you give to the, to the forum here regarding the the elements that have the greatest impact? So we can start turning some ideas because we are exposed to this every day. But we need to try and find out which, which of those are, are having a greater, greater impact so we can start having some ideas. Is it the the gas emissions from the anesthetic machine? Is it the disposable the packaging, the drapes, have we, have we looked into this in any detail? Thank you. Um Exactly. Um So what we've got to think about as tangible changes and not just saying, oh, sustainable sustainability, blah, blah, blah, actually delivering those changes um as an individual and actually as an organization, we don't have those answers and I don't think we ever could really training organizations. And that's why we have to integrate with like our speakers earlier from government, from the, because we can't produce that data as a training organization, even if we made changes, how do we determine that actually has changed anything? How is that going to be built into changing things long term? So II think these are really important points and they need to be built into our strategy. So thank you for bringing that up and I don't have an answer for you at the moment and I think that's ok. And I think it's about acknowledging that in the first place and sort of leading that change forward. So, thank you. Thank you. But isn't, isn't that a call for auditing? I mean, we, we have that capability, we can start auditing this. And I think that's what is going to drive ideas for change. So it's our responsibility isn't absolutely in terms of auditing itself. So there's a lot of initiatives ongoing at the moment about green, say putting the green theater checklist into department. So I think it was only about two per cent of our respondents actually said that they use the green theater checklist. However, there's a lot of noise about it. Um And from my side until I read these results, I thought people were using this in their trust. So yes, we can audit it. But again, to what standards so we can audit the green theater checklist, but is does that show a department is more sustainable than another? And I think it's an evidence basis which is quite exciting that we're building as we're going along. Um And I think that in terms of auditing. Absolutely. And who's best placed to do this, it probably is surgical trainees because we can make those changes on the ground. So, thank you.