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Good afternoon, Doctor Pain. Thank you for joining us this afternoon for the NATO meeting 2022 chairing this session. So I will hand over to you now. Thank you very much. Thank you James. Very smooth meeting as ever, right? So our first speaker is Doctor Visual Patil. Um and he has consultant Easter's Am Brooks has been there since 2004. Started off his training in India, did lots there and then came over here in 95 um did some of his training at North Menorrhage. Many years back. Some of you may remember him um as well as having a very busy clinical practice um practice where he does transplant, hepatobiliary and um urological oncology, surgery, hugely involved in patient safety work. So he's the regional Lead for the Safe Anesthesia Liaison Group or Salve uh regional co lead for the College Quality Improvement Network and author on some of the G pass work and an axe, a review. So clear, very busy chat. So visual. Thank you very much for presenting is recording and then he'll be available at the end for questions. Thank you. I'd like to start by thanking the organizers for the invite for the purpose of this presentation, particularly when mentioning are discussing incidents. Chatham House rules supply, which means information disclosed may be used by those attending, but the source of that information may not be explicitly or implicitly identified or attributed to me or my organization. This is to facilitate and maximize burning. My name is Michelle Patil. I'm one of the anesthetic consultants at Addenbrooke's Hospital in Cambridge. That's my email address and that's my credit handle. Should anyone wishes to get in touch? Do you got the relevant uh disclosures for the purpose of this presentation? This is going to be the structure of the presentation reticulated on through the definitions and history and then we'll go to the cracks about learning from incidents. Patient safety is prevention of others and adverse events to patient's associated with healthcare. Basically, it's maximizing things that go right and minimize things that go wrong. This is to highlight that patient safety is one of the domains of quality. Ara Darcy gave us the Lord Darcy, give us the definition of quality. The first three domains on the list is how quality of care in the NHS is judged. Uh The agency for healthcare research and quality also includes the bottom three domains uh and all in composing different definition of what constitutes an incident. When does an incident become a serious incident? Uh They're approved assets to the objective serious had one is there is other serious learning or there are serious consequences, either can be a reason to call an incident in sa uh calling an incident uh as far news judgment and offers managers some flexibility which depending on the culture in your organization may be a good thing. There is no definitive list of incidents or events that constitute uh S I and none should be created locally as this can be too inconsistent or inappropriate management of incidents. This brings us to never events, all never, events are serious incidents though not all never events necessarily designed in harm or death. So if you leave something behind in a patient, you go back, take it out. It doesn't necessarily cause any serious harm or any harm or death. Uh Governments are deemed to be holy preventable because there are strong systemic and protective barriers to stop them from happening if they're implemented by healthcare providers uh for a barrier to be strong system, it and protective. It has to be a successful, reliable and a comprehensive safeguard of remedy. Now you wouldn't agree or you may not agree that they're necessarily preventable because we've had 248 never events in the seven months from April to October 2021. Uh they included 101 wrong site surgeries and 59 retained foreign objects including 10 detained guidewires from vascular access. This is the W H O definition of harm, uh impairment of structure of out function of the body associated with healthcare when does harm become severe. Uh when it meets the characteristics that I have underlined and putting italics on this uh slide. Uh This is important because uh if you're krait, if you meet the criteria for severe harm, one will be pursued it to call the incident. Uh as an S I so now become to learning just a dictionary definition. Uh in the context of patient safety, I wouldn't recommend learning to experience too. The publication of the paper organization with the memory was the first attempt to put in place a comprehensive program to learn from adverse events and weirdness. Is it collected the formation of the NPS A, the National Patient Safety Agency and we moved from paper incident forms uh the Royal College of Anesthetists access data based on a CV Rome. And then we think of the long uh with the web based specialty reporting system and to the national reporting and learning system a bit about the early days of incident reporting origins in aviation used in the 19 forties to improve patient, to improve safety and performance among military pilots and used by any cities as early as the 19 seventies. So how do we translate uh incidents to learning without having to experience the incidents are such uh these are the various uh components of structures of an incident reporting system. We need to have a system to include the data, the data. Then you have to analyze the data and then feedback. Most of us now use commercial systems to input data. I don't actually know the attribution of this but essentially no one clicks beyond the first page of a search result. So your incident reporting system should make it easy and simple to report. This is the C U H red portal and Q's is quality and safety information system which is that incident reporting system is like that in the top in the center. And so is critics, which is our equivalent of learning from excellence or appreciative inquiry, the right on the front page uh and clicking on cue, Asus takes you straight to the incident form, complete with a smiley face on the right top corner. And if you click on great takes, it takes you to the to the learning from excellence form. So good system makes it easy. Uh compelling in this context is not forced or mandatory. It's compelling in an irresistible way. It should be non punitive and independent of performance management. The system should be able to uh taken near misses. Uh Use the iceberg analogy when it comes to near misses. Every incident has had numerous previous near misses as the underlying pattern of failure is invariably the same and you should be able to report excellence to. So you have a system. What about the data? Uh taxonomy is the key determine allergy and science of classification is important. You should be able to do thematic classification, which can help in formulating plans for prevention, able to link common causes, common contributory factors, specialties, procedures, et cetera. Uh There should be an opportunity to narrate our version of events which are honest and in chronological order. Uh so that we're able to link the factors in the evolution of the incident. And also we should have ability to highlight our own cognitive biases which have contributed to the evolution of the incident. Then we come to analysis. Uh The idea of analysis is to convert the report to a lesson. Uh It is very important to have multidimensional input in uh the analysis. Domain knowledge is obviously very important. Uh So is a knowledge about human performance and safety science. The idea of the analysis is to be able to link front line, front end failure to the different components of the system and should do this by using standardized methodology in the interest of just culture. It is useful to use the City Decker uh tunnel analogy, what might seem like an inappropriate decision from the outside. And in hindsight might have been a reasonable Axion as the decision was made when the incident uh award. Uh the idea is to award hindsight bias or outcome bias. Uh award the NLD quest for the root cause analysis often that isn't the root cause analysis. Uh That is uh uh there are multiple factors uh which constitute the sort of root cause. Uh I'd like to think of it as uh the incident report or the analysis used to drain the swamp that is to uh uh to look at the latent conditions that have contributed to the active failures, which is spotting the mosquitoes. So, so think about how you write your analysis of your report. And it's quite important to align the corrective actions to the appropriate causal factors uh in terms of analysis and, and writing the report. Uh there are certain actions which have uh strong effectiveness, but they also require a lot of effort. There are certain actions which are really community comes to effectiveness, but they are sort of more readily or easily done. So, uh retraining or reeducation or uh warnings or labels or rules or policies are easy actions to do, but they're very weak, strong actions are culture change, forcing functions, redesign or uh redesigning your environment or uh equipment. Somewhere in between is checklists and cognitive rates or simplification or standardization or computerization. Uh Then feedback is very important. Uh Feedback needs to be timely, particularly for near misses. Uh uh The idea of the feedback, feedback is actually by directionally, it is to learn and improve the systems. And uh we need to really put blame and recommendations aside and share ideas and abandoned defensiveness. A brief what about appreciative inquiry uh chill upon critics early on uh in the presentation incident reporting in an increasingly complex health care system should not depend on the find and fix support. So we can't just uh look at the, uh, the negative things that happen, uh, and expect to improve the system. Appreciative inquiry is embedded in positive psychology. Uh huh. Things basically happen in the same way, regardless of the outcome. The purpose of the investigation is to understand how things usually go right as a basis for explaining how things occasionally go wrong. So what can be done at an individual level, uh frontline level to learn from incidents? Uh This is uh Elon Musk tweeting that every child should learn about cognitive biases. And normally he tweets about Cryptocurrency. But in this sense, since I'm inclined to agree with Elon Musk, I'm gonna talk a little bit about cognitive biases. So what our cognitive biases essentially, they're deviations from norm or rationality in our judgment. And why do we deviate from norms or rationality? It's because we take shortcuts, we take shortcuts from your processing information. It's because our brain has limited processing ability. We have motivations, moral or emotional and we have uh social influence and we have distortions in uh retrieving our memory or storing on memory. We tend to act a little bit irrationally. Now, cognitive biases are largely products of revolution because they simplify information processing. They allowed us to make a quick survival optimized judgments. There are future, they're feature of human existence, they're not a bank. So we're all susceptible to cognitive biases. This is just to highlight that there are a huge number of community passes that have been described in the field of psychology. If you Google community bias codex, you can buy a high resolution poster uh of all these numerous computer biases for about $50. Uh So let's look at some examples of proper devices. Anchoring bars. Uh This is a photograph I took on holiday in Seychelles many years ago. Anchoring bars may lead to failure to adjust initial prognosis based on later information of modify initial diagnosis due to new events. So we rely too heavily on the first piece of information that we had given about a topic and we interpret new information from the reference point of our anchor rather than seeing new information objectively. So uh examples in clinical practice uh would be a failure to adequately appreciate blood loss in the case in which no bleeding is expected. Uh So this happened to me recently uh in a case of uh ideological procedure, uh surgery for benign prostatic hyperplasia, it also happens because of other factors. Uh there's no visual cues for bleeding. The bleeding is seen on a small screen which is not very obvious and it has happened in other cases as well like bleeding during like a scope because it's a stacked on me uh bleeding in fact have no incidences where uh patient's are black at the point of cardiac arrest. Another example would be when reputed instrumentation of the airway caused the effectiveness of mask ventilation to deteriorate. How will we stay anchored on our initial easy mask ventilation uh and thereby delay the recognition that the patient's clinical status is changing. Similarly, we do a very straightforward spinal, easy flaws of CSF easy injection, there's no sensory block, but we think the block should be working because we are anchored to the belief that it went in straight forward, you know, uh confirmation bias. And so this is another which is characterized by seeking to uh by seeking confirming evidence. So uh read up on mind uh any evidence that is presented, if it uh valleys or alliance with our opinion, we evaluate anything else that doesn't uh resonate with that uh opinion. Even if it's more definitive or more objective, we tend to increase them. So we focus on tube misting, we focus on chest rising because we have seen allegedly seen the end articular to go to the cult. Uh We discount the fact that there is no uh CO2 on the capnograph and we misdiagnose use of regional integration. So what can we do about about this? Can we devise ourselves? Uh So, uh it is possible to do uh the prerequisite to devising is to appreciate the full impact of it. Uh uh It is a feature of us, it is not a box, I appreciate the full impact of it but dismiss the pessimism around it and refute it's inevitability, it can be done. So how do you do it? Uh It's by practice and reflection, uh searching for and being open to alternative diagnosis, willingness to engage in thoughtful and effortful reasoning and be able to reflect on one's own conclusions. There are cognitive forcing strategies which have been described, I particularly like this one. Uh the acronym Slow. What is slow? So s is, are you sure about it if you're so sure about it, why are you sure about it? L look for the data, look what is lacking, does it all linked together or opposite? What if the opposite is true? So this is particularly important, been thinking about an anchoring bias. What if the opposite is true? W is what are the worst best scenario? What else could it be? So I quite like this ACA rooms look, are you sure about it? Look what else? Uh This could be uh what is lacking, look at the data opposite. What if the opposite is true? And w for worst case scenario, what else could this be fundamental attribution? Other is an individual's tendency to attribute other sanctions to their own characteristics. But uh while attributing their behavior, the attributed to external situation factors. So if I'm uh poor timekeeper, then it's always because there was a traffic or there was something else, other peoples' flaws uh because of their own individual characteristics, my flaws on because of uh external circumstances, this is a useful fund. This is a useful uh bias for the manager to be aware of. Uh okay, let's go into situation around on the face of a situational awareness is a, is a straightforward fleas, but taking it at face value limits our grasp of the concept. Uh situation awareness essentially has three components. It's the perception of the elements in the environment that surround us comprehension, the understanding of that uh perception and the projection of its status in the near future. So, and sometimes they're described as level one, level two and level three situation awareness, perception is one comprehension is too and projection is three. So in a level one situation awareness that can be failure because sometimes the data is not available or it's hard to retact or discriminate or it is misperceived. Uh in level two situation awareness, we form an incorrect mental model or we because we haven't perceived the data correctly, we rely on default values. And in level three, situational badness uh relax the mental model. So your pre oxygenating a patient, uh your pulse oximetry is playing up or the patient has got cold peripheries or the BP cuff goes up and the d saturation is not obvious you fail to detect it. Uh So that's a perception gone. Uh The FDA gives you an airway. When you start to mask, ventilate, your mask ventilation is not ideal because you haven't perceived, you don't realize the need to use an airway because if disordered to uh rely on default values, you formed an incorrect mental model. Um If you think of the alien Ramly case, that's a good example of uh lack of mental model and level three situational awareness in terms of projection because nurses went about booking an eye too bad. Uh So they perceived that this patient is going to need an eye too bad. Uh They even got out of a tree customer trade. But the anesthetize involved uh make uh the mental model really did not project the information or the comprehension that they had into the future. This is just a bigger slide really. So uh common devices, situational awareness. Let's talk a little bit about forcing functions. So forcing function is a, is a aspect of design that prevents a target actions from being performed or allows it's per formacion only if allows its performance only if another specific actions performed. Uh good example is uh cars, automobiles, they're designed so that, you know, you cannot shift into the reverse here sometimes without putting your uh foot on the brake. Modern 80 um's will not allow cash to be dispensed unless the user removes their card from the machine there by preventing uh stopping you from giving the card behind in anesthesia. We have the pin index safety system uh to prevent unintentional basement of an oxygen cylinder of a wrong medical gas into the hunger yolk of the anesthesia machine. Excellent system outside of anesthesia. One of the first forcing functions was the removal of concentrated protection from genital warts. Uh uh It prevented the inadvertent uh intravenous uh injection of concentrated potash. Um An adult that had produced small but consistent number of deaths for many years. Uh This is an act time to acknowledge the contributions uh any citizen the region. Uh This is an excellent forcing function. You can't physically inject into the arterial line. If you use this uh the contribution of Peter Young and Joe Carter on inventing something which is really on part with dependent X system. Excellent. Uh Let's talk a little bit about uh cognitive aids. The term cognitive aid is a longstanding academic term encompassing all the sources that help people to remember or apply relevant knowledge of property. So we have no hesitation in using the B N F. Uh We should have no hesitation in using the association of the city's quick reference handbook when it comes to crisis scenarios. So, uh why do we need a reference handbook or why do we need a cognitive aid in crisis? So this goes back to your keys and Dobson to psychologists were back in 19 oh eight, realize that increasing stress leads to an increasing performance but within physiological limits. So some stress is better because it helps you to increase your performance. Uh as your stress increases, your performance increases up to a point and then boom, it goes down the level of stress, you can corporate for a simple task is higher uh than a level of stress that in corporate for a complex task. So uh when you're in complex complex tasks, a performance goes down a bit earlier. As your stress level increases with simple task, you can manage bit higher stress levels for a bit longer. Why does that happen? The upward limb of the performance and the downward limb? How different causes when you get stressed? Initially, there is an energizing effect and expansion of resources available uh to deal with the task. So you get improvement in performance and the performance Dettori it when uh stress becomes too much because you develop selectivity of attention or cognitive tunneling to specific cues, you basically narrow the spotlight of attention, sorry about that. Uh So those are the reasons for the upward and the downward uh limbs. Uh Your keys and Dotson came up with this. Uh a lot of uh psychology experiments are done in rats. So that is the cabinet that so this is done in uh this experiment was done in cat in rats, uh basically electrical shocks to rats in a maze. And uh the rats were able to get out of the maze up four point beyond that, they just did random movements, but we're not able to successfully get out of the maze. But this seems logical in terms of uh stress and performance. So it doesn't suit me. Uh Is that a good example? Of using cognitive aids uh in real life crisis. Uh The Hudson River landing is a very good example. When the flock of these hit the airplane and the engines failed, the crew initially utilized a dual engine failure gently. So they basically got to check your stock. They quickly adjusted that plan because of the altitude and the limited time they had available. But what it tells you is that uh if you train with emergency manuals or cognitive aids, it will influence your initial behavior. However, what it also tells you is that you should not let manuals rigidly dictate your actions because after the experience and judgment is important, selling in this case was uh well placed to land uh the airplane on the Hudson River. He teaches in simulation centers for the airlines and nearly was well placed. My hypothesis is that uh the initial use of manuals helps crystalize your thought process before you start skidding down the downward limb of performance. Uh more flights as we come to the end of the presentation, this is because of my regional lead for uh salad. The safe uh anesthesia liaison group stopped before you block is getting a revamp a refresh rebook. Uh We were getting uh the wrong side and no blocks in spite of uh stop before you block. There were too many local radiation. So we are going down the part of an S O P. Uh The local variations include stickers, some people say we should mark them. Some people said categorically don't want bill them. So stop before your block is because people is becoming a prep, stop and block. So pleased to have a look at the website if you are a practitioner of regional blocks. Uh and you'll have more about this in the next few weeks. Uh The next thing which is, it's not new, it's been there for a while. It's getting a bit of a relaunch. Uh no trace around place. We've already talked about this in the context of confirmation bias, but this is getting early launched because of another debt due to so visual integration in the last year, a flat capnograph after an attempted integration, uh social integration must be excluded. Capnograph Albert attenuated will be present even in the presence of cardiac arrest record without CPR and Excel's you to remains detectable long after the onset of cardiac arrest and its absence should never be attributed to the cardiac arrest state. Uh Let the state's not going then Glenda log, Stale, Sharon Grierson and Peter's Peter ST uh appreciate the full impact of uh your cognitive biases, uh refute inevitability and dismissed the pessimism surrounding it. Um This has been the summary of what we've been through. Thank you for your attention and we'll have questions a little bit later on visual. Thank you so much. Indeed. I think you're somewhere in the ether if your pardon the expression. Um Thank you. Very much yet. Now we're going to take questions um at the end. Um So we are going to move on now to our next presentation. Who uh and, and that's going to be from Visual Sharma who is um has many hats. He is a cardiologist um uh in Liverpool, but is heavily involved with B M A rolls and has done an awful lot of know, where am I looking at the right screen? Um Yes. So he is the chairman of BMA Pensions Committee, the chair of consultants committee and an appointed negotiator for consultants. So a whole lot on his plate um having taken over the reins from our own doctor Harwood uh last summer. Um So he's been instrumental bringing a lot of change to the pensions scheme and is leading the charge for further reforms. Um and a good advert as to why we should all be members of the B M A. Um It's great to have you with us fish. Thank you so much for uh coming to speak to us to help shed a bit of light on what is uh generally seem to be a phenomenally complicated topic over to you. Yes, that's, that's great. Uh Yeah, apologies for that. So yes, I'm going to try and go through this um as much as I can in the in the time available. So it is, as you say, very, very complicated. So we're going to start uh we're going to cover today is how things used to be because I think the talk is the impact of the changes. I'm gonna talk a little bit about how things used to be and then the changes both of the scheme and then also to tax. And I'll give you some examples of why it's become a real problem. And also talk a little bit if I can in time allowing about mccloud, what the BMA are doing. So when I go back to the good old days, which actually weren't that long ago, so you can go back as far as 2005. And actually, things were really fairly straightforward. There's only one scheme at the 1995 scheme, there was only a single contribution rate effectively for people earning over a certain amount, which was 6% there was no pensions tax. And when, even when it first came in, the levels are so high that didn't really impact most doctors. Um it was essentially a plug and play scheme. You just sign the forms and you joined, you forgot about it and you could reasonably expect by the time you retired, you got a decent pensions, roughly about half your final salary and you didn't need to do much about it. And also the consultant pay scales and we're actually negotiated to work very well with the pensions scheme. And so that actually got the most benefit out of it. And it was really seen as a long term reward for actually all the dedication you put into the NHS for many years, including all those years when you were a particularly junior doctor, working very long hours, often very low rates of pay. So just very quickly, I'm sure you all know this, but the 95 scheme is a final salary scheme. So it's the final pensionable post talk around a second. And basically, it's very simple number of years of service divided by 80 time, your final pensionable salary, you also got an automatic tax free lump sum, which was three times your pen shin. But you always have the option to change pensions to a lump sum of 1 lb of tension that you give up for 12 lbs of cash up to a maximum of 25% of the lifetime allowance, which is essentially the limit that is tax free. Um But there were a few issues that have been truly honest. There are a few things that probably weren't quite right about the NHS pensions scheme back then. So the first was, it was probably stacked very much in favor of a higher earner. So the rates were essentially the same. So that's 6% for almost all stuff, including some of the lowest paid. But the very very lowest paid had a 5% rate. That's a gross rate. Uh And obviously the basic ratepayers had basic rate tax relief. The higher rate taxpayers had higher rate tax relief. So actually if you look at the net rates, the higher owners were paying slightly less for their pensions, even the very lowest paid in the NHS. But perhaps the biggest thing was that it was a final salary scheme. So if you look at doctors, they had really quite steep career progression. So you start off on a very modest salary and you pay a percentage of that salary for towards your pen Shin. But actually that year as a as a pre registration house office, for example, in terms of the Pen Shin, when it came to take it, it was based on your final salaries. You may have paid 6% on, on 10 or 12,000 lbs for argument's sake. But actually, when you came to retire, you essentially got that one year based against your final salary. So it was really stacked in favor of those who actually had fast career progression. And of course, there was no tax story about in those days. And generally speaking, higher owners lived a bit longer than those who are, who are less fortunate in terms of their earnings. So actually everything was really in our favor and that kind of led to the 2008 reforms. So we accepted quite a lot of this. There's an engagement with the, with the government and all of the unions, including the B M A and we accepted that actually, it probably was some things are a little bit unfair. So we went to this what was termed a once in a generation review of pensions and we had a reform of the pensions scheme and that was a modest reforms. So it was a different section of the current scheme that we had. That was the 2008 section. The key changes for that were essentially that we had this tearing of contribution rates coming for the first time with tier rates within 28.5%. There was a later normal pensione age up to 65 but with a faster crawl to offset that. And I'll talk about that later and there was a change to your final reckon herbal pay, rather your final pensionable pay. I'll talk about that in a second as well. So this is the comparison. So you got later retirement age in 2008, you got faster. A cruel and the reason for that is that essentially because you retire later, you want to accrue your pensions faster. So, in effect, if you retired a little bit earlier because of that faster. A cruel, you end up more or less the same place. So actually a lot of people don't realize that and it just look at the retirement age, but actually it's built in. If you retire a little bit earlier, you actually got more pensioner had retired with a cruel out of 80 1 80 s sorry, there's no automatic lump sum in the 19 in the 2008 pensions scheme. But again, you can commute your pensions as previously from, you know, given a 1 lb of tension for 12 lbs of lump sum. But if you decided to choose to go from 95 to 2008, any lump sum that was payable from the 95 section seclude, you must take as a lump sum. So this is quite important and it's important for annual allowance calculations as well. So you're, you're pensioner pays actually your final pensionable pesos the best of the last three years. Uh And that's how annual ounces also calculated. And it's usually the last 12 months before it happened, but not always. Um reckon herbal pays, it's slightly different. It's much more complicated, but it's the, the average of the best three inflation adjusted years in the last 10. And the reason that's important is because of the, the later retirement age. If for example, you were a clinical director or you had responsibility. Payment's when you were kind of 55 or 58 between 55 58. And you want to give those up, your pensions would be actually your, your pay would be higher in that period. It may have dropped towards the, towards the later career. And actually by having wrecking will pay actually based your tension on the highest bit during that period. So it allows you a bit of flexibility if your pensions will pay drops towards retirement. Um just for time, I won't commit any detail. But these are the things that are pensionable at the moment. So your basic salary, any old star C A S, any limp and waiting, any availability supplements or other regular payments like CD, payment's management allowances, etcetera. But despite having this once in a generation review, it didn't really last very long. Just two years later, the government came calling again this time via the independent Public Sector Pensions Committee uh commission or the hot um report. And they just noted the cost of pensions across the public sector were rising. Um It noted that the unequal treatment that we'd already addressed in many ways between the higher and lower paid with the same profession. Um We also, they also noted the unfair share ing of cost between members employers and taxpayers. But we would argue that again, a lot of this would actually addressed from the 2008 reforms. So the 2015 scheme came in Hutton quite clearly said that you didn't need to protect older members when you made these changes. And that made perfect sense because the closer you are to retirement, the less the changes impact with you. But despite that, the government's the last minute offered protection to older members. So as you know, those within 10 years of retirement, we're able to effectively stay in the old schemes. Whereas those who are younger um couldn't and those taping protection for people in between. So everybody was in the 2015 scheme who are not protected from April 2015 onwards. But, but actually um those who joined from 2012, we're automatically kind of given no protection either. The this is a different scheme altogether. So it's not a final salary scheme. It's what's called a career average revalued earning schemes every year. A portion of your pay goes towards your pen shin. And then that would be valued over time to take into account inflation. But importantly, that's not just inflation, it's inflation put plus another 1.5% on top of it. The other big change is the uh the normal pensions age is related to the state pensions age. If any changes, state pensions, it happen, they automatically transfer through to the 2015 scheme. Whereas in the in the 95 2008 scheme, the pensions ages are fixed at, at 16 65 respectively. Um If you had added years, which many of you might do um that, that carries on it was a separate contract. And importantly, you still have accrued, right? So if you have um dual membership of 95 2015, for example, your final sorry link is protected provided, you don't have a career break it more than five years. The other big thing that changed though, and I'll send a bit of time talking about this is the contribution structure. Um So before, if you remember, it was five or 6% for people in the HSE scheme. It was changed with agreement to a maximum 8.5%. But following this hidden report, the contribution rates went all the way from 5% to 14.5%. And actually, these were higher than the government initially suggested. And they were changed after consultation because the other unions across the public sector said actually, you need to correct for tax relief. So actually the initial contribution rates that were suggesting were lower. But the all of the unions said, well, actually you need to correct for tax relief for the higher paid because actually, we're paying partially more for them than they are. So the government agreed with that and essentially had a top rate of 40.5%. And if you look at other public sector schemes, um that is much higher than other schemes. So if you look at the civil service, for example, they pay top rate of 8.1% and there's 100 and 75% difference between the highest here and the lowest here. Whereas for the NHS, the highest rates 40.5%. And it's only three times the difference between the top and the bottom. So it's much higher. And the significance of that is that these top tiers remove the benefits of tax relief almost completely, you know, for, for higher paid members in the NHS. So it's really stack the balance the other way now. So we we pay 14.5% growth rate that works out as close to being 8.52% as an average net rate is now a care scheme. Um and obviously the lower paid get a lower rate in return. And that was all before pensions taxation came in. So the first thing that came in was a lifetime allowance and this was the max what the lifetime allowance is. It's the maximum capital capital value, your pensions and it's assessed our retirement currently at 1.73 million. Um and that's been frozen for at least in 2026. Um It was previously as high as 1.8 million in 2011. Capital value is 20 times your annual pensions. Um And you added any, any additional lobster on top of that. So for the 95 section, for example, if that's the only skip urine, it's 23 times your actual pen Shin if you exceed the lifetime allowance, anything above face subjects, extra tax. And that basically works out 55%. So if you take as a long some, you pay the 55% straight off. If you take it additional pen shin, there's an additional 25% charge on top of your normal income tax, but both ways it works out 55% and most doctors will hit this lifetime allowance. Um in that kind of early to mid fifties. Um some even earlier than that. Um it is more difficult to calculate the lifetime. And if you're in two schemes and it's also difficult if you start having scheme pays loans or you plan to retire early because your pensions produced by retiring early. What is the annual allowance? Well, that's this is more complicated. Um It's the maximal, your pensions can grow in a given year. So one misconception is nothing to do with the contribution rates because that's an average. It's nothing to do with how much your employer puts in, in defined benefit schemes. It's just how much of a pensioned grows. Um And the total allowance supplies across all schemes. So you have what allowance for your 95 section, 2015 section and any private pensions or any armed forces pensions, etcetera, as well as all one annual allowance when it first came in again in 2010. Um it was 255,000 lbs. You know, such a high level, it didn't really have an impact, but very quickly, it dropped from 50,000 lbs to 40,000 lbs, which is the standard annual ounce still today. But in 2016, 17, the coalition government introduced the tapered annual labs and this is what caused all that trouble a couple of years ago because it really drove people to effectively paying to go to work because the tax charges, you got an additional income could have been higher than the income you receive from the first place. Um And previously, it could taper down to 10,000 lbs and it kicked in over thresholds of 100 and 10,000 lbs and adjusted income of 100 and 50,000 lbs. But that's now been increased fully BMA lobbying and is now essentially a threshold income of 200,000 lbs. And it's just thinking to 240,000 lbs. So what are these threshold adjusted income levels? Well, the first one is the threshold income which is now 200,000 lbs I mentioned um and this is uh the type of not slides up from 100 and 10,000 lbs of 1920. That's the total income from all sources minus any personal contributions. Now, most in most cases, this just involves your pensions. So things like um sort of sacrifice are generally added back in now unless they're very historical that added back in. So they still count towards your threshold incomes. Essentially, this is your taxable income. So your total income man is any personal employee contribution sort of tension? You're just an income is just your threshold income plus any pensions growth on top of it. And that limit is to drink 40,000 lbs. How do you calculate the tax? Well, if you don't reach the threshold income and that's important, then your annual allowance will be 40,000 lbs. Um No matter how big your pensions growth is um, if however, you kind of exceed that threshold income, even buy a pound, you then have to look at your adjusted income level. And that is essentially uh important because your pensions growth can easily be above 40,000 lbs. So for many people just going over that threshold income could actually trigger significant tapering. If you breach both of these thresholds, your annual allowance drops in a similar way to the personal allowance that tapers, it drops for 1 lb for every 2 lbs. You go above this 140,000 lb level and it goes all the way down to a minimum. Now of 4000 lbs, if you've got earnings of 312,000 lbs or more, any pensions growth above this is then taxed your normal pensions rate, your normal tax rates. If you're a higher rate, taxpayers, 40% if your additional rate taxpayer, which these people are likely to be now w 45% again, important, you don't get a bill. So HMRC expects you to magically know that you have a charge and then to pay it and they come after you if you don't. So you have to sort of work this out and be aware of what's happening. There are two ways of paying it. One is to pay obviously with cash. Uh, the other is to pay it from your pensions using something called scheme pays. This is effect of the alone against your pensions. So your pensions effectively loaning that amount to the HMRC and that attracts a rate of interest in everywhere. Apart from Scotland, that rate of interest is measured by inflation CPI which as you know, is very high at the moment plus an additional rate, which is 2.4% on top of that at the moment. So this is why it's having a big impact because as I mentioned before, these are the kind of net rates that you have and looking at income tax rates only. So you can see already that once you just for tax relief, um the doctors are paying significantly more than the lower paid. The NHS 8.52% for a high rates, uh for a higher tiered earner and 4.48% and for the lower paid as net rates, but that doesn't take into account the additional tax and, and both the annual allowance and the lifetime allowance are trying to claw back tax relief that hasn't been given in the first place because it's addressed by the contribution structure. So if you add in the effects of annual louds lifetime allowance, you'll find that actually this is a model on a junior doctor starting in 2020 working all the way through to become a consultant and retiring. And uh kind of state mention age, you'll find that the total lifetime earnings they'll put towards their pensions is 43.46%. Uh that compares to 4.48% for a domestic, some very, very big difference. Uh um And essentially the Treasury's own advisers have noted that it's first of its nonsensical to have two separate mechanisms to try and quell back tax relief. So they argue that actually, you either have annual allowance or the lifetime allowance, but not both in any given pensions scheme. But actually given that actually, if it's already removed by the contribution structure itself, it doesn't really make sense to have either of these in the NHS. That there was a little bit of talk. I'm sure it hasn't gone away about dropping the lifetime allowance to 800,000 lbs. So it's frozen at the moment, but there's been talk about it going even lower if that were to happen, obviously, the amount would be even higher for the doctors rather than 44%. It's 47% of your lifetime earnings that would go towards inattention. Oops, but actually it starts to drag, you know, even at this level, starts to drag in your kind of eight D managers, your ate a matron's, but even your band, five nurses are starting to be impacted by the lifetime allowance. That's just how damaging this taxes for the NHS. Um I still, that's life of time. So why is this a problem for everybody? Well, we know that this is, this is changing behaviors. So if you look at the voluntary early retirements that happened since all these changes started to come in place. So going back to 2008 when the first scheme changes happened all the way to 2020 21 which is the latest date we have V E R is the voluntary early retirement. Look at how many people are taking early retirement. So GPS, it was 265 in 2008 and that effectively tripled, you know, all the way to 2019, 22 nearly 600. Um, it's been even higher in various points to 7 20 which is coincidentally when the taper really came in. So actually, you can see when the change comes in, it has an impact. And the reason I'm focusing on GPS with this audience is that generally speaking, they're much more financially savvy than most consultants because they manage their own business. They have their own a councils, they tend to spot these things before we do. Um, but the same thing is happening with, with doctors. So 100 and 42 people retired early in 2008, 2009. And that went all the way up to 520 for in 1920. A big jump. Now, those who have got keen eyes who have noticed, actually, it's come down again in 2020 21 you might think, oh, that's, that's good to use. Things are actually getting better. But this is probably a false reading because we know anecdotally that people who could have taken early retirement in 2020 chose not to because the NHS was hit by the pandemic and chosen to stay on. And we just expect that these people retire as soon as things have settled if they ever do. So, just gonna talk very briefly and just looking at time about the key fiscal drivers are forcing people to consider early retirement. So I've talked about pensions tax, but I'll just show you a case example in a second, why this is important, but also pay restraint is very important because we've had a year upon year of glow inflationary pay awards. Whereas your pensions, when you take it is linked to CPI. Uh we talked about the lack of late retirement factors in partial retirement in the 95 scheme, the effects of freezing the lifetime allowance and the cloud. Uh our concern is that when you combine all of this with the work pressures in the NHS, we know that many are seeking the exit door and that's been backed up by all our surveys we've done so far. So lots of people are planning to retire in the next 15 months. Um Workforce data also suggests about 10 to 12% of consultants are in that high risk group between the age of 55 60 and a very likely consider retiring in the next 18 months. And that's actually consistent with a very big a royal college of physicians serving. It was done last year that showed that 18% of consultants are plan to retire in the next 2017, consultants plan to retire in the next three years with nearly half of those going in the next 18 months. So this is the impact of tax and this is that if many of you go to a financial advisor now and start planning this, this might, this might be what you find. So when you get to the point where you are impacted by the annual allowance and a lifetime, that's particularly the same time, you can often find that you are paying more in contributions, annual allowance and lifetime lifetime allowance tax charges and you ever get back in pensions and at that point, you've got a couple of choices. Do you opt out of the scheme? Um Do you retire in return or do retire and completely do something else? Those are your kind of main choices. Um If you just opt out of the scheme, this is, this might be what you're faced with. So this could be anybody, you know who's between 55 60 for example, who's hit the lifetime allowance just exceeded it. So they've got a 50,000 lb pensions after all the, all the deductions that happen. Um oops. So they got 55,000 50,000 lb pensions, 150,000 lb tax free. Non some their salary working 12 sessions including on call is 100 and 37,500 at the top of the scale with no C A s. Obviously, they're not receiving their pensions. They're not retired yet. They've also got a mortgage of 21,000 lbs and their take home pay after income tax, national insurance before the changes next year and mortgage is 64,000 lbs. If they retire, they take their pensions and they come back on, on four sessions. Um, they've got a salary of 44,000 lbs 50,000 lb pensions. I mentioned if they use the lump sum to pay off their mortgage, which have 750,000 lbs, then they've got no mortgage payments that taken pays or their cash in their pocket if you like is 64,000 lbs. So they've got exactly the same amount of money in their pocket despite working two days rather than working 12 sessions with an on call. This is why recycling is important and we're pushing very hard for that and other solutions as well if they were able to access the employer's contributions. Um as, as a payment after tax, you know, it's 100 and 61,000 lbs and actually they take, hopefully they will push up their salary 261,000 lbs, the mortgage they're still paying. But actually after tax, it's now 77,000 lbs they have in their, in their back pocket and they can use that access to either invest it in ISIS or to pay off the mortgage quicker. But actually, it changes the balance of what this person could do. But pay restraint is also important and I won't get this in a lot of detail. But actually, we've had pay restraint for many, many years. And although this is the top of the pay scale last year, it was one year out of date. Now, if our pay scales have kept it with our P I, the top of the scale will be 100 and 40,000 lbs. And this has a massive impact on your pensions because it's the final salary pensions. If you dropped your final, sorry, by 30,000 lbs, it has a massive impact on your tension and just, I won't go through a lot of detail for time. But the headline figure of this is if you look at the difference of somebody who was age 50 and 2010, what would happen to their, their lifetime earnings if they had proper pay awards for the last 10 years. Um And that, rather than what actually happened, you'll find that cumulative lost earnings is nearly 854,000 lbs over the rest of their working life and their retirement only up to the age of 80. And actually, we expect people to live beyond that. So if you live to 90 would be even higher than that has a big impact. And obviously, we are heading into difficult times again. And if we're going into austerity with low inflation pay awards, again, many of you can retire and actually make sure your pensions goes up with inflation, which is currently very high rather than being subjected. But to pay erosion very briefly, this is, this is really important and hopefully we're making some progress for this. There are, there are two things to be aware of. So if you go early, your pensions reduced and for many people, they think that's a terrible reason not to go early, but it's not designed to be a punishment that going early. It's simply a mathematical calculation because the earlier you retire, the longer you receive your pensions. So if you retired early and you got the same level of tension, you'd actually have a financial incentive to go early and that obviously wouldn't be right. So it's meant to balance. So to give you an example, and this is the 2015 scheme. If you retire at 60 rather than 67 your pensions goes down by approximately 30 and 35%. Um And if you had a 60,000 lb pensions, the age of 67 by the time you were 80 you'd get 780,000 lbs, a natural pensions because you got 13 years until you hit the age of 18. But with the actual reduction, if you go at the age of 60 your pensions now, 39,000 lbs and by the time you're 80 which is now 20 years, you get seven and 80,000 lbs. That's exactly the same, just meant to balance out. That's what it's meant to do. Um, and similarly, um, you know, I should say life expectancy is important though because if you, if you think that you will live before, live more than 80 of course, you never know. but you think you will live more than 80 taking your pensions early might even be more beneficial. Um So if you die operated, you take your mention earlier is better. But if you live beyond dating, then actually you might be better off kind of working a bit longer to make sure your pensions higher. But in the 95 scheme, there's a problem because you don't have late retirement factors in the other schemes you do and late retirement factors of the opposite of this reduction. So what they're saying, what, what they're designed to do is if you don't retire at 60 in the 95 scheme, what should happen is because you're not taking your pensions, your the pensions received when you do take, it should go up, but it doesn't, it stays flat and only goes up with inflation. So it's give you an example. Um if you have 30 years service in 95 a final pensioner pay of 80,000 lbs and just use the math simple here. Um, 1995 your pensions, 30,000 lbs, okay if you work beyond 60 and you continue to, you continue to accrue your pensions. So it still goes up because you're crewing extra years. But after one year, you have a pensioner of 31,000 lbs because you've got an extra 1 80 but you haven't got the 30,000 lb pensioner you could have taken for that year. And what should have happened is your pensions, you went at 61 should have got to 33,000 lbs to offset the 30,000 lbs you've lost. But that doesn't happen to you just get 30 you get extra 1 1000 lb per year, but you've lost this 30,000 lbs. So it would take a very long time to actually offset that balance. So we'll be pushing very hard to get late retirement factors including the 95 schemes. Otherwise, if you don't retire at 60 you're essentially burning your pensions. The other way of doing this is to allow partial retirement, which we're hopeful we're making some headway on. This allows you to draw your pensions from 95 at the age of 60 but carry on working and carry on contributing to the 2015 scheme if you like. So it's not retirement turn, you just basically carry on and just take your pensions while you're working. So that's something we're hopeful. We'll come in in the next. Well, in fact, this year now uh towards May or June, potentially. The other thing that's important is the freezing of the lifetime allowance. And essentially what we found that when we surveyed around this, around 70% of people said they were tight even earlier when the chancellor announced that they would freeze the lifetime allowance. And if you, if the lifetime have kept with inflation of 2% it's now higher than this, the lifetime lance would be 135,000 lbs higher if it had kept up with inflation. So that's a big difference. And for a consultant at the age of 60 they could lose 5000 lbs. As was this this change? Um Just conscious times, I'll skip that. Um fine. Just get mcleod for the moment. I'll cover in the questions, right? So the other thing to bring you up to date on is the contributions consultation. So we've been pushing very hard that the contribution structure is not fair because as I mentioned before is 14% of the top and um 5% of the bottom ba we've argued that actually should be a flat rate because everyone's in the care scheme. So everybody's buying the same pound of pen shin and you wouldn't charge the doctor more for a loaf of bread that he would um somebody who was lower paid to what he did for pensions. We've got some progress on this. So we're expecting that from next year. The top two rates will disappear. So we'll go from 14.5% to 12% as being the top rate. But that will probably take two years to happen. It'll drop to 30.5% next year and 12.5 of the following year. That does mean that, you know, to keep the average feel the same. So the lower rates will start to go up. That's a slight issue for some junior doctors, but the majority do doctors are still going to be better off even in the year, but long term, we're all going to better off from these changes. Um Some other changes that can happen is that for part time workers, it's been a big push from the B M A for a long time is that the contribution tears were based on that actual pay rather than the whole time equivalent. Um That's, you know, that's fair because I couldn't have been over paying for pensions. We're going to now start the indexing of the tear boundaries. So actually when pay rises eventually do happen, that the tears will go up. Um And the changes I mentioned probably coming over two years rather than being a big hit just very quickly. Uh once going to any detail, it's not quite too late. So if you had an annual last tax charge in 1920 do you make sure you need to do? You do what you need to get the scheme pays compensation policy we negotiated. So you need to make sure you pay any having a large tax charge by scheme pays. Um send your scheme pays for um to HMRC. There's still time to do that and send a separate compensation scheme form to NHS pensions you've got until March of this year to do that. So make sure you get on with that. Um The BMA is doing loads of work um to actually try and make this easier to people, for people to understand we're producing some tools to help you with through the mcleod remedy that's happening. And we're taking legal action on a number of areas as well. Um In particular, one thing to, to raise with you to taking legal action against the cost, cat pause. So back in 2016, when the first valuation happened, the scheme was effectively in surplus um by, by a significant amount and the government was duty bound to actually increase member benefits by as a result. But what they've done is they've actually paused that mechanism. They've seen the impacts of the cloud. They're essentially trying to put the mcleod cost back into the cost caps, essentially what they're trying to do or how he phrased it is the government made a mistake by offering uh protection older but not younger members that was found to be unlawful. And now they're trying to use the member's money to actually pay for their mistake and we're taking legal action against that. So I'm going to stop there for time. If you're not being a member, then obviously, I would strongly urge you do join, particularly around the pensions piece that we're doing because this is going to be a very, very complicated area for the next, you know, well, over a long time, but for the next few years in particular can be very complicated. If you want more information, we do have a um a pensions Twitter handle myself, Tony Goldstone, who many of you might know and Christian who got the deputy chair of the committee were tweeting fairly regular on pensions. Again, there's lots of information on there, so do feel free to follow us on there as well. Okay, thanks very much and I'll stop there and hopefully got some time for some questions. Thanks. Thanks very much, MS. Uh Is there any bad news there are saying it's going to be rich in retirement? Thank you so much as a great talk and I look forward to watching that back just to go through that in some, some detail um for all the figures, but great loved it. Thank you very much. And we'll take questions after the next talk and our next speaker is going to be um and Booth who is a neuron East pissed at and Brooks but has a major role in an orange jumpsuit uh in prehospital care in the region. Um She's worked with mag Pass Air Ambulance for 20 years and she is a finalist in the Air Ambulance UK Award of Excellence 2021. Um She's has uh International Women's Day. She's quoted as saying, I want to tell you that women can do whatever they like, like lift the bags, run with the team and climb over the fences. So if you fancy that, then uh speak to her about joining MAG Pass. Uh she draw on a considerable experience to coordinate um service for the transfer of critically or COVID patient's by Mag Pass. Um And with so much experience, prehospital care and transfer medicine, which is the obvious choice to help establish a regional transfer service for critically critically ill adults with Alistair steel. So and thank you very much for agreeing, agreeing to speak to us and over to you. Okay, perfect. So hopefully we get called out. Thank you for the very kind introduction uh to take off where we were at with the slides. So I'm just going to run a brief overview of why the service came into being talk a bit about how to create a new service in the NHS. This is something that certainly didn't get very much of during my training, but it's been a really interesting aspect of this job. Um and then discuss the scope of the east of England critical care transfer service where the services at now where we're going to look to move towards in the future. And most importantly, I hope for you lot how to take part and support future plans. Would you be interested in? So, looking at the history of critical care transfers just in our region in 2019. So this was just straight before COVID, there were just over 1900 transfers occurring every single year in the east of England. And those these are critical care that level three transfers. Um historically, these have always required the referring hospital to provide the medical team. So doctor and nursing team and the equipment and I'm sure most of you here have at some point been involved in a transfer and realize how difficult it can be to find clinicians that are available free. Had some transfer training, get the right equipment, get the people together and then find a 999 vehicle capable of undertaking the transfer that was pre COVID. And I think you can probably imagine now with our current staffing and the 999 pressures faced how difficult it has become. Um This left often quite junior doctors being asked to do the transfers, most of whom will have done the transfer training, but may not have been heavily experience and transfers and pretty much routinely, your first transfer would be done as the sole doctor. Um that led also to the end of the transfer of you being exhausted maybe well over your shift hours because you are now in hospital many, many miles from your base hospital. Um, and you need to then find a way home. I remember as a trainee in London doing a transfer and then the 999 vehicle offering to take us back to our base unit but got diverted to a cardiac arrest call. And we were then some more hours off shift. This leads to this kind of response when you're walking around the hospital looking for a transfer team of no way. I'm busy. Please. Not me, anyone but me. Um quite understandably. Um And that's before you look at the danger to the patient involved in transfers. So there are numerous papers out there. This is just one of the most recent ones. This is our colleagues down in the Southwest appraising ad hoc systems for transfers. Again, this was 2019. So just pre COVID, it was published in 2020. Um The the two things I wanted to pull out from this paper were firstly, people think that transfer it would be quicker always to send the referring hospital team. But the medium time in this service from the request tech leave the hospital so that you've already made the decision to transfer, the patient's probably had all the scans have been packaged. Their plan has been made to actually leaving the hospital was an hour and three quarters medium with the range of 77 to 1555 minutes. So it's not quick you know that, that pressing the button that's ready to go, it's not quick. Um And again, I think you probably well aware, critical incidence in transfer are really, really high even more so with adult teams. So just looking at these time, critical patient's critical incidents were occurring a very, very high rate in patients who are already are sickest um in the region at one in 14. And most of these were equipment, fault, equipment failure and familiarity um and malfunctions. So I've been involved in transfers for a long time and run a pilot project for a trauma outreach service back in 2012 and very much wanted as, as Alistair to create a region wide transfer team for the east of England that would hopefully fix many of these problems. Um Alster and I got appointed back in February 2016 by the ODM two to run this project and to set up a service. Um And it has been a steep and interesting learning curve, I can tell you but how that involved, how do you actually do it because it felt like in 2012 going around the pilot, we didn't really get anywhere. So this, if you want to create any service, you need to uh to write a business plan, which we did in very close conjunction with NHS England and Improvement. Um and the specialist commissioners. So getting your commissioners on board right from the absolute outset and getting them really heavily involved with understanding that business plan and being involved in writing. It is really key we worked with the national teams. So uh there are national needs for critical care transfers and also all of the other regions are in various stages of setting up transfer teams with the Southwest established Midland's established and some other services yet to come online. But collaborating to ensure that the sort of key performance indicators, all of those types of aspects of the transfers are uniform, certainly going to make our lives easier in the long run. Uh The key part of your business plan is the case for need, a sort of stakeholder options, appraisal. So the case for need, um it was really important to write to, to really get a very clear narrative on the numbers of transfers, the ad hoc uh element of them and also the impact that that has on East is our 999 service provider and on for the referring hospitals that the actual financial impact it has on them to have uh members of team offsite particularly weekends or when staffing is low and the impact that may have on theaters or intensive care for even into the sort of within the next 24 hours when shifts get struggled around. Um And in that case, we need, we also put a couple of patient sort of real patient scenarios as well to explain the human aspect of it as well. And in terms of that sort of risk of air early increased bed stay dates. Once we've got that it was important to get stakeholders engaged. So we went across all stakeholders. So the leaders of the critical care units, uh the CDCs I see s is um the patient group involvement. So making sure that everyone who is your stakeholder is able to, to make a point about what it is that they actually need. There's no point creating a new service. If it's not wanted, it's not needed or is it going to be useful? Um So it was, that was an important part and quite a lengthy. So that feels like a really slow burden. Um So, uh we're gonna do an oxygen is appraisal, bringing in all those aspects together and work out what might work for the region and present those options and present, which we believe is the best one and why that is? So our options appraisal ended up with the plan for a 24 hour, seven day, a week, 365 day a year service to cover the entire east of England from a single fairly central hub and spoke model with to transfer teams on daytime and one transfer team on overnight to ensure that all of the patient's who would require us have uh as fair and equitable access to the service as possible once that's been done and approved, um and passed through the commissioner's, we then needed to appoint a host trust. And the host trust is there to assist with organizational issues and this is about occupational health medical staffing recruitment appointment. Um uh And then the services then run as part of a strategic partnership board where the host trust sits on that board as does our ambulance provider as do our clinical representatives, NHS England and the other critical care network leads as well. So there was a due process for appointment of a host trust with expressions of interest and some interviewing from specialist commissioners. Uh Cambridge University Hospitals was appointed as the host. Uh So we were pointing February Kim's University Hospitals who appointed to the late summer this year, we then needed to source a base. So the team need to physically be somewhere um equipment abdomen. And again, that was another options, appraisals with looking for space, looking for cost and then finding suitable places. I'm actually in the new transfer office space as we speak, which is very lovely. Uh I need to appoint staff, so get a staffing, wrote a plan for what you need, why you need it run that through finance committees and then go through the recruitment advertising stage and we are recruiting for more doctors. So I'm hoping at the end of this, I'll get some emails from some of you. Once we've got staff in place, we've got to provide equipment training for them all and plan for a go live date. Which was quite a big challenge because we were appointed 16th of February with a planned go live date of the first of December. So it was a pretty fast pace project particularly in terms of N H S um speed. But COVID had really helped us and the standing up of temporary transfer teams across the region through COVID was a real demonstration that it could be done at pace if needed. So thank you for all of you who were involved in the regions transfer teams throughout phase one and two of the COVID surges. So um looking at what we wanted to include, so as an adult critical care transfer service were included, all people age 16 or over and wanted to keep the terminology relatively broad. So it's requiring critical care transfers. Most of those will be level three transfers in terms of critical care, there will be some level too. But what we wanted to ensure was that um we didn't miss patient's who would like you to deteriorate. So anyone who would benefit from the presence of a doctor and nurse undertaking their transfer, who may require an intervention on route, who may require some additional needs. Um uh certainly within scope. Um and all of the patient's start destination hospitals, one in the east of England hospitals. Uh we are available for the whole range of transfer. So, escalation where specialist care, for example, to cardiac surgery or for burns um transplant, whatever Uh and some of those escalation of care have actually been into other centers. For example, London do repatriation, critical care. And it's really important for flow in the region that once patient's have received their specialist care or they've had capacity transfers, they then go back closer to their family costa units to make sure that the bed is then available. Uh for the next patient, perhaps in the specialist centers. I've done quite a few capacity transfers as well. I'm sure you can imagine. Uh December was quite a bit of load leveling across the region. Um There was a misconception at the beginning that uh we might be just doing urgent and non urgent critical care transfers but actually were available for time critical as well. And if you go back to Scott Greer's paper, just from PRE COVID, remembering that the median time in these time critical patient's to leaving the hospital from when the decision is made to transfer being an hour and 45 minutes, there isn't a hospital in the region that we would take longer than that to get to. And we're also very happy in the time critical patient's for your hospitals to deploy the team before that referral process has been approved. So we're accepting that sometimes you'll deploy a team and then it'll be actually that we don't really need the team. It's okay and that will be acceptable. The team will go back and be available for the next transfer. So this is the east of England area. We cover pretty geographically massive and we work very closely with our collaborative borders. So uh Southeast London and the Midlands or border our region and we work with the other transfer teams uh as well to provide mutual aid if necessary, etcetera. This is where the transfer office is. We were ideally going to be based just probably slightly to the south, but there wasn't a suitable building available anywhere near that. The base itself is just north of Cambridge and it's got really good major road networks with the A 14 and A 10. And so we're able to get across the region in relatively short period of time. The team are available from eight AM currently to eight PM and mid today to 10 PM. So not quite 24 7 yet, but we will get there were certainly available seven days a week. Um A team ready as I am currently now, uh we have two teams on at the moment. So when are out um available, ready to go with the ambulance with all fully loaded to make sure that we can benefit these time, critical patient's as well as the less critical or the less urgent patient's just looking at the distances are look for furthest hospital as James Paget and uh this normal road conditions is just just over an hour and a half away. So on blue lights, uh we'll be able to reach James Paget according to our own quarter. And certainly, if you call us early, we get on the road whilst you're still preparing, the patient may be running scans, we can really cut down the transfer times. Uh This is our office yesterday morning. So lots of parking, uh freely available, easy to get I/O of. Um, we've appointed teams but we for the first month in order to get that go live date, really, really up and running swiftly, we've had the team's needed to be covered by low comms and banks turn off. So we had our core team that underwent training uh and the uniforms. All of the transfer doctors are currently consultants and the national guidelines are that they need to be a consultant in intensive care medicine or anesthesia or within six months of A C C T. So those of you in your final year of training um would also be eligible to join. Um And we provide the training for that. We've got a core group of ban six transfer practitioners, which is great. And we for the future, we want to provide training opportunities in terms of training modules for trainees in the region as well as to if anyone that would be interested long term in doing some bespoke transfer training, education training. Um Then the opportunities are there. We had a really short time to get the training up and running. So this is uh needed to train them in our electronic patient records used to the laptops, offsite. The main bit of training is making sure that they, everyone on the team knows absolutely backwards how to use our equipment. And we're really lucky in that. We've got some beautiful, um, this is just some of it. We've got really lovely ventilators. We've got the bronze space plus pumps, which state of the art? We've got great monitoring. Um We've got the Mickey is a fantastic blood warmer and these are just some of the equipment we have. Uh this is uh bariatric vacuum mattress, which this is part of the team training day, just testing on the lovely doctor Johnny Martin and it doesn't seem like anyone went really rushing to let him out, but it's the still ist I've seen him in many a year. He is one of our team doctors. The on site training was backed up by um some training on bridge. So we've got a bridge sub account that's got a critical care transfer training modules on there as well so that team can get certified on them. Um And then the process is being rolled out over three phases. So we're currently in phase one, which went live on the first of December and this was mainly to aid with winter pressures and make sure that the transfer service was up and running as soon as possible and didn't miss this sort of key winter where we really needed. Um So as I said, these were 100% staffed by bank and locum shifts. And you can imagine people are pretty flat out in their court jobs. So to be able to have our core team provide to date 63% of available shifts with a full staffing model. It's been absolutely amazing. Looking forward at the rater were pretty much close on 100% going forward now for our staff, um now that we've got ban six practitioners as part of the permanent team. Um to date, we've done over 50 critical care transfers. We've been as far as Sheffield, we've taken quite a few into London. Um and today touch weird, we've had no adverse clinical events. Um And it's been lovely to see a few of our patient's have actually seemed a little better at the end of the transfer. So who knew? Um part of the service is having a single dedicated oh 33 number. Um And this is a consultant advice line which is also used to deploy the team. We have had 100% coverage of that and we will continue to have 100% coverage of that as one of our key performance indicators. To guarantee if your your departments need us, you can phone the number and you will get an answer within five minutes from the transfer consultant. Um This is the model I showed you before 63% to date of the shifts free staffed and 92% of the days have been covered by the transfer team from the first of December and going forwards. This is looking even better. So I'm really pleased with that. We've had a whole range of the patient is transferred. We had quite a soft touch in terms of advertising. In the early days, we kept it mainly to critical care and haven't opened up as much to the time critical ones. But we are now really wanting to push the service now that we really some robust live testing of it and see that the processes do indeed work so big range as expected uh cases. Um So it's good to see that looking forward to what's next. So we are in a temporary office, but we're moving two doors down with in this same building to a permanent office which will have a dedicated simulation center as well. So we'll be able to do some bespoke training for the region and for our new teams. And phase three is where we'll go for the 24 hour cover ups at the moment between midnight and eight AM. Uh There is a gap in the, in the, in the system, but that is temporary, which is good. So we're really looking forward to that. We really want you to be involved. I realize that it's located relatively close to Cambridge and I know I'm an amorous consultant, Alistair King's Lynn and James is part of the team, which is fantastic from an nuh we've got a consultant from Peterborough. It's very, it's very, very important that the transfer service is representative of the entire region. And it is great to have consultants from, from all of the units as part of the team. So if you are keen on being involved, we would love to have you and I can share with you a link to apply, which would be a short statement, the C V, a brief interview um and the training, we do ask for a commitment for anyone who does get involved in terms of being part of the team on the medical side of completing the training and then undertaking two shifts a month uh for the team. Although you're welcome to do more than that if you want. So we have a website, feel free to note it down on that is the telephone number also button to request the transfer team, but do feel free to email me directly if you have any questions at all or if you're interested. And for those of you who don't want to join the team, get it must feel really sick in the back of ambulances, but do feel free to take it on the down and share the word and think about it next time that you're stuck in E D looking for a transfer. So thank you very much and happy to take questions and thank you. Uh Thank you so much. I think we all owe you a huge uh debt of gratitude for, for the work that you've done in setting this up. I mean, it's been like all their Christmases have come once, you know, we have a sick patient suddenly here. Well, come and move them for you. I mean, it's almost is too good to be true. Um So um if I can invite the other speakers now to come back. Um First Michelle and where's the other visual? Have we got him, James? Have we got James? Okay. Let's let's start off an um questions for you one in the chat. Do you do any of the transfers by air or are they all land ambulances? So yeah, good question. We did consider air transfers but we all of our transfers are by land. I do do it, transfers with my pass. It's just a slightly different skill set. So no, currently all bespoke gland vehicles. Okay. Um Now you mentioned about the training time if people want to join and the service, what, what form does that take? How long is it? So the in person training is a short day. So we're not training you on your clinical skills because you've already got those in your department. So we're training on the equipment. So they it's 12 hours paid training of which the majority of it is at home online and then sort of 56 hours on a single day on the base and that day you'll get your uniform and the training done and anything signed off as well. Okay. Right. So it doesn't sound like it's too much for anyone who wants to get involved. Say James is doing it. Uh, so rumor has it. Um, he in all of his spare time that he doesn't really have. Um, so who's actually paying for it? Because it's a, it just sounds too good to be true. Um The individual hospitals paying towards it. No, we've got separate funding from NHS specialist commissioning. So we get such nice responses were coming to the hospitals and it's so lovely because literally, we're going to take your patient for you. We're not going to charge you anything and you don't have to provide anything. So it makes us popular, but no, especially commissioning of paying directly for the service to the transfer team. So, no, its fully funded. Wow, that is indeed amazing. Um Any more questions for an, if you can pop them in the, in the chat? Um That would be great. Um So have you actually are hoping that you're writing a book or a manual in terms of how one goes about setting up a new system because you can face enormous challenges and all done within COVID season. Um So, yeah, I hope you're writing a manual on, on, on a process to do it because, you know, as you say, it was a steep learning curb. Yeah, that's a good idea. Actually, when I get some time back I might, it has, it has been amazing and the things I have learned from, you know, licensing, leasing hr rules, drug laws for offsite locations, procurement processes. It's, yeah, it's been really interesting but a bit mind going good. Okay. Um I can't see any more questions for you and, but thank you very much. Visual Patil. Hello. Nice to see. Uh Good. Well, thank you very much for your presentation as well. Um Now a few questions running about that, just ones that were in the chat. I know Cathy asked about. So the feedback when individuals complete forms and then they go off to be reviewed. Um And then you mentioned that the feedback is sent to the individuals who may have completed the forms. That's correct. And um just to so and, and trust wide, how do you, how do you share the learning both trust wide and maybe further within the region? So within the trust, the NRL S uh safety updates get circulated. And from the medical directors office, there is a uh there is a monthly update which does include the the number of uh patient safety incidents that have happened in the trust. So there will be some sort of, you know, an overview of what has happened in the trust in the previous month with regards to how many happened and whether it's within the normal variants or not or whether uh there have been any never events. So that sort of thing gets distributed from the medical directors office on a, on a monthly basis and the NRL S safety updates. So the last one I can remember which is relevant to our specialty was about using FFP three masks with wolves when patient's are undergoing sterile procedures. So basically, you know, that, that that was distributed. And the other one which came last year, which was relevant to us was uh I don't know if you remember there were instances were in uh the plastic bit of the E C G cynical that was accidentally sort of left behind in patient's when they were connected when they're, I think an LMA or a Cuban session. So those sort of things come at a hospital level because they are another less. But otherwise we get regular updates at departmental meetings here. Okay. Now, obviously the the reports are anonymized in terms of patient's. But are those reports that you come that, that come from the uh your trust? Are they in the public domain or are they still? No, no, no, not that's not in the public domain. But we've actually had, I mean, I don't have a formal role in the trust now, but you know, when I did have, I did encourage patient's to come and present. So we had uh we had at least two incidences of patient's coming into the department of meetings to present. So one of them was actually a nurse by background who was diabetic and her care was sort of, you know, not optimal. Uh So, so she got very upset about it and she came and presented at a departmental meeting on how things could go better. And uh so, so so some patient's choose to sort of, you know, uh not be anonymized, not be anonymous and they come and, and present about their experiences at meetings and, and that I think is a very powerful learning. Yeah. Yeah, that makes it all that much more real, doesn't it? Yes. I mean, it's, it's one thing for us to say, you know, that about how to manage insulin. It's another thing when the patient comes and tells you, you know, uh, I'm a type one diabetic and insulin is like oxygen to me. So, you know, uh, please, you know, don't mess it up and I think that has got a huge impact. Yeah, quite, I totally agree. And I think it is that, that link between the science of human factors and, and incidents and so on and, and actually clinical cases, which I think is, it seems to me is often hard to, to, to marry the two together. Um, I mean, in that vein, do how higher profile is the science of this in training trainees? Um, is, are there any other specific sort of training packages that, that, that, I mean, we all know how to manage malignant hypothermia. But is there, uh is there a way of embedding more that the science that, that the, that the extensive research has been done in this um into the, into the training? I don't think that is, that, that is a murdered very well. So, so I talked a little bit about cognitive us is, I mean, I think, I think they're, uh they're very well known that that research exists, but I don't think we talk about it enough. So, so we talk about human factors a little bit now or a lot more actually compared to say when I was a trainee. But things like cognitive us is so if you look at the, the no uh no trace wrong place incidents, you know, is a vigil intubations. So for the, so the latest one, uh they actually uh one of the things that is actually misinterpreted the pressure away form as, as, as a CO2 way form. So you can see how, you know, you, you want to look for ASIO to be a form. So you see something and you think it is a CEO to perform. So, uh I don't think we talk enough about cognitive biases having said that I think things are getting better, I think last year, I mean, in November uh in the B J educational supplement, that was actually an article about computer viruses. So I think, I think we need to talk about this because like I said, you know, they're, I mean, they're ingrained in us, you know, they're, they're a part of us, you know, they are a feature, not a bug so everybody's going to have them. Uh, so, uh, I don't think we talk enough about it but I think we will be talking more about it in the near future. Yeah, I agree. I totally agree. Um, now any more questions for visual, I can't see anymore um on the text um one more that occurred to me. So um uh most of their lessons are learnt retrospectively from disasters and bad outcomes to patient's. Is there any program for sort of proactively looking for problems? I mean, I wonder whether you get a pilot or something like that coming into an anesthetic room and knowing very little about how things work, but just seeing if they can do things that sort of break the system in inverted commas and things that you might then take maybe a novice and anesthesia. The sort of mistakes that they might make is anyway, sort of road testing. These are systems. So I'm glad you asked that Jonathan because we don't do that. But if you look at uh say for example, the Cambridge rowing team, the Cambridge drawing team had an ethnographer which who was embedded in the team and basically the ethnographer sort of, you know, lived with the team for four days on and what they can see is they can see when things are working well. Uh, and I think, you know, more than a pilot or anything like this, I think, I think that is probably a role for, uh, sort of in a resident ethnographer to come and see how teams work and, and, and they will be able to sort of, you know, get nuances about what a good team is and, and, and we can use that information to sort of uh spread good practices. I don't think we do that and I probably is going to be difficult but, but we did that when we had, when we had incidences with retain guidewires, we actually had a medical student who came in and started observing procedures about uh necessary is doing in central lines and they were able to pick up the variations in practices and highlight some of the practices which some people did, which others things. So, so simple things like, you know, uh some of the old fashioned uh senior consultants, you actually put a guidewire in far too much, actually used the, the presence of ectopics to decide, you know, that you're in the right place. Uh So, so, so there were a lot of variations uh because the medical student was not very knowledgeable about it, they were able to highlight differences in practices. I wouldn't recommend using a medical student, but definitely uh ethnographer, I mean, I think, you know, they will be able to pick up good practices. Yeah. Yeah. Good. Okay, Fishel. Thank you very much. Indeed. Thank you. Move on to uh fish again. I don't know quite how you get all of that stuff in your head and keep it there. I mean, it's, it is so many facts and figures and as I'm saying, I will look forward to watching the recording back when I can actually sort of look at it, slide by slide and, and think through how it applies to me and I'm sure many folk would do the same. Um, so, um, if to get decent financial advice, it seems to me is it can take a bit of digging around, do the BMA themselves. I mean, obviously they'll give you general advice on pensions. But do they have an inhale service where you can get someone to sit down with you and look at your figures and so on and advise you on what to do? Yes, not, not exactly. So as you say, it's very complex um in terms of what needs to be done. So what, what the BMA is focused on doing is trying to give members the level of knowledge that, you know, in terms of talks like this about when they think there might be a problem or when they need to start getting advice. That's the first thing we're doing, as you say, the be Emma's pensions department is able to there to sort of support you with any particular queries, they can't give a financial advice at all, but often, uh, they might, you might find their errors or those things you're not sure about. They give sort of general advice from that level. We do have a kind of partnership with chase severe who are financial partners. But actually, this is very complex and I think one of the things that we've noticed it and I think I may have wanted to before that actually lots of accountants, lots of financial advisers are completely, they're confused by the pensions scheme as well because it's so complicated. Um because it's not just the pensions scheme itself, it's the interaction between the pensions scheme and the tax scheme. So in a defined contribution world where you literally, you pay a bit in, your employer pays a bit in and that's your pensions growth, which what is what most financial virus and the counters are used to. That's relatively straightforward. You can sort of work out the tax consequences of that with a bit more ease. But when it's, when it's complicated like this, um it's really, really difficult and we haven't really got yet, you know, a team of real specialists that can actually deal with this. So the advice out there is quite variable, unfortunately. Okay. So tying in with that salary sacrifice. Amazing. I get myself a Maserati for 300 lbs a month. Amazing, isn't it? Can you just sort of, I've heard this isn't the entire truth, is that right? Maybe you can brief a couple of problems with salary sacrifice. So you, so you do get the tax, the income tax benefits. So, so the reason it's, it's attractive or seems to be attractive, um is that when you take a salary sacrifice scheme out your essentially, you know, it's like your pensions contributions, you make the payment, whatever it is you're buying, be it, be it cars, be it, you know, school vouchers, etcetera and, and be warned as well, only certain things now are eligible for salary sacrifice. So actually, it's only low emission cars, not all cars, for example, uh cycles and school vouchers are, it's much more limited than it used to be. But the benefit that you get from is you don't pay the income tax or national insurance on it effectively, the downside is um in England, at least it's slightly different in Scotland because they do it a different way. We're trying to get it aligned in England as well. But in England, what happens is that deduction is taken from your pensionable pay and it's taken uh from your pensions pay before they take all the, all the tax off it. And that means that your pensioner pay is reduced as a result of your your salary sacrifice. And that causes two problems. The first is obviously your pensions reduced as a result. And whenever you look at those figures of that 300 lb for Maserati. For example, it doesn't tell you how much pensions you've lost for the rest of your retirement by having your Maserati. Um, that's one thing. But then the second thing is that because it reduces your pensionable pay when you end that, that loan, okay, when you end the salary, sacrifice your pensioner pay jobs up again. And it, it is treated as if it's a pay rise, even though it's not really a pay rise, it's treated as if it was a pay rise. And as people know, one of the pressures you have is that when you get a pay rise, be an increment or pensionable, see a that can trigger a big annual ounce tax charge mainly from the 95 or 2008 scheme and ending a salary sacrifice in England. And Wales can do exactly the same that can trigger and they announced tax charge. So we know people who've taken on, for example, a 10,000 lb a year salary sacrifice. I think they've done really well because they're, they're getting something, you know, very nice kind of inverted commas tax free. Only to find that when they give the car back that they actually get an announced tax bill, it's much bigger than any of the savings have actually made, actually worse off good. Yes. So I think a lot of people aren't aware that there are significant downsides to that. So thank you for explaining that very clearly. So one last thing, so is Mr Sumac, is he going to tax the lump sum? Oh, you have any ideas I would say to that one? Um That is something that is it put this place a risk. So it's a risk that the tax free lump sum is uh is days may be numbered in some ways. Obviously, the being able to fight that tooth and nail because it's inherent part of the scheme. And obviously, if that would change her to come in, the, any accrued, tactically lobster you've got already should be, we would argue that has to be protected because you essentially you've built that benefit up already. But this whole thing is, it's a mess. And actually, our view is very simple rather than trying to claw back tax relief, you know, all the way through, give us a scheme that's similar to the judges where there is no tax relief. And as I mentioned before, most doctors don't get to actually from the first place. So actually, you don't have a tax free in the first place. You don't need to get your annual allowance, you don't need your lifetime allowance, you don't need to tax attack your tax free long, some etcetera because you're not getting a taxi from the first place. That's what we're pushing very strongly for. Let's just have a simple go back to the simple days, okay. It's not gonna be as good as it was. Plus you have a simple system where there, there's no tax relief you need to worry about. So you don't have to deal with these extra taxes, right? Thank you very much. Well, thank you all three speakers for your excellent work for the greater good in three very different areas. But thank you for, for all that you're doing. So that brings into the end of that session. So I've been told to say if you just dip out and have a quick loo break and then get a drink, come back. Um We're going to start again at 3 15 and I'm really looking forward to this. I think the thriller in Manila will be hugely eclipsed by the meeting of what we think unstoppable force meets, meets an immovable object. I think it's going to be quite something. So uh come right back.