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Thanks. Okay, good afternoon, everybody. My name is English Dine, but I'm from the Center for sustainable Healthcare. And I'm the chair today for this breakout session on environmental impact. Um Rosie, do you want to introduce yourself quickly? Hi, everyone. I'm Rosie. I'm also from the Center for sustainable Healthcare. I'm co chairing this session. But yeah, if you've got any questions or comments for any of our speakers and presenters, please pop them in the chat as we go along and then we'll pick them up at the end. Fantastic. Thank you, Rosie. So, and we will start straight away with our first speaker. Um We've got until 3 45 for the breakout session. Um Lauren is from the Sussex Community NHS Foundation Trust and she will talk about care closer to home. Thank you very much. She Lauren for joining us today. Uh I know. Thank you for having us. Um Hopefully you can see my slides. Um So my name is Lauren. I'm a junior doctor and also clinical sustainability manager for the Care about carbon team. And we're based in Sussex and working with a range of trusts across Sussex. Sorry, and Hampshire um to help deliver Net zero healthcare. Uh This presentation has been put together by myself and Amy Born, who you're here in our next presentation um about the Green Impact Assessment Tool. Um But for this session, I wanted to talk about the carbon footprints of community care. Um Specifically, we're talking about emergent urgent community response services. Um So first we'll go into a little bit about what they are. Um And then we'll talk about what carbon footprints for units of care we already know about in the literature, the methodology we've used to calculate the carbon footprint of a, you see our care contact our results and then also the next steps for this project. So urgent community response services, um our teams based in the community and there an alternative to hospital admission. So they provide urgent care to people in their homes. They're part of key part of the NHS um in England long term plan. And it's now mandated that every single I see s is required to deliver a urgent community response service and they're um statistics are nationally reported. Um So in the literature, we know that there's um different units of care have associate with different carbon footprints. Um Mostly these are known for the acute sector, with the exception of uh units of care, for example, for G P appointments. Um However, it's less well known um what the carbon implications are of community based care. Um And therefore, as we move care out of the hospital into the community. As with urgent community response, teams were not entirely sure of the carbon implications of the transfer of that care. So to calculate the carbon footprint, we um first of all mapped out the pathway with our clinical colleagues which is shown here from referral to discharge. Um And we've included within the carbon footprint, all of the activity carried out by the, you see our teams. Um So from three charging, two armored referral or discharge, then we've collected data on business mileage, consumables, number of patient contacts and caseloads in the future. We're looking to include other areas of the impact highlighted in the middle here. Um And we've excluded um these areas which are either due to the fact that they're excluded in other calculations for units of care or because the data is unavailable or unattainable. So these are the results for our care contacts. Um So the data for this has obtained um from records inputted on the um the electronic patient record system system. One. Um Here you can see the graph um some of contacts by the by month for the financial year 22 to 23. Um The different colors are the different teams across our geography and Sussex. Um This is a Sussex based project. Um So the total number of contacts for the entire year was just under 100 and 70 k which was um corresponded to just under 10,000 patient's who were seen an average of 9.45 times per day. So seen an average of every other day. Um For these contacts, the vast majority of these were face to face. Um So just over 90% just under 10% were telephone consultations and there were two instances of video consultations across the whole year. These are results for their business mileage again shown by month year. Um These are obtained from business mileage claims which staff put in once they've traveled to uh deliver the care student to done their face to face appointment. Um As you can see, there's a significant drop in March. Um This is due to the delay in processing um and uh submitting uh business mileage claims. So, as a result, we've decided to exclude this month from the overall calculations. Um But here you can see that they, the teams across Essex um that over 500,000 miles in the financial year, which is an equivalent of 100 and 61 tons of C O T. These are results for consumables. Um So this is data from the NHS supply chain. Um and the um carbon footprint is calculated using their E class codes and factors um from the Center, the Sustainable Development Unit. Um As you can see here, this is by month, year and there's a significant increase towards the end of the financial year. This um corresponded with the instigation of a new, you see our service. So there may be an element that this was them establishing their stock. Um And it may be that as 2023 goes on that it returns to more stable units seen earlier on in the year. Um As a result, this is a bit of a limitation of our calculation overrule. Um So in future, we look to continue to measure this um uh to measure the consumables purchased and see whether or not um the carbon factor needs to be revised accordingly. Um So they uh procured over 291 k items with a total annual carbon footprint of 240.7 tons of C O T. Um And then we can see up here. I'm sorry if it's really small. But the most uh highest type of item that was procured was medical and surgical equipment, followed by office equipment um and telecom's so putting it all together. Um So the overall comfort front for the year for the uh you see our services at Sussex community was 358 tons of C O T. Um 56% of that was consumables. Um And 43% of that was business mileage that works out around 2.3 kg of see two per you see our contact or because not every patient was visited every single day. That's around 1 kg CO2 per patient per day that they are under the care of you cr before they're discharged. So we can see here where how that compares to other forms of units of care of activity. Um So for example, you see our context right down here. Um and we can see that it's an alternative to the inpatient bed day, which obviously is um significantly higher. This is with the caveat, of course, that we haven't got all the other measures of carbon impact that these figures do have. So for example, this this pie chart here shows the relative contributions for different aspects for the low intensity inpatient bed day. Um So for the next steps of this project will look to include as many of these items as we can. Um We're also going to look for further clinical input to iron out any figures and also to pave the way for projects to reduce our carbon footprint even further. So, thank you for listening and understand will take questions at the end. Is that right? That's right. Thank you very much Lauren. Really interesting because as you said, that's, that's something we haven't looked at very much. So to get an idea what the scale of the emissions are is really great. Um So yeah, if you've got any questions, if you can put them in the chat and Rosie will pick them up at the end of all the presentations and I will hand over to Amy now for next project. Thank you, Amy. Thank you, India. Um I just share my slides. It's just taking a moment. I did think I'd uploaded them already, but it's, it's re uploaded. So it might take just a few seconds. Can you see them? Okay. Yes. Fantastic. Perfect. High. So nice to meet you everybody. My name is Amy. I work with Lauren in the Care without carbon team. So we're the in house sustainability team for us. It's community trust and I'm here today to talk about the green impact assessment tool and we've had loads of great sessions today. So it's been fantastic to be a part of share conference and to hear all the interesting discussion's in terms of this particular topic. So we all know that kind of moving care closer to home has been a priority for the NHS moving care into the community and out of the acute setting. Um so that in order to meet the net zero targets, and we need to ensure that sustainability of community care is first and foremost. So achieve this, we've piloted a green impact assessment tool. So this has been designed to educate and engage staff measure the impact of services and support sustainable change. And we did this in conjunction with the Southeast region of the Green NHS team and we got funding to support Lauren doing some work on piloting the tool and progressing the tool further in terms of engaging with different teams across the organization. So the project aims, the overall aim was to embed sustainability in project work. Um And then subset of these aims was to develop a methodology. So this is the actual tool used to assess and measure the environmental impact of projects. We also wanted people within the organization to be feel empowered to then make sustainable decisions within their projects and to not just use a tool but actually use it in practice with regard to sustainable decision making in healthcare. We wanted to use it as an education piece. So a way to help staff understand what sustainable healthcare delivery means and also to integrate into current project governance. So when people are making service changes or undertaking particular projects, they have the sustainable impact to all the green impact tool as a step to follow in terms of the process, so that sustainability is integrated in a similar way that people think about things like finance or other elements of quality. So pre study analysis showed that sustainability was rarely considered during service change, we looked at a number of projects prior to doing the work and not out of 16 projects sampled had any assessment of environmental impact. So to understand there's some more depth before people use a tool, they fill in a survey. And from the nine participants surveyed, we found that um the people that uh sorry, the people that completed the survey, these the results. So in the first table And I'm sorry, it's quite small. Um We asked whether environmental impact was considered during project work and it was rarely considered the second one. So people, how confident do people feel and making sustainable decisions during their project work? People didn't feel totally confident, they felt more confident with regard to their everyday practice and their knowledge of sustainable healthcare. And it positively there was lots of appetite for people considering sustainable healthcare and the impact on the environment in the future. So what do we mean when we think of sustainable healthcare, what is it that we're trying to get across to staff in terms of health care delivery? So we developed the green impact assessment tool based on our sustainable healthcare principles in our care without carbon framework. And these are very much inspired and aligned to center for sustainable healthcare principles that we've talked about earlier today, the principals have developed around three key areas. So the main one, the first one is healthier lives. And I know those people that were in the medicine session. Earlier, we talked all about kind of health inequalities, prevented ill health and thinking about those aspects before the patient's get to hospital, to the care setting itself, uh streamline processes and pathways. So minimizing waste and duplication and the organization kind of traditional Q I and process in terms of lean care delivery and then finally respecting resources. So thinking about when those resources are required, how do we choose the most sustainable and low carbon um products that we have and products and treatments that we have to the green impact assessment tool itself. As we mentioned, it's a line to the sustainable healthcare principles and it's building into the governance processes during the times where services are designed, evaluated and changed. And the intention of the tool is to kind of highlight to staff where these carbon hotspots are within their service. So broaden their understanding of how healthcare and system design impacts the environment and also kind of facilitate targeted approaches to reduce its impact includes different areas within the tool to provide more information on the different aspects of the sustainable healthcare principles and also a basic carbon calculator in terms of the areas that we've worked on within the organization. So the tools being piloted such as community and we've spoken to members of staff in different areas including Digital Transformation, um P one and P two projects as part of our service transformation team, the quality improvement team has been a massive help in terms of piloting the tool and capital projects. We've also approached the clinical audit team and the research and development team and had conversations more widely with the I C s and other trust within the region. It's already prompted people to just to consider sustainability impact. So for example, the, you see our project that we talked about earlier people considering the mileage and other aspects associated with those services. And also in the diabetes team, people considering the procurement aspects of products such as blood glucose monitoring in terms of next steps. So the lessons that we've learned from the project. So through PDS A cycles, we've reflected on feedback, made the tool, more user friendly and more prescriptive. We've put some functions in the tool now where it spits out three top environmental risks and benefits to make it very practical for people to understand. And it's already, as I mentioned, prompted people to consider the sustainability impact of the service changes that they make. And now we're in the kind of evaluation phase. So utilizing post tool staff survey and comparing to other ways of measuring kind of decision making and sustainability, things like process mapping in carbon footprint. NG. And we're working on integration of the tool into the current process and governance, which as you can imagine, it's quite challenging within the organization to make it more practical and more used within the organization going forward. Thank you very much. Happy to take any questions as part of the Q and A session at the end. Thank you very much Amy and keeping so much two time. That's fantastic. Uh Yeah. Do you, do you put any questions in the church for a me and we pick them up later on? So um can I ask um Omar to come on and do his presentation? Omar is part of the Shuli um school of medicine and dentistry in Can ID A I hope I pronounced that correctly. Yeah, Julich, uh welcome Omar. So I'll be presenting um my review of factors contributing to the carbon footprint of cataract surgery. So as we know, climate change can actually influence human health. This can be through direct causes such as like immediate harm after a natural disaster, for example, or through indirect causes such as food displacement or um pollution exacerbating underlying health conditions that someone already has. So as doctors, our goal is to actually treat patients' and improve the quality of life. However, the healthcare sector as a whole is also a major contributor to greenhouse gas emissions. For example, in Canada's medical services contribute 5 to 6% of the global emissions associated with the healthcare industry. But this is a disproportionate value because Candida makes under makes up under 5% of the global population and a large contributor to the emissions associate with health care in Canada's specifically is cataract surgery. So cataracts are leading cause of blindness worldwide and this can be caused by various things, but it's also a natural process of aging. Uh and to treat this, an ophthalmologist will actually go into the eye and replace the cataract lens with an artificial intraocular lens. And while the surgery has become incredibly efficient, lasting only minutes, um surgical volumes have increased rapidly, which naturally leads to a lot of waste accumulation and emissions associated with this. And as volumes are increasing. For example, in Candida on like Ontario, the province alone, volumes will be over 300,000 cases per year in about 10 years. So our objective was to actually determine what the carbon footprint of a single cataract surgery is through our literature review. And this is to ensure that we can actually implement this surgery sustainably as we continue to treat cataracts. So we conducted a literature review in the three search engines pub med Google scholar in MEDLINE. And we use these following keywords which really covered our bases in terms of determining the literature out there that is actually investigating the carbon footprint of cataract surgery as well as the waste accumulation of cataract surgery. So from the literature, we found that the carbon footprint of cataract surgery varies greatly from center to center. It ranged from approximately 6 kg co two equivalents to over 100 and 80 kg co two equivalents and the major contributors. Uh there was consensus throughout the literature that the major contributors of the carbon footprint of cataract surgery was the procurement of materials. So pharmaceutical surgical equipment, gowns and then also building an energy use. So energy used throughout the surgery, uh heating the building and so on and then also travel associated with the surgery. So travel for the patient's for the surgeon and for the staff to and from the center. So what influenced the lower carbon footprint? Well, as we just saw with our keynote speaker, we can use the Aravind Eye Center as an example. This is the center in India that is actually an exceptional example of um center using, having a low carbon footprint. Uh They're unique in the sense that they host to operating tables. So the surgeon will operate on one patient. And once they're done with that patient, they'll actually turn around, move the single microscope over to the second patient on the second table that's already prepared, sanitize their gloves and then continue operating on that person. And as we just learn, they sanitize their gloves and dispose of them about every 10 surgeries. They also reuse a lot of gowns and equipment which actually reduces the waste accumulation of a single case. Interestingly, they also have a modified sterilization protocol. So they have a shorter cycle and actually able to sterilize a lot more equipment at once. And this really allows them to reduce their energy use. And despite all these unconventional practices, the rates of post operative complications such as endophthalmitis actually remain relatively low, uh sometimes lower and even comparable to centers that actually don't even implement protocols like these. So it seems that I just noticed that it put my slides out of order, but this is the output literature that we had. So we reviewed five papers uh looking at the heart carbon footprint, two papers looked at waste accumulation and one paper was unavailable. So a total of six papers were reviewed. So there's also areas for improvement that we learned from the literature review. The manufacturing process uh in the healthcare industry is one example, specifically intraocular lens packaging. So a single intraocular lens actually weighs 1 g. Whereas the packaging for this small lens weighs 64 g. So it's 64 times the amount. Additionally, they also have um an extensive paper booklet in this packaging that typically the ophthalmologist won't even read. Uh it may be better serviced online. For example, there should also be ways to actually package more intraocular lenses in one single package to reduce the amount of packaging per lens. There is also area for improvement in changing waste protocols. So actually a study done in Malaysia found that the waste associated with the day of cataract surgery, 50% of it that was sent to landfills is actually recyclable material, but it's not recycled because the protocols are in place. So we should actually look to see if we can add recycling bins and uh implement those protocols in all cataract surgery sweets. Lastly, we should also look to see if we can change our uh patterns of practice. For example, studies done in the United States found that unused pharmaceuticals after cataract surgery. So for example, unused eyedrops, the amount that accumulated after a day of surgery at various centers resulted in about 23,000 gasoline powered cars, the emissions associated with that many cars and two potential there's perspectively, that's just one center and the unused pharmaceuticals from that one center. So being able to actually change our patterns of practice to ensure that we're actually using all the material that were um buying will actually reduce the carbon emissions associate with this procedure. However, we do recognize that there are barriers to lowering the carbon footprint. For example, there's just no data out there. So there's such limited literature that we can't actually understand why the carbon footprint is so high and also the lack of generalize ability. So because policies differ from center to center, it's really hard to say that oh, this will be the carbon footprint in the this center because it was in that center. So we actually just need to do more studies in various locations. Next, there's also just limited incentive to actually change the way we practice. Uh for example, billing practices, uh one suggestion that we had was actually doing bilateral cataract surgery. So both eyes on the same day, which would reduce uh travel emissions, for example, but the problem with this is that compensation policies differ in the states. The second eye is actually not as compensated highly as the first i it's actually reduced by 50%. And in Candida, it's actually reduced by 15%. So we should actually change the way we um compensate physicians and reward them for doing procedures that actually result in lower emissions instead of rewarding them for procedures that result in higher emissions. So to conclude cataract surgery is a high volume procedure resulting in excessive emissions. To address this, we need to first conduct more research to develop solutions and to ensure, encourage a shift in patterns of practice, which is more of a cultural change which may be more difficult. Thank you for listening to me. Thank you very much Omar. Um And yeah, I encourage you again to put some questions for um a in the chat. Um and I passed on to a um a for the last presentation. Can you all see my slides? Yes, there, Elizabeth. Thank you. Perfect. So, hi, everyone. My name's High Oma. I am a HIV and sexual health registrar in London. I'm going to talk to you about the carbon footprint of long acting reversible contraceptives. So, within the UK, um just over half of our population of female and about 70% of these women are on contraceptives. Um There are two different types. So there is a user dependent type and then the long acting reversible contraceptives or as I'm going to refer to them, Lark, um they're the most effective forms of contraception because they aren't dependent on the user taking any actions while they're in situ. So there are four different types of Lark. The first is the injectable contraceptive, which is um an intramuscular injection, which is taken every three months. Then there are two different types of inter uterine coils. So the first on the top right is the copper coil which can last between 5 to 10 years and can also be a form of emergency contraception. There's also the hormonal coil which can last between three and five years. And then the implant subdermal implant, which can last about three years. And this graph shows the proportion of use for each of those contraceptive larks. And we know that over the last decade that um the uptake of lark has been increasing gradually for all forms of uh long acting contraceptives, except for the depo injection. But there is no information out there about the carbon footprint um of contraceptives. And if patient's ask us about these things, we don't have any information on that. So the main objective or the primary objective of this project was firstly to benchmark the greenhouse gas emissions associated to the insertion of long acting reversible contraceptives. And I hope was by benchmarking this week and then identify any hotspots to implement changes to try and minimize our emissions. And the image on the right is basically like a process map um to show the process of how our patient's came into clinic. And when we did this project, it was during COVID. So people would mainly self refer for the insertion clinics. But there were also a handful of people who would walk in, for example, for emergency contraception have the copper coil inserted. And the dash line shows the inclusion of uh what we mapped so that staff and patient travel into the sexual health clinic there, time in there with us and the consultation and the insertion and then also their travel home. I used a hybrid approach. So um we use the top down environmentally extended input output analysis for the procurement data. So that include included the medical equipment um such as uh cultural that um you know, speculum, things like that and the pharmaceuticals as well, unless there was already pre existing life cycle analysis data available and then for the activity data. So for physical things used a bottom up approach. So we work in a clinic that's separate from our hospital. So we have specific estates information available which was very handy. So they were able to give me the electricity, gas and the water information. And then um I also worked out the travel emissions based on a sample surveys for staff and for patient's attending for either implants of coils. Assumptions that were made was that as an outpatient appointment, that waste would be negligible. Um It also seemed that the clinic would be open for the whole day regardless of how many coils or implants were inserted because we obviously provide uh separate sexual health service as well. There are a couple of different types of copper and hormonal coils. So we use an average of that and we didn't include the removal process in this project. It would have been wonderful to be able to break down the coil to it's raw materials and do sort of a life cycle analysis. But unfortunately, that was beyond the scope of this project. And so these are the results. So as you can see, um the I U S which is the hormonal coil had marginally higher emissions compared to the copper coil, the IUD and the implant. So 100 and 39 kg of CO2 covenant gas compared to the others. And then if we look at this in terms of the source of the emissions, which I'll show you in the next slide. Um obviously, because we had a steam that electricity and gas was for the full clinic day. That is about 70% of the proportion staff and patient transport was a very small amount. And actually what was quite good to see was that actually our patient's were all very local. Most people would walk to our clinic and in most cases, it was the same for staff, but we had someone who lived particularly far away who skewed some of that data. So then I wanted to adjust this information based on if we just looked at the uh physical data for the consultation. So if we adjusted this for 30 minutes, which is how long are consultations are for hemlock insertion, we can see how the emissions change. So we've gone down to 17, 19 and 10 kg of CO2 equivalent gas and the majority of our emissions are due to you. The medical equipment of the device is um for the implant, the device itself is quite costly. Um And the implant, actually, the inventory of our consumables are slightly higher, but they're cheaper compared to when you have a coil inserted because they're slightly more specialist equipment used. So we use the trans sounds um and forceps and that's probably what accounts for this change that we see in the source of the emissions. So what this project has shown is that the hormonal inter uterine system demonstrates a slightly higher um a carbon footprint, but we have to bear in mind the duration of use. So the implant, as I said earlier, last three years, whereas a copper coil which had the least of the emissions would last about 10. So if you put in a 10 year single rud, you'd require three implant insertions with removal and exchange in between as well. Due to the methodology, it's difficult to make accurate comparisons. A lot of the data is based on financial costs as well. Um As I said, it was not life cycle analysis. And so trying to put all this information into context. What does this mean for patient's if they're aware an eligible, would it change? Maybe what they would decide they might want us a form of contraception? And equally what does this mean for staff? Is this information that people would be comfortable to discuss with patient's other aspects that we'd ideally like to include, to expand this project is to include removal emissions to look at the injectable contraceptive. And then ideally to compare it with oral contraceptive pills. So, larks make up about 46%. Currently of the contraception used within the UK and the shorter acting, which is mainly the contraceptive pill, but also the patches and the ring makes up about 54% and from a hotspot analysis. Um Although we would expect to see some dick are been ization in the grid, there are definitely things within our clinic that we can do to try and reduce our emissions, especially for electricity such as uh installing led lights or put in times and lights in our clinic creams. So thank you uh for most men and these are my references. Brilliant. Thank you very much. A UMA if if all the panic can put their cameras on, that would be fantastic. Um Rosie, do you want to fire away with the first questions? Yeah, we've got two questions in the chat at the moment. So the first one I think is for Amy and it asks um what is the source of the green assessment tool used in the study? Hi. Yeah, I was a bit unclear with the question. Um So the green assessment tool that was in the presentation. Um So Lauren, who's on the call also um is the clinical sustainability managers has she designed the tool uh based on our sustainable healthcare principles. Um and did some kind of resource gathering in terms of the different aspects of the tool based on things like carbon calculations. Um Information from our Green Plan Lauren. I don't know if you want to elaborate with other aspects that you brought together to put the tool in place. Yeah, and, and generally, um haven't, we haven't necessarily collated all the references for this um presentation, but we, you know, took inspiration as well from the literature and sustainable healthcare. And um for example, outputs from the center of sustainable healthcare um about, you know, about general um principles about things to consider during for sustainability um healthcare setting. So, and, and incorporated that as part of the assessment. Thanks both. Um And then our next question is for I OMA. So how applicable are the outputs to other clinics providing the same service? Um I think that's definitely something that we need to look at in general. There's guidance in terms of standardized, how you would do insertions, but the equipment that people use, for example is very different. Um So actually within our own clinic, maybe about five years ago, we would have a set um coil insertion kit which had a lot of things that weren't used. It sort of touched on what Chantelle had spoken about in a keynote speech as well in the morning that there was a lot of waste from that and now we have just single items that we use because we know we're going to use them for the insertion. So it's something that we definitely, I've talked to a different trust in South London about comparing because it would be really interesting to know if there is a significant difference. Sorry. Um So yeah, I don't know, is the answer, but it would be good to get that information. I think that's all of the questions that I can see at the moment inga but there's a uh it's more of a comment. Are you might for you as well? Um Perhaps looking at the rate of success of insertion and how that varies between. Yeah, I think the thing is um what we would consider a success, there's almost clinical success and then there's also the patient experience. We very often see people who um have a form of contraception inserted and then maybe they have side effects that they may not be happy to, to experience. So the there's varying um sort of definitions for failure and why things need to be removed. Um But yes, it would be interesting to see how that plays into, obviously add into the emissions and then people having to come back into clinic even if it is just for assessment of those side effects, if people have problematic leading and they wonder is it related to my coil or something else? Um All these things add up. I think if there are no more questions, I've got a question for Lauren. Um I was just wondering if you're, if you have shared your resides already with your trust, the acute trust, but also the, the I C S you're part of and what the response was if they were interested in it and if that's something they think they will consider uh income when they commissioned services. Um Not yet, that's definitely part of our plan for the next steps of the project. Um We found that even getting to this stage has taken us longer than anticipated, um particularly getting activity data and engaging kind of relevant stakeholders at that end as well. Um So the figures are have have been relatively recently kind of finalized to this to this stage. Um But yeah, agreed. Um That's definitely the next step. There's um there are other um kind of community organizations who are providing similar services as well and we would also look to um do similar calculations for those services. Um So there's a, as a, a company called first community who also work within, within Sussex and provide the same service. So it would be very interesting to compare their carbon footprint to Sussex community and see where the differences are and even across the organization. So um what we didn't necessarily have time to go into it today about spitting it up in different ways. But looking at um more referral patches versus more urban patches in Brighton and Hove or, versus West Sussex around Chichester. And assuming that they would have to travel more miles um to be able to deliver their care. Um looking at the relative inefficiencies or, or, or kind of other areas of kind of variation across the board and see whether or not that's something we can design into the um to the care pathways from the start and maybe we can, you know, incorporate more video consultations in more of oral areas and more support for those teams um in a kind of targeted approach. But yeah, we'll also come but will provide an update at the next share conference. Fantastic. Um And um maybe we've got time one last question for neuroma. I was just wondering that the six studies you looked at from which region in the world were they apart from the study in Aravinda? And I think you mentioned a US study. Um It looked like to me there might be one UK studying. Um But where were the other three studies from? So there was one study from New Zealand, there was one from England and then there was one study that looked at a bunch of different places. So it included um like South uh South Africa and Mexico and a few other countries. It's a little all over the place, but they're yet has yet to be one in Candida. So is that your next step is for you too? Okay, also for the next year conference. Yes, brilliant. Thank you. Thank you so much. We just sort of finishing right on spot. Um Thank you so much for presenting really interesting studies and would be great to hear an update of your projects. And also want to mention the center for sustainable healthcare has got network. So if you've got case studies, we would love you to put them up on there and share them and for other people to read them because it's hard work to reinvent the wheel all the time. So I'm sure they can learn a lot from you guys. Um Thank you and I see you at the main stage.