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If it's okay, I'm going to start this session. My name is Anna Jones and I work at Brighton and Sussex Medical School. I'm going to chair this and Florence Wetmore, Florence. Do you want to just briefly introduce yourself as well? Hi. Yeah, I'm, I'm hello, friend. I'm Florence. I'm, I'm currently on the Chief Sustainability Officer Clinical Fellow Scheme were working at the BMJ and I'm a doctor by background. Wonderful. Thank you, Florence. So, for the line up this afternoon, we have three presentations um each um with the guidance of lasting about seven minutes each. Um Yanez going to go first because she has to leave around 3 30 then I'm gonna suggest that James goes next and then use if, if that's okay. Um What I would like to suggest is that because Yan has to leave ordinarily, we would do questions at the end. But I think, you know, obviously hang around as long as you can, you can. But if you're able to take questions immediately after yours, that would be really good so that people don't miss out on that opportunity as you will all be aware, there's no audio function for questions. You need to put this in the chat, but we myself and Florence will be monitoring the chat. So please do say anything that you want to ask any of our three speakers. Wonderful. It is nearly five past three. Again, apologies for the late start for this session. It is one of those things in conferences like this. But anyway, we are starting. So thank you. Yeah, I will leave you to introduce yourself and your team. Wonderful, right? Uh Got up from, my name is Young. I'm from a Gyn Earing. My background is manufacturing. So I'm not medical stuff. I don't have much in medical. I have quite a lot of experience in remanufacturing and I have some experience life sec analysis. So today's study um you know, look at is uh what is different in terms of uh environmental impact between virgin device and remanufactured device. So we have the, the uh this presentation is based on the two research paper. The first one, somebody else will work at. The second one is we used some of the data from this first paper and we carry on with more contacts in the UK and in the in the remanufacturing by working with N H S. So the aim of this studies compared to understand the environmental impact for the end of life product that we use to have the seven functions and the quality as new, which we call it remanufacturing compared to the virgin product. So we were undertaken real life cycle analysis. The first question is what is the system boundary? And all the life cycle analysis is based approximation. So you will need to consider for example, materials feels electricity, water, gas packaging. And we also look at what is the system, water is outside the system, the waist and the emissions and within this boundary, we are considered for example, the production for the new virgin product inspection, sterilization packaging and the final packaging. And then the transport use an end of treatment for this specific case because this at the youth stage, it doesn't consume any electricity, doesn't consume any energies. So we treat the youth stage as doesn't have any environmental impact. We have similar diagram for remanufacturing because remanufacturing a starting point is end of life used product which have been classified as a single use product by the manufacturer. So starting point is they used considers medical device and then they have been collected normally at the hospital clinics, they have been transported to a remanufacturing factory. And for this case is uh one guard in the, for example, in Germany, then they're going to go to the medical remanufacturing process clinic, sterilisation, all this kind of process inspections, then they are looking at the final inspection to check the quality is as good as new and then they steroids pike packaging and then the final package for the you know for to be used again into in the, in the system. And then if you look at the environmental impact that we will consider the same as a fuel, electricity detergent, what? Sterilization gas? And then you look at what is the waist and the the emissions to the f short. So we have collected the data. Some of the data is based on the allergy research paper. Some of the data is we work with the remanufacture who provided the data to us. So based on the data and we use the environmental data, use the equal event and we have started to get some results on this one. So the first work we're doing is very data. The work which conducted by the other paper and then were undertaken, the sensitive sensitivity analysis is to do further analysis based on previous work. So this is based on previous work. On the right hand side is the virgin production, the life. Second, you know, the impact of virgin product on the left hand side is the medical remanufactured product. As you can see from here, there are quite a significant difference in terms of environmental impact. You're talking about almost 50%. And where is this? You know, and uh receiving came from the same and many came from production because the production of the product is where the most of emission is generating the waist is created. And with the remanufacturing, you don't have this production state. However, because it was remanufacturing and they, they need to make sure should they are sterilized that they are safe and the same quality as new, they have more kind of uh water and detergent sterilization process is needed for the the compared to new one. So you will see more kind of uh electricity is consumed as well as a bit more or for the sterilization, detergent to be used for the remanufacturing process. We also, you know, based on previous work, we need, we also undertake the sensitivity analysis for a sensitivity analysis that we're looking at is what are the impact of the factors? Various fact on the total emissions, which is looking at what is the stakeholder, what can each stakeholder can do to reduce the emissions? The first fact we look at is the rejection rate. If you recall, right, the boundary here for a remanufactured product, we are quite significant for rejected can sit at a different stage of the remanufacturing. They talk about about 50% of products are rejected at the remanufacturing stage. So the first where modern is what happens if the productor now is rejected, how much emission we could say, then we look at a different transfer scenario if we remanufacture in the UK and we used in the UK compared currently remanufacturing the UK. So usually in the UK remanufacture in Germany, and we'll also look at at this moment, we're only looking at the remanufacturing ones. What happens if we can remanufacture several times. And the statistically they remanufacture, tell us they can remanufacture after six, so seven times. So what is accumulated impact? And for NHS, they're more interested in not only one saving then interesting how at the national level, if you have one sol int product, if you have remanufactured product, how much saving you can have at the statistic at national level. And this is what we're looking at. So we're looking at first is you're looking at the rejection rate currently is 50% rejected. But if we can increase to, you know, reduced to 2% 100% are being remanufactured. And then this is amount of for the emission you could uh save, compare all the virgin product. And we'll also investigate on the, you know, if you look at the transport, if you remanufacturing the UK and the use them in the UK, as you can see the transport, the remanufacturing the UK and used in the UK, you significantly reduce the transport. However, very interest. Certainly, if you look at here, you make, making the UK also reduce the electricity. That is something because in the UK, because they have more radio over energy compared to Germany, actually, the electricity, we usually have less emission compared to the general. Then we're looking at what is the impact if you increase the number of times uh product is remanufactured compared virgin product and we look at the impact around them. So if it's the first time you only have every virgin product. And then the second time with the virgin, you know, remanufacture once and the third time they remain remanufactured toys and forth. As you can see, every time it's being remanufactured, you significantly increase or reduce the number of emissions. Then the next one is uh we have down the left second Alice, we have done the sensitivity analysis so well. So what the point we're trying to make is the left second analysis you need to be undertaken at a holistic view. And we need for each stakeholder need to understand how much they can contribute to the emission saving. So for this case, for example, for manufacturing point of view, if they could, for example, design the product in a way, make them easier and then make it the structure less complicated. They can make the product we manufacturing more times instead of 34 times, they can make increase the times they can be remanufactured. And and also in addition to that, if they are, you know, the the the um messages easier, they can make them more to be remanufactured from remanufacture point of view, if they could, you know, increase the process, improve the process, reduce the number of products to be rejected and then they can contribute to the emission saving from and the use of for example, hospital point of view if they could correct more end of that product and maybe they can process them in otherwise clean them doing some initial community. Then before they send it to we manufacture, then they could increase the product to be, be used instead of being disposed. So that is explaining the in the system contact, each stakeholder could have a contribution to the life second and to the image of the product. Sorry, that's my message. Just wanted to check just you know, half a minute remaining. I'm finished. Oh, thank you. That was good timing. Thank you again. Wow, that's excellent. What an incredibly comprehensive, interesting presentation. Thank you so much for taking us through all of those steps in that way. Wonderful. Um Hopefully we've got time for just one or two questions. Him um asked the question, I don't know if you can see this in the chat. Yeah, man, presumably the plastic production and processing are also where most of the profits are generated for the industry. Really good question. How do you financially incentivize the more sustainable remanufacturing option in our current global economic model? I'm probably not the best person to answer this question because I don't really, I'm not in the medical industry and there is uh because this work is supported by NHS. The motivation for them to undertake this one is they have that zero drive and that's what they want to understand statistically, if they have this amount of number of casitas and how they've been women fracture and what kind of saving they can have and also in terms of from my conversation with them in terms, financial is because it's cheaper we manufacturer, you talk about minimum 20% cheaper compared to original one. So financial is also good for NHS to look at this as well. Can I that that was going to be my question actually was the financial side. So just to clarify 20% cheaper for remanufacture rather than virgin manufacturer, that is in generally speaking of all the controversy. Okay, wonderful. Thank you. And Dugal, how can modern technology can support better life cycle analysis? Because I know that Elsa is a complex and frequently difficult and challenging process, isn't it for people to do? Yeah, I think I'm not sure what does it mean by modern technology. So the biggest challenge for for life cycle analysis is getting the data. Yeah. Yeah. So a lot of the analysis we use the equal event, which is you get statistically about, you know, if you provide materials, you look statistically what kind of energy consumption with that they generate after the sector as a whole, which is not really accurate because different people have different practice and different way of process it. And you don't really, you know, don't have this amount of uh the data for us to understand, you know what exactly. And we don't even know what kind of variation from pro company a to company be, they can be do it completely differently. But because they use exactly the same kind of statistic data. The result will be exactly the same. So basically two company, they're doing something completely differently. It could end up have exactly same emissions. And the current practice doesn't give us enough data to be able to differentiate different company for doing the same, you know, doing something different. Okay. So Dugal has just come back with a couple of clarifications about N F T and Blockchain, etcetera. So I don't know if that's something you want to tackle or whether you need to leave because I appreciate were late. Yeah, block chain is uh big good as the track and trace and the same as the bar doctor because I'm working with them at this moment. And we're also using Blockchain on the track and trace of copper in visions at the products supply chain. So they are brilliant in terms of your truck and you know where is emissions generated and the how much at one place, for example, the images generated. And also again, it it is useful we know where the emissions generated but it still doesn't address the issues of a lack of the specific data for us to to understand that the emission as as some specific operations. And this granularity of the date is the biggest challenge for the life cycle analysis. Blockchain can address it as some ex extent but not unless the company are willing to provide the data, it will be difficult. And finally, because I know that you're needing to leave big question from James Smith here. Do you think we need to, should be trying to do, get lcs on everything or can we get lcs on some products and then develop assumptions and approaches for the rest of the without having to do lcs for everything. The I think EL SE is a very important uh especially if you want to understand, get a more holistic view or for a product er and what happened? However, the L C A is based on, for example, uh the you based on the mass of a product, for example, and then you look at the unit emission of that product. So from this perspective, you don't have to do everything in every step because sometimes if you understand for materials A have unit for this one and then for the same materials, you just scare them up if you know the unit emissions. So you don't have to do everything, repeating everything. If you know the unit emissions, all you have to do is just times of the mass or the weight or, or the volume, then you can calculate the emissions. So to some extent, you don't have to do everything if you know some kind of data or you have done some work before, to some extent, we could reduce the data and the result. Does it make answer your questions? Gyms. Yeah. Thank you. Wonderful. Thank you. So much. Yeah, and that was really, really fascinating, great start to this session, please obviously stay as long as you can, but I appreciate that you may need to leave. Thank you very much. Thank you. Wonderful. And shall we go now to, to James? Is that okay if you're happy to share and start presenting, and I'll leave you to introduce yourself, James if that's okay. Sure. Brilliant. Hi, everyone. My name's James Smith. I'm a G P and public health consultant and I work at the University of Cambridge. Um And uh I'm presenting some work. This is not completed research, this is a research proposal we're developing. Um Basically, I want to share it because I think these are important ideas and really to get feedback and input from anyone who's interested. I'm developing this work with Tim Most Tomasky Puros from our engineering department. Um And on a, if he is on the line, he may be able to join us for questions if, if possible. Um So, uh yeah, so I just want to explain our ideas really and, and get any questions about them. So, um the idea that the, the I was stepping back a while ago, I've, I've done a bit of research on inhalers. Um and I do a lot of teaching, but I was trying to think what can I do that would have the most impact if I was wanting to get into uh research related to sustainable healthcare. And the thing that I'm really attracted to or thought was really important was thinking about the big picture system change and how can we do it more quickly. Um But particularly this question, how can we do it really, really quickly? Because I think that's what we might need to do in the future. We've already got really ambitious targets over the next sort of years and decades. But what if we need to do it quicker? And that, that's what I I wanted to explore. And the other side to that is thinking about how do we do it in a way that improves health outcomes and improves equity in the in the health system. So that's what we want to explore. And we've taken this uh this sort of decision that we want to talk about rapid decolonization, meaning to get to net zero within five years. So obviously very ambitious and challenging. Um but there's some logic to it. So the, the logic to it comes from understanding systems don't change linearly and smoothly and gradually over time, they change with accelerations and slower periods. And, and this, you see this in the natural systems, which is, is what this, this uh quote starts with. And uh the risk assessment by David King and others a while ago um uh was, was talking about um but then this also can apply to social systems and really we wanted to apply to social systems so that we can get really fast change in response to this, this uh these potential accelerations and uh in the natural systems. And, and so authors like symonds, symonds sharp have, have taken this on board and started to bring it into their thinking um about our response to climate change. So we want to think about what that we want to think about what that means for the health system. Um And then the other thing I wanted to just put up, which I know people will be familiar with, which is the NHS targets of reaching net zero by 2040 or 2045 including the supply chain. Um Is to say that, you know, when I started working on, on climate change a while ago, we were talking about the original Climate Change Act target of 80% by 2050. We're now talking about 80% by 2032 that sort of interim target that the Green NHS team are, are talking about. Um And so that's, that's I know we've put 10 years have passed since then, but it's, it's um it just shows that the targets moved. So I don't think we should think about these targets ecstatic and, and the only thing that we're aiming for and we should prepare for a potential scenario, future scenarios where we want to accelerate really rapidly. Um And think about what, what does it mean to do that well, and that was what the little graphic I put up there was to say to do it. Well, in our mind means not just reduce the environmental footprint, but also improving the health outcomes and improving the equity outcomes. And that again is important because when we look around for examples of really rapid transformation, the obvious one recently has been the COVID pandemic and the response to it. And we know that that worse in some outcomes, health outcomes and widened inequalities. So um that, that's the logic to what we're doing. So then the question comes up. Well, how on earth do you approach this really big challenging question? Um And, and obviously, we're trying to get some research funding and to do that. But what I've done is I've teamed up with our engineering department who have a group uh led by Professor John Clarkson, which to Moses part of that, think about how you bring engineering system design ideas into healthcare. And so they've developed something called the Improving Improvement Toolkit, which is based on this report, they previously wrote on engineering better Care. And so this this I've got more about this, this method on the next slide, but it's, it's basically just a way of, of thinking about system change and trying to approach it logically. Um So it includes things like gathering the evidence and all the literature about rapid change, engaging stakeholders, both professionals and patient's. Um And um I think in the coming year, we want to be thinking about how now we're going to develop a full research program around this and part of that has been identifying, where might we do this? So we're based in Cambridge, but we also want to work with other parts of the country and we've, we've started conversations with Cornwall and West Yorkshire in particular. Um They were areas that we selected because we know they've got climate change leads in there. I see s um in the I C B, the NHS structure for the local drug fi there, but Cornwall particularly has ambitious local targets of wanting to get to net zero by 2030. Um And uh West Yorkshire again brings a whole lot to the, to the table in terms of having different populations, the populations we have in Cambridgeshire and, and uh being in different place when it comes to climate change. So we want to work across different biographies and where possible. We'd really like to actually get to the stage in the full program of trying out things. Obviously, we can't try out full system change. That's a one off thing that will happen when it happens. Um So the, the ultimate aim of this um when we, when we pursued this method is to, to get to a stage where if something like NHS England in England turns around and says, look, we do really need to accelerate, we've got a political mandate or a social mandate to really accelerate change we want to be able to say we've been researching this and this is how we think you can do that really well. So we want to develop a conceptual framework, we want to develop scenarios that we think might, could potentially play out. And then with list of recommendations and actions all the time thinking about how do we optimize for health and equity and carbon reduction. Um And if possible, we want to say something about the things that we know have worked from trialling out in some of these different biographies. And this graphic on the, on the right here is, is uh an example of some of the things in the toolkit that we're going, we're planning to use. Um And none of these individual questions are particularly revolutionary. And if you look at them, you think, well, obviously we would ask that. But the nice thing about toolkit is it puts them all together and it gives you um uh tools to use for answering any of these particular questions. So that's, that's what we're going to uh do with the research. Um We've, I think it's really important research that is necessary because there is a chance and I think it's the most likely chance that there is a chance that we will need this to do really rapid change in the healthcare system. It's so important that we get it right. And I've got another quote from that, that report on climate risk that David King did about how important this is. And it's not about, you know, we can't be fatalistic to the scale of climate change. It's um we need to think about it, how we respond in our social systems and in our healthcare systems. So that's all I've got to say. I just want to finish by thanking all the people who've been helping us so far in the engineering team with Press, the clerks and in N H R with Amber and um some of my students um and just to acknowledge that we've had some initial funding from the Natural Environment Research Council to get this work off the ground. So that's me done. And uh thank you. Wonderful. Thank you. Thanks, James and really thought provoking huge scale work and really interesting. Wonderful. Any questions from people, comment from Tim Malone Rapid Transformation is essential to save lives. If anyone is in any doubt, look at John Valence, latest publication. Great. Any other questions on the methods or the proposal or feedback? And I know you've got your collaborator here on the line as well. Alright, Emo's. So Tymlos is the person to ask about the methods. Fantastic, Tymlos. Is there anything you would like to add to that? I mean, standard, very comprehensive to me? Yeah. Yeah. No. So thank you very much James and the audience to listen to us and uh we're always accessible. If anything else comes in mind later on to try and conduct us. Yeah, I mean, as a another public health person, I was interested in what you said James, right at the very beginning about the potential for this to widen health inequalities. And I guess I think making that parallel with COVID and yes, you know, there was this rapid transformation for which there is a lot to celebrate, but that anxiety about the inequalities, is there anything that you can say about how that maybe, you know, things from COVID in terms of what to avoid, presumably that's around access, that's around data, that's around surveillance. Yeah, I mean, I don't know the answers yet because we haven't really done the research. But I think the, the, I think the, the what we, what we're doing at this stage is recognizing that that needs to be central. So recognizing that, that, you know, when we're talking about when we're developing scenarios and thinking about metrics and thinking about interventions like that, this is, this is put in and it's a large driver for this work because we, you know, there's a potential future where we something happens, we come along, we want to do uh more rapid dick are been ization and we repeat that what happened with COVID, you know, we, we, we sort of go down that route again and I really don't want that to happen. Um And, and so I think, and the other thing that we're thinking about in relation to that is uh trying to involve lots of people in the research process over the coming years. So, so that's why we've gone out to different biographies and um why we really want to sort of make that sort of central to the research. So I don't really know the answer in terms of the intervention. And I think, I mean, to say a bit more about the things that I think we need to be looking at it. It really and maybe I didn't emphasize is that levers for change. So there's, there's people doing individual research on, on, on buildings or inhalers or, and those sort of things, it's, it's taking a step to the level where you're thinking. OK. So is it financial interventions, is it regulation, is it devolving governance like we saw in COVID where people said to the trust you can do what you like to sort it out sort of thing? And how do you, how do you go through that process in a way that that is actually um how do you do that with avoiding these pitfalls of widening inequalities or worsening some services over the over others? Um Yeah, I didn't really understand Tim's question. Just Tim, do you want to add anything to that? I guess my other thoughts which connects with this obviously is the ethics side, isn't it? Which presumably the ethical dimension of this is something that will be incorporated and that's also enormous as well. Isn't it? Which, you know, I guess we learned something about COVID wise as well. Yeah, I don't, I'm trying to avoid. So me and Tim also, we'll talk about tradeoffs but I'm trying to avoid, I'm trying to focus on the win, win because I think there are so many, when you look at this scale to change, there's huge opportunities to, to take this agenda and at the same time address some of the structural problems in the NHS or whatever, you know, and we don't part of the logic of doing scenarios is I think we'll have to have scenarios where there's lots of funding and scenarios where there's lots of social pressure and not lots of funding and we'll have to play through those, some of those. So yeah. Wonderful. Thank you. I will just double check the chat one more question in the chat or a couple coming through now. So someone says, when you mean various regions, do you mean within the UK or is this international? Yeah, at the moment we're talking about within England. So I mean, sorry, I meant regions within England. Um uh It would be lovely to do this internationally, but because the NHS has this sort of green NHS structure and NHS England, it would be a clear audience for this research then it seems that's where we're starting. But I know we've talked Tymlos and I have talked about whether we could build an international collaboration around this and certainly one of the things just because it's within England doesn't mean we don't want to learn from other parts of the world. Mhm. Um, and then we've had one final comment and, um, somebody saying that, uh, in leeds they're doing lots of work or climate change as counselors involved in El CPS and health partnerships. Um, which I guess more of a comment, that question, but I had a question of which maybe you've already answered of where your system boundaries are you? Are you looking just at what the health service doing or are you going to be looking outside of those other things that we know, affect health and, but maybe like I without, you know, where you draw the line of, of what healthcare, I mean, it's sort of a nice thing and a weakness that the NHS sort of defines itself by labeling. This is the NHS I, I'm fully aware there's all social care and voluntary sector and all sorts of things around the N H and local government that are absolutely vital to this. I think again, it goes back to that thing of ill. I want to make it as policy relevant and as usable as possible. So while we have the current institutional structures will probably think focus on the NHS. But, but, but you know, we're talking about working with I C B S and that their mandate is about systems, local systems. So I think we should um you know, there will be spillover, but the, the logic is about the NHS the focus. Fantastic. Thank you. Thanks James. That was great. Really, really fascinating and just I like the, the idea of this model to propose and sort of to take us forward. Uh There's a couple of other comments in the chat, but if it's okay, I'm going to ask use if, if he's able to come and present, please. Thank you, Seth. Mhm. Good afternoon, everyone. Can you see my slides, hopefully? Um Yeah, so uh my name is Yusuf. I'm a medical student and I've got my colleague here with me Lyndon. Uh and we'd like to present our project on the climate vulnerabilities of cardiology procedures. And we did this with the support of the University of Dundee and Doctor Emily Stevenson. So unsurprisingly, um we were doing a topic in cardiology and we decided to focus on PCI. So primary coronary intervention. Um It was one of the main treatments of ischemic heart disease. As many of you are all aware and with ischemic heart disease being the leading cause of death globally, uh we thought it was particularly relevant to focus on it. It's in high demand and it's carried out frequently with over 100 and 18 centers in the UK. So we knew we wanted to do something uh in the cardiology field and we also wanted to have a sustainability element to our project. So, initially we explored kind of measuring the carbon footprint of uh PCI procedure. And um we kind of contacted manufacturers of companies, we spoke to uh procurement staff within the department and also kind of on a national level as well. And I think at this point, we realized that it was maybe there was, there was, it was quite complicated, especially in terms of the data. And I think you touched on that earlier in her presentation, just kind of sourcing the right data. And I think also there's not maybe a standardized way which has also been briefly talked about earlier today when it comes to carbon food printing and the kind of procurement staff uh kind of also talked about that um in terms of NHS Scotland. So uh at this point, I mean, in terms of the cardiology department staff, they were also kind of more concerned with patient outcomes rather than carbon footprint ing PCI, which is very understandable. So it kind of we reflect to this point and decided to do a different approach and that kind of led us to supply chains. So we've seen how can a COVID 19 has disrupted supply chains as well as kind of conflict between Russia and Ukraine and the sanctions that have been put in place. And that's obviously had an impact on uh medical treatment. And I think it wouldn't be unreasonable to think that extreme weather events or natural disasters could also um propose a problem to medical treatment and patient safety. So with that in mind, um the aim of our project was kind of to map the origin of PCI equipment and assess the environmental vulnerabilities of each location in an interactive and engaging way. So just to briefly touch on what we kind of did, so we attended, we wanted to get a snapshot. So we went to one case and we can have collected the material from it and content some manufacturers just to fill some gaps. And then we also uh when it needed a data source that was gonna, you know, give us a number that could quantify countries vulnerability to climate change. And also it's kind of readiness and its resilience to change. So for that, we uh we used the University of touchdowns and D gain index which um had kind of good data behind it and you know, fitted what we were looking for. So what was the outcome? So this is the map that we produced and you know, we call it a climate hazard map of percutaneous coronary intervention and just to go into it a bit more detail. So on the right hand side, we've got a key and that kind of talks about the different countries uh that kind of were involved in the production of some of the equipment. For that case. For example, Mexico produced the guide captors and the angiographic captors as well as the guideline ear's. This is specific to nine Wells Hospital, but these were, you know, major brands and we've got the number on the top, right, which is 47.5 from Mexico. And that's the N D gain index, which is roughly in the middle kind of, you know, reflecting that it's, it is vulnerable to climate. And in the case of Mexico, that's kind of because of its coastline, tropical cyclones and hurricanes, it's particularly vulnerable to Uh and then the symbols at the bottom kind of in the circle. So that's reflecting the guide captures the angiographic catheters and the guideline ear's. And we've got the red horizontal bars, which is kind of demonstrating, you can see they're different lengths. So Mexico is a bit closer to the UK than Vietnam and Thailand, which we again thought was important to include uh you know, in terms of sustainability, you know, the mileage that this material is traveling. Another feature of the map was these kind of, we tried to incorporate a cardiology element to it. And that's um we've got these kind of cross sections of arteries and that's kind of trying to show how vulnerable country is. And for example, if it's a very vulnerable, it's almost included. Whilst if it's kind of, you know, very sustainable, low extreme, you know, there's low possibility of extreme weather events and it's got a good resilient system, then it would be kind of an open flowing artery. And we've tried to show that in the kind of link between kind of the UK and the different countries. Um And I'll just pass you on to London now to talk about some other aspects. Great. So uses we'll chat about kind of the map that we've produced and, and some of our methods. But what is the most impactful way to take this project forward? And so we'd love to hear ideas. We've got a few suggestions. The first one is to create a roadmap for the procedure of PCI. And what that would involve is looking at the different options which clinicians would have at each individual step of the process. And it's clear that different conditions use very different equipment for the same procedure. So why can't we equipped clinicians with the knowledge to make environmentally sustainable options at each point within the procedures that they, they're undertaking every day. A second consideration and kind of thing that we want to think about what it was. It's quite important to think about the impact on the actual country who's manufacturing these goods. And it also raises all sorts of quite important ethical questions. I think about withdrawing trade from an individual country. And just because something is, is more sustainable, is what is the human and economic cost to a low income country when we're withdrawing this labor? And or it doesn't perhaps encourage manufacturers to become more environmentally friendly, these complex issues that I think it's more this study raises and it's quite important to have a chat about. And finally, the kind of major thing that we kind of learned from this was that carbon fruit printing is, it is really quite a difficult thing to do is and it's notoriously difficult and, and the process is complex and requires quite qualified and experienced individuals, often engineers. And in this project, we were lucky enough to have use it on board, who, who does have a previous degree in engineering before medicine. But if you don't really have those information from reps, which is almost like drawing blood from a stone at times, getting information from these individuals, you don't have an initial input and it's near impossible to carbon footprint these procedures. This is really quite a large buyer and limits medical departments and their ability to assess and evaluate the environmental impacts off the products that they use. This is really quite a big learning point within this and kind of project that we'd like to share. So, and the other option of course, would be to ask individual manufacturers to state the carbon French footprints and do this kind of workload themselves. But there's no guarantee that these figures will be accurate or correct and specifically putting into their hands. I think so. And as such, we don't think that carbon footprint NG is potentially a possible avenue to go down in the future for this um project. So we go to the next slide and just to conclude things and finish things off. So are kind of main can conclusion this, this kind of study and map that we produce was our supply chains need more thought and not only to make them more robust and resilient, but also to make them more environmentally friendly and the products that we, we use and these procedures come from far and wide. So let's educate ourselves about the equipment that we're using and, and sort of be involved in making better, more well informed and sustainable decisions about what we're using. And, and also we sort of wanted to open up that debate in that discussion about carbon footprint ing, how useful it is, how difficult it is. Should we make it easier or is really carbon footprint is something that she popped this side and think. Actually, it's just a surrogate marker anyway, for environmental burden. And let's think of other ways about educating our staff educating ourselves about the different components that we're using and how we can better, um sort of you make better decisions in order to make and the procedures that we're doing more environmentally friendly. And so thank you very much for listening. Thank you very much to Emily Stephen, are Stevenson, our supervisor and we'd like to open to any questions that they might be. Thank you, Lindon. Thank you. Use f great. It feels like a bit of a cardiology session this afternoon apart from James's. So that fits really neatly with Yan's at the beginning. Uh But obviously coming in it from a different viewpoint and I love the global nature of this as well. I think that's fascinating. I think whilst we're just waiting for any, any questions in the chat, I think from my point of view and we only have a couple of minutes actually before we go back to the main stage. But from my point of view, I thought some of your imagery was excellent. I loved how you use the sort of occlusion of the car, you know, coronary artery to illustrate those tensions. Um I also, I think your point on this slide actually, in terms of the ethics again of this, um that low income countries need trade and there is already as we know, huge, you know, global inequity in terms of climate change. And we've got to be careful, haven't we in terms of, you know, further disadvantaging um low income settings like that. So thank you for that. Any questions from anyone Florence, anything that I haven't noticed or need to pick up? No, nothing has popped up in the chat. I also just want to say how amazing those maps are really, really like lovely representing it. It's a really unique at, it's not something I've heard people talk about that like looking at the healthcare system in terms of those vulnerabilities. It's, it's not something you hear a huge amount and it's a really important work. The only thing like to add that you may consider adding, but it's also complex is the ethical supply chain in terms of where these products are made. And it's something that Professor Mood Botha has done a huge amount in particularly looking at glove manufacture and the conditions that people are working in, in terms of forced labor, etcetera. So that's another sort of dimension to that sustainability. My question whilst we're just wrapping up is, have you been able to discuss this with any cardiologists? Have you had the opportunity to present that clinicians? Is this something that's on their radar? Uh I appreciate that some, you know, it's maybe a difficult topic but just interested in that. Yeah, it was, it was we had quite a sort of a varied kind of reaction to, to our map as well. And we actually worked with a consultant cardiologist to create it in the first place. But the, I think of the very nature of PCI is that it's a life saving procedure. People are very focused on their patient's focused on saving their lives and it's quite an acute scenario. Therefore, I think kind of when you think about the sustainability kind of aspect of things, it's kind of perhaps put to one side. So I think we're able to focus on these kind of procedures which are done day and day out and use so much plastic on an individual patient and they're, they're done. So frequently and it's really quite a good place to start. And when you're thinking about cardiology and getting people on board, and I think educational tools such as this map are really the kind of starting point and getting people on board and um sort of instigating change. Well, I think as you were talking about the resilience of the supply chain and the threats to this supply chain, there are so many angles to this because it's not just that the supply chain may stop. It's exactly as you just talked about with, with energy from Russia and Ukraine. It's the fact that prices may go up, you know, from a huge point of view. So it's that cost implication as well as the actual supply being interrupted. Um So I think it's, I think it's fascinating. It's um a huge piece of work obviously, but I think you make the very good point at the end about the ELCA being a sorry, the carbon footprint ing being a complex process. Um I'm just looking over at the chat that there aren't any specific questions for you, but just to say, I think that was a really good session. Thank you to all of the presenters uh for three great presentations, really thought provoking, ambitious, interesting and um yeah, really relevant to everyone's work. Um If I can suggest that we move now back to the main stage where the third keynote speaker of the day is due to start fairly soon. And um yeah, thank you all again for your time and for presentations. Thank you very much. Thank you. Thank you, Anna. Thank you for your arms. Thanks James. Thanks, Lawrence. Good to see you. Thank you.