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Hello? Are you there? Hello? Yeah. Hi, everybody. I'm so sorry. I have been drafted to be on call at the same time. Is this so? I will be doing this with hopefully, no bleeps going off so you might be able to see me. Can you see me? Okay. Yes. Lovely. Brilliant. Well, I will share my screen on day start talking about sustainable. It says that my disabled enabled him. I said, you need to let me just unsure my screen on vessel Italy. You should be, um, yours. You're sorry. Get best. Second is It's so not like, Stupid up. Not yet. Okay, How does not? Good. Um, just give us two seconds. Sure. I had wanted to be here before. I was just making sure that all the bleeps we're going to go to somebody else, right, Horton? You promote me to be a host? Maybe that works. Or just Yes, you should have upgraded you, Teo. Okay, Hopefully that has just popped up the option for you at the bottom. Yes, I can know nothing. Effects. Thank you so much. All right, let me start. So let me get rid of all the other boxes. Hello, everybody who is here very nice that you are joining us on this evening. And as I said, I'm really sorry that I'm on call, but I guess that's realistic in terms of what our reality is working in the NHS. Unfortunately, quite a lot of sickness at the moment going around. So, um, I'm gonna talk about sustainability in quality improvement. Or you could call it quality improvement for sustainable healthcare. So I'll try and sort of give you a bit of a whistle Top store, whistle stop tour of what I mean. So when I talk about sustainability, I mean it is obviously the buzz word. It was a hot topic. Everyone is talking about sustainability in lots of different ways on. So when I talk about sustainability, I mean about thinking about the way that we use resources today and don't deplete the ability of future generations to meet their own needs. So meeting the needs of the present without compromising the ability of future generations to meet their needs, and that it compromises sort of three main pillars which are environmental, social on day financial aspect. And so you would never run a business which was completely unprofitable. So the same way you shouldn't run the planet down on Think that we've got endless resources that we can use. So that's the kind of principle which I took about sustainable healthcare. So, um, that that principal kind of came around to me as being really important as a pediatrician because I realized that pediatrics as a specialty, you know, I care for very young people, you know, babies that just born into the world. And I was very concerned about the effects of climate change on future health outcomes on do the sustainability of healthcare itself. So I'm an education fellow at the Center for Sustainable Healthcare, which is low goes down there in the corner on I really teach about sustainability, um, concepts. But I'm really trying to get people engaged in actually doing something rather than just sort of a free floating anxiety about the climate, um, change problems that we're facing and sort of think about what they can practically do inside there. Spheres of control. So Q I d. Is like a new ish term. I was never talk about cure I medical school, but the idea of the Q. I journey in health care comes from the idea that you sort of learned these foundation concepts and skills in your very early medical school education. And then you sort of start applying that and trying to make changes to improve healthcare and and maintain quality. And then, actually, the most foundation programs do require you to do a Q I project as a foundation doctor on then you're supposed to kind of teach and lead and facilitate further quality improvement. And that is part of the GMC requirements, and people will be expected to be doing that. So people are really doing these quality improvement projects. Why know, include sustainability within that teaching so that we can really harness all that effort that goes into making a healthcare system more sustainable and, you know, high quality but making it more sustainable. So lots of people said that they wanted to do que I projects, but lots of them felt that they were been overloaded and frustrated on, didn't feel acknowledged or felt like it was a tick box exercise. So try to reducing that. Use a supervisor who has an interest in your project. So if you're interested in doing a sustainable cure. I project to make sure you find someone or make a team around you. Who would be used. Want to engage in that on share the experience by joining the Q Network Got my little Cuba John on. That's like a really way of accelerating your ideas and spreading ideas that you've had on day. I think I'm mostly talking Teo trainees or people in training or medical students. At this point on, I think that we actually come into the health system with fresh eyes and really see the problems that they're there. So make it part of your personal development plan and really let people know about what you've done and how it's been successful. So the different models for improvement, tech quality improvement most of you will be familiar with the Plan D Study Act model. Um, I'm going to talk about how that fits in with sustainability now. So when you want to think about how we're going to reach this target of net zero, um, the This is the plan. I think you will have covered this in the committee. It's conference, but the idea is that we're going to try to get to net zero as a health service on each one of these segments. Along that graph show ways in which that's gonna be achieved now some of them are beyond your role is a clinician or beyond my role or anyone's role. But some of them require leadership and innovation on do the This's the area that I think we really should be excelling in a zoo as health professionals on. But they also that's where we can sort of look at preventative medicine and look a low carbon models of care. So hopefully that will be sort of where we'll make the big changes. So in terms of leadership for innovation, previously, that's been really about patient experience and patient outcomes. But actually sustainability is being sort of the energy. Carbon cost aspects has been sort of estates and facilities, and the two of us don't really talk to each other. But if you control talk to those people and bring those people together, there's a lot of shared common values on. But, um, if we bring that into mainstream Q. I Onda, you can will go away and try and engage people to do that. Then I think that we can have mass effect rather than individual change, which is never a defective A system change. So what are we trying to accomplish? We're trying to improve patient outcomes for patients and populations whilst reducing environmental, social and financial impacts. So we need to be able to measure those impacts to know that the changes we're making your improving things on down, what changes will we reserve? What we make, that resulting in improvement? And that's the real challenge. How do we know that what we do it will actually improve those things on? Make sure we push down the triple bottom line on improve patient population outcomes. So it framework that we teach from looks at the kind of these four aspect. So you set a goal. You study your system before you make a change. Then you design an improvement effort, and constantly you're trying to measure the changes that you've made so that you know that you're making an improvement. So in sustainable quality improvement, the goal is to deliver care in a way that maximizes health outcomes on avoids financial waist and harmful environmental impact impacts on dad social value. So that should be the goal of any cure project. And you can write that in as in a way, like I want to streamline de referrals from primary care to maximize positive patient outcome and avoid financial waist and environmental impact. So, you know, any time that you come up with a cure, I objective. You can make it specific to those triple bottom line outcomes on, but it could be Some people are worthy. Some people are more visual in equations. And so if you look at the idea of value on, put it into this equation, that's you know what a different way of saying exactly what I said in words. So in terms of what you might want to do next, study the system. Every one of us will be working in different settings, and so understanding the system you're trying to change is really important. So many people come in with an idea of what will be an improvement before actually trying to understand really the context that they're working with, including the people that they work with on how they might communicate their changes and why those are important. So, yeah, you got to study it and that really shouldn't be skipped out. So many of you, maybe already doing that, or maybe already have tried to implement changes and found that they haven't worked. So I would go back to studying what it is that you're trying to change and how that might happen. So that's why the NHS is really unique as a health system in that we have actually studied the environmental impact of our system. So what do you need to find out in your cue? I projects you might be already thinking about this on Go write a few things down. What is it that you really need to find out? You might be able to write it in the chat. How will you go about finding out those things? So if it's about reducing medicine waste, who do you need to contact to find about how many how many duplications you're getting in your, you know, assessment units? Or how many X rays are done, which have, like, are done on a protocol that is outdated. So those kind of things that you might want to sort of find out depending on the context you work with and just thinking about who, who it is that has that information and how you might measure and get that. So we will have our own lenses. But if you build a whole team of people, you will have a better chance of capturing the picture. So one way of capturing the picture is to do something called a process map. Eso. This is just a process map of someone kind of coming to an outpatient appointment on it is really helpful if you haven't really done it and you're already on that process of doing a cure project, just try writing out exactly like a flow chart. That's all. The process map is what is actually going on in the areas that you're thinking about. So you could do that for inhalers prescribing or an anesthetic gas machine. Or you could do it for any of the carbon hot spot areas in your particular specialty on. Then you go through, and you can actually pinpoint where there might be an environmental or so sure a financial cost of on those points. So a disappoint you can use, um, sort of different categories, like patient or care, a travel staff, travel, air pollution, energy use, and you can put those into where those hot spots there areas are on. Then when you try to make an improvement, you can see where the bottle next might be or where you might have the biggest impact in the changes that you're I'm suggesting. So it is really important to do. This is a group so that people might say, Well, actually, no black We don't really book follow up at that point or we don't really get them to book in a reception, so you might have an idea of how things should work, but actually, is the process actually happening in that way? So this isn't the ideal. This is the real on, Ben. Once you've kind of studied your system and understood what it is that you're going to try and, um, change. Or you might have come up with ideas already. We then teach about sort of improvement ideas on the drivers behind high carbon use within her health care. So if you think about this as a kind of the outcome that we're aiming for, so this is a driver diagram. I am. We are aiming to reduce carbon in healthcare delivery without reducing health outcomes. And actually, you could even go as far as saying, reduce carbon intensity whilst improving health outcomes. That's our goal. Onda. So how might you do not you look at your primary drivers in different services will have different ones. These are the only ways of looking at it. But I would say that one of the primary drivers is theat itty of the health system. So if you reduce activity, you will reduce carbon on, so you can look at that from a sense of prevention. So if you prevent illness in the first place, so any public health doctor will be happy to hear you talk about prevention. But preventing asthma, preventing respiratory illness will have a far bigger impact in reducing the sustainability of the health and system, then actually reducing the care delivery. So even if it's primary prevention or secondary prevention, that's still so important to be promoting it. Every contact that we have with patients, um, and then you can look at ways to empower patient so that they will feel more able to own their own, like have more ownership of there, illness or their health in general and that can help reduce activity. And you can also look at sort of lean a pathway so really reducing on streamlining the way that we deliver care to reduce the activity of that system. The other way of looking at the reduction of carbon within health care is to reduce the carbon intensity. So can you switch our product That's higher carbon intensity and replace it with a low carbon alternative on. There are products like that that we can switch over to, but they aren't going to be the whole part of the the solution that we need. So we need to look at the other drivers as well on top. Aeration or resource use is sort of a term for looking at lots of the other estates and facilities mawr less management off the service that you deliver. So the low carbon alternatives like I kind of think more about the medicines and the pharmaceutical kind of options. But it could also be looking at how you are and looking at travel for a service, for example. So I'm just giving an idea of in mental health. For example, if you were to try and prevent mental health issues. You could have early intervention for exacerbations before it got beyond the point where by people needed a mission. So making sure you've got community service for mental health Patient empowerment, making sure you could pierce a port services. Making sure you've got, um, tailor made plans for people's mental health problems, making sure you've got recovery based models of care rather than always looking at dealing with the next sort of catastrophe. Um, Onda. If you're looking at a low carbon alternative in mental health care, there is a lot about social prescribing on green of walking for mental health on Dyken. Talk more about that if if you want. But maybe that's a bit off topic for just talking about sustainable Q y this point on there's also looking at operational resource. You so looking at sort of pap, public transport or active ways of transporting yourselves to him from work So any any kind of service this could be applied to so you could use this driving. Hi, everyone. Just trying to figure out what's happened. It looks like dots spooners, WiFi by have dropped out, eh? So just give us a second. Hopefully, we can get her back to keep talking to everyone. There you are. Thank you. So sorry, but I hope it don't cut out very recently. Yes. Yeah. So I was talking about measurement. Is that right? I believe so, yes. So measuring impact for your project. And I'm going to talk about how you do a carbon footprint off a Q I project. So when you want to measure your impact, think about the resources that you're using in a cure project on times that by the emissions factors involved. And you might think I know what I'm doing. I can just make changes. But if you want to share those changes and really make other people understand what you've done is so important to try to use his resource this and this opportunity to really capture the carbon footprint of what you're doing on share it with other people. It's more powerful that way on day. Yes, you can make sort of changes that might, um, have immediate effect. But measuring them and then sharing them means that that that knowledge can be spread on. But I do think that we often skip out on this aspect because we've kind of come up with solutions before we've really studied and measure the system. So, um, what you would do if you wanted to say so You did a project that tried to reduce the energy use in a radiology department so you'd look at the energy in terms of carbon emissions per kilowatt hour that you can get that emissions factor, associate it with one kilowatt hour off energy from, um, a database that the government produces. So it was an average on obviously different times of day, have different missions factors, and this is never gonna be a perfect science. But you can get that for things like travel a swell so you can get one on kilometers. Things like medical supply. So the like, say, a cannulation pack that use we do it on pounds spent, which is actually quite a brushstroke. Broad brush stroke off what is actually involved in the emissions factor. But it is the best way of measuring it. That we've got a moment is not a full life cycle analysis of a product, but we've got those kind of emissions factors available to us that we should be trying to start measuring them So we become more carbon literally as time goes on. So you do that you use your resources, you times it by an emissions factor, all of which are available on the website that I will show you at the end on. Then you come up with your total and then you you can measure that. So say you did a project looking at reducing asking exacerbations, and you're able to measure the reduction in inhalers used. You could come up with a carbon footprint of of that as well as the improvement in patient outcome. So you can also do it by units of healthcare so you can add up a unit of a healthcare so GP visit or any D visit. Um, that was those are produced by the sustainable development unit, which is now called the green or any chest. Um, some of them aren't quite up on their new website, But if you're interested in doing a carbon free by unit healthcare do contact me and I can help share resources on that. So social impacts also know often measured because we you know what is social value and how do we make that measurable my advice would be to think about the different people who might be involved in the project that you might be looking at so care of staff, the individual kind of team member that you might be working with on what impact area it could have and then how you might measure the outcomes of it. So those are more sort of larger scale cure projects and some of things we do. But a lot of projects recently have looked at staff well, being on, you'd want to try to think about how you're measuring that accurately. So thinking about sustainability and Q. I What I would say is you can apply sustainability any stage of any project. But you can also choose a project area that relates closely to sustainability. So you can use those principles that I talked about or you can apply it at any stage. Is that helpful? I come early? No, that's it because I can't see anyone or know anything. But I'm hoping that those that was kind of a useful whistle top whistle Stop it all. There's also this website sask you I don't or it's got loads of resources on how you could do a sustainability project or how you might teach other people to do sustainability projects. So I see what's in the chat. As I mean. Yes, that was helpful. Good dozen. Okay, so I can talk through case studies, but I also want to make sure that got time to talk to you about ticking questions that you might have, um, about doing these kind of projects in your own settings. I Rosie, I think thank you so much for that. I think that's a couple of case studies would be very, very useful. Okay, good. A bit of context to our listeners, But sure, people will have their own questions as well that we can submit. And I've I've certainly got a couple of questions to you as well. Brilliant. So I will go through a couple of thumb. So on, I will show you how you can use the principle of principles of sustainable healthcare to help guide you for them. Say, and this was a project that was done as part of the Green Award. So the Center for Sustainable Healthcare also has a kind of consultancy kind of branch where it goes out and it sort of works with trusts to really in bed sustainability into the trustee for us, and this was one that they did it. Bart's and different kind of teams could bid to be part of it on the cataract Service said we would like to do, um project with you because we've noticed that a lot of our patients are coming in. Um on. They have been booked for general anesthesia for their cataracts, but we could do like clams. The's here, and General anesthesia has a high carbon footprint. So what should we do? So they worked with the team to come up with some ideas. They they looked itself. Carolyn. A pathway and low carb and alternatives is term in terms of principles on from keeping patients awake and safe in the cataract surgery. And for rather than putting, um, do a general anesthetic, they were able to save 1.7 tons of come dioxide hurts. Sort of an, um um, Andi. They also managed to save a huge amount of money. So this is a massively popular kind of choice for Hello. I've got a child outside the window throwing a ball. It it and, um for the trust to be involved in. And there was also, like patients felt less, Um, there was less time in hospital, so it had positive patient impacts. But it also made the staff feel like they'd work together as a team. And they collaborated on day felt empowered by the changes that they'd be no way to measure. So that was like a really it was a team project, but it made a big change. Um, and it reduced operation risked on. There was a shorter time for surgeries, which meant that the waiting lists went down. Um, and in the time of cove, it obviously general anesthesia, if you could avoid it, was, is preferable. So that's just one example. Another example comes from this was done in Exeter again, one of the Green Award projects. It's a really great one. It was reduced in the use of nitrous oxide. I have So nitrous oxide has a high global warming potential. Um, it's one of the anesthetic gases that makes up about 1.7% off the NHS carbon footprint. So they looked here. What they could use that wasn't nitrous, oxide said they really went for that low carbon alternative, and that is often a very popular one for medics to look for. But don't forget the other principals because they are so important as well, eh? So they sort of worked with a department to look at how they might capture and reuse volatile gases on booked at how they made sure that they could turn it off on. They really went for that kind of powerful messages in, like, a lot of us have a lot of sort of guilt about our carbon footprint individually. And so we're doing all these changes on our own individual level at home, you know, trying to cycle more or eating less meat. But actually, if you wanted to look up how you might reduce your carbon footprint by a huge amount every day, you would be looking in your work environment at Harry would reduce nitrous oxide. You. So this was their poster they produced on. But, you know, they're kind of comparing it to your average UK citizens carbon footprint daily and what nitrous oxide does to that if you go to work and then produce one of those things. So there is a kind of powerful message to be had in terms of engaging people in a coupon project if you include sustainability as one of the kind of measures that you're looking at. So this was just a kind of comment from their consultant in Estes. So he was just sort of saying he never realized that it was such a huge contribution. Um, and it was entirely happy to stop using it. That isn't the case, but all of the things that we're talking about switching or how we might use preventative health. So it isn't always gonna be the answer, But I do think that having a bit more education and awareness about the high impact areas makes people change the way they practice healthcare in more sustainable ways. Chuck it going, I will s Oh, there was another exam pulse. I'll keep going. So why don't we go to the about 6. 47? Then we can do some precious for 10, 15 minutes. Well, thanks for Yeah, I again, Rosie, you're on mute at the moment. All right. Welcome back, Life. So I was talking about cannulation Any d on how they looked up Some body process maps. Did I miss anything. Was there any? Well, no. Since about to blow, Not sort of what I thought is we could go for another five minutes or so and then starting some questions found good to me. Okay, so let's go to share my screen again. So I just show you the what they did. Okay, So can you see that? Yes. Lovely. So, um, they looked at where the kind of hot spots were, and they realize that people were being can really cannulated, but then they weren't being used, so they were kind of idling these cannulas that weren't actually happening on. Sometimes they were being used, but was it entirely appropriate? And when I say appropriate that people were be able to have an intramuscular when they were having a you know, they were having IV fluids when they could have been drinking, for example. So they had quite strict criteria about what they included a PSA unnecessary cannulation and what was necessary. So if you may deteriorate, it's always important to have the cannula in situ. But if for example, your presenting complaint was very low risk of deterioration, then it wouldn't be entirely appropriate. Just about Canada and when you could just take bloods if you needed to. Eso they kind of worked with the team to think about this issue on the looked at a sort of leaning pathways for what they were doing in terms of the principles of sustainable healthcare on D, they measured the number of cannulas worked were inserted per week on the number of cannulas that we used or not use. So that was their baseline measure. And then they kind of did a campaign with the eating staff and it was really important that everyone was sort of engaged in this and it wasn't just one or two people who had, like, yeah, we should do this message on. But they did it. They took over one of the team meetings and talked about sustainability and they talked about Cannulation and they talked about the zero plan. And all of these things kind of helped build that enthusiasm between the staff members on. They actually managed to reduce the number of cannulas buys of 60% that we're just being inserted generally, which had a big impact in in sort of waste a Z well as reducing the amount of resources that we used on day also looked at the unnecessary once and reduce that by two thirds well, so in terms of reducing infection rates that has a positive impact and less paying for for for patients on do. They also managed to sort of make a big savings because they're using less stuff and stuff always cost money, so that was good on do. They estimated they probably save about eight tons of carbon dioxide a year just for making this. Q. I project in the D on D that improve patient's mobility and independence and decreased paints. All of those things were really positive outcomes that they made and on D. If you wanted to try and make that and calculation yourself, you could sort of look at the number of cannulas you might be using per week and then times that by the cost of the weight. Why is the weight important for a product? Because the weight leads into the cost of waste incineration. So that's done on pertinent of waste, whereas medical surgical equipment is done on purpose downed spent. So you put that into a nick way shin like this. I mean, it's really not very complex. Equations know algebra. It's just times in things and adding them together. Um, Andi, even my basic math is able to do that. So then they were able to come up with this. Estimated carbon dioxide savings or kilograms of Comdex had equivalent savings on the pounds that they would estimate be saving per week. So, yeah, that's kind of some examples. Join me to start there. Or should I just talk about teaching sustainability que In general, I am, I think, Let's, um, let's start with your questions, if that's right, her head. Apologies. I'm about to go to my night shift, so I mean my cycling. You we've got a question from, um, machine shop on day is how can we justify the reduced activity off primary drivers for a really units? How can we reduce carbon footprints without compromising emergency patient situations? And I think you've answered some of this, especially with the last last example is well but essentially want to extend you. So I think if you're talking about sustainable Edie, there's a lot of work that's going into that particular topic, and you could join the network of sustainable Edie doctors, which is on the greener. Um, there's a network on sustainable healthcare, green and networks, and that's got most of the doctors on it particular. But I think if you use the principles of sustainable healthcare, one of the So I working pretty D right now one of the big drivers that's bringing people into hospital is often to do with not having the right information about where they should go on. But I think that one of the things that we could try to do is improve patient empowerment, to manage their own healthcare issues more appropriately. And 111 is the vehicle that that could happen by but currently doesn't always seem to be appropriately giving the right information or appropriately used. So as clinicians, we could work better with, um, other sort of members of the healthcare team to try and reduce those E D admissions on then in the actual delivery of that acute care and at the time of delivery. I think patient outcome always has to be the most important thing that we can do. But if you use those principles that I was talking about, sometimes you can find ways of delivering that in a little in a way, on reducing the waist in that system. That could make that. There's another question in the chat, which has just come up from S mark on it ties in with one of my questions, actually, as well. So she says, water, the likely challenges and setbacks that we might face in carrying out our cure I projects or engaging with decision makers on 11 challenge that I've always faced in trying to do que eyes, especially with it potentially being a tick. Bob's exercising portfolios that we have 22 is that we have quite short rotations into create change and then create lasting change within a short rotation when you're moving on from the department so quickly is quite a challenge for me. But I wanted if you could, uh, can elaborate a little bit about the other challenges and set back so we might face Is this conditions? So are you talking from a junior doctor perspective? And I'm assuming that's the case. But I would say one of the biggest challenges for junior doctors is lack of time. So the short time of the rotations and also the lack of time that you've got to actually carry out those projects. So one way, as I mentioned at the beginning, sort of thinking about ways that you could try to overcome some of those barriers is working with more permanent members of that team. So making crossing the lines and working with nurses on oaties and physios and pharmacists, they are more ingrained in that department in there. Sometimes you are. So if you're trying to make those changes instead of coming with the solution, talk to the people that have been there for a long time. Understand the challenge is that they have in trying to address these things, and you'll find so many people who are engaged in wanting to to make changes in terms of sustainability on then, off the the knowledge that you've got about implementing Q. I projects on the framework for how you, you know, use your PDS a cycles to measure that change and continue. You don't you don't have to get perfect measurements to make changes, but I think that that's one of the ways that you can overcome it. And also choosing a project that's got consultant involvement always helps a swell. Yeah, I'm totally, really there And actually one of the projects that I've been running in my intensive care unit, which is the cup. The removal of off single use plastic cups within its partner. That's something I found. I'm sure I'm shortly moving on to the department, and I found it very useful to get get a couple of the nursing team involved over there permanently. You can take over when I when I leave and I have a question of my own. It's about smart tapes. So where we are, it's not drilled in about using smart times when we're formulating quips. Do you think smart times it useful? I've been reading a book called Switch by Chip and Down the Thumb on. It's about creating Change. The change is difficult on, you know, they They say small teams have their advantages, but also that they're short term things as well. Um, do you think sustainability should be incorporated into the S M A R T framework? So I think that you can have an oval aimed, um which are goal, which is to, as I said from the beginning, like the Q. I overall goal should be to improve patient outcome was minimizing the triple bottom line on creating social value. So you have the overarching a month, and then you come up with more smarter goals underneath that, so I don't think it necessarily needs to be part of the smart A Mitzi. But I think that you need to measure against the triple bottom line one. When you carry out that project, so and then it becomes more sustainable. So the great thing about this is it's not just about longevity said people talk about sustainability in terms of lovin Jevity is a project on There is that annoying thing about our language that includes those two things. But I think that we should be looking at. If you include in your spot a muay of thinking about the triple bottom line, you will have it more sustainable longevity as well. We've got one question from Sarah Crow on that. Is any particular suggestions for general practice? Thank you. Oh, whole lot of thumb. So, um, in terms of general practice, I would check out the greener and hs green. No green or practice is website, which is started by to really inspirational GPS up in Sheffield, which has got loads of ideas of what you could do in terms of sustainable projects in primary care. But I think the carbon footprint of primary care settings is becoming more commonly understood. On down there is a carbon footprint ing DP who will come and come footprint a single practice. But inside primary care, the carbon hot spot areas are pharmaceuticals generally travel on the states of facilities. So if you focus on a carbon, the carbon hot spot area in primary care, that's where you can have a big impact. Um, so, yeah, I don't have a kind of tailor made list off projects for people to do, but I sort of think that if you apply those principles and look from there, you'll get a lot of ideas. There's also the green impact for primary care, which has a whole list of more prescribed ideas For where you can start. Certainly found GP generally is a good place to make change because of the quite small community like that you've got there are everyone is very much working together. It's quite small team. Yeah, and there's loads of opportunity for impoundment, a swell on DTaP's. You're more ownership of having currently care. Primary care is sustainable. Care in general like that is, you know, we should be putting more money into primary care and looking to that. So we have a question from Durant Barrera. Um, do you have much experience with ppd Use and disposal and minimizing the waist and environment? Lindback there, across specialties? Yes. So there is a lot of work going on a mister tickle area on. I know Shanteau, this one on my mood eater from Brighton have looked at the carbon footprint of PP on that paper is available Arab. Do you know that paper? Have you seen that people don't actually could link in the chart? He had made a link in the story. I can't multitasking with the questions that if you could look up that paper, she's She is a surgical registrar who looked at the and cup. Okay, it looks like Dr Spooner has frozen once again. We will hold on for a couple of minutes and see if she comes back. Where do you 27 anyway? So if anyone does have any last questions, please do submit them now and then when she comes back weekend, weaken blood through them. Very it. You're never gonna ask me to do anything again. Our if I'm sure. I'm so sorry. Expert. Thanks for being so fast. Very, um, so yeah. Okay. Oh, no. Hi, everyone. It looks like, um, that connection is getting worse. So we'll just wait for her to come back and probably close up the session. I hope you found it helpful, though. If you have any more questions, please do put them in the chat. And we can get in touch with Rosie towards them by email, And I'm sure that she be. Please, Teo. Pleased. Want any? Any questions you might have A Me. I will try and get the link to the website Rosie was talking about, um on. We'll just wait the rosy come back. We can question if you did want to calculate your carbon footprint. In the meantime, we do have a tool available on our website Will share the link in the chat as well. On that also gives you some ideas and inspiration of how you might be able to, um, kind of combat that. And so we'll show that in the chat now a zoo? Well, as the just generally comics website going soon if you need to leave. I'm sure people recently said it was gonna be seven o'clock finish. Um, so if you need to leave, we totally understand. Just before you go, though, if you had to our Echo Medics website, you'll see at the bottom a link to something called by me a coffee. So, Peter, medics is non profit. Um, we we completely so do this in our own time. And if you found this session useful where you found the conference on the eight that may useful, please do consider buying us a coffee on the website and those those funds will just go into further events for you guys on further sustainability events for for healthcare. Um, please hang around if you if you want to hear the closer the session. But as I said, if you need to leave, that's absolutely fine by Rosie, your news. So So I'm gonna have to go very shortly, but I hope it's being helpful. Teo, talk about how you could use sustainability principles on D. I can share my sides with you so that you cannot really useful on, would it? Wouldn't be right if we shared your contact details with our with our attendees. They want to get it signed. All right, in there. Okay. And on on, uh, if there are other questions that people could just email may or you could put them to me, um, I convinced them in your, um, use letter. I mean, I think it's really great that ico medics, is it just, like, organic startup idea? And I think it's really amazing that there's lots of people that enthusiastic and engaged in this topic. And if there's any ways that we can share knowledge on D helps support other people to be using those principles that were very think we were hoping to the same out objective. Brilliant. Well, thank you so much, Rosie. I think I speak on everyone's the half there. It's been really, really useful to hear from you. I'm sure you might get some questions in your inbox on do. Yeah. You're very welcome to ask me on. I can try and help any way I can, and hopefully we can stay in touch as well. Have it have a fantastic end of day. Not gonna end for another 10. And it was okay, I would be. Yeah, well, thank you very much for both of you and for putting up with me coming in and coming out. I'm really sorry. It's not very professional. It's just weigh these days. Yeah. All right. Thanks, guys. Have a good shift. How about are you?