Speaker 1: My name is, as I mentioned, Olivia Bush. I'm the clinical program director for the Center for Sustainable Health Care and and the topic really today is is following on from some of the presentations that we've heard. Looking at transformation for sustainable health care, really recognizing that we have really good policy environment, but the question of how to move this into practice is a at scale is a is a big one and there are lots of obviously lots of people But I'd like to share some a few tips really from from our experience of working directly with with a clinical with with clinical colleagues. And I suppose when we're starting out with this with big people who come into this fresh, I know that many of you quite experienced. Just a question of helping people put their green glasses on, look at things through a sustainability lens, reimagine their care and then take action as teams and at and at scale, which which sounds simple. Obviously more difficult in practice, so in terms of reimagining and sort of changing that view, I think we are very fortunate to have the carbon footprint developed by the for the for the NHS, which I won't go into detail because I know that Boo presented that beautifully to you to you earlier. But obviously it's, but I suppose there was two things I'd like to highlight about this. So first of all, in terms of the supply chain, I know that some of you involved either through the NHS or through being involved in industry or through health technology assessment and just really highlighting obviously procurement decisions are absolutely key interventions to reducing the carbon footprint of the NHS obviously including health technology. And just to highlight that NICE are integrating environmental impact into their guidance at the moment. One example here is inhaler choice, which for which there is already a guideline, which some of you might be aware of. This is very much work in progress and certainly not implemented across all guidance. So if you would like to collaborate with us on looking at environmental impact in HTE do contact my colleague, the carbon modelling lead Ingeborg Steinbach. And also just for those of you involved in this, it might you might be interested to know that there will be a sustainable procurement index for health which will be launched in September, which has been developed by the UN Development Programme, which may help in this area. Moving back to more than sort of the clinical aspect, as Boo outlined a lot of these areas that are contributing vastly to the carbon footprint do involve clinical staff. And so in terms of taking action, the one mechanism that we have found really helpful in making change in this area in health care organisations and the communities as a whole is through quality improvement. So you'll see here this is a graphic from a doctor's report graphic from a document from the Royal College of Physicians in 2010. Really outlining that there were thought to be seven. There were six domains of quality and sustainability was added as one of those domains being one of the essential areas of quality. And I suppose why have we chosen to integrate sustainability into QI? Well, it's really because QI already has a methodology which is designed to take knowledge and translate it into action, which is what we need. And furthermore, we sometimes see that we need, although there are obviously tools out there, really there are lots of areas that are uncovered and not and not covered by various tools. So if people want to take action or organisations want to take action, it helps to have a methodology to empower people essentially. And we found that we found that very. Very, yeah, very powerful. You'll see even if this is happening at the grassroots and sort of at a at a larger level. So this is Helen there on the left who she said she was a sustainability lead for her department in recovery in the surgical pathway and she felt it gave. This approach gave her the knowledge and tools to use when considering other areas to change, and this has also been borne out in education as well. Radically changing how those in leadership approach quality improvement and deliver that that teaching to students and those they're training. I just like to recommend this this resource to you, which is a collection of resources that we have we have put together to really help people at all levels, whether that's whether that's an educator, whether that's a person working frontline or whether working in a transformation program to help integrate sustainability into into those disciplines that we're working into into those decisions. And we've seen some wonderful examples here from from Boo and Paul just before me. So what what are those? How have we done this? So I suppose the place to start can be the aim of of the quality improvement effort. So here we've defined it. To deliver care in a way that maximizes positive health outcomes and avoids financial waste, so nothing different there. Really, this is a different bit, and obviously you're avoiding harmful environmental environmental impacts while adding social value at every opportunity. So really looking at the financial, environmental and social sustainability and bringing them all together when you're designing transformation and. Measuring really looking at those all together when making decisions so we can define it in terms of an equation and you'll see at the bottom there if you're looking at sustainable value and looking at all the costs and impacts and you'll you'll consider the environmental, social and financial impacts all together and defined as sometimes called the triple bottom line, which some of you might be aware of from sort of health economics. So another way that we we've looked at integrating this is when if you're if you are involved in transformation, often the process map will be your your map your process essentially to start with your pathway. This is just a an example, but on those you can. You can look at your environmental, social and financial impacts of your existing pathway, and you can see that those have been sort of. Designated here in more detail every at every step, which can be useful just to get to get an overview of where your where opportunities for change might be. This is being used in so Doctor Andrew Appleton who's pictured here on his dinghy is the CCIO down in Bristol and he used this method when he was looking at a digitally enabled dermatology pathway down where he was based. So once you've mapped that and looked at looked at the impacts, the question is the next question is how you actually going to change your change your pathway and these are some what we tend to advise is using the these principles of sustainable clinical practice. So this is it's we've we've formulated here in the form of driver diagram which you're if you're involved in quality improvement will be familiar to you, but just taking this diagram from left to right we're looking at the outcome needed. Clearly, as we've been talking about this morning, the aim is to reduce carbon without reducing health outcomes, and then we look at our primary drivers. We either reduce activity or reduce carbon intensity, and the the methods that we can use are really around. We can use prevention and. Elements around sort of self care, the patient patient empowerment, co-design shared decision making those sorts of things and lean pathways and making every every step count which which Paul was describing recently and then obviously low carbon alternatives. So we could be at the inhalers would be a specific example. Quite an inhaler swap. So for example, from a puffer inhaler to a a powder inhaler would be would be an example of that and of course then the buildings side of things as well. Then the buildings side of things at the bottom and energy. So forgive some examples of this. I know that many of you from a digital background so I've picked out some of those examples but if we were looking at sort of prevention and patient empowerment patient view would be an example of that which enables patients who are who have who have a risk of renal disease to be to be monitored and over a period of time. So we're looking at and and to pick up those who might be at risk so that for early intervention essentially so looking at the prevention side of things and patients can also enter this platform and and see their blood results and be partners in managing their condition in a in a much more powerful way using by access to their data. So that that's that's a useful example of that. Similarly, lean pathways. We've had some examples today, but a simple example would be telephone appointments which of course have been frequently employed during during COVID. If you wanted to find out a bit more specifically about remote consultations and their role in sustainable health care, we have recently convened some discussions about this and have a series of resources relating relating to this. So we're piloting a new carbon calculator around this at the moment. In collaboration with the Health Foundation, there's information about specific environmental and social impacts specific to digital pathways, which we've devised in partnership with NHS Digital, NHS England, and there are also resources there for to use with clinical teams for reimagining consultations for sustainable health care. So that's sort of given you an overview of sustainable quality improvement and a little bit of an insight into the methodologies that can be used to to integrate sustainability within the transformation programs, for example. I suppose the other element here is is is human factors and cultural change. So we know that obviously tools are not are not the only answer you need. Support in terms of implementation of in terms of that cultural change, which I think if you're involved in digital aspects, it will be the NASSS CAT tool will be very. From Greenhalgh et al will be very, very familiar to you, and I suppose the way that we work is either working at organizational level or at national and international level. So I'll just talk you through those, those those methods really of of igniting cultural change in clinical communities. So an organizational level, we've got a couple of programs that we use the Green Ward program and then working to integrate sustainable quality improvement into trusts. So if I start with the Green Ward program, we we often use the device of a competition and that's that's working to develop case studies within a trust to to to paint a picture really of what sustainable sustainable health care looks like and we find that often it's more powerful if if people have local examples. This is really a device set up to to create those and start changing culture within that within that area. And so how it works is this. You recruit across the trust, which raises awareness and really starts that that process moving. Run workshops for a set number of teams creating project ideas and planning their first steps all based upon that sort of putting on their sustainability lenses and looking at the carbon footprint in their area. So we could be working with respiratory teams, anaesthetic teams, all sorts of teams and you then move. The the benefit of this is very flexible. Our process can be applied to any any team essentially and then teams move on and they run projects. They'll be mentored by our our team and they measure the impacts. They're measuring that triple bottom line which I discussed earlier. And then when we move to the judging and awards, the teams present their projects and learning to members of the senior leadership team, often sort of people from finance, the medical director, those sorts of people and we work at spreading their ideas through through the quality improvement team, getting things happening in practice, social media and more workshops at that. At that judging event and there's a choice for the most impactful project. And that we come out with some really nice case studies, and this is an example here of a project that we did at Frimley and a look at the carbon savings and the financial savings of those of those six projects. And this often leads on to working, thinking about integrating sustainable quality improvement into trust so that that method is being used in the in the case studies and this is a bespoke kind of phase looking at either training the quality improvement team, looking at integrating sustainability into their existing quality improvement materials and training sessions, and we're currently working with this way in at University Hospitals Dorset. In terms of a sort of national and international cultural change, we've we've decided to work. We work in terms of specialties, so we've worked in a range of different specialties to date. You can see the list here and one of our we're actively working. Then yeah, the new specialty working at the moment I'm leading on is is transformation and surgery and I know that we're soon to be working with a with a fellow in gastroenterology as well, which which some work that we're working with Boo on. So just to give you a sense about how this works, I'll just present this diagram which looks rather complicated, but we'll we'll break it down and look at it in steps and there are various elements to this, start start with is is looking at when we're changing that to the culture of that particular professional group we develop. We're developing a network essentially, so we have a network on sustainable operating theatres. And often there's a fellow who's who's who's working full time on. He's often a trainee in that in that particular area to to really spearhead and push forward the work in this area over over over a year or so and currently we've got Chantal who's a surgeon down in Brighton in A&T. She's in post and has a research focus and there's a new fellow who will be appointed this this year. So I mentioned research is a really important element, and in surgery we have a there's a there's a research group that's that's forming down in Brighton, which of which Chantal is is part and important element. And then moving on at the moment where we're moving to kind of increase the capacity of those of that network and really get some really get people a wider group of people taking action in. Yet you're taking action and learning from from from the work that they're doing the change they're making. So what we're doing the moment is working through again a sort of competitive process. The Green Surgery Challenge, which has a very similar process to the Green Ward, but it's at a national level and we've got six really dynamic. Dynamic teams working on areas which will I think resonate with some of some of our early presentations. So looking at more sustainable anaesthetic processes for different for different for different pathways. So that the pre-op assessment cutting out various elements of that to reduce carbon, including working on the group and cutting out group and save at the moment, which is which is astonishing in the amount of sort of travel and resource that will save. As you can read all about, I will put a link in the chat later. You'll have a look at see what they're doing. And they'll be presented later at the at a launch which will happen on the 4th of November. So if you want to come along, please do. It's a free event which is delivered in in collaboration with the Royal College of Surgeons, England and Edinburgh, NIHR and our industry partners. And obviously through all this work with developing knowledge and tools to kind of to kind of contribute to cultural change along with innovation and also the industry partnerships as we've as we've discovered, as I've discussed earlier, that we're that we're, which is absolutely vital in a sense, because if we we have some gaps, we have a certain element we need to implement the solutions that we know about. But of course, there are still gaps that need to be filled by by solutions for which we need we need industry collaborations to make them happen. So just rounding up, just thinking about this really is a call for collaboration. So thinking about ways that you could collaborate, depending on where you're where you sit. And obviously you could look at integrating sustainability into your quality improvement programmes, your strategy, transform, if you've got a large transformation programme going on, you might like to think about integrating sustainability right at the beginning in that design process and in the process of measurement. And then, of course, governance as well, embedding it in governance. If you want to collaborate on assessing the environmental impact as part of health technology assessments, do do get in touch. And similarly, obviously, industry partners as well are also very welcome to get in touch. They're looking at looking at want to look at the environmental impact of how they work. If you're looking at cultural change, obviously, we've got the Green Water Programme and fellowships, which do often happen at a national or international level. But also we've had regional fellows as well. So at the moment, we've got a Wales Sustainable Leadership Fellow and also sometimes at trust level as well. We've got a fellow at Barts Health at the moment. And then in terms of development for staff or for yourselves, you may want to look at our courses, join our sustainable health care networks, of which there are many different flavours. And also, if you are a member of the Q, the Health Foundation's Q community, an online quality improvement group of those in health care involved in quality improvement, we do have a special interest group which is dedicated to sustainable health care. So that is a great way to meet other people who who've got similar interests and will be able to share. It's a good way for sharing expertise and asking questions. So my question I'll leave you with really is how could these tools, methods and programmes help you to generate change for sustainable health care where you are? So do feel free to get in touch. That's my Twitter handle and there's a link to our website and the main email contact. And if you're excited by sustainable health care and sustainable quality improvement, do tweet about it. Thank you.