Good afternoon everyone and welcome to this session of Value Based Healthcare Week, where we are going to explore the intersection between value based healthcare and environmental sustainability. My name is George Leipnik. I'm the Director of Strategy and System Priorities here at the Ministry of Health and I’m going to act as the facilitator today.

Before we begin the presentation I’d like to offer an acknowledgement of Country on behalf of all our speakers. I’d like to begin by acknowledging the traditional custodians of the respective lands from which we're all calling in from today. I’m dialling in here from Cammeraygal land and we honour the ancestors of yesterday, the custodians of today and those of tomorrow and pay our respects and recognize the continuing connection to land and water.

Just to give you a sense of what we're going to hear from our speakers today. Firstly, Kate Charlesworth will explain why the climate crisis is a health crisis and what we as a health system can do to act. We're then going to have a couple of case studies to show how particular streams of work can contribute to reducing NSW Health's carbon footprint. Ellen Ralston will describe a value based healthcare approach to surgery and how it can contribute to environmental sustainability. And that will be followed by a presentation from Karol Petrovska who will provide an overview of NSW Health virtual care strategy and its role in environmental sustainability. We're then going to finish the presentations with a q and a session with all three presenters, so I really encourage you to type your questions in the chat function throughout the session as we go. We're going to collate all of those here and then have time at the end to talk with the presenters.

So I really hope you enjoy the session and our first speaker Dr Kate Charlesworth will be with you in just a few moments.

Kate Charlesworth: Thanks so much George and thank you for the invitation. I’m delighted to speak with you this afternoon. So I’m Kate Charlesworth. Just by way of background, I’m a public health physician. My main interest and expertise is in climate risk and sustainability and I’m now Senior Advisor in the new Climate Risk and Net Zero unit, which I’ll be speaking about today.

So firstly, I’d just like to briefly add my acknowledgment of country. I’m also on Cammeraygal land and to note that Aboriginal people have been tremendous stewards of this land for more than years and that these themes of stewardship and caring for country are particularly relevant to what we'll be talking about today. Just of note there, I’ve referenced the Lowitja Institute report that climate change is compounding historical injustices, which speaks to the fact that Aboriginal people, and of course many other groups within society, are being disproportionately impacted by climate change and so in addition to everything else this is also an issue of social justice and health inequity.

So for me today pretty much reflecting what George has already outlined but these are the three key points. The first one is that the climate crisis is a health crisis. It's an environmental issue, it's a social issue, it's an economic issue, but fundamentally this is about health and about care. Secondly, then outlining what it is going to take to get to net zero. What are our principles of sustainable health care and how value based healthcare is integrated into those principles, as part of those principles and as you'll see value based healthcare is critical to our net zero journey. And then lastly, working together - so a brief, a couple of examples, as George mentioned, of how value based healthcare and sustainability are very well aligned. And then briefly about our unit and how we hope to work together with our colleagues across the system.

OK, so there is now overwhelming scientific evidence that climate change is supercharging the climate. It's making more frequent and more severe extreme heat, storms, flood, bushfires, droughts. And the Australian Academy of Science report has Australia currently on track for a three degree rise in temperatures this century. That would mean thirty-degree days would be common in Sydney and Melbourne. It would mean black summer bushfire events most years and it would mean that storms and floods have violently reshaped our coastlines such that many coastal ecosystems, including the great barrier reef, would be long gone. And so the health impacts of climate change as set out on this slide from the CDC is not just about extreme heat and severe weather, but also all these associated and flow-on health impacts shifts infectious diseases, food and water insecurity, forced human migration and civil conflict.

The key point here as I mentioned earlier is that these impacts are not going to be equally distributed. It is the most vulnerable in our society, it's babies and children, it's the elderly, people on low incomes, Aboriginal communities, rural and remote communities. For a whole range of physiological, social, economic, environmental reasons, these are the groups who are being hit the first and the hardest. And so this is also an issue of social justice and health inequity.

But this last one, this is the key point. Climate change is not going to be a linear process. Earth is not a line; it is a system. It's a series of interconnected ecosystems and we have now left this so late, we have ignored scientists warnings for decades, that our carbon sinks - our oceans, permafrost areas and mangroves - are pretty much full. Those carbon sinks are full and so we are now dangerously close to hitting tipping points. And if we hit tipping points, then rather than a three degree rise in temperature, we're looking at a temperature rise of five or six degrees above pre-industrial temperatures. And in that situation, of course, much of the planet would not be habitable.

So that's why the IPCC report which came out in March this year, which is the most comprehensive and authoritative climate change report ever, has said that we need to rapidly reduce emissions this decade to avoid catastrophic climate breakdown. So every sector is going to have to get to net zero. It's going to have to rapidly reduce emissions in the next years. Energy, agriculture, transport so on and the health sector to us has a particular responsibility, because currently we're a big part of the problem. In our health system we use huge amounts of resources, we produce vast amounts of waste, we still use fossil fuel energy sources in many cases. We have an enormous carbon footprint. Globally, if the health sector were a country, it would be the fifth biggest polluter on the planet. So the irony is that we are currently contributing to the climate crisis, which is harming human health and that is of course completely inconsistent with our core business and with the values of most health professionals.

So we need to get to a net zero health system. The first thing that you need to do if you're going to get to net zero is to understand what your baseline carbon footprint is. We have done some of this research in Australia and indeed in NSW, but I’m using this. This is data from the NHS - the National Health Service in the UK. They first set up a unit tasked with decarbonizing the NHS more than years ago, so they have been doing this foot printing now for more than a decade. And this is the most comprehensive and detailed analysis that I’ve seen. So this is the NHS's carbon footprint. So as you can see there the green section is travel, so patient, staff and visitor travel is of their footprint. In the red section you've got delivery of care. So you can see the usual suspects -  fleet and business travel, water and waste, building energy - but also anaesthetic gases and MDI's (metered dose inhalers). These are big carbon hot spots in clinical care. And then of course the key point is that blue section of the pie graph  - the supply chain. More than half of the health systems of the NHS's carbon footprint is from its supply chain. Emissions from pharmaceuticals, medical devices, equipment, right down to food and catering.

So the key point here is that energy is very important, travel plans are very important, fleet and building design is very important, but we also need to be looking at clinical care. We're going to need our nurses, doctors, allied health, pharmacists and so on to be involved in and engaged in leading on developing low carbon models of care.

So then this is the principles of sustainable health care - and for clinicians - I’m talking to our clinical staff - you know all those groups mentioned - this is the most important slide for them. This is our overall approach; these three core principles. This is based on work from the Centre for Sustainable Healthcare, which is in Oxford in the UK. And the principle number one is keeping people healthy. And well that's because of course one type of carbon neutral system would be a system in which we didn't have any patients, everyone was healthy and well and independent in their homes and their communities. Okay so all of the, so many of the things we do across the system - our public health work; our health promotion work; tobacco control; obesity; immunisations - those are all in a sense sustainability measures. So that's always our first principle.

The second one is about minimising low value and harmful care. We know there's a substantial amount of over-diagnosis, over treatment, within the system and those things have harms and risks for patients and also costs - not just financial costs - but also carbon costs. So that's what I’ll be talking a lot about today. Second principle.

And then of course the third principle is about evidence-based effective care. How do we decarbonise that? And that's about choosing, you know, what type of anaesthetic gas are we using? How can we use telehealth appropriately? How do we set up a circular economy and surgery? Those sorts of questions.

So a couple of examples here from the literature. So this is a paper published in the in the BMJ which talks about, which brings together this intersection over diagnosis and carbon and it makes the point that a lot of clinical care, is high quality evidence-based care provides value for money, provides good outcomes, but that research over the past three decades has shown a substantial amount of harmful and low value care. And specifically, they talk about over-diagnosis. So as you would know over diagnosis is detecting some sort of clinical condition that would never have caused the patient any problems, but once it's diagnosed sets in cascade, a whole series of investigations and procedures. And the point made here is that over diagnosis basically generates carbon without improving health. They talk about the fact that, as it says here, this takes on a new urgency in the context of the climate emergency. Okay, this provides a fresh focus or lens or urgency for it, but that this is the sort of work you know that is important in any case you know to reduce harms and risks for patients. They also make the point that success to date has been quite patchy in terms of producing low-value care and talk about some of the reasons for that.

This is a paper published in MJA which sort of links up previously with that the BMJ article but talks about the fact, you know on that last point, that a lot of education programs so far have been targeted at clinicians. And actually what is needed is for some similar programs to be targeted at patients, and for patients to be more understanding of these sorts of issues and much more engaged and involved in their care. And this I guess is probably one of the key papers that brings it all together. We published this in the MJA last year. So on the left there is a pie chart that is a representation of the Australian health system's carbon footprint. So broken it down roughly into two parts - the grey section, which is buildings, electricity and gas - and then the blue part, which is clinical care, so that is you know everything to do with clinical care: pharmaceuticals, medical devices, equipment, you know right down to patient travel, food, service and so on, anything that is related to clinical care. And then they've taken that across and said okay of the clinical care, we know from the literature, and they've referenced breakthrough out there, that amount of clinical care is actually harmful care. It is care that would not have improved patient outcomes and actually, the patient undergoes that investigation or procedure, they have a bad outcome. There's harmful care. Another is low value care. The key point there is, they've added up the carbon cost of those, so if you add together that . and . more than million tons of carbon is currently wasted on harmful or low value care in Australia.

So to our second point of principles, reducing that, eliminating that is the critical thing and then our next step is decarbonizing. The green section for effective care, okay so in terms of working together, just some examples now, about how this sort of intersection comes together. A few sort of examples from clinical practice and then a bit about our unit. So one of the papers actually references the choosing wisely Australia, which you would be aware of this program, included in this is that medical colleges put together a list of low-value investigations or procedures in their specialty and in this example the Australian College of Emergency Medicine's recommendations are being displayed in Queensland emergency departments. So you can see the one there about imaging of the cervical spine, and so it's an important sort of awareness raising tactic for clinicians. This is an example from surgery, so the point that and it's actually co-authored by an orthopaedic surgeon Ian Harris, so it makes the point that last year in public hospitals in Australia there were more than orthopaedic surgeries that were undertaken or funded but that a lot of orthopaedic surgeries, when you look at high quality evidence, there is no evidence that they are better than a non-surgical option, such as an exercise program. And they call out a couple of specific examples. The first one is spinal fusion for back pain. Based on high-quality evidence no indication that it's any better than a non-surgical option and in fact of the patients who undergo that procedure about one in six experience a harmful, a serious complication, such as a blood clot, nerve injury or infection. The other example they give in this paper is about an article, is knee and shoulder arthroscopies for pain and again when you look at the evidence no good quality evidence that's any better than a conservative measure, a non-surgical measure. So again, the question is, why are we continuing to do these surgeries when they're not evidence-based, they're placing people at risk of harm and they're financially and environmentally costly?

To change tack, an example from primary care. This is about vitamin D testing. So this research found that in Medicare funded four and a half million vitamin D tests, vitamin D blood tests. That is about one test for every five Australian adults. From the literature that said we know that about to of vitamin D blood tests are unnecessary. Okay so that means that three to four million of those tests were unnecessary. That cost Medicare more than million dollars and it cost us tons of carbon. So again, generating carbon for no improvement in health.

And then sort of similar sort of example from tertiary, this at Shellharbour Hospital, but I know that a number of hospitals across our system have been looking at these sorts of programs. It was found anecdotally that there was a high amount of blood test ordering particularly among some JMO's at Shellharbour Hospital and so they ran an education program about appropriate blood test ordering. As a result of that program they reduced their pathology testing by about, with no change in patient outcome, and they stay at about four hundred thousand dollars, just in that pathology department, in that one hospital. So again, no change in patient outcome, but saving money and carbon.

So just briefly about our unit. Firstly, as you may be aware the NSW Government has set a target now of halving greenhouse gas emissions. So that is our overall target, you know for us NSW Health does recognise its responsibility to address both physical and climate risk. That is, both to decarbonise and to adapt and in our new future health strategy, sustainability is one of six priority reform areas. And as you can see there, we've committed to an environmentally sustainable footprint. We are now setting up a small Climate Risk and Net Zero unit which sits within System Purchasing, which is in the Patient Experience and Performance area under Wayne Jones currently. And the unit is overseen by a steering committee which is chaired by Wayne Jones. And the tasks of the unit are set out there: our core objectives are set out there for our team. So I guess the first point to make is that there is a lot of great work going on, is underway already across the system. Knowing energy in fleet and infrastructure with Healthshare and Health Infrastructure, procurement with Healthshare, and indeed across a lot of our local health districts and networks.

But the task for this unit is really to start to coordinate and scale up that sort of approach and to address. Our main focus will be clinical care, decarbonising clinical care, because that's the sort of gap that we've seen so far, and setting up the appropriate structure. So I’ll be setting up a formalised NSW Health sustainability network, and I’ll talk about our network teams.

The second thing is objectives, so looking at policies and levers so that we can meet our requirements - legal, government and regulatory requirements. Third one there is about research and innovation. So a key thing in terms of research is, you know, as I mentioned in the start, we need to firstly understand our carbon footprint. What is our baseline carbon footprint? There has been some research in this space but we need a much more robust measure. Then how we're going to measure, monitor and reduce our emissions over time. And to keep out of the research and then innovation if for when we have more capacity and innovation program because there's a lot of things that we need we know, that we need to do, to get to a net zero health system. But there are also a lot of gaps. So need innovation and investment to address those gaps.

And then finally empower. There are a huge number of staff across the system who care deeply about sustainability and a huge number of staff have been trying to implement sustainability projects and initiatives in their services and in their hospitals. The task here is a big staff engagement, capacity building program so that we can start to really scale those sorts of things up and better direct efforts as well. So one of the things we're doing it will be a net zero team. So we've got approval now for net zero leads - these could be existing staff, so from nursing, medical, allied health and pharmacy- who will be funded one day a week to lead and coordinate net zero projects or initiatives in their service or in their specialty. So really trying to bring together that sort of clinical engagement with sustainability. It's based on a very strong model in the UK, which has been very successful. They actually have clinical sustainability fellows who step out of their clinical work for a whole year to lead on sustainability work. We've just got funding for a day a week so far.

Finally I’d just like to finish with these two key messages. The first one is about risk and I think that John Kerry sums that up pretty nicely. But then secondly about opportunity. Clearly the climate emergency provides a real urgency for us to do this work, but as we've noted, this is critical work that we should be doing anyway. We want to improve patient outcomes, for patients to have a much better and safer experience, to reduce the harms and risks for patients, to focus on value-based health care and so many of the other things in there in the strategy, that it ties in well with innovation, with digital advances, with keeping people healthy and well and so on.

So this really is a great chance for us all to work together towards actually just a much better health and care system. Our team really looks forward to working with everyone towards this shared goal. Thank you.

George: Great. Thank you very much Kate for your presentation and I’m sure that's going to generate a lot of discussion come the q and a time later. Our next speaker is Ellen Ralston, Executive Director from the Agency for Clinical Innovation. Ellen will be with you in just a moment.

Ellen Ralston: Thanks George and thank you Kate for that first presentation as well I want to kick off as well by acknowledging that I’m also joining you from Cammeraygal land and like to pay my respects to elders past, present and emerging and those meeting with us today.

So I’ve been asked today to reflect on the intersection of value based healthcare and environmental sustainability, but with a particular focus around surgery and the work that's been happening. So there are three areas I really wanted to talk about as part of that process. The first is really to explore what does a value-based approach to surgery look like in NSW? And we've been doing quite a bit of work on this over the past five years.

The second is how are we approaching this and how should we approach this in the future in NSW, in terms of action? And then that third area is really around how does it intersect with environmental and Kate’s already given us quite a number of teasers about that part of the process already. A couple of things to bear in mind as I work through my presentation today: the first is that surgery is really expensive and costs the system about four and a half five billion dollars every single year and the second is that it has a huge impact on the environment.

I also just want to quickly issue a few acknowledgments. This work is not possible without the value-based surgery work that's being led by the surgical services task force and the clinicians. It's work we're doing in partnership with the College of Surgeons for the NSW branch and it's work that's being driven by the ACI through its Critical Intelligence Unit, through its Evidence Directorate and through its Surgery and Anaesthesia team.

So what does the approach look like? So in about we conceived this idea of the five p’s of value in surgery and this was really around how do we start a conversation about a value based healthcare approach? And so we acknowledge that value is multifaceted, there isn't one thing that is going to be a value-based approach to care, just as there's not one thing that might be a low-value care approach to surgery. And low value for one patient may not be low value for another. So the first P is really around the Patient Needs and that's is the surgery indicated for this particular patient, will it lead to little or no benefit, or is it even contraindicated for that particular individual?

The second P is Procedure and this is really around is the best option for a particular procedure used - it might be an open procedure or a laparoscopic one or even perhaps something else entirely - and we know that poor choice of procedure can lead to poorer outcomes, to a longer length of stay in some instances, and both higher costs for the system as well as for no benefit for the patient.

The third P was really around Process. How do we make sure that we've got the processes in place to deliver optimal care? How do we reduce - and Kate’s reflected on this already - unnecessary diagnostics? How do we address issues around longer length of stay and how do we ensure that patients are prepared for their surgery in the best possible way? Do we have pre-admission processes well set? Have we identified that this patient may be suitable and it might be in their best interest to have a day-only procedure?

The fourth is Proficiency. This one goes without saying. We need our clinicians to have the right technical acumen and for our procedures to be to error-free. We know that evidence is looked at all the time, the hospital acquired complications. We know litigation costs contribute to the costs of care and we know for patients that it can contribute to avoidable ICU and returns to theatre.

And the fifth area is Procurement. Are we making best efficient use of our resources? Do we have overpriced prostheses? Do we have more, too many choices? Are there too many consumables in the system and do we have things that are unsustainable? And Kate has already talked to us about the global supply chain issue and we're going to come back to that as part of this presentation. The next bit is really around making sure we look to the evidence. The evidence on low-value care or value-based care and surgery is plentiful, it is all over the place, and I encourage you if you haven't had a chance, here's just a snapshot, whether or not it's the Australian literature or looking more abroad to some of the other international jurisdictions such as the NHS Canada and even the United States.

So the next part of this process for us is really around, we've got an approach, we know it's evidence-based, we've got our five P’s and that's something that we've been working through and exploring what are some of the best areas to tackle as we work through it, through a value-based approach to surgical care in NSW.

So the next thing we started to talk about was this concept of the perioperative trajectory, understanding that surgery is made up of lots of different stages of a patient journey. It has a contemplation stage, usually at the referral stage from your primary care practitioner, and then it has stages through the decision to surgery through the pre-operative period, the intraoperative operative period and the post-operative period. So I’d like to just take a moment to reflect on some of the things that we're actually talking about as we work through, as we approach the various programs of working surgery in NSW.

So it's an obvious place to start of course but the pre-operative period - how do we make sure that we've got processes in place to support supportive care and surgical avoidance? Is it the right decision for a patient to have a joint surgery or would they be better suited and better served if we referred them to an osteoarthritis chronic care program? Do we have criteria-based indication assessment? Are we ensuring that we're following the best practice guidance around things like tonsillectomy or even around things like knee arthroscopy and shoulder arthroscopy and are we talking to patients about their goals of care and ensuring that we understand what they want from a process around their quality of life and their goals of care?

The second part of the pre-operative process that we're really focusing on is around how do we support the patient being in their best physical condition ahead of their surgery? So right now we are doing work around rehabilitation and later in the year there will be a set of key principles that is based on work that has already occurred in the system that assists people to really identify the nutritional or exercise or other goals that patients need to meet as part of their rehabilitation process. The pre-operative clinics are part of that - which patients are best served by going to a pre-operative clinic? What tool, what tests, they actually need to have and how do we ensure that we're planning some of those rehabilitation programs in as part of that process? We're also, there's also a number of examples of high-risk clinics and this is an opportunity really for multi-disciplinary teams to work with patients to explore what is in their best interests in terms of a particular procedure that might be very high risk and might lead to a situation where they have a greater risk of having the procedure than not having it. And the anecdotal evidence from those clinics is that many patients, together with their families, are opting against a decision to go to surgery and instead choosing different goals.

The next one is around the operation itself. We have work currently underway to define key features of high-volume centres and specialised centres. Lots of this work again is based on key examples that are already happening in the NSW health system, but is looking to how we can support theatres that are more efficient. And these are options like do we need an entire list of left eyes for cataract surgery or do we need slightly extended hours so that we can have day-only patients first thing in the morning and those patients who are staying overnight scheduled for later in the afternoon? Recovery, so another area we've been focusing on, is enhanced recovery after surgery. Now this one's a bit misleading because ERA’s doesn't sit as purely a recovery program, it is something that actually works across the whole patient journey and is critical to their process, to their to their outcomes, there might be rehabilitation elements there might be pre-operative elements, there might even be high-risk elements in an ERA's program but this is really around ensuring that we have the patient's goals through each stage of the process at the front of mind and there's lots of good examples happening in our system that we're looking to leverage off over the next six months. We're starting with colorectal and we'll have key principles for colorectal ERA’s released by the end of the financial year. But beyond that we're looking to other specialty areas such as orthopaedics or even gynaecology where we might have more to learn there's always opportunities to look at hospital acquired complex complication avoidance programs and things like our national surgical quality improvement dataset are critical to that allowing us to identify complications not only that happen in hospital but also those that happen after hospital in the days post. We know that patients are in and out quite quickly and so often we aren't always certain about their trajectory of care after they leave hospital. So it's a good opportunity for us to close that loop.

And then we've got post-acute care and I know Karol will talk more about virtual care opportunities later on and I will as well, but really how do we ensure that we've got the right poster post-acute care approach for our patients? Patient reported measures both experience and outcomes are critical to that but do we need to think about different ways of delivering that care? When we think about not only what's in the best interests of our patient, but how we reduce our carbon footprint, what is the role of virtual care in in post-follow-up? What is the role of virtual care and rehabilitation? And then of course that critical point around how we ensure that we've got a clear relationship and a strong relationship with primary care around ongoing care and follow-up, given that so much of the partnership between the patient and the clinicians happen at that level.

So the third aspect I wanted to reflect on today was really around the path to environmental sustainability, but in a context of the surgical space. We've already heard Kate reflect on what the evidence is telling us: the climate crisis is a health crisis. We know that not only is it contributing to poorer health outcomes for our community all over, but we know that healthcare itself, and particularly surgery - you saw the anaesthetic and medical gases pop up there - is a significant contributor. And so one of our things is really around how do we explore what are the things that we need to do more of? So the positive deviances versus the things we need to do less of or stop doing altogether and those negative deviances. And I think critical to this - and Kate reflected on this as well - and really around a number of the articles including Malik’s article that I’ll reflect on a little bit later, talk about that of Australia’s healthcare emissions are indirect and stem from that global and national and international supply chain. So in the words of Yoda, there is do or do not there is no try.

So what do we need to stop doing? The Barrett article talks about that - a cull of low value care would save kilotons of carbon dioxide equivalent emissions per year. That's massive and I know that kilotons is not a number that that means a lot to all of us, but I think the evidence is there in front of us and so I take us back to the perioperative trajectory that I talked about, but also refer back to this article that Kate also talked about that's co-authored by an orthopaedic surgeon, but there are many examples of situations where there are things we might need to stop doing. Orthopaedics is one and we've done a lot of work in NSW around knee arthroscopies, but there's more work to do. So in these two areas around is the surgery indicated and is the procedure itself the best option, I just wanted to take a moment to reflect on some of the specific surgery examples that we know we need to be aware of. In the top right-hand corner there is a reference to the Malik paper around savings from reducing low value general surgical interventions. If you haven't had a chance to look at that paper, I encourage you to do so. Malik really taught and his group really talks a lot about both low value procedures that are of low volumes but also talks about high volume procedures that are also low volume and we know that when you look through that paper there are some things that maybe don't have as much bang for buck in terms of both best interests of patients, in terms of the best interests of our value-based care, but also in terms of the environment as well.

So here are a couple of big examples. So in terms of taking a value-based approach for surgery – tonsillectomies - we know that many of those occur outside clear indications and what the evidence tells us, myringotomy and grommets, the evidence tells us there's not always clear benefits for the individual patients. Hysterectomy is often used as a treatment for heavy menstrual bleeding but the Australian Commission on Safety and Quality Healthcare's clinical care standard and many much of the other evidence indicates that that is not always the best treatment, that's in the best interests of the patient. We're aware that there is increasing evidence around repeat investigative laparoscopic procedures for endometriosis, particularly in situations of asymptomatic or small lesions. Hernias, commonly operated on but often minimally symptomatic and if they're minimally symptomatic we know that it might be in the best interest of the patient not to take the risk to have a surgery. Kate’s mentioned lumbar spine fusion for back pain, cholecystectomy procedures for asymptomatic gallstones is another one where perhaps we're starting to look at how we can stop doing those procedures and instead have different conversations with patients, and gastroscopies and colonoscopies which are frequently recommended that are outside Cancer Institute and national guidance.

So before I move on I just want to reflect on these two P's. This is from the five P’s earlier in my presentation. Because we do need to remember that there's no one-size-fits-all approach. There will never be a procedure that is of no value to anyone and we need to be aware of that. That we assess patient need on the basis of what's in their best interests, what are the opportunities, so what are those positive things that we can start to think about more and be more aware of? Procurement. We've talked about the supply chain. I think that's a critical part of the process. How do we have less options for products? Do we really need more knee prostheses or can we make do with five? How do we ensure that that's a key part of our process? And there's other options there - cardiac valves, sutures, staples and ports - all things that we can start to look at. And I know that lots of that work is underway.

An example that might be centralised - acquisition of consumables. Consumables are necessity of the surgical process but sometimes for rare technologies or things that are lower volume we don't have economies of scale. In how we approach this problem on the other side of the positive virtual modalities, when should we use them? Covett has been a great opportunity for teaching patients and clinicians alike around the best use of virtual care modalities. Pre-op clinics went to virtual care opportunities and many others but there's lots of other opportunities to contemplate as well. And there's a paper there I’ve referred to around mobile health technology for remote home monitoring after surgery and there's lots of potential for actually partnering with patients and with healthcare providers on an ongoing basis to ensure that we've got the right processes in place after we discharge our patients.

The other thing we need to do is leverage local innovation on the left is a sustainability quiz that's on the ACI website which was conceived as an idea by a number of clinicians who are part of our Anaesthesia and Perioperative Care Network and they really wanted to provide a tool that would help people start their journey locally in terms of tackling sustainability in the operating theatre. On the right, although not surgery focused specifically, are examples from the Innovation Exchange, which is where local facilities are already driving this process. And so we need to look at what we can identify early in the pipeline and scale.

So lastly, what do we need to make it happen? I think collective leadership is critical. We need clinicians, managers, consumers and the system to drive this change. Individuals can take it so far and they must be a call to action but they can't do it without executive sponsorship and the sponsorship of the system. We need to look to innovation. There's lots of great ideas out there, let's not reinvent the wheel. It needs to be evidence-based and there's lots of emerging evidence not just about the impact of the carbon footprint on in healthcare but also around how. What's the link between innovative things in health and carbon footprint? We need to leverage existing work, big and small, and we need to share learning both amongst ourselves. But also data benchmarking, ensure that we have those feedback back loops in place.

And then I just wanted to leave you with a quote from Bill Gates. He talks about needing to find solutions for all five activities and I think this is critical. There's lots of problems and opportunities to tackle all at once whether or not it's tackling value-based care or environmental sustainability. These are multi-faceted problems that need a range of different solutions. There is no single panacea and we all need to be a part of the solution. Thank you very much for the opportunity and I will hand back to George now.

George: Fantastic. Thank you so much Ellen. I think your presentation has definitely given us some really compelling evidence for specific areas in surgery where we can act and we've definitely thrown the challenge down to us as a health system to look at those opportunities. Our next presenter is Karol Petrovska, the Director of Virtual Care at the NSW Ministry of Health. Karol will be with you in just a moment.

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Karol Petrovska: Hi everyone. Thanks George and thanks to Ellen and Kate for really compelling presentations and I can see that there's a really common theme running through all of our presentations today so we are very much on the same page. I am Karol Petrovska. I’m the Director for Virtual Care in the Ministry and I’m coming to you from Cammeraygal land and I’m here today to talk about virtual care.

Some of you may know that we have a virtual care strategy. I’ll talk about that, but I’ll talk more broadly about whether or not virtual care is green care and some of the interesting things we need to do I guess to make sure that we have the most appropriate and correct approach in decision making as to what virtual care can do from an environmental sustainability perspective.

So if we go to the first slide we'll note that the NSW Government is one of the largest emitters in in terms of government agencies in NSW. And as I did some research to develop this presentation, that to me just says that we've got the greatest potential for change. And to see the work of Kate’s team and the work of Ellen’s team and all of those amazing clinicians in ACI, I do think that we've certainly signed up to committing to net zero emissions and I’m very pleased to see that virtual care does have a role to play in this.

So if you go to the next slide I guess the question that we're here to answer today is can virtual care play a role? And I’m pleased to advise that we've got some subject matter experts on the next slide that will tell us that absolutely we do and I’ll just warn everybody that we've got a few animal pictures in here. I thought it was appropriate and I’ll tell you why I’ve done that. It's I guess it's sort of trying to lighten a very serious subject, but I’ve got a bit of an anecdote to tell at the end of the presentation that might let you know why I decided to do a presentation with these kind of pictures.

So if we go to the next slide, so this is not just NSW Health, this is the World Health Organization, this is other jurisdictions around the world, very much focusing on technologies and how we can use technology to address climate resilience and environmental sustainability. So for those of you that are interested in light reading, on the next slide I’ve just taken a snapshot of a couple of the reports that I discovered in my research for this work. So the WHO have done a really great document to consider how we can develop climate resilience systems, as has the World Bank and some of this connects very strongly to the work that Kate’s outlined in great detail in her presentation. So if we go to the next slide, so for those of you that haven't seen me or heard from me, virtual care is a very much a key reform supporting the NSW Health vision of a digitally enabled health system.

There has been certainly a lot of work during the last two years on upscaling our capability in virtual care, particularly over the period of the pandemic, but for the purposes of those online that might be less familiar with virtual care, our definition of virtual care is any interaction between a patient and clinician or between clinicians occurring remotely with the use of information technology. So deliberately very broad and we are constantly trying to catch up to what the new technologies are enabling us to do. And NSW I mean, of course we would say this, but we do consider ourselves a national leader in the delivery of virtual care. Not only did we develop over the last two years ACI and eHealth developed Australia’s only bespoke video conferencing platform for clinical care the my virtual care platform but we have even pre-pandemic a lot of rural and metro LHDs were already well-versed in this space and delivering care virtually. From a technological advancement perspective but also out of necessity for some of our LHDs that cover quite a lot of territory this is not just a response to the pandemic but certainly the pandemic has turbo charged our focus on virtual care and it very much occupies us a lot of real estate in the future health strategy that NSW has developed.

So if we go to the next slide again for those of you that might need a refresher, I’m not clear on who's on the other end of this presentation, so I did throw this slide in just to go over what modalities we might be using for virtual care. Some of the obvious ones are video and teleconferencing, but the ones that some may be unfamiliar with are the remote monitoring, which Ellen did mention, and that is the use of wearable devices to transmit data via an app or Bluetooth to an app and the facility will I guess use software to monitor those readings of patients that are based in the community and then striate according to risk depending on what those readings are telling us and that was used significantly during the last two years during lockdowns; and store and forward which is a type of asynchronous care or not in real time care where data – photographs, videos - are sent from patient to clinician and a clinician may look at that information outside of usual work hours or outside of clinic time. So virtual care can be done in real time and not in real time.

So if we go to the next slide so this is the virtual care strategy it is available online and it very much sets out the strategic direction and the vision over the next five years. I do believe we'll probably get to the end of and have be having to think about where next to virtual care. And I say that because this is a I think quite a cultural and generational change. It's going to take time but certainly we've had a lot of positive feedback, particularly through the work that the Bureau of Health Information has done on people's experience of using virtual care during the pandemic. A lot of it was quite positive and it really is quite a revolutionary way of bringing benefits to both the health system but more importantly the experience of patients and the convenience for patients. We have an implementation plan and a lot of stakeholders within the system have signed up to be responsible for actions under that implementation plan and they include ACI and eHealth as well as Centre for Aboriginal Health and Health and Social Policy branch, Activity Based Management, the CEC;  it's very broad and deliberately so because this is everyone's business.

So if we get into the media part of the presentation, is virtual care green care? Yes, as our penguin friends did advise it is. There are a number of ways that virtual care can benefit the environment and contribute to sustainability and climate resilience. The major one that seems to come out in the data is travel. It's quite obvious reduced travel time for patients and staff, contributing to reduced transportation related emissions. There's the element of the physical infrastructure and while we position virtual care as a complement to face-to-face care, it is not a replacement of face-to-face care, there will be a time where we have virtual hospitals. There is already a couple. There are already a couple of virtual hospitals in NSW and that will mean a smaller footprint from a capital perspective. And there's also a potential for prevention by improving access to care and information.

So I think the next slide speaks to that a little bit more readily but ultimately we're looking at reducing activity and reducing carbon intensity. So I sourced this slide from the University of Toronto and I thought it illustrated quite well how virtual care can contribute to environmental sustainability. And the positive feedback loop, here you can see the elements of savings that virtual care can provide: reduced carbon emissions and then mitigate the climate change impacts and associated health impacts and therefore a lesser need for care. And it sounds quite ambitious and aspirational, but I really do think from what we've seen today this is real and I certainly feel like the evidence that we've seen from Kate and in particular Ellen’s presentation too really do support what this graphic is telling us.

We go to the next slide I think ultimately what we're seeing is more care close to home fewer in-person visits and I guess that equitable access element which is a significant part of our strategy. We do want to see more of those end-to-end models where our rural and regional communities don't have to travel kilometres to access specialist care. And then by reducing particularly that travel element, we're hoping to reduce carbon emissions and ultimately hospital admissions. Particularly from a remote monitoring perspective, there's some good evidence emerging where we're seeing remote monitoring impact positively on that reduction of hospital emissions. And I will add if we go to the next slide, part of the focus, the early focus of our strategy is to look at how we can reduce travel emissions and the figures that we're seeing here and on the next slide as well show us that the reduction can be quite significant. There's just a few studies here and it's interesting to see that this is not new, as Kate mentioned, our response may not have been as fast as it could have been, but certainly for the last years now we're seeing researchers look at the impact of virtual care and the emissions savings that we can make. Interestingly the type of care that did come up quite a lot in the data was the outpatient care. Naturally that requires probably the most travel and pleased to admit that one of the early areas of focus in implementing the virtual care strategy is embedding virtual care and outpatients. And Ellen if you don't already know, you may be pleased to know pre and post-op care is one of the focused areas for us. So we're working with the ACI to develop that model and scale it state-wide.

If we go to the next slide there is a catch and I sort of went on this journey in doing the research for this presentation and it was all very exciting and another facet to virtual care and there are some I guess cautionary points that I unfortunately have to raise. It's not all roses, but I still think that ultimately the story is positive. So if we go to the next slide what the data is telling us is that unfortunately ICT is a con. A significant contributor to carbonation, carbon emissions. So in particular, hardware. And there is literature suggesting that the patient journey needs to be over kilometres to be carbon cost effective. Now I still think that's a fairly good news story because most people don't live that close to a hospital facility, perhaps there are some in metro areas, but these are the kind of areas that we I guess we need to keep in mind as we move forward.

So if we go to the next slide, this is a quite a small study that I found from the UK and I guess it just sort of demonstrates the savings that we've been talking about in terms of carbon emissions for virtual care. But if we click on the small animation here, that might come up, I want you to notice the amount of emissions that telecommunications have. I guess for this study and it very much ties in with what I was just mentioning, so if we go to the next slide there are some ways that we can mitigate the impact of ICT related emissions. I did have a chat to our eHealth colleagues about whether or not we do life cycle assessments. This is something that's recommended from one of the larger ICT providers that are involved in virtual care, but life cycle assessments really are having a really critical look into the use, particularly in the disposal of the hardware that we purchase. And I think I’d be interested to sort of dig a little bit further in our procurement requirements to see if this features as strongly as it could. And Kate perhaps in the q and a, you might be able to enlighten us a little bit more on this one, but if not there's certainly something to think about.

So the last few slides, there are a couple of papers that I did find. They are old but the quotes I thought were compelling and still very real for us today. And it's touching on that sort of cautionary approach where we don't yet fully understand the balance point between the costs and the benefits. And we need a certain level of prudent examination in claiming that virtual care can give us those savings from an admissions perspective, but I do think there is a potential, and I do think if we do our homework then we can move forward from a stronger evidence base. And if we move to the next slide again, another quote that's over years old now but still a call for more accurate assessment of the environmental benefits and I think factoring in travel distance and doing those economic analyses would be really beneficial to see where we get the best value out of using virtual care and again I would employ I guess colleagues who are working in this space to consider that as we move forward.

So if we go to the next slide, this is my last slide, and yes it is a bit twee, but and I was going to take it out my husband sort of said oh who's your audience and do you think they'll you know accept this kind of you know pictorial presentation but my ten-year-old daughter was looking over my shoulder as I did this presentation and she just got a great kick out of some of the wildlife photos that were involved in in in this presentation that I inserted in here and it did bring home to me why we're doing this. You know, we are doing this for now but we're also doing it for the future and I think if you know, we can keep that wonder about our environment and our fascination with the environment I think that will hold us in good stead to keep doing the good work that we're doing. So thank you very much.

George: Great thank you very much to Karol. We're just going to get set up for our q and a session, and I’ve seen a bunch of questions coming through so if you just stand by we'll be with you shortly.

Thanks everyone for listening to our presentation so far and sending in your questions. I’ll start with a, I guess, a general one to anyone on the panel that wants to have a crack at it and then we'll move into some more specific questions. So value based healthcare is all about maximising outcomes and experiences relative to the cost of delivering care, how do you suggest we incorporate environmental sustainability into that equation?

Ellen: Do you want me to start and others feel free to feel free to jump in? I think the really critical thing about environmental sustainability is that this is not another thing that we want to do. Our key thing is to be incorporating this into everything that we're looking at. So you know, we very much are pushing for sort of the triple bottom line approach that is in any policy and every procedure and every initiative. What is, what are the health outcomes? That's always our first consideration. What is, what are the patient experience, the health outcomes that we're seeing? What are the financial costs? And then also what are the carbon costs as well? So it's about integrating that sort of lens, that climate lens I guess, or the carbon lens into all of our assessments. I think that's you know that's what we need to do. We have a lot of work to do in, sorry a bit of an echo in our, within our unit in terms of metrics and looking at a robust carbon measurement and then baseline footprint and then measuring monitoring that going forward. But I think in everything you know in Karol's virtual care strategy and in surgery what are the starting to integrate carbon costs into that it is the approach.

Kate: I think for me we're certainly driven in the virtual care space by the patient experience and the clinician experience. And I’ve sort of talked through the efficiencies from an environmental perspective. Yes, there are efficiencies potentially from a financial perspective but we are very strongly led by what patient choice looks like for virtual care and supporting clinicians to have a positive experience in delivering the care virtually. And certainly the monitoring evaluation work that's being done for the virtual care strategy has triangulated data and part of that is the patient experience and the clinician experience. They spent quite a bit of time last year developing a baseline for those. So for me, it all lines up certainly from a virtual care perspective. And I would just add that I think it needs to be built into the change process.

Karol: I agree with Kate that it's another facet of the existing processes and I think it's got to be present for people and we've got to start small and build it into those actions and those change processes because I think often people are overwhelmed by the by the size of this problem. And I think the other thing is in terms of reflecting on patient experience and staff experience, I think this is an expectation of the community. I think there's a really strong ground swell in in terms of the community's views about what we should be doing on climate action and I think they have an expectation that health is a part of that definitely.

George: I think all three answers really resonate with me there when thinking about the value based healthcare and our quadruple aim objectives it is really part of all of those objectives isn't it it's part of the cost and as Kate said that triple bottom line approach and building on your comments there Ellen it is part of better outcomes and better experiences, so I think it's fundamental building off from one of the points you raised Kate about sort of incorporating it into everything.

How are we going to build capability in our staff across the system to better consider environmental impacts in their you know projects, business cases, evaluations, because probably not something that everyone's thinking about each day. So how do we make that business as usual?

Karol: Yes that's a that's a big question George. So we have to train up our whole system in sort of carbon costing, carbon accounting. It's no small task. I think you know it's critical we have a, staff engagement is one of our you know responsibilities as a unit. We're setting up a web page, setting up the right structures, offering webinars. We'll be piloting a group of, offering places for or staff to go on a carbon accounting course, which is run out of the Centre for Sustainable Healthcare in Oxford to see you know what the feedback on that sort of thing is. So I guess you don't have to have and then with our net zero leads, some experts specialists in their areas who are aware of this sort of thing.

George: So you know that that's their initial plans but I mean yeah there's a huge there's a huge amount to do you know because you're right this is this is new for most people you know many people pick up on Ellen’s point so many of our staff care passionately about this sort of issue and they want to be changing but who don't yet have the skills or the to do that, so yeah it's an it's a big question. And Ellen a question from you that was raised during your discussion was clearly there's a lot of evidence for things that are low value care or not providing great benefits, why is that not translating into action? In your opinion, what are some of those barriers for disinvestment, when clearly the evidence that it's more costly or not providing good outcomes for patients is there?

Ellen: Yeah, excellent question George. I think there's a bit in that I think the evidence changes so quickly that it can be hard to keep up with it. I think we also have to own that it can be challenging to actually make a change. It's you know when historically, we've been doing the arthroscopies for osteoarthritis and that's been the way of doing things. It can be hard to suddenly introduce that change into the process and to convince people of the evidence and I think it's about how do we make sure we've got that localised data, that localised experience, those localised outcomes, to be able to influence that discussion. But also how do we have those levers of change? And we know that they can be quite simple. It's often that just by putting it in front. We know in the case of knee arthroscopy as an example that where clinicians were asked to seek approval of their Director of Surgery to conduct an arthroscopy, it had a massive impact in terms of reducing the amount that actually occurred. So I think it's also about finding the right levers of change. And then I think the last thing I’d say is it's about partnerships right? It's partnerships with clinicians and managers, it's partnerships with all of those key societies and specialist groups who have a role to play in this so that we're all talking the same language.

George: Great thank you Ellen. Segueing there, you were talking about the levers of change and probably a question to both Kate and Karol for your respective areas: what are going to be some of those levers? Are we expecting to see sort of KPIs and targets and how are we going to drive some of this system change? Might go to you first Kate.

Kate: Yeah I can talk to that. We have been asked to develop some fairly firm KPIs in the service level agreements around virtual care. It's focusing solely on the outpatient space at the moment. We do have a lot of work to do in the outpatient space in terms of embedding virtual care into outpatient models for various cohorts, but I also have been asked to develop some deliverables not just around activity and I’m very so very cautious around focusing on outputs because that is not what we're talking about when it comes to value based healthcare, so some other deliverables that that we will be featuring in the service level agreements for the next financial year are focusing on LHD engagement in embedding virtual care and outpatients and also engagement in remote monitoring and this is for disease cohorts that aren't covered positive patients necessarily but for the leading better value care cohorts. So some of those really you know the reasoning what you know for some of some of the cohorts for leading better value cares to you know why they were chosen as a focus you know fit very well with the remote monitoring work that we're doing so that's certainly going to be part of the service level agreements going forward however I am repeatedly told by my colleagues in the CEC, you know the philosophy of value-based health care is again, not about our outputs it's about outcomes, so my preference is to work on relationships and I guess I’m trying to bring people along for the ride rather than sort of use the more punitive methods to get results. But certainly it is a tool that that that we'll use but my preference is to sort of do things in a more pleasant way.

George: Thanks and what about in the environmental sustainability space Kate?

Kate: Yeah no thanks George I mean well already we have some performance deliverables out for discussion in the service level agreements. They are you know about identifying you know carbon hot spots and starting to you know set up identify leads those sorts of things. Look at your adaptation and so on so it's signalling that you know it's coming yeah. There is an expectation we have a NSW government target of having emissions by so we expect that there will be KPIs you know but we need to get the metrics right first. We need to know what our footprint is and actually have a robust and transparent and fair way of measuring that and just to pick up on a point that Karol made in her presentation it's critical with his stuff we have good numbers. You know it's all well and good to say we're going to measure the carbon savings, this patient's postcode, they didn't have to travel this distance and it's that much saving but to we need high quality evidence. Did we have to purchase more equipment or laptops? You know, what would or do people have them anyway you want to know which might be the case you know. What is the extra equipment? What is the what's the energy source for running that equipment? Is it dirty energy or if it's renewable, that makes a big difference. And I’ve seen you know some papers also about clinicians concerned that they're actually ordering more checks, because they can't see the patient, they're ordering more tests you know which is obviously an issue. So we need good quality evidence before we can start to measure those things.

I mean from what I’ve seen overall, I agree with you Karol. I think there are significant benefits of telehealth in Australia particularly given the big distances that are involved in many cases, but we need a more solid evidence base before we can confidently put things in KPIs so I think there's a lot of you know there's a lot of work to do in that space but we need to start there with action research starting to measure the carbon cost as we're going along so that we build that.

George: Yeah it definitely seems as though this is an issue that touches every part of the healthcare system. A question about virtual care. Karol, you talked about some of things like you know remote monitoring and other innovative technologies, has there been any discussion about augmented reality and as part of virtual care?

Karol: Not here yet I think we would probably scare the horses. I think at this point we're looking to start in the obvious places like our patients using telephone and video conferencing. It's not to say that there aren't some really innovative local health districts that are doing some amazing work in really high-tech spaces but I think as a system provider we're looking to get some really strong foundational consistency across the state in terms of use of video conferencing in particular and remote monitoring. We see that over the next couple of years is providing the best value in terms of our energy and focus our energy so not at this stage it's very foundational at the moment. We're looking to build that strength across the state.

George: Great thanks Karol. I think all of you mentioned NSW leadership in the space of you know virtual care and environmental sustainability and identifying and addressing you know low value care how can we influence I guess providers outside our direct control so I’m thinking for example the private sector where there's you know high volume potentially some lower value care in that space because our citizens obviously see themselves not as you know seeing NSW Health seeing their GP, seeing a private provider, they see us as one health system. So how can we influence other areas? I might throw to you first Ellen in terms of influencing care provided in the private sector.

Ellen: Thanks George look I think it's some of those things we've already talked about. How do we ensure that we've got local data and local information and local evidence? But I think it's also around what are the other options that are available to us in terms of influencing for example the private providers? I think the insurers are key. I think increasingly the health insurers are looking to what is value-based care and they are giving consideration I think to other these other areas such as environmental sustainability as well purely because their communities are saying that to them. So I think it's about being open to a range of, a whole cast of characters who can contribute to that discussion and have influence. So insurers are one but how do we leverage groups such as even the national registries? What are the roles of the other jurisdictions and how can we have a partnership approach that might be about what we're going to do in NSW, Victoria and Queensland? And why do we have to stop there? So I think it's about being open to a range of partnerships.

Kate: I might just add to that George if that's okay the Commonwealth stands out for me is one of the bigger ones that I feel that NSW could be a leader in you know sort of lobbying in terms of certainly from my perspective, some of the MBS items around telehealth and that space which is quite fraught but I do think that I’m just picking up on Ellen’s point joining with other jurisdictions that are at a sort of a similar level to where we are in terms of maturity can be quite compelling when approaching the commonwealth to sort of lobby them in that space. I know there was a focus on private providers in in that question but I just always bring the Commonwealth into the discussion because they're so key. And just to add from an environmental sustainability perspective that's critical for us as well, we need international leadership on that particularly. If you know pharmaceuticals are about carbon footprint you know what are we doing on a national scale you know we know the international farm companies and others are moving but how we're doing that and MBS items and so on there's a lot that needs to happen there. I speak a lot with my state counterparts, a lot of other states are setting up similar units to us, but there needs to be there's a clear role for national leadership there. I think lots of things that we can't do ourselves and then also I mean we in sustainability we're looking to work with a range of partners you know medical and nursing colleges have very strong targets on this the AMA has said we need to be net zero by and I think bodies such as the Australian Commission on Safety and Quality and Healthcare is key. Now as you may know they are developing a climate risk module that will be optional in the first instance but with a view to becoming a mandatory part of hospital and healthcare accreditation standards, so these are the importance of policies and labours that we need to be you know working together with.

George: I might stay with you now for the next question Kate. One of the ones that came through in the chat was all about the impact of single use products in our health system. Obviously throughout the COVID phase with masks and all the card testing that's become a big issue. Are you aware of any particular projects or work underway to address single use?

Kate: It's a huge topic I mean there and there is there is so much to do I guess we are speaking a lot with I mean DPA, Department of Planning, the environment have a sort of circular economy team. So the idea of course is that we, I mean, I guess from our perspective the first thing is to think about the waste hierarchy. It's reduce, then reuse, then recycle okay? So the first point ties in very well with value based healthcare - reducing using items in the first place. And we'll share, no, we're trying to have a, you know, very good sustainability policy. Would love you know not to be dealing with so many thousands of items, so that's the first point. And then you know recycle. So that, but that's like the next best option. But you know we'll always have to use plastics in healthcare, you know they're actually very useful in many, in many circumstances. So how can we set up appropriate circular economy type projects in that whereby high you know plastics which are very, in many cases, healthcare plastics are very high quality plastics, can be you know captured and reused and recycled into new products? There are a number, I know DPE and ourselves are speaking with a number of plastics manufacturers and providers who are coming in a lot of the ones I’ve spoken to won't be set up and operational, so until sort of next year but it's something that we're you know actively exploring. And I know been a sustainability in the districts now for four years, I know that it's the number one, you know, plastic pollution waste, number one concern for staff, but also patients and visitors as well, when they see those sorts of items. So yeah, there's no magic wand there's a huge amount of work to be done there and probably some that, you know, we'll start with some of the high use areas – theatres, critical care areas - those sorts of things. But yeah it's on it's on the list.

George: Something I might finish up with, a final question for each of our presenters and it's really, if you could give one key message to staff across the health care system, how would you advise them to consider your, I guess, work in their respective roles? So you know Karol, like what can people out there be doing whether they're a nurse or a health service manager to embed virtual care? Kate, in terms of consider environmental sustainability in each of our diverse roles, and Ellen, as well, the impact of low value care? So I might start with you first Kate, I’ll then go to Ellen and then I’ll wrap up with Karol.

Kate: Yeah so I mentioned our net zero team. So this is, you know, the way to sort of engage and support our staff. And the key task for those leads is how do you rethink and reimagine your service or your specialty with a net zero lens? What does a rehabilitation service look like in a, you know, carbon neutral or low carbon world? What does an anaesthetic service look like? What does, you know, plastic service look like? So that's the sort of thinking that we want don't get caught up too many of the small things, you know, recycling is important, but you know, really what are the big issues? But to do that we need to understand, you know, carbon costs and so on. So I’d say, you know, hopefully over the next few months, we'll be setting up, there'll be sustainable events and clinical leads in every district and net zero teams and leads. So that's the way, you know, connecting up with, you know, like-minded colleagues in your areas. And some of them will understand that the carbon, you know, the hot spots and then focusing on those areas. So that's, yeah, that's the regard. It's about imagination really and creativity.

Ellen: Thanks. I would add, George,  just to what Kate said, that I think its about also taking the opportunity to become informed. Become informed about the evidence, become informed about what's happening locally in NSW and in Australia. Often you don't have to reinvent the wheel - someone's already had the idea. And I think part of the low value care discussion or the value-based care discussion or the environmental sustainability piece is about starting the conversation. It's not about trying to do the really minor thing, it's about building that momentum. And I think you know you can't boil the ocean and you can't do it by yourself. So I think it's about creating that community around you, so that you can tackle those slightly bigger problems, as Kate said, rather than just sort of biting off around the edges. So I think that's the, that's the part where I’d start.

Kate: Sorry can I just jump in. A quick plug. So our new team will be setting up a website, which we want to be the like one-stop-shop. So all the best information, you know, in each of those areas, you know starting out with areas. So that should be a really useful resource for people. Also webinars and other things, so that they can start to as Ellen said get informed about this. You know, it's the first step so it should save you a lit review. And I will just finish off by saying what I say quite often, and that is to not treat virtual care as if it's a separate way of providing care. We are in the business of treating virtual care as a BAU way to deliver care. Yes, there are things we need to do to make that a smoother way of delivering care. Certainly from an ICT perspective, education and training for consumers and clinicians, absolutely, but to not to not treat virtual carer as if it's some sort of an exceptional way of delivering care over here, and then face-to-face care is our BAU. We're looking to weave it into BAU. So that would be my message. Consider the patient and what's suitable for them and if it works, yeah, it's a normal option.

George: Well thank you very much, Kate, Ellen and Karol. I think your presentations today have been really informative and interesting and I think I’ve set a real challenge, but one that is very future focused and aligns completely with future health and our vision for NSW. I think what I’ve taken from it, and hopefully what the audience has as well, is how complementary all these approaches are and the synergies between them. These aren't about adding something new onto, I guess, an already fatigued system. This is about a perspective, and a mindset we can take to doing the work we're already doing. And really when you look at the vision for NSW Health, which is a sustainable health system that delivers outcomes that matter to patients and the community, is personalized, invests in wellness and digitally enabled, I think today's session has been a great demonstration of almost ticking all of those boxes. If we're able to focus on value-based approaches that consider environmental sustainability as part of the outcomes, and costs that look for digitally enabled ways to improve outcomes, and to look at the and question, the care that we're providing and ask does it improve outcomes, experiences and what's the environmental impact? Then I think we're well on our way to achieving our future health vision. So thank you everyone for joining us today, and remember, recording of the session will be available if there's anything you missed and wanted to read again. And please feel free to reach out to any of our presenters for further information.​