Understanding the tipping point: When elective becomes selective in NHS surgery

Simon Parsons (Divisional Director of Surgery at Nottingham University Hospitals NHS Trust) joins Tom Clarke (Director, Mtech Access) to discuss how decisions, such as the postponement of non-urgent elective surgery, are made, the impact this has on patients and staff, and how the NHS might adapt to provide care for these patients.

In addition to his role as Divisional Director of Surgery at Nottingham University Hospitals NHS Trust, Simon Parsons is a Consultant Oesophago Gastric Surgeon. He works as part of the team of gastro-oesophageal surgeons in Nottingham carrying out a full range of cancer surgery on the stomach and oesophagus.

As Divisional Director, Simon is passionate about transformation of surgical services and believes technology plays a pivotal role in this transformation.

Simon is also a director of EIDO Healthcare Ltd., a company specialising in information for informed consent. EIDO has used technology to transform the way it delivers its services.

We were delighted to welcome Simon to the #WhispersWordsofWisdom series.

This podcast was first recorded as a video on 23rd October 2020.

Learn more about our NHS insights services at: https://mtechaccess.co.uk/uk-nhs-insights/ 

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Transcript

Tom Clarke: [00:00:32] 
Welcome to this special edition of the Mtech Access Words of Wisdom webinar. Today, I'm delighted to be joined by Simon Parsons, the Divisional  Director of Surgery at Nottingham University Hospitals, NHS Trust. Simon is joining me today to discuss what it's like to be responsible for surgical services throughout this COVID pandemic against the backdrop of the Trust's recent recent decision to suspend some non-urgent elective surgery.

Simon will explain the challenges, his trust and others face in maintaining activity and how they might adapt to provide appropriate care for their patients in the future. Simon welcome. Thanks for joining me today. could you briefly introduce yourself and your role please? 

Simon Parsons: [00:01:19] 
Yeah, sure. Thanks a lot, Tom. I'm regional director for surgery. We have 2000, staff in the surgery. It's one of five divisions in, Nottingham University, Hospital  NHS trust, which is one of the biggest trusts in the NHS.  Most of my life has been, dominated by the hospital's response to COVID,  over the last few months.

Tom Clarke: [00:01:46] 
Thank you. So your trust is obviously under huge pressure at the moment. Can you just summarize how things feel for you and your colleagues? 

Simon Parsons: [00:01:54] 
Yeah, well, we are all pretty tired  and, we have spent the last six months initially, responding to COVID first time round. And, you know, there are a lot of lessons that we've learned along the way.

And then it was a case of as COO as the first  COVID peak dropped, you know, let's get back to normal and catch up with all the things that we've stopped doing. And so we were really going flat out on that and we would just getting up to, normal levels and just beginning to put a dent in the backlog. And then suddenly the second wave hit a little bit sooner than we were expecting and a lot harder than we were expecting.

So the staff were pretty tired, and having to go again, you know, the, the morale is not, not brilliant right now, but we're, you know, we're all pulling together and, we'll see this thing through. 

 Tom Clarke: [00:02:51] 
Fantastic. Let's hope so. How does this differ from the first time around ?

]Simon Parsons: [00:02:56] 
Okay. So it's really interesting because the first time around, we obviously were completely in unknown territory and, You know, we saw the horror stories coming out of Italy and China, and we pretty much shut down all the non-essential, elective work.

So endoscopy shut down apart from emergencies or their elective surgery shut down, outpatient shut down, and we stopped doing everything that was not essential. In addition to that, of course we had the lockdown and, for,  certain emergencies also stop like major trauma. People weren't driving their cars fast, they weren't outside. They were. safely tucked up in their houses. And so we had very little major trauma, which meant that we could, allocate those staff to the COVID effort. but also strangely a lot of other emergency work load reduced.  People stayed away from, from hospital as much as they possibly could. Whereas now, in the second wave, people are going about their business pretty normally, although we've got different levels of, of a lockdown and Nottingham is currently in tier two, although we, we expect, we may end up going into tier three. Nevertheless, there's still lots of people out and about doing their normal things working normally. And so the normal emergencies are continuing to happen. People aren't staying away from hospital because they, you know, there's been a lot of media over the last few months saying if you have a problem, you should go. And that is correct. but so our workload, our emergency workload is, is still a hundred percent. We're keeping going the outpatient clinics. And, we're keeping going as much normal work as we possibly can whilst also trying to deal with, a huge influx of COVID patients. So, that's quite a difficult combination, you know, when, when we were shutting down elective work initially. then we had extra resources to cope with COVID. The other difference is that, in the first wave we use the independent sector a lot, and that's not, we don't yet have an agreement with the independent sector to, help us with the elective surgery workload. So lots of differences, which actually, make it a lot more difficult this time round than first time round.

Tom Clarke: [00:05:40] 
Are there any positives this time, the things that might be, you might be better prepared for, it might be easier this time around?

Simon Parsons: [00:05:48] 
Yeah, well of course we do know a lot more about COVID than we did six months ago. And, you know, the NHS has been one of the leaders in COVID research, and Nottingham, played a full part in that.

And one of the things we're seeing is at the moment, and we hope it continues that although we're seeing similar numbers of patients needing to come into hospital quite as high patient number of patients going to intensive care. So that's encouraging. And you know, we hope that we will be able to get a lot more patients through mission, and hopefully, although intensive care is filling up, hopefully it won't be quite as much of a pressure point as it was in the first week.

Tom Clarke: [00:06:37] 
Yeah. Okay, wonderful. Thank you. You've obviously mentioned about the, the scaling back of, of surgery services. one of the first trusts in the country to take the decision to reduce non-exec non-urgent elective surgery.

Can you just talk us through the, the decision-making process behind, behind that step? Yes. Okay. So there, there are two major components to this first, the first thing to say the risk to the patient. And the second thing is resources. So let me just expand on the risk to the patient, because we know that, from initial data that came out about COVID, is that the patients with the highest risk of death or patients who catch COVID whilst having an operation. So there's really quite an alarming rate that was published in The Lancet. There was a big paper in The Lancet suggesting that back 20% of patients having elective surgery, actually died if they also, if they had COVID now we, we were very alarmed by that first time round. We were very cautious in reintroducing surgery, but actually we, we have avoided anything like that. In fact, we've had very little COVID related harm in our surgical patients because we've set things up to keep them free of COVID and so forth. But that is nevertheless a concern that we still have that if our patients in the post-operative period catch COVID  then there is a significant risk to them. So for that reason, non non-urgent surgery and non-cancer surgery probably should at this peak, be deferred to a later and a safer time. However, of course, one of the risks with any pandemic is that more harm comes to patients without the, the pandemic, without the COVID, than with the COVID. So we absolutely do need to operate on patients with cancer and clinically urgent and emergency conditions. And, you know, part of my job is making sure we can do that in it, in a safe environment with a very, very low risk of them catching COVID. 

Simon Parsons: [00:09:03] 
So that's the, that's the, the risk to the patient side, but also there's the whole resources side of it. Andthe main, decision that we had to make last week, which was well publicized was the fact that, you know, now our hospitals are being overwhelmed with COVID patients and we can't do everything that there is, there are limited resources. And so as happens every winter, to be honest, when we have a really bad winter and lots of patients coming in with a winter viruses and so forth, then we have to sometimes reduce the number of elective surgery that we do.

 And that's what we're seeing now. But this time it's COVID and it, of course it's only October and we're not into winter yet. 

Tom Clarke: [00:09:50] 
Yeah. Okay. And obviously, you know, like you say, we're just starting winter or winter is around the corner. I don't think anyone's really expecting that things are going to improve, within the next few months, but how will you monitor, sort of your level of provision over the next few months, in terms of when you might start to either increase that non-urgent work or possibly even you have to scale things back further. 

Simon Parsons: [00:10:17] 
Well, just saying that we've been monitoring things day by day is an understatement because we'd be monitoring things hour by hour, and sometimes we've made a decision, in an afternoon and the next morning that decision is no longer. True because things have changed overnight. And so we're, you know, we're monitoring the situation hour by hour and taking decisions accordingly. And one of the lessons from the first time round is that we will very much, up and down, reflects our capacity, much quicker than we did first time round. The modeling data really has been pretty accurate. And so we got a pretty good idea of when the peak is likely to be. Of course we can't say exactly how bad it's going to be. And that depends on, you know, government measures in terms of tier two and tier three lockdowns and so forth. But you know, you know, we, we, are having to be very responsive, to the changes that we're seeing. 

Tom Clarke: [00:11:21] 
Yeah. Okay. So, so you've mentioned  the patient risk and the resources as the two key drivers in your decision-making, we've spoken with previous guests about the block contracting model and that the change in the NHS finance is obviously that that all changed from the beginning of October, does the financial position in terms of. The amount of activity you're going to be able to achieve over the next few months. Does the financial position have a bearing on your decisions around service provision? 

Simon Parsons: [00:11:53]
To be absolutely honest? No. that's not, it's not a limiting factor. You know, the government made it very clear that whatever was necessary, they would support and, They have done that, you know, since COVID, you know, we can all look back and, you know, I've been doing this role for three years. I'm stepping down now and handed over to somebody else, but over the last three years, we've been asking for money to  build new wards with side rooms and, and had we got that money that would have made a huge difference in how we could cope with a pandemic. Now we didn't get that money. And so we've had to make do, and in Nottingham, our, estate is very old and, it doesn't have many separate rooms. but. Right here right now, the money is not a limiting factor. The limiting factor is our estate and is our workforce. You know, that the nursing workforce in particular are really stretched. And, you know, if we wanted to open a half a dozen extra wards, well, we don't have the nurses to, to mandate, so we don't even have the nurses to open a single extra ward. So that's why we have to take down certain elective activity in order to allow the emergency stuff to continue.

Tom Clarke: [00:13:17] 
Yeah. Okay. Thank you. So inevitably waiting lists are likely to grow, as activities been reduced, what are your concerns about the people that you're not seeing at the moment? 

Simon Parsons: [00:13:29] 
Well, I'm very concerned about the people that we're not seeing. I mean, all the work that goes on it in a trust, all the patients that we see are patients that need healthcare.

It's not optional most of the time. now elective surgery,  can wait by definition. It's not something that is emergency or urgent that needs to be done in the next month, but it, it should be done in a timely way. And we are seeing patients who need surgery or need treatment of some sort, who aren't able, who we, who we aren't able to offer that right now.

And so waiting lists are going to, increase. And there will be some patients who will come to harm. We were very clear with our patients that if they're concerned about coming to harm, that they need to get back in touch and we will do our utmost to expedite. but nevertheless, we can't do everyone right now. So there will be the risk of patients coming to harm whilst waiting on all the waiting list. 

Tom Clarke: [00:14:38] 
Within the trust. What might you do differently to try and mitigate some of those concerns about those patients? 

Simon Parsons: [00:14:46] 
Okay. So, I mean, there's always things that we're trying to do in order to, do more for our patients.

One of the things when we don't have COVID patients, when the COVID rate drops and, and, COVID patients are able to return home and empty out those wards,  then we will very rapidly start up the elective program again, and then we'll be looking for more. And that's what we've been doing over the summer is how can we get back to normal?How can we be even better than normal? and you know, working, weekends and evenings and so forth. And the other thing that we have done over the first wave is work very closely with our independent sector colleagues. And that's been great because there's not much private work going on. And so using that capacity for our NHS patients has been really useful  so, we're trying to do that again. And, and, but obviously that first time around there was a national contract between the private providers, and the NHS government led. That isn't in place at the moment and that's causing a little bit of anxiety, but we're have good relationships with our, local independent sector. And we're hoping that we can continue to use that resource because without it, then, you know, patients are gonna wait significantly longer. So there are lots of things that we can do, but ultimately we have a limited resource and it has to risk bond to the emergency patients first. And right now it's, COVID, We will continue to do as much elective work as we can but, there is that only have that limited resource. 

Tom Clarke: [00:16:35] 
Yeah. Okay. So I'm going to guess the answer to this question, but are there, are there any opportunities, or would you be looking sort of within surgical pathways to make changes that might have a positive impact on efficiency, for want of a better word?

Simon Parsons: [00:16:51] 
Yeah, so, so I mean, that's one of the things that I've been, particularly, interested in over my three years as divisional director. How can we. make elective surgery more efficient and best practice. and. Of course, if we had the perfect real estate, if we had the perfect hospital, it would be a lot easier. We don't, we have quite an old, estate. And so  there is the limit and, and that elective work is not protected from the emergency work that we have to do, which I've just been talking about. And that is one of the restrictions and prevents the efficiency that I would like to see. but it's very much something that we're interested in making sure patients are at that peak fitness before their surgery,  the pre-habilitation as we call it, then they come in have enhanced recovery protocols during the recovery from surgery. As well as minimally invasive and robotic type procedures, which we're keen on. And then post-op, post-op, there's the post rehabilitation, trying to get patients fit again as quickly as possible and reducing readmissions.

So those are all things that. I've got a real passion about that we're really interested in to try and make sure those patients are treated in the most efficient way for them, but also in the most efficient way for the hospital and for taxpayers' money. 

Tom Clarke: [00:18:27] 
Yeah. Okay. You talked there about pre-habilitation.  Are you doing a thing with the wider system obviously  we're on a road to integration in the NHS? Are you doing anything with the wider system to help reduce the need for surgery in the first place? 

Simon Parsons: [00:18:41] 
So, yeah, absolutely. You know, we have one of,  the largest specialties that I deal with is orthopedic surgery patients, with hip and knee conditions. Often arthritis ,often requiring hip and knee replacement, but we know that, if they see physios, along the journey, then that can, give them a good quality of life for a period of time before they actually need their, that joint replaced. So we have community hubs where patients are referred up , for their knee pain and then they're seen by physios and they have a pre-habilitation program to try and get them avoiding surgery, ideally, but if they can't avoid surgery, then at least getting them as fit as they can before their operation. 

So that's really important. And we're working across the integrated care service, in the whole of Nottinghamshire to make sure we do as much of that as possible, delivering care, close to the patient's home, where that's possible. 

Tom Clarke: [00:19:50] 
And in terms of the surgery element to that, is that there's something that the Trust's leading or is it really a system effort to address the needs of your population?

[00:20:00] Simon Parsons: [00:20:00] Well, it's very much a  system- led thing, but the Trust is very much at the heart. Our chief exec actually, is in, is also the chief exec of the integrated care system. So, you know, we're very much in the heart of that, but yeah,  we recognize that if a patient can be treated in their local GP practice, why would they want to come up to the hospital for the same treatment? It's much more convenient for them and it's probably cheaper as well.  So, yeah, absolutely. But we've got to make sure that's safe and of a good quality. 

Tom Clarke: [00:20:39] 
Yeah. Okay. I suppose, the most, most prevalent, most prolific means of addressing the NHS is needs over the COVID pandemic has been the introduction of virtual consultations or at least the acceleration of the implementation of them.

In terms of that move, how, how do they impact on your own clinical practice and do they affect the way that patients actually engage within a consultation?

Simon Parsons: [00:21:05] 
Yeah. I mean, that's been a really interesting and a very positive thing from COVID and, you know, for every disaster like a pandemic. There are always lessons that we learn and good points that we can take away. And this, I think is one of them, the virtual consultation, it's something I've been trying to promote for a number of years, but, the traction has been quite slow, but suddenly within a few weeks, everyone was doing it. And, you know, it was slightly uncontrolled.  And you could argue that the pendulum swung swung a little bit too far now I'll explain what I mean by that. But, you know, I mean, most of the patients that we see in the clinic are now, telephone based clinics or video consultation. So we're, we're rolling out video consultation among in the trust, but you know that again, that takes a little bit of time. But there's a lot you can achieve with the patient over the phone or, the internet, video consultation. But of course you can't examine the patient. So there is a limit and sometimes, there's a lot of non-verbals that you can't, get as well if you are just doing it by phone, which is the way I've been doing it, it's simply because our clinic hasn't been prioritized for the video consult yet, but, Yes. So, so there's a lot we can achieve, with a virtual clinic. But one of the things that we, do with virtual clinics is,  we're normally being presented with a patient who has a provisional diagnosis and we still have to arrange for them to have imaging and so forth, which they're going to have to come up to the trust for. Once we got that imaging result back, we can come up with a diagnosis and a management plan, but then of course you have the whole informed consent, shared decision making process, which is really important. And we are used to doing that face-to-face with the patient, but we're having to think about doing that remotely now as well.

Tom Clarke: [00:23:12] 
So, so how feasible is that shared decision-making. Is it,  a significant shift in how able you all to do that? 

Simon Parsons: [00:23:20] 
Well, it's a barrier, so, so, you know, the fact that we can't, eye ball the patient directly, and, have the nonverbal communications is, is a slight barrier to s hared decision making, but obviously we, if so long as they can, understand English and speak to us, then we can, share that information.

One of the things that we we do is give patient information, to the patient, and we can email that to them. And, we can use digital technology now. to deliver that information. And so, so long as they can receive that information, then that two way communication, that interaction between the doctor and the patient can still happen. It is something I feel very passionate about. And, and in fact,  I worked with a company called Idaho healthcare that I've been involved with right from the beginning 20 years ago. And, that's all about sharing information with a patient in a way that the patient can understand.

 Traditionally, it was a paper form but now we've developed the technology to be able to deliver that digitally. and so that really helps, and, helps get over those barriers of, the breakdown in, or the restriction with the, virtual consultation. It remains absolutely key. You know,  we have to have the patient being fully onboard with the treatment that we're recommending otherwise  we're not doing the best for our patients. 

Tom Clarke: [00:25:02]
Yeah. That's really  important. And we've heard,  certainly I've heard from colleagues in primary care that  actually patients being in their own environment at home can actually sometimes be really positive because they're feeling safe in their own cocoon almost, do you find that in terms of patients sort of digesting information and being able to come to the right decision, is a home environment preferable for them than a clinical environment or have you not really noticed that.?

Simon Parsons: [00:25:26] 
Well, I think it is, I think, you know, the fact that the patient, if they can, absorb and, read information in their own time, not just in the precious few minutes that they're with the doctor. That's really important for the patient to actually, understand and come to a decision.

And yes, that has to be facilitated with a conversation with the clinician, because you know, the patients, need that. They need someone to be able to ask questions of things that they don't understand. So that's absolutely essential. but yes, it, you know, it does the fact that they're in their own home and there isn't the time pressure in quite the same way that that's that's good.

It doesn't help of course, on, on the old occasion where I've phoned a patient up and they didn't realize I was going to be phoning up and they were asleep in bed. Well, thats not the idea there's been relaxed and there is being over relaxed.

Tom Clarke: [00:26:25]
 Yeah, absolutely. Yeah. Just thinking, just pulling you back to, you mentioned in terms of the virtual consultations is something that you've been trying to implement for, for some time in the future. It's happened literally in some cases within the NHS that these technologies have come in, do you get a sense of frustration that you had spent a lot of time and then it was just one pandemic switched things on overnight. Or do you see that just as a positive? 

Simon Parsons: [00:26:57] 
I see it  as a great opportunity and, and we absolutely need to build on that.

I think it was a frustration before when there was, you know, it was quite a slow uptake, initially. I'm a believer in the single meaningful consultation. that is, you know, once the patient needs to come and see me as the surgeon, once all the results are in, and we know exactly what the problem is.

 I don't need to see the patient face to face to say, I need to send you for a test. So that's what we're working towards. We're working towards, being able to get all the results together, inform the patients of what the problem is. These are the suggested and now come and see the surgeon and have that single meaningful consultation where they can look me in the eyes, I can look them in the eyes. I can examine them. I can see what issues problems we might anticipate to at surgery. And we can have a discussion about the risks and benefits of surgery, and then we can make a joint decision together. So I think, you know, that's, that's what I've been trying to promote over the years. And, I think the experience with the pandemic has really brought that forward and accelerated that. 

Tom Clarke: [00:28:12] 
Yeah. Okay. Thank you very much. obviously we're talking about the virtual world or the digital world that, that we're, we're living in increasingly living in. Do you see further opportunities and do you have an appetite for looking at new technologies to help improve the standard of care throughout the trust throughout your system?

 Simon Parsons: [00:28:32] 
Yeah, absolutely. Look, I mean, we know that industry have a really important part to play and  in my role as director of EIDO Healthcare, I'm involved in that to some degree. Yeah. And you know, any, any good, idea, any good solution is something that not only will work in Nottingham, but we'll work across the NHS and indeed across the world. And that's the business model, you know, EIDO have come up with and that's true of all the other, providers out there and industry partners out that, you know, they've got, they've got a solution to a problem.  Now, not every solution. will work in  every situation, but you know, if it's, if it's a good one, then it will.

And, and of course, getting that digital technology to work in our hospitals for the benefit of our patients is something I feel passionate about. And actually Nottingham, also, sees that as a key way forward so that we can help each other industry and the NHS to develop a patient pathways, which are efficient.

We all recognize, you know, the technology we have in our pockets, the phones that we have know. Communicating with our patient. We can give them all that information, whilst they're at home relaxing and, you know, that reduces the burden on patients having to come up to a hospital. It also saves money for the trust in terms of keeping the patients out of the hospital when they don't need to be there.

 So that there's huge things that we can do. And I think we're probably at the beginning of the curve in of improvement in the NHS.  You know, with technology, in some ways is very advanced in terms of our imaging and, that sort of thing. But in terms of our computer systems that we use,  there's a lot, lot to learn from other industries.  If you think about, financial technology, you know, we all use banking apps and the technology just works brilliantly, doesn't it?  Why, why can't it work like that in the NHS? And that's what, sort of, again, another passion of mine, I feel that we can really revolutionize health technology in the next few years. 

Tom Clarke: [00:30:54] 
And would there be particular points in pathways that you're particularly looking at? Is it detection, diagnosis, treatment itself, or is it looking very open-mindedly at, if the right things are out there, let's try and embrace it?

Simon Parsons: [00:31:11]
 I think, I think all, all parts of the patient pathway. I mean, I think the imaging technology that we have is actually very good. I think that, you know, we've talked about, virtual consultations and there are a lot of partners coming into that space now, but it's a rapidly developing field, but we haven't got a single product that really does everything and it can be improved.

 So that's a really important, development area, which everyone appreciates at the moment. Yeah. But  there's electronic, referrals and how we can, triage those referrals so that the patient goes to the correct place without having to see me as the surgeon. I only need to see the patients who've had the tests done and have come back with a condition or a problem, which I can help with.

So, you know, that referral-based system is the digital enhancement. There is really important because. You know, we see there are a lot of referrals which are unnecessary. That's not putting any blame on anybody. It's just, just the GP is not sure whether this is a referral for hospital or not. Whereas if we had an electronic triage system, we could sift out and make sure the necessary information is accompanied, by the referrals. 

And then of  course there's reducing length of stay. That's really important. So can we manage patients at home, send them home a little bit earlier than we would do, but monitor their vital signs at home, you know, hospital at home type technology. And again, all that is developing. And we need just to bring all those things together in a coordinated way, so that we can offer the most efficient service for our patients. But again, if it's good for our patients, it's also cost-effective and good for the trust.

Tom Clarke: [00:33:04] 
Yeah, absolutely. Yeah. And would you hope to see more self care amongst patients as a result of technologies?

 Simon Parsons: [00:33:13]
 Absolutely. I mean, you know, promoting self care is really key. Patients do have to take responsibility for their health. and you know, it's not about just going and being sorted out by the doctor. You know, it's it  people understand much better these days about risk factors and balancing those risk factors and your chronic conditions are a really good example of how the patient with some, testing from, from the, the NHS, we can inform the patient of how they're doing on, on their chronic condition and what their markers are. And are they beating this disease or do they need to come in and have some further consultation for advice?

And actually many patients we can don't need to come and see the doctor. once they are empowered to understand and to be able to monitor that chronic condition without the doctor being involved. But knowing that they've always got that call back into the, into the system, if they need it. 

Tom Clarke: [00:34:20] 
Yeah. Okay, fantastic. So as we're coming into winter, as a lighthearted, end note, if you could write a list to santa  what, one thing would you ask for it? If he was a health tech company. What one thing would make your life easier if you had a technology there? 

Simon Parsons: [00:34:39] 
Well, I knew I was going to say a new hospital. I suppose that covers a number of technologies.

Well right now, I guess the problem is, is not primarily a technology solution, what we need now is, is more nurses. and, and, you know, to improve or encourage and support the morale of our nurses. So, you know, that's very much a human thing obviously, and maybe that's not the answer you want, but, that's the biggest thing that we could do with right now, you know, and,  I have to say the sort of, the clap for heroes, the, you know, that we had in the first wave was immensely powerful at encouraging the NHS staff who were working in it above and beyond.

Maybe that sort of thing doesn't happen to now we, of course we wouldn't expect it, but, you know, the NHS staff have continued throughout the whole period to do more and go above and beyond that. It's difficult as a manager to keep asking for more and asking for more, you know  . Our greatest asset is our healthcare staff and we just need to look after them and support them a little bit. Because it's going to be a tough winter for everyone. So if you've got some digital technology that can do all that, that would be great. 

Tom Clarke: [00:36:06] 
We've got a couple of minutes left. So what, what do you think your staff would ask for? Is it just understanding from the public that this really is a big issue? Is that the main thing that staff would ask for? 

 Simon Parsons: [00:36:19]
 I think staff would asks people to, you know, comply with the lock downs and restrictions that we haven't because they're none of them they're not perfect, but they're there to reduce the spread.

You know, we have to reduce the spread of this disease. They would ask that people look after themselves and yeah. And, you know, pay attention to those risk factors, like the obesity and so forth that, you know, we can do something about, so that would be the biggest ask and, you know, our patients  they're always delighted with the care that they get and they, you know, they're not, they don't, they're not the most demanding patients. They, they just so appreciative of the care that they get in hospitals. So, you know, I wouldn't say anything to our patients. They need to be there. And, and you know, we will look after them and make sure that they get the best treatment, but obviously for the community outside, you know, look after each other, do the necessary precautions so that we're not having to spread this infection further than is absolutely necessary.

 Tom Clarke: [00:37:28] 
Wonderful. Thanks very much time. And they are good words to end on there, sound advice. So thanks Simon for joining me today and thank you everyone at home for listening. we will be back on November the 13th with Dr. Peter Brambleby who's an interim director of public health. to have a look at the public health situation around COVID and how public health is working with the NHS to overcome this pandemic. So thanks again. Look after yourselves and we'll see you next time.