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Edge Talks November 2016: Fixing Patient Flow Transcript

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Edge Talks November 2016: Fixing Patient Flow Transcript

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Edge Talks November 2016: Fixing Patient Flow Transcript

  1. 1. SPEAKER: I am hoping you will be able to use the chat room to tell us what you think about the area, and also, use #EdgeTalks on twitter to let us know about what you think about flow. I am your host for today, and Dominic will be supporting in the chat room. Please use the chat box to contribute, and also tweet using the hash tag, #EdgeTalks. This is me, Janet Wildman, and Dom Cushnan here. We have been working with Sasha since June this year and he's a fantastic guy to work with. I have worked closely with him on a number of projects, and he has been a member of the Nuffield Trust, and has had a recent publication, "Understanding patient flow in hospitals." I am looking forward to hearing more about that. He has held a number of senior positions and will tell us more about tackling the complex issue that we are faced with today around patient flow. So, we will be looking at the recent Nuffield Trust report, looking at decision-making and complex environment, and what to do when data doesn't fit. So, I will hand over to Sasha and take it from there. SPEAKER: Good morning, everybody. It is a pleasure to be here talking about this topic. I found this first picture from a jigsaw. I think this is good in understanding flow, and I will take some time in understanding why. If looking for Christmas presents, this is a great place to start. I have been involved with flow for a long time and have been trying to understand the challenges. I have been working with colleagues to stand back and have a look, and I want to talk through that experience, hoping that I trigger some useful ideas. So, understanding patient flow in hospitals is what this is about, and I want to highlight a couple of pieces that are likely to be published soon, in particular the health foundation and what they are doing. I will look a bit at whole systems, but most of today's talk is about the in-hospital part. This is where the major constraint is. I want to start here, and one of the first things I did when I started with the Nuffield Trust was look at the four hour standard. In 2014/15, the top 12 trusts breached 4.2% of the type, so they were achieving just over 95%, and those furthest from this type had a breach rate of almost 18%. The differences are quite interesting. Those trusts that are furthest from the target are almost twice as NHS IQ Webinar (UKNHSI0411A) Page 1 of 13 Downloaded on: 18 Nov 2016 9:11 AM
  2. 2. big as those hitting it, and length of stay was only 0.3 hours. It probably only boils down to that, and solving that solved the problem of flow. So, we looked wider at what was happening in the system, and you can see some interesting differences. Those achieving the target by using more beds per person as opposed to those who aren't, and they have a higher admission rate which is slightly counterintuitive, and more space available at midnight. This got us thinking about those differences and what we could learn from them. So, we will tell you a bit more about that. So, one of the big challenges when in your individual hospital at any point in the system is trying to understand the perspective, and I thought I would illustrate this with a picture. This is part of a mosaic tapestry, and I'm sure none of you can work out what the picture is, but if you stand back a little bit, you can see who that is. It is actually Desmond Tutu. I think this illustrates the problem of needing to bring together information and ideas from lots and lots of different parts of the system, and to do that in a very nonhierarchical way. Bits of information are not more important than other parts of the story. What is critical is to build a whole picture of what is happening to inform what action can be taken, and I feel that very strongly, and we will talk about that more as we go along. What I want to say about the data is that most of it has originated from stories, so I firmly believe in the management by walking about, trying to improve flow in hospitals by talking to people at lots of different points in the system to understand their perspective. That is tremendously powerful, and then starting to add numbers to inform those stories, bringing the different parts together. I hope that gives a rich picture, and we will talk more about that as we go on. The work we have done in the Nuffield trust links together with other pieces of work that were recently published. This paper was brought to my attention recently, and instantly, you can start to see that there are lots of ingredients to get right. I will start off by looking at this for today's talk, taking those things out of order. I will talk about population, capacity and process. Firstly, the population is changing. This chart just shows the likelihood of spending time in hospital, and it's no surprise that the older we get, the longer we spent in hospital. It is quite profound. Most of us involved in this call today are probably likely to be spending no more than half a day on average in hospital per year, yet by the time you reach 85, the average is just under a week per person per year. Over the last six years, there have been small improvements, so people are spending slightly less time in hospital, but when you look at this chart in relation to future population change, you can start to see a potential problem. NHS IQ Webinar (UKNHSI0411A) Page 2 of 13 Downloaded on: 18 Nov 2016 9:11 AM
  3. 3. This chart shows that. What this shows is that, on the left-hand side, the number of beds that are used across the country in relation to age, so eventually, there are about 10,000 beds for people up to about 14, ranging up to just over 100,000 for the total population. By 2020, there is an increase, and by 2030, a bigger increase, leading us to about 140,000 beds if we continue working where we are today. That is a big change, and the question is, can we optimise our current systems to deal with that increase, or do we have to change the fundamental models we are operating with? We will discuss that as we go on. Someone has put in the chat box, this is largely a result of the post-war baby boom. By 2030, that group are increasing massively, and that will have a big impact on what we do. This underlies one of the key problems that are facing us at the moment, so people were routinely hitting the four hour standard in 2011, by 2014, they weren't. That use has been increasing and the number of beds available has been pretty flat. I think that creates a constraint, with more people trying to fit through a narrow gap, and we will talk more about that in just a moment. What is interesting is that that use is partly driven by population, and as the system gets more ingested, it takes longer to be treated, which is a double whammy. The classic question, which line would you like to change and which line can you change? We can say that we would like more beds, but is that possible? We have to train staff to work and operate all of those beds, which is also not that easy to achieve. In reality, we need to think much more about how we use the capacity that we have got. I want to use a picture to illustrate this, and we will all be very familiar with this picture. It tells us a lot about the problems that we are facing in hospitals. Firstly, that the design of the motorways has been remarkably stable for a long time, and typically they have three lanes. You can see a recent innovation of a managed motorway where we have bought the hard shoulder into use. It is tempting to say it is the extra cars that are causing the problem, and it is tempting to say it is the lorries that our problem. In reality, it is the interaction of all of the traffic in a particular situation. We need to think about that. I then thought I would illustrate some of the concepts of flow, putting a few numbers to this picture. Those who have read the report will have seen these numbers before. The left-hand lane is travelling slower than the right-hand lane, and there is variation across the lanes. The fastest driver complying with a 70 mile an hour limit should take about 28 seconds to cover a NHS IQ Webinar (UKNHSI0411A) Page 3 of 13 Downloaded on: 18 Nov 2016 9:11 AM
  4. 4. kilometre. This goes up from taking 28 seconds to cover a km to 37 seconds. As you get up to heavy congestion, you can see the number of vehicles in a kilometre obviously increases massively as does the journey time. This is really illustrative of some of the problems. If you imagine a congested emergency department and think through the amount of time it takes to care for the patients in a free-flowing situation, it might be around 28 minutes, and in this illustration, it is nearly 7 times more by the time you get a heavily congested situation, so the workload in a constrained area massively increases. As we all know, it is massively more stressful driving in those situations, so we have to think also about what kind of environment we are creating for people to work in, and more importantly, to be cared for. Let's try and apply that to a problem we are dealing with daily. I want to talk about it in these terms. How do we better measure and manage flow? What can we do to transform the way we look after people, and to what extent can we avoid the need for people to travel through the system? Starting off with a chart of occupancy across the country. It is relatively complex. You can see, we can week, the pattern of activity is pretty similar. You can see that over the summer the level of activity drops. You can see a massive fall on Christmas Eve when virtually nobody is left in hospital, and you can see the winter period over to the right just after Christmas. The red line in the middle of the chart with a couple of little steps in it is the number of beds recorded as available across the country. The dashed line right at the top of the chart is the number of beds you would have required in 2014/15 if you decided to apply the 85% rule. You can see at that level, there would be enough beds for all sorts of situations. You can also see a huge number of white space above the number of beds we actually use, which suggests we would have a huge amount of spare capacity for much of the year, if we use that rule. There is a judgement between the number of beds being used and the old, if you like, rule of 85% – where do you draw that line? The other important point is, should we be planning to merely cope, or should we be planning to maintain a consistent level of service? In many other walks of life, we as consumers expect to get the same standard of service pretty much whatever we want to consume it, and why should hospitals and healthcare be different? We need to be building insufficient resilience to cope not just today, but next month and next year to make sure the quality of the experience is high. The other point to note – this is really important – we used to measure and still measure hospital occupancy at midnight. In the old days when matron went round admit night and checked everybody was in bed, that probably made sense, but since then, we have massively increased a surgery on the day of admission surgery, the amount of emergencies and emergency patients spending less than a night in hospital has increased massively, yet we haven't change the measurement standard. I want to talk a little bit about that in a moment. But just to say that floor planning, actually plotting the data over NHS IQ Webinar (UKNHSI0411A) Page 4 of 13 Downloaded on: 18 Nov 2016 9:11 AM
  5. 5. a year, and ideally even longer, will give you useful information. It is an important discipline of being able to visualise what is happening, as opposed to just seeing data on a spreadsheet. This chart takes it further and looks at bed occupancy during a day across a couple of month periods where it is smooth data looking at each day of the week across a two-month period. You start off with… The zero is the bed occupancy at midnight, what you would normally see if you look at hospital occupancy. I have calculator this to say an increase in bed occupancy is a negative thing because we need usually to find more beds, so you can see between midnight, which is zero on the chart, and eight in the morning, occupancy in most hospitals increases. It is actually worse on a Friday and Saturday night for not massively surprising reasons. There is a net reduction in occupancy from 9 AM. By six, seven in the evening, is the lowest point of occupancy. If you walked into most emergency departments, I think you would be surprised by that because that is when the biggest queues happen. What is happening? We will come to that. One of the key points of this chart is to differentiate between the idea of the occupancy, which is actually not when most of the flows happening, and the notion of peak flow. Peak flow is when the grass is almost vertical, so lots of people moving each hour, compared to when the graph is almost horizontally flat when virtually no movement is happening, or net movement, in the hospital. You can see a big difference between the weekdays and weekends in this particular hospital. In fact, over the weekends, there is no net improvement in occupancy over the weekend. That is in many cases a problem. What happens when the system is not designed to deal with the flow rate? This charter tries to explain that. What you have is, on the top line, the flow rate per hour, so you can see that at four or 5 AM, just under 2% of the day's work per hour is happening, compared to 5, 6 o'clock in the evening, when nearly all of the activities happening. And so just to see what happens, this chart then said, what happens if we designed this system so that only 5.5% of the day's work and be done in an hour? This applies particular to things like hotel services potentially, how many doctors you have in the system, potentially how well resourced your radiology department is, but this chart is not specific. What you can see is, if there is 5.5% supply and demand any 8%, somewhere around 6 PM, you have nearly 10% of the day's work waiting. That starts to resolve somewhere around 8 PM, but there is still 4% of work waiting at 11 PM. We have ended up with a big queue. If you think of the work rate at around 5.5% per hour, you are adding almost 2 hours to patients' waiting time. The interesting thing to say about this is it is not just about the beds. You could have beds. You just cannot get people to them. It is a little bit like the motorway situation when you get stuck in a traffic jam, and then you find an empty road and you wonder what it is all about. This is the same. There may be beds at the end of the system, but because we have not matched the internal flow through the hospital, you cannot get to them. We will talk a little bit about that now. NHS IQ Webinar (UKNHSI0411A) Page 5 of 13 Downloaded on: 18 Nov 2016 9:11 AM
  6. 6. This is a slightly retarded point, but does your bed change to look like this? I defy anybody to stick into the chat box that theirs does. There is remarkably little data about what happens during the day, how long does it take to get a bed ready for the next patient, how long does it take to move a patient. One of the big challenges we have is that actually the systems we use in small hospitals and big hospitals are remarkably similar. I quite often like to test whether something appears sensible in one situation, is sensible when you look at it in a different place. Just imagine the twice-daily landings meetings at Heathrow airport where at 8 o'clock we have about 500 planes arriving today, and it will be checked what will happen at 2 PM, and see how it goes. Where you have a lot of movement, the need for real-time coordination increases substantially, and the ability to save only a few seconds and a few minutes matters a lot. How do you choreograph the interaction between teams in the hospital? It is an easy question to ask. It is difficult to do in practice. These sorts of interactions might be one of the ways we can at least make our existing systems work a lot better, and should be an awful lot easier to do than just building more beds. This does not have to be difficult. As I said when I started, lots of the information in this report has come from talking to people about their experience and trying to piece the individual parts together. A lesson I learnt a few years ago about how do you run an airline? They all have control centres and the interesting thing about them is they do not try and build one big computer system, they basically say the individual types of aircraft must have train crews to fly them. If you're flying 737's, you don't have to know much about 787's. If you're running a crew in London, you do not have to know about what's happening in Manchester. You coordinate between them. I think that starting to think about what each of your individual teams knows and how you can bring that information together in a more structured and real-time way take you quite a long way forward, but if you can move to real-time data, particularly where there is a lot of movement, it will help massively. I will explain a little more about that in a moment. One of the challenges of why this is important is actually that average length of stay is a varied measure of planning flow through hospitals. We are now in a situation where 58% of activity is zero day. That is clearly a mistake because people have been through and left. It is like measuring traffic over the Avon Bridge on the M5. If you measure it in the afternoon, it is very different to two o'clock in the morning. You have to work out how much the zero day patients are using. In this report, we assume it is 12 hours because there is no national recorded data. It is probably a lot less than that, but one thing that has changed more is the volume of zero day patients. Zero day activity increased over six years, and unless you have matched that, it is highly unlikely you will end up with the same thing. NHS IQ Webinar (UKNHSI0411A) Page 6 of 13 Downloaded on: 18 Nov 2016 9:11 AM
  7. 7. At the other end of the extreme, only 10% of patients now stay in hospital over seven days. They use 65% of the beds. Going back to the motorway analogy, when I talked about motorway traffic varying, this is a much greater variation. Those patients typically spend 30 something days, see you are looking at 50 to 60 fold variation, and that has huge impact on what is happening. Very easy to think we can go back to where we have come from, and I would caution against that. A lot of the reasons that have driven as to day surgeries, units, bringing people into hospital to get the right kind of diagnostic and interpretive skills are not that easily removed. For example, we created something to speed the process up, but also, to manage the directive. We introduced day surgery to improve the quality of experience and to free up beds. All of these changes have been made to improve efficiency and effectiveness of the system, but they come to a point when they create new constraints, so we need to think about new solutions to problems, and I just think that we can re-engineer the past. One key point of this talk is that we need to not look in the rearview mirror. We need to look at novel solutions that deal with the current problem, but also take account of the problem we will have in the future because the population is continuing to change. We are taking a medium- to long-term view as we make decisions. One of the big challenges is that people say it is all about getting people out into nursing and residential care, as well as getting the same amount of domiciliary care. This chart looks at people who were discharged, and there's been a 30% increase and length of stay has increased. We're not making sufficient progress to keep the system imbalance. When you compare that that increase to, for example, the space required for the zero day patients, it is not that far removed, and when you compare it to the likely increase of bed increase, that looks to be about 6,500 beds over the period that this report is based on. So, as fast as we are improving, other pressures are moving in the other direction, and that is one of the problems of our planning mindset. We hope we can improve from where we are, but we don't always wait sufficiently with the countervailing forces. So, before I come to solutions, I just wanted to pick up on a few thoughts. This challenge that we are all dealing with now to improve flow has emerged over a three- or four-year period, and we are only just starting to get a really good grip on what is going on. I would argue that our approach to problem-solving has contributed to that. This is a picture of the NHS IQ Webinar (UKNHSI0411A) Page 7 of 13 Downloaded on: 18 Nov 2016 9:11 AM
  8. 8. constitutional court in South Africa, and for those who have been to Johannesburg and seen this building, you will know it is a very powerful piece of architecture. The picture on the right hand side illustrates the atrium, as the big pillars that other men to replicate palm trees and the African story of, if you have a problem, sitting under a tree to think about it. Sometimes I can take quite a long time. Actually, sitting and talking, discussing, are really important parts of problem-solving, but doing it from a qualitative point of you without bringing some data to the discussion is not a good way of doing things, so balancing storytelling with data is something I would strongly advocate. The second part is listening and thinking in a structured way, and this is very illustrative of that. The windows you can see just behind where the judges are sitting, and those are symbolic. It is there to act as the public, telling us something important about the transparency of the process, reaching a consensus as a group. So, when we have these complex problems, thinking a lot about the decision-making environment and how to make it as nonhierarchical as possible offers real opportunities for speeding up the decision- making process. Just moving onto that and what else is a problem. When Nigel Edwards and I started looking at flow, one of the key quotes was that the current data doesn't describe the problem. That can mean that the data is wrong, but also, that the environment is changing. So, I think we have to use all of our senses to solve a problem like this, checking that the data is telling you what you think, but if it isn't, it is not time to sit back. It is time to think about how we can get new data. Intuition is important, and one of the key messages from this piece of work is that lots of individuals had key parts of the jigsaw but not the whole picture. The challenge of leadership is to build that whole picture in a way that gets appropriate action to happen. What the story does tell us is that the environment is changing. Over the last few years, death rate has been declining in the country, and it's now predicted to increase over a very long period. A lot of the past expectations of continual improvement need to change, and when you get those inflections in data, it is usually sign of the significant environmental shift, which means that planning assumptions looking backwards won't help very much. This takes us to the latest news. We contributed to this work, but yesterday, the House of Commons health committee issued its latest report on winter pressures, and one of their conclusions is really important, that the response is to focus both on managing the patient's journey through the hospital and in addressing the increasingly inadequate provision of adult social care services available to NHS IQ Webinar (UKNHSI0411A) Page 8 of 13 Downloaded on: 18 Nov 2016 9:11 AM
  9. 9. enable safe discharge. I think the key here is that we need to be doing both, so most likely, the best strategies, I think, are to improve data collection as part of workflow. We are also thinking about longstay patients, and if you could halve the amount that people were spending in hospital, you would release about 30% of the current bed stock. This would move us from having a bed problem and a flow problem to organising out-of-hospital care. So, as we move to solutions, think how to speed up the journey. Think of what is required. One size will not fit all for people, so it needs a differentiated and thoughtfully put together approach. So, in conclusion, the environment is changing rapidly, and we all know that we can't tackle it the way we are at the moment, and that we need to find different ways of managing flow, thinking through the needs of different segments of patients in the system. I will leave you with this picture. That's what comes out of that jigsaw that I started. I think it is time to remove the blockages, and for those of you who are interested in the theory of constraints, that is absolutely vital. I will leave some time for discussion, and I hope that has been helpful to you. Janet, do you want to… Come in and see if there are any questions? JANET: Thank you. That was fascinating. There has been a lot of activity in the chat room. I wondered if I can go over to Don to get a summary of the things that have come up there and on Twitter. SPEAKER: Apologies. It looks like we're having some interesting conversations. One of the questions that has come up is what is driving the zero day patient trend? There is a separate conversation around real- time tracking. SPEAKER: I think what is driving the trend is multifactorial. It is not completely clear. I think it is coming from two directions – one is were getting better at solving problems faster, so some of the growth is by stopping the need for one or two day stay in hospital because we are much slicker at it. Some of the need is this increase in complexity, and in GPs on doing a fantastic job of intuitively managing people with increasingly complex needs, but the size of the population with three, four, five long-term conditions is growing enormously, and you get to a point where you need access to specialist diagnostics, and you NHS IQ Webinar (UKNHSI0411A) Page 9 of 13 Downloaded on: 18 Nov 2016 9:11 AM
  10. 10. need that in a coordinated way, which at this point in time is difficult to do outside a hospital setting. So I would say those are the two key nonelected pressures. On the elective side, again, more and more day surgery is happening, so all of those things are good, but it requires a different standard of flow management, and the move towards real-time data to do it slickly, I think. In terms of data collection, I think it is really, really important. A few years ago I met a chap who was the research director at Microsoft, and he was actually a doctor by training. We asked him, "Have you any tools to manage flow-through hospitals?" He said he would love to solve the problem. It was so difficult. It was easier to map traffic flows around Seattle. At least the staff could get home in time and think about it. Over the last about five years I've heard that story. Over those five years, the ability to get data really cheaply has changed exponentially, so very few hospitals now don't have Wi-Fi. We have a whole raft of tracking devices, we have new sets of tools around visualising data, and I think there is a role for many of these, but it is really, really important to think about the workflow and experience we have designed both for the patients and for the staff. If we simply add this into a chaotic system without thinking about how to simplify, I think will end up in a bad place. Just to illustrate that, asked the designer to have a look at some of the patient flows for complex patients and one of the hospitals I worked in. He said, do you know how questions are asking patients? The answer is 1400. Some were duplicates. We had invented 28 different forms for the staff to fill in. You can't think that process will be very quick and all of those questions will be that relevant to the safe delivery or the efficient delivery of care, so I think we need real-time data, but we really need to think through how to present that to people in a way that is useful to them. SPEAKER: Interesting. "Is a motorway more like the flow of under 65 patients rather than the patient's use in hospital today? SPEAKER: It is a very good question. I think the interesting thing about traffic is it represents everybody, and I think the flow through a general hospital represents everybody, so you will get some people on a motorway travelling one junction, you will get some people who you would not want to be driving next to, because they aren't quite as aware and responsive as others. The same applies to hospitals. We have a pastoral people moving very quickly, but we have some slow ones. I think it is a reasonable and allergy. I think the important point, though, it is not just about the people using the service, it is about the interaction between them, so if you think about your own car, it is perfectly capable of travelling at least the speed limit, but if you're stuck in congestion, you will not be able to use that potential, so actually it is the interaction between patients that matters as much as the specific types of patients in a flow situation. NHS IQ Webinar (UKNHSI0411A) Page 10 of 13 Downloaded on: 18 Nov 2016 9:11 AM
  11. 11. SPEAKER: Thank you, Sasha. One comment – Melly says if staff and patients think beds would be a solution, but we can do for them, it would be a massive barrier. But it is more about safety. We must value our patients' time and we need to deliver this message in a strong way, and we cannot afford beds. SASHA: I think that is a really good point. I know that if I suffer a poor experience, it makes feel angry and unhappy in a hospital situation. I think that notion of valuing firstly the patients' time, but also valuing colleagues 'time might well help us handle the resource constraint. SPEAKER: That is really helpful. We are slightly early, but I found that hesitation fascinating. What do you project for the next couple of years going forward in terms of flow? Do you think we have the right technology, right know-how, right approach to how we manage data to move this to another place so we will not be having the same conversations in a couple more years? SASHA: That is a challenging question. I think we really difficult. The challenges are real. We will have to run faster to stand still. That said, there are significant numbers of really innovative players in the tech sector who have interesting ideas and approaches that could make a big difference. I'm aware of really interesting innovation in out-of-hospital care that is starting to make a big difference. Those sorts of innovations, the harder we do rehabilitation, how do we systematically enable people to connect to voluntary help in their communities and so on? I think, for those who are entrepreneurial, those who really want to make a difference, the next two years could be really exciting. The biggest danger is saying it cannot be done, or trying to be too cautious. I think we need big energy, and to use the best skills that exist within the health service, also the best skills that exist without it. SPEAKER: In terms of having three main points you would make to NHS England and maybe MPs today, what with the three main points be following some key issues you mentioned? SASHA: In terms of your last point, I think we have to aim of the problem as a system. We have to be precise about the request to MPs and people outside the system. This is largely a technical problem, but we have to have a very clear ask, how would we like customers to respond? What help do we need from wider society? I don't think we should ask a panic to a general question. NHS IQ Webinar (UKNHSI0411A) Page 11 of 13 Downloaded on: 18 Nov 2016 9:11 AM
  12. 12. My key message regarding problems is this is not a time for people to be acting in a hierarchical judgement away, it is time to be acting to be bringing the knowledge they have to the table and to make sure we use all of the parts of the jigsaw, not just a few of them, because it is a very complex situation, it is a fast moving situation, and that implies the need for very active teamwork, so my metaphor for that is the Apollo 13 film, for people who have seen it. We need that kind of urgency and collaboration to really drive innovation. SPEAKER: I wanted to go back to your role within Horizons. How do you think the team and what we do could not necessarily resolve the issues, but bring it up to the priority list for NHS England to address? SASHA: in a number of ways. One of the really interesting things is there are lot of people close to the front line, involved in the school for healthcare radicals who have fantastic ideas, and we can help, I think, in convening those ideas and helping people to test them and put them into action as quickly as possible. The other thing we can do is to share our knowledge of innovation happening in the world. Early in the week I was talking to some European colleagues. They were judging a connective health award. We had ideas from all of these sorts of themes I talked about earlier on today, so we don't just have to look within the country, there are some interesting ideas emerging right across Europe and around the world, so I think we can share some of those ideas and hopefully get them into action faster. SPEAKER: Fantastic. That is it for now. Do you have any last minute thoughts you need to share? I think you've taken us through quite a journey today, and a lot for us to think and reflect icon. We have a couple more minutes. Is there anything to end with? SASHA: I don't think so. I hope that has been really useful. I am happy to respond to questions or thoughts that people have after the event, and if there is anything we can do to help, we are open to having a conversation about that, so I hope that has been useful, and it has been a pleasure to put together. SPEAKER: I think everyone in the chat room would like to say thank you. It has been helpful, useful and lots of positive comments coming through. We appreciate you sharing all of your expertise with us today. We are going to be talking about the next Edge Talk coming up shortly. Empowering people to be heard and helping leaders to listen. We look forward to seeing this and hearing about this fascinating subject. We afford you coming on the next Edge talk session. We hope you have a fantastic weekend. Thank you for contributing and supporting the session today. Thank you to everybody. Goodbye and have a good weekend. Bye. NHS IQ Webinar (UKNHSI0411A) Page 12 of 13 Downloaded on: 18 Nov 2016 9:11 AM
  13. 13. SASHA: Bye. NHS IQ Webinar (UKNHSI0411A) Page 13 of 13 Downloaded on: 18 Nov 2016 9:11 AM

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