Ep 24. INNOVATORS - Pioneering cost-effective biologics prescribing with a shared decision making tool

Can a new web tool drive shared decision making and cost effective biologics prescribing across NHS trusts?

In this episode of our Innovators mini-series, Emily Rose-Parfitt and Philip Hamann join Lizzy MacPhie to showcase the truly pioneering RxInvolve web tool, which aids shared and clinical decision making for biologics prescribing. With patient feedback indicating high satisfaction, plus cost savings of over £200K for North Bristol NHS Trust in its first year of use, development of the tool won the team a 2024 BSR Best Practice Award. 

Our guests discuss how the RxInvolve tool can be used effectively in different clinical settings, lessons learnt from their funding and development journey, and their exciting plans for expansion across Trusts and specialties.   

Want to find out more? Explore these further resources:  

• Find out more about the team’s award-winning project 

Thanks for listening to Talking Rheumatology! Join the conversation on X using #TalkingRheum or tweet us @RheumatologyUK.

BSR is the UK's leading specialist medical society for rheumatology and MSK health professionals. To discover how we can support you in delivering the best care for your patients, visit our website.

Transcript

Voiceover: You’re listening to the Talking Rheumatology podcast, brought to you by the British Society for Rheumatology.

Lizzy MacPhie: Hello and welcome to this special series of Talking Rheumatology, where we're focusing on rheumatology innovators. I'm Lizzie MacPhie, Consultant Rheumatologist and quality improvement enthusiast, and over the next year I'll be meeting some fantastic members of our rheumatology community to find out more about their examples of best practice. 

 So this week I'm talking to Emily Rose-Parfitt and Phillip Hamann from North Bristol NHS Trust. Their work to create a web tool to improve equality of access to cost effective biologics and shared decision making won a 2024 BSR Best Practice Award.
 
 So welcome both and thanks for joining us today on this podcast. So I'm going to start with a round of quick fire questions just to get to know you both. So I'm going to come to you first, Emily, and then to you, Phil. So Emily, what's your current job role and organisation that you work for? 

Emily Rose-Parfitt: So I'm a Consultant Pharmacist in rheumatology at North Bristol NHS Trust. 

Philip Hamann: I'm a Clinical Consultant and Honorary Clinical Lecturer at the University of Bristol. 

Lizzy: Great. So, Emily, do you have a special interest and how long have you worked in rheumatology?

Emily: So I started in rheumatology back in 2013. So about 11 years, but with a sprinkling of maternity leave in between. I think my passion really is service development. So particularly upscaling the non-medical prescribing workforce and pharmacists and empowering patients. And then really sharing that sort of best practice to save others reinventing the wheel. So that's where my passion lies. 

Lizzy: Great. And Phil, same questions to yourself.

Phil: So I've been working in rheumatology for 14 years and my special interest is in remote monitoring for patients with inflammatory arthritis. 

Lizzy: We’re on a sort of theme of ‘what's your favourite?’ and we're not gonna go watch your favourite cheese – we’ve got to keep it rheumatology focused. So Emily, first to you, what what's your favourite joint? 

Emily: Gosh, what a question! I am going to have to say probably one of the small joints of the hand. So let's say probably the MTP joint. Really boring, but I've just been doing my ultrasound training and, having revised the anatomy of all the joints, I think it's back to our bread and butter. So I'd say the MCP joint. 

Lizzy: Right, and Phil, have you got a favourite joint? 

Phil: Well, I struggle to narrow it down to one. I would say the foot and ankle generally because I think it's a… overlooked part of the body and has huge impacts on other parts of it. If anything, it's the underrepresented joints of the body that are often forgotten.

Lizzy: Great choice and one that we’re always a bit fearful, I think is fair to say, of examining, so great choice. And then finally for this round, so Emily, what was the best thing you were taught in your training?

Emily: I think something that's really kind of stuck with me throughout my career so far is don't be a stickler to change. So despite time and money pressures and, you know, whether you're new in your career and sort of trying to learn everything or late in your career and close to retirement, with all the sort of pressures and staff shortages, it's very easy to slip into trying to keep things the same. But I think we should always be embracing that change. Often things are an invest to save strategy in terms of time and money so it can often feel like we're taking on
more work, but actually we're only really going to hopefully make change to have a positive impact. So I think we have to remind ourselves regularly to embrace that change for the better.

Lizzy: Fantastic. And Phil, how about yourself? 

Phil: I think it's probably to make sure that you take a holistic view of things, both patients and also circumstances in the clinical setting broadly. I think that's really what… what drew me into rheumatology is how we have the opportunity to really look at things in the round to try and improve things for patients.

Lizzy: So we're going to get to hear now about your project and what you did. So, Emily, I'm gonna come to you first. So first off, what need did you seek to address with this project? 

Emily: So we know that biologics are high cost drugs and account for a large proportion of our spend in English hospitals, and their use is governed by NICE technology appraisals and multi appraisals in rheumatology. But at each stage of the pathway, we have a sort of degree of flexibility in which particular therapy to use. There are clear reports in literature, and there's a national survey that's been recently done by NRAS and BSR showing that actually there's national variation in access to these therapies and there are some restrictions in certain ICBs. And in areas where there is a degree of flexibility, we often find there are really engaged clinicians that want to choose the most cost effective therapy for patients but actually knowing which is the most cost effective therapy is not always easy. You know, these have complex pricing, we have lots of things we have to consider, like administration costs, home care fees, mg/kg dosing, for example, and we have a very dynamic pipeline of therapies. We've got new therapies coming to the market, biosimilars coming to the market and things that can affect pricing as well. We also felt that there was a real opportunity to increase patient involvement in the shared decision making process. So we really thought about a project where we could try and improve equity and access to these therapies and but really not undermining clinician judgement and really empowering our patients. 

So we wanted to support the timely cost effective prescribing of biologics and targeted synthetic disease modifying therapies in the clinic setting. So how can we get that sort of complex costing information and make it accessible to the time when you're trying to make that decision, particularly when there's a patient in front of you. So we really wanted to facilitate methodical shared decision making. We wanted to empower our patients to understand how we make those decisions.

So it's not all about cost. Actually, we want to make sure we're considering a patient's clinical factors and their patient preferences. And once we've considered those, then it's important to make sure we understand cost effective prescribing. So we felt that if we took the patient on that journey with us and we demonstrated how we came to that shared decision making, when we then chose cost effective therapy, it would be very clear to them that we'd already considered their sort of clinical parameters and preferences first.

We also felt that there was an opportunity to improve our governance around our shared decision making. There's a lot of variation in the team and in the region, so we wanted to try and streamline our processes, improve our documentation and ultimately improve patient satisfaction and hopefully good clinical decision making in that shared consultation. 

Lizzy: Great. Phil, have you got anything more to add?

Phil: Well, no, I think it's really just that, you know, as Emily was saying, the importance of understanding the multifaceted nature of prescribing these complex medicines is really important. The tool doesn't have like an overriding, you know, cost driver. It is there as a thing to feed into a decision making process whilst considering the other aspects that are important to clinical treatment. 

Lizzy: It's good to hear you highlighting Emily, it's really complicated to work out the cost of these drugs. I know that our pharmacist spends an awful lot of time working that out and all those hidden costs, isn't there, the, sort of, home care and delivery and how you're going to administer. So yeah, it's great to hear that that's all factored in.

So Emily, coming to you again. What steps did you take to address this need?

Emily: So the project's been a a long time in the making – about, sort of, eight years really. So we identified the need, you know, some time ago and one of the biggest, most important things for us really was that we wanted to make sure that this was developed within the NHS for use in the NHS and it wasn't, sort of, sold off to a, you know, industry or a third party. We need the value is that it needs to be equitable for all of the therapies available and it needs to have all of those contract prices and it needs to be, you know, done within the NHS. So we wanted to seek appropriate funding from within the NHS and, as you can probably imagine, that wasn't easy, and that's what took so much time. So we presented our concept to a number of parties. So we went to present to the regional Medicines Optimisation Committee South, we presented work to the Medicines Value programme, the Academic Health Sciences networl, specialist pharmacy services and NHS England. And it was unanimous; everybody was in favour of the project, everybody felt there was a need, but nobody had any money.

So you know, we were passed around and we decided to develop our own local version. So we did an Excel spreadsheet initially and brought in all of those costs and, sort of, had all the calculations working in the background and made a, sort of, filter drop down list. And that was bespoke to our Trust. And then we shared that with our other rheumatology teams in our region and it became very challenging because the prices are commercially sensitive. So we wanted to be able to share this work, but we also it was very difficult to get security that we needed in the in a sort of Excel spreadsheet. So we were very fortunate to after getting sort of stakeholder endorsement and agreement, we then managed to get some money from NHS England to get the project started and sort of scaled up into a web tool. 

So back in 2021, we partnered with the company RX Info Limited who are… they solely do analytics for the NHS, so they host lots of other platforms that we use regularly for reporting, so things like Refine and Define that lots of pharmacists will be familiar with, and they do lots of stock surveillance - they manage things like a stock control over Brexit and things like that. So they were the only company that have access to the NHS data because they already produce software for the NHS so it was very straightforward. It was a single tender agreement that was awarded to them to build the platform for us. So we worked really closely with them using our initial spreadsheet that we've been using locally and we built this web tool together.

We then got a small working group, an MDT working group, together from our hospital and around the region and we undertook these testing. So we did a sort of pilot roll out of the tool, collated a lot of feedback and then we've been sort of streamlining and developing the tool. And now at the moment, it's being sort of scaled up for national use and we're also, and we'll probably talk about that later, but we're looking at sort of rolling it out to other specialties.

Lizzy: Gosh that's incredibly complex and lots of people involved.

Phil: I think the other thing, Emily, was just the fact that involving the whole team in the development phase is really key to getting these things, sort of, well adopted. And so it certainly wasn't something that was imposed upon the team. It was built to address that need that we had, but also took into account the different perspectives of the different members of the team. 

Lizzy: So can you talk me through how you would use this tool in a typical consultation? 

Emily: Absolutely. So I think the most important thing and with all of the service development work I do, I, you know, advocate for, you know, we are not undermining position judgement at all. So the tool is a technical tool to support your clinical decision making. It's absolutely not telling you that you have to use a cheaper drug A over drug B and then drug B over drug C - it's not a restricted pathway by any means.

So what we do with the tools, so in our hospital we use it actually in that patient consultation, but we'll discuss how others might use it as well. But we tend to use it in the shared decision making process. So as a non-medical prescribing team, we start the patient on biologics or targeted synthetic therapies. So often a consultant will refer a patient to us to make that shared decision making with the patient. We will sit down with the patient. We've produced supportive documents that go alongside the tools so we have a clinical workbook, for example, and we discuss with the patient and document any clinical parameters that might affect our decisions, so any comorbidities, any previous response to treatments, any drug intolerances. We'll go through a list of clinical parameters and we will then discuss with the patient if they have any particular preferences governing around their choice of therapy, and we have prompts to do that. And it's a very dynamic process because, you know, the majority of patients would ask for an oral therapy over an injectable therapy for example. But actually when we then discuss their clinical parameters and perhaps comorbidities that would prevent the use of one of our oral therapies, they can see well actually maybe I would need to consider an injectable therapy. So it's a very fluid process. 

We discuss the common patient preferences and then we go to the tool in front of the patient. So you enter a patient's weight and their clinical indication. There are then a number of filters that you can add or remove. So, for example, if a patient's previously tried a treatment, you might remove that. If a patient has had no response at all to a particular class and you want to change mechanism of action, or for example they had a class side effect, we could remove the whole group of therapies. So you can tweak these targets to then… and if, for example, a patient absolutely refuses to have an injectable therapy, or if a patient only wants an infusion and only wants to come into hospital, you can remove the subcut therapies so you can apply these filters and you will then get a list of therapies tailored to your patient with the cost at the top. And so it's ranked in order of increasing cost.It shows you a scale compared to the most expensive therapy and it does actually include absolute cost because you have to have an NHS login to have access to the data. And that's really helpful because if a patient has a particular preference to one therapy, for example they've been chatting to a friend or they've been on one of these support networks and they've got in their mind they want a particular drug, if it's really suitable for them clinically and there's only a marginal difference in price, then actually that that is a decision we could go with. But if there's, you know, £8,000 difference per year and it's not really justified difference and actually we've got a really reasonable alternative, we can have that conversation with the patient. So there's a really clear visual but patients know that we are going through their clinical parameters and patient preferences first. You can click on lines of the tool and it gives you more information, so it tells you how the pricing was calculated. It tells you whether home care fees were added, whether VAT was added, whether there was administration cost, whether it's weight based dosing. It gives you links to BNF guidance, it gives you links to the relevant NICE technology appraisals and the dosing used in that cost estimation.
 
And you can also then, when you click on and get further information, you can look at all the products available under that particular drug. If we listed every alternative product on the first screen, you wouldn't be able to see the wood for the trees. You know, it would be… the water would be muddied. So you can click on the links and get further information. And that's essentially how we use it. It's a very dynamic process. We're applying filters and removing them. And I say to a patient ‘well actually if you were happy to consider an injectable therapy, I'll add that filter back in and then look at all these other therapies that are available to you’. So, you know, you can have that conversation and if they have a particular comorbidity or we need to remove a class, I'll show them and say ‘actually let's remove those as they're not appropriate for you, but we've still got these options for you’, so we're using it in that sort of very dynamic way. 

The tool pulls all the information, so all the pricing information through from the Commercial Medicines Unit, all of your regional contracts bespoke to the trust that you are logging in will all be pulled into that. So it's very useful that all of that, sort of, number crunching has been done for you and is being updated regularly when the contract price has changed and patient access schemes and things, they've all been sort of built in. So you're able to use it in a very dynamic way with the patient in front of you. 

Lizzy: Goodness, it sounds sounds great. Philip, have you, have you got any other alternative ways in which you use the tool? 

Phil: Yeah. So, I mean, as Emily said, a lot of our initiation of biologics is done by our non-medical prescriber team. But from a consultant point of view, often where I'd use the tool is in… potentially in patients who maybe failed on one or two biologics that you're thinking about where to go next, what the next options are, and we've got obviously so many different drugs that we can try now.
 It's a fantastic thing, but it can also add a lot of complexity, and the fact you can sort of filter it down according to comorbidity and then also have an idea about the costing, it can really help focus your decision making for particularly more complex patients. And I think what's really important is that that costing is important not to change your decision but to inform it. I think quite often - I mean working in the NHS - we have the luxury of not usually having to think about exactly how many pounds stuff is costing that we use, but if you've got an, you know, an idea about what the actual impact of your decision is, it can, it can really help. And as Emily said, if you've got, you know, a toss-up between two different medication and one ends up costing double the other, and both are sort of equally clinically valid, you can avoid making those sort of needless spend areas on drugs where you could save quite a lot, and that obviously facilitates and allows more resource available for other stuff as well within the NHS. So I think it really does play to the strengths of the organisation of an NHS to be able to use something like this.
 
And as Emily said, it also sort of allows that shared decision making. It's not just ‘oh, I'm a certain doctor, I always prescribe a certain type of drug, and that's just my habit’. And it is, I think a lot about sort of habit prescribing that is often a problem, particularly in a dynamic and diverse drug landscape that we operate within in rheumatology now with new biologics coming on the market, different mechanisms of action, biosimilars. You know, to have an idea about all of those pricing differences as a clinician is impossible, so to have it all in one place as a tool is really helpful.

Lizzy: Completely agree. So I'm really keen to understand how you involved, I mean you mentioned a little bit about involving the MDT, but the MDT and also patients in this project.
 
Emily: Great. Thank you, Lizzy. Well, first of all really, looking at the… going to the initial scoping and the design, we undertook a patient survey to explore need and actually to find out, you know, do patients even care about the cost of treatment? Did they think that was important in the shared decision making?

We also sought ideas from them about what was important to them in terms of those patient preferences and starting biologics, and we presented that work at BSR back in 2023. We also worked very closely with our patient representatives group at our hospital for those supportive documents, so we have a pathway and the clinical workbook that I mentioned that document that shared decision making, and patient information leaflets. And they were all designed to support the tool, so we had really valuable input from our patient representatives group in the design of those.

In terms of the MDT, so we met with our local MDT regularly to discuss the pilot, the roll out, to seek feedback and the sort of design. We also undertook a survey of the rheumatology pharmacist UK network to sort of find out from other trusts really whether they felt there was a need and a benefit of having this sort of tool. We then devised our small working group. So it was an MDT working group across our region where we undertook that testing of the first version of the web tool and had meetings to get their feedback. 

And then we worked really closely with our ICB partners. So I think, going back to Phil's point about the sort of costing, we have really built up a great rapport with our ICB partners, and there's that trust. So we are saving money and we're not using expensive therapies unnecessarily. But then when we do need to use an expensive therapy and we've justified it clinically or even with a, you know, a really powerful patient preference, cctually, the ICB trust us to do so, and we've had some local agreements where, you know, we have a bit more freedom with our choice of therapy because the ICS and ICB partners know that we will absolutely be using these drugs as leanly as possible if it's appropriate to do so. So I think they've been really involved as well. So it's been cross sector as well in that sort of working group.

Lizzy: Phil, anything to add to that?

Phil: I think, you know, within our team it’s the involvement throughout the process that's been been so critical to its success. It's not a tool that's been, you know, forced upon us to use to save money. And so in that respect, adoption has been much more straightforward because clinicians don't have a feeling that they're being told that they have to do something to save money. And when you have... if you have that sort of negative feeling about a new tool or a new project or something that's being implemented, it feeds through to patients. Patients realise, you know, that ‘oh, I have to use this tool because we've got to save money’. And that undermines the whole concept of such a tool, where it's not about just saving money and giving the cheapest option to patients. And so I think that involving the whole team was so key. 

Emily: I think it's worth mentioning that the tool is quite flexible. So we know not everybody has the same model that we have in that sort of individual patient consultation. Some have, you know, we've seen presentations from the virtual biologic clinic, I think up in Manchester. Some have that sort of MDT model where they will get the information from the patient, make an MDT decision and then relay that to the patient. And so it the tool can be used in that way as well in the sort of asynchronous way with the patient. And similarly, it can just be used for guideline development and looking at those, you know, most cost effective therapies. So it's absolutely a supportive tool and it's not mandatory, it's really to support however you make those decisions for your patient starting these therapies. 

Lizzy: Yeah, I mean this is the privilege of hosting these podcasts, is you're sat here thinking ‘goodness, how could we…?’ And we have an MDT high cost drug meeting where we discuss each patient and I think it would be fantastic to have that tool sat alongside. 
 
So I'm really keen, I have a funny feeling you've got some ideas as to where this projects could go further so I'm keen to know what are your next steps for this project?

Emily: So in terms of next steps, we've got a few things really. We are already, as I said, looking at the national roll out. So it's been designed that it has got access to all of the contracts for all of the regions. The company are looking at the funding model. So I'm really passionate about it not having to be funding for it negotiated at the individual team level. We don't want teams to have to be writing business cases for this. We've done lots of outcome data collecting, we've proven its worth as it were in terms of money and we've collected that data. And it's these volumes and the cost of the tool is very low in comparison to, you know, a couple of patients… using it for a couple of patients already will save the cost of it. So it's not really about that. It's more about having it as a tool that's available for teams that want to use it in a similar way that Refine and Define are available to pharmacists that want to report. So the funding is agreed either at the ICB level or nationally. So I set the task for the company to follow with all of their other suite of tools to follow the same so that we're not having to write business cases or have all of those conversations with management and with our ICB. So that's underway already and there are other ICBs or other trusts within ICBs that are already signing up to it. 

There's been a lot of talk about the tool and interest in other specialties. So there's a proof of concept already I think for gastro and possibly dermatology, and a lot of interest… so our ICB have offered to sort of fund the development into those areas because they've seen the value of it in rheumatology from a governance, a cost and you know a decision making empowering patients point of view. So they're really sort of pushing that. 

I'd like to see possibly looking at improving a patient facing version of the web platform. So you know we explained to them and it's very much a list of drugs, but actually it'd be really nice where we have links to BNF guidance and to NICE TAs, it'd be very nice to have links to patient information leaflets so actually they could sit at home and look at the therapies that are available to them. It wouldn't have obviously absolute cost in, but even if it had a rank of therapies, or even if it just showed them the therapies and had a tool of what's available for their indication, even a simplified version. I'm very keen to empower our patients. It would be really nice to improve the patient facing version.

And then another idea that came up from somebody in our Best Practice Award was actually should we audit clinical outcomes which I think would be really interesting. So looking at drug survival and is that improved in patients where we've you know spent a lot more time in the shared decision making process and really trying to get the best outcome for the patient. So they're sort of next steps in my head at the moment. 

Lizzy: So Phil, coming to you now. So how could BSR support you to increase the impact of your work?

Phil: Well, I think obviously the Best Practice Award is fantastic for highlighting you know best practice, but what I think might be as an idea to try and help a bit further would be about facilitating adoption of successful projects nationally. I think the first step is always highlighting where things are working, and then often the more tricky step is how can we widen that successful practice to other places that might be interested. And I think you know obviously when you have people you know attending the Best Practice Awards or submitting to the Best Practice Awards, these are highly engaged groups of people who are obviously, you know, themselves maybe innovators. But how do we reach out beyond maybe the natural audience of these awards? And so potentially something, you know, that BSR might be able to do, and I don't know, would be using sort of regional representatives to identify potential hospitals or teams at that might benefit from new Best Practice Awards that have been identified, and potentially either flagging it up to them or putting them in touch with teams who've used it and facilitating that transfer of knowledge to these new places. And maybe having sort of shared business cases that you know you could use in your regional area. Because I think it's often these sort of relatively small but significant barriers that stop people from implementing successful projects in their local area. Everyone's very busy. Everyone's got huge clinical workloads and then if someone says, ‘oh, can you just, you know, put together a business case’, maybe you haven't done one before and maybe you don't fully understand the ins and outs of it. Maybe you can't work out where the cost savings or cost improvements or efficiencies or, you know, patient experience improvements might be or how to how to put a number on that. And then the idea immediately sort of withers on the vine straight away. So if there was a way that BSR could use its networks and potentially sort of facilitate, almost like a proactive identification of places that might be suitable for this, I mean, obviously it comes down to the teams, they might say it's not for us, that's fine. But sometimes just saying, do you know what, I know someone regionally, they're always saying it's a problem, I think we should reach out to them and let's try and make this work. I think that would be where the BSR can use its networks really well.

Lizzy: And Emily, anything more to add from you? 

Emily: Similar really, but I think I'm inundated with requests from people that have maybe heard me present and say, ‘oh, can we have access to the tool?’ or ‘we've done lots of service work, so we've got a remote therapy clinic, we've got a, you know, ten years ago we started our biologic dose reduction’ and I always get asked for requests like can we meet and discuss it, can you share resources and it would be really helpful if we… so we, for a number of our projects, we develop a sort of resource pack where we have Word documents and things like information leaflets and things that could be edited for your own Trust and, for example, I've shared business case templates and I think it would be really helpful if they could all be hosted by BSR so that for the motivated and sort of proactive individual, you know that you have a go to place on the BSR website where you can access those resources and that we can signpost people to so that we can say, you know the presentation is saved there, the resource material, the training materials, everything is in this one place. We have shared things previously, but we all know there have been sort of barriers with the clunkiness of the website at times, and just to have a resource toolkit page, I know when I've listened to things at the BSR frantically writing down, well, that's a great idea, I'm trying to get down someone's e-mail address of how will I follow that up or I’ll listen to the session again. But actually if I know that I can go to a tool kit on the BSR web page a bit like the, you know, the podcast and spotlights are all saved. Actually, if I can go and get a toolkit for all of these initiatives, I can start looking. And actually if you find yourself with a spare hour or two when you want to start a service development project and it was some time ago you went to the BSR, actually you could just have a browse through there and start looking at what might suit your practice. So I think that would be really beneficial from the BSR to help members.
 
Lizzy: Those are great ideas and I'm sure someone will be listening to this behind the scenes at BSR and hope they’re writing those down.

So just a final question to you both. So thinking of this quality improvement project, what would be your top tip to anyone starting out on such a project? I’ll come to you first, Phil.
 
Phil: I think start small and just start, and start with just even, you know, far smaller than you even think you need to. You'll you learn so much from sort of just those rapid iterations and with small groups of people, it's really easy to identify the problems that you won't even have thought about, and to fix them is very easy when you've only got a patient cohort of five or ten, and then you can scale up. And it also is much easier to start bringing people along with you if you can show some initial traction with an idea. And it just saves you having to go through sort of waiting for all of the stars to align, all of the paperwork to be in place for some sort of massive service redesign and then to find that there was a small problem that you could have identified at the outset. So start small and just start, really.

Lizzy: Right. And Emily?

Emily: And then at the other end of the spectrum, I think if you've done that and you’ve put the effort into change services locally, think about upscaling it and sharing that work. So I'm really passionate about, you know, streamlining and across the board I don't expect somebody else to have to start from scratch and reinvent the wheel when I've done this on this project, but equally I'd like to learn from them and we can share our work. So, you know, look at your project. Could other trusts benefit from your findings? Could you trial this in a different patient cohort? Would other sort of groups, regions or even specialties benefit from your findings in your work? So upscaling and sharing and publishing that work is also really important. 

Lizzy: No, I think those are two really valuable lessons, especially, you know, when we're working within the NHS where we're everyday told there's no more money and we all feel like we're drowning. So let's share these fantastic pieces of work. Let's not waste time reinventing the wheel and going through that business case development stage and I think Phil that that concept of small changes so that you don't feel like you're going through this massive, sort of, transformation type project, which can feel daunting, especially when we know how pressured everyone's feeling at the moment.

So thank you to you both. Thank you Emily, thank you Phil for your time today. It's been absolutely fantastic hearing about what you've done and I've got a funny feeling I'm going to be dropping you a line to see whether I can introduce you to our ICB Chief Pharmacist. So you've already you've already engaged me to make that call. So thank you ever so much. 

And to those listening today, thank you for your time and I hope you've enjoyed and you're feeling enthused. And look out for another Innovators podcast episode on Talking Rheumatology next month. Thank you.

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