 Fawr 깬gwch chi. Fawr gwnnw'r 5th ddweud o'r Ymwngorffod 19 y Prifysgredinifyddion Cymru yn 2023. Fawr ddweud hynny'r ddweud o Cymru, Jim Fairly, a fawr gwnnw'r ysgawddol Stiwrn Meir Beatwm. Mwngorffod mwy o'n ffantau i'ch bod ni i ddweud i ddweud i'r eylabau? Do diolch i ddevelopu arlai. Rydw i ddweud i ddweud i'r eylabau. ymlaen i ddechrau Llywodraeth Cymru. Clar Jones sefydlu clinical practicyniaeth ac mae'r Llywodraeth Cymru lleid yng Nghymru yw Betsy Cadd Walder, eu gyflwynoedd dechrau Llywodraeth Cymru, sy'n ti'n teimlo i'r ddefnyddio amnylch hynny. Dr Melissa Hytman, lleid olig o'r Llywodraeth Cymru yng Nghymru yw Llywodraeth Cymru, myfyrtaeth Llywodraeth Cymru a'r Llywodraeth Llywodraeth Llywodraeth Cymru, Highman is also a national specialty adviser for the long Covid programme at NHS England. Dr David Strain, senior clinical lecturer at the University of Exeter Medical School and lead on long Covid for the British Medical Association and member of the NHS long Covid task force who joins us online this morning. Thank you for giving us your time. We estimate this session will run up to approximately 10.40, and each member will have approximately 10 minutes each to speak to the panel and ask their questions. For those witnesses who are attending remotely this morning, if you'd like to respond to any issue being discussed, please put an R in the chat and we'll bring you in. I'm keen to ensure that everybody gets an opportunity to speak, and I apologise in advance therefore if time runs on too much, I may have to interrupt members or witnesses in the interests of brevity. Can I just ask witnesses to briefly introduce themselves? You never could start with David. Hi, I'm David Strain. You've already heard all the introduction about me. I've been working both in long Covid through the British Medical Association and clinically doing our local long Covid service as a Covid lead and also collaborating with Mel as part of the stimulate ICP trial into the best management of long Covid. Thank you very much, and can I bring in Claire? Good morning. My name is Claire Jones. I'm an advanced clinical practitioner, and I lead the long Covid service at Betsi Cadwaladr University Health Board. Your pronunciation was absolutely fine. I set up the service around 18 months ago, and I've been working there since. Thank you for inviting me along today. Thank you very much, and Dr Heitman. Hello. I'm Melissa Heitman, and I'm a general and respiratory physician. I've been leading the long Covid service at UCLH since May 2020, and we've seen about 4,000 patients. Since September 2021, I've been working with the national long Covid programme at NHS England as a national specialty adviser. Thank you very much. I'll now turn to questions. If I may begin, the committee has been very keen to see what works have been doing around the whole of the rest of the UK in relation to long Covid and the support that's being put in place. I'll start with you if I could. Dr Heitman, how are the long Covid services organised in England? They were commissioned at the end of 2020, and it was envisaged that there would be at least one service per integrated care system. We've currently got 90 services within England, and they've expanded from what was initially envisaged as an assessment clinic to now a sort of holistic assessment and treatment pathway. They're designed to bring in the whole range of clinicians that are required to manage this multi-system condition, and that ranges from doctors with different specialty experience to a wide range of therapists, including psychology support, and also important involvement of primary care. So they've evolved really to become integrated networks within each integrated care system and trying to drive proactive treatment of long Covid as a multi-system condition. Thank you very much. Can I ask, when people present themselves with Covid, are they referred by the local GP initially? That's right. Referral is via primary care, so you do require for an individual to present to their GP. So first of all, to understand that they might have a long Covid illness, then have a conversation with their GP and discuss whether they need referral onto the pathway or whether they could be managed by the GP themselves. So referral is currently always through the GP or via another hospital specialist, and then patients who had an admission with acute severe Covid were proactively followed up after discharge as well. Okay, thank you very much. And is it consistent around each county within England as well? So the commissioning guidance sets the framework for what we're all trying to work towards. So the goal is consistency. It's definitely been difficult to implement these complicated services with the constraints of the NHS at the moment and the workforce shortages. So I would say that the successive implementation does vary around the country, but we've seen a steady improvement in terms of reducing waiting times and patient experience of accessing the services has been very positive through the friends and family test data. Okay, thanks very much. That's really helpful. Can I bring in Claire just to find out the same sort of issues in Wales? Yes, so in Wales we have the all Wales community pathway for long Covid, which was drawn up to complement the nice clinical guidance. This has been used to inform local pathways and ensure a consistent approach across Wales, but it does also recognise that the services may be organised differently according to local needs and circumstances. There is some variation. The pathways are in place to ensure that patients can get personalised assessment and treatment for their needs, as well as ensuring that care is provided as close to home as possible so that we have more of a community model in Wales. The aim is to treat symptoms that can be treated and to promote and support self-management and value-based care, which is accessed in the community and agreeing that care with the individual tailored to their specific needs. All the health boards now—we've got seven health boards in Wales—have all developed multidisciplinary recovery services that GPs and health professionals are able to refer into once screening has taken place for more serious symptoms. What's quite unique about our services in north Wales is that patients can also self-refer. This came as a direct result of our collaboration with people with lived experience of long Covid and from their desire to have ease of access. It's been a huge success, although there was some concern and worry about it before we launched it and some people said that it's not a good idea. It's actually worked really well. We haven't had any issues with it and we've seen quite a high number of referrals for our population area. We're not seeing more inappropriate referrals, for example, than we would with healthcare professional only referrals. We have a triage process in place to ensure that safety and adequate screening is taken place so urgent investigations have been initiated, for example, at the point of referral. In terms of variation, there is definitely variation within Wales. As I said, to meet local needs, it could be considering the different types of areas—urban areas, rural areas—that we have in Wales and how pre-existing services might be organised already. We do link in regularly with other health boards across Wales as part of an all Wales team. We're aware of that variation for the reasons mentioned, but we all continue to work to that community pathway. Delivery methods may vary slightly with virtual consultations and sessions offered in some areas. Others may offer more of a hybrid offer face-to-face or virtual. Again, MDT teams may vary slightly due to probably recruitment challenges and service design. I'm going to bring you in in a moment, but if I can just ask Dr Hyman, just with the referral in England from the doctors, is it diagnosed with long Covid and then referred, like officially diagnosed, so it's on their medical record, or do you do self-referral as well? They can have suspect long Covid, so the GP doesn't have to be able to 100% confirm the diagnosis. Often that's the reason for referral, because confirming a diagnosis of long Covid can be really difficult in some people. The decision was taken against self-referral just because of the uncertain medical risk within the patient group. People with long Covid present with breathlessness, fatigue, chest pain—there could be other medical causes for that. I know that one in 20 people we see in my clinic doesn't have long Covid as an explanation of their symptoms, and we've picked up some very other serious conditions which are actually causing them. So it's just how you manage the medical risk with self-referral. I think there are ways to do that, so long as you've got the right medical support. I'm not saying it's a bad idea, but that was the reason it wasn't chosen initially. It was obviously long Covid services in England started very early, and it was a time when there was a lot of risk in the system. Okay, thank you very much. David, did you want to come in? So, like Mel, we have the referral through the GPs, and also like Mel, we picked up a lot of other diagnoses coming through. In fact, the worst we've had was a lung cancer who came through the long Covid service and had just been missed, and that's why that initial primary care assessment is absolutely essential to get those core investigations. The geography of Devon where I'm working is very different to central London, and we've now moved away from a specific long Covid service per se, more of a long Covid assessment and triage base. So we are currently having a hub and spoke model, the referrals are coming in, they're all being assessed by an MDT, but then they are referred out to an appropriate team locally depending on what their needs are. So for example, if their key needs are based around their breathlessness, they'd be referred to the respiratory rehabilitation team wherever their closest hospital is, similarly to the cardiac rehabilitation team or the ME chronic fatigue service team if their main symptoms are the fatigue and the brain fog. So rather than moving to a pure long Covid service, we are far more now looking at a multidisciplinary assessment and then following on by utilising existing services, and that's driven partly by the geography and just partly by the staff shortages that just aren't the additional staff with the appropriate expertise to run a pure long Covid service without taking away from other essential services within our health service. Thank you. I'll move on to Modo Fraser. Thank you. Thank you, convener. Good morning to the panel. I really just want to follow up some of the issues that you've really just highlighted. I think it was really interesting to hear how there's three different approaches being put forward by the three of you. One of the things that we found as a committee when we speak to long Covid sufferers in Scotland, there's a very persistent theme that comes through from them. They feel that the services are not there to support them. A lot of them have latched on to the notion of long Covid clinics, which we don't have in Scotland at the moment as a solution. But we've seen some evidence suggest that these have quite a mixed response from patients, people complaining about long waiting lists or only remote appointments, not face-to-face. I'm interested from each of you to understand how your approach is positive, is working, what are the pros and cons, and what evaluations are being done in terms of the patient experience of the approach that you take. Dr Heitman, maybe just start with yourself. I think that we had ring fence funding available, which was a real enabler for setting up something new. But as we learned more about the condition and understood the breadth of different inputs that individuals need, the vision grew. I think that, as you've heard, we've all got slightly different models in our own systems, but they're all trying to achieve the same goal, which is where your post-Covid network, if you call it that, are acting as one team, joined up, taking decisions around the patient, avoiding them experiencing multiple onward referrals like a scattergun, which is an awful experience for a patient. But also in a new condition, learning together. In 2019, I didn't know how to manage this condition, I didn't know it existed. Through 2020, we learned at pace, but that was only through learning together with other specialists and the broad range of therapists, and that process hasn't ended. This remains a condition that there's still a lot we don't understand about, there's lots of research we need to do, and we're just learning now about what are the most effective treatment strategies. For me, the concept of a post-Covid service is one that sits at the interface between primary, community and secondary care, but can draw in on all the elements that that individuals need. There will be different ways of making that a success depending on the region where you're working. The geography in particular is very important, so I think that that's where we're at. But what we've seen is very exciting innovation actually in many services, which I think would bring transferrable benefits to many other long-term conditions. So we're starting to think as we try and transition to a more business as usual model in England about what are the elements that have been very successful, what must we keep going forward after this year of funded services, and I think there's a lot of potential. Thanks. Just before I bring the others in, can I ask, have you involved sufferers of Covid or long Covid in the drawing up of these plans' design? Yeah, so the lived experience partners have been a key part of the national programme in NHS England and have co-designed the commissioning guidance and the plan for improving services. It's also very important at regional level that you have strong lived experience voice because actually you need to look into the granularity of what you're offering, and that's really challenging for people who have very severe fatigue, but it's something that we will be really encouraging as we move to that business as usual model. In terms of the patient experience, it's really variable, so you hear quite negative reports from some patient groups and there's been other surveys, for example, by Ibsosmory describing the barriers that people are experiencing in terms of accessing care, their dissatisfaction with virtual support, which I would completely agree with. I think it's very difficult to manage somebody with long Covid entirely virtually, and given that we're all face-to-face it's very hard to justify that, so we have to listen to that negative feedback, but also there is some really lovely positive feedback where the model is working well. Okay, thank you. Dr Strain, similar question. Like Mel, we've involved our patient partners from the outset, keeping them coming, and that's actually been a major part of our recent redesign of service. I think one of the barriers to providing an optimal consistent service is actually a lack of knowledge. We genuinely don't know the natural history of this disease, it didn't exist three years ago, and the most similar disease to it, the myalgic encephalomyelitis, there's been a dearth of research into that area, so we don't yet have an understanding of the similar condition. We are utilising existing services where there are similarities, so those who've got severe Covid, who've been hospitalized, actually are being followed up in exactly the same way as anybody else who's got a post-ITU syndrome and are receiving the same management. So I think the lack of consistency is bound on to be consistent. There just isn't a defined treatment, there's no proven treatment as yet, and as the research comes through, I'm hoping that we'll start to see defined treatments, we'll get better ideas, and then we can generate a consistent approach going forward. Okay, thank you very much, and Claire Jones, please. Yeah, so as we know, long Covid doesn't sit under a single specialism, we're seeing cardiac issues, respiratory issues, neurological issues, gastric issues, and without a service in place, patients report feeling abandoned or passed from pillage at post with appeals to multiple specialisms, long waiting times, and so co-ordination of care and case management is another key approach and is fundamental for such a complex and multi-system condition. We know that there have been calls for long Covid services in Wales to be in the form of consultant-led clinics, and I was really pleased to hear Dr Amy Small's take on this last week. Those clinics are expensive, and who was going to staff them? We don't have an abundance of consultants from a variety of specialities that are available to run clinics for long Covid, but more importantly, our argument is that it's not always necessary. With our model, we have a variety of skills within our team. I'm an advanced practitioner who works, I've worked with cardiac and respiratory patients for years before setting up the service. I had experience of working with patients with POTs, and I was fortunate to work and learn from a cardiologist who actually had an interest in POTs. We've got a GP with specialist interest in long Covid, and we have other allied health professionals and the psychology team. Those are all the things that Dr Amy was highlighting that allow a team with those skills to assess and manage the symptoms from within that service, rather than having to refer to all the different specialities or have it all in a one-stop clinic that could be run by one consultant from one specialty. We think that we have a model that works because our service is staffed with the correct skillset and the correct mix of MDT professionals. We were able to do what Dr Amy suggested last week. We organised diagnostics and we reviewed results from within our service that avoid the need for secondary care referrals in the majority of cases. We were already working collaboratively with secondary care colleagues and that allows that and ensures that a smooth pathway for on-wood referrals where necessary, and we're preventing or diverting unnecessary secondary care referrals in some cases. In short, we feel that we are doing what the consultants would do in their clinics for those that we can and the good pathways and communication between the services ensures that, without that, it wouldn't be possible. With those differences in services, those are the things that I feel really need to be worked towards. For anything that we cannot do, we are of course referring directly to specialist. We're discussing cases on a weekly basis to ensure that we're not missing things and that we're not doing anything that they wouldn't be doing if they were being seen in their clinic. We're able to offer medical treatment where indicated to treat some of the symptoms of long Covid. Pots, for example, as mentioned, as well as management of comorbidities and risk factors for other chronic diseases. Importantly, alongside that, we're providing a comprehensive biopsychosocial group programme to support self-management. That is focused, it's solution-based for the interventions and it includes things like vocational rehab, support with managing cognitive difficulties, support with coping with fatigue and sleep difficulties, support for improving emotional wellbeing and coping with this difficult condition. There's also practical breathing sessions, gentle individualised, mostly seated, strengthening exercises to support activity and avoid the risk of post-exertional symptom exacerbation. We're so careful with recommendations for exercise because, for so many with long Covid, it is not appropriate and it can, in some cases, be harmful. Truly supported self-management is not just about education. We're not sitting there preaching at people telling them they need to take their time and they need to breathe properly. This is about engagement, it's about listening and it's about that individualised support. As part of those group programmes, we provide personal one-to-one sessions, interspersed with the group sessions to allow space and time to provide individualised support, to really embed those practical interventions from face-to-face sessions. I think the term rehabilitation comes up a lot and some people don't like that term when it comes to long Covid and I think rehabilitation might need different things to different people but this is rehabilitation. Rehabilitation doesn't just mean exercise, it should be holistic, it should be values-based and it is about finding those strategies to help people live a follow-life and that can be done alongside the medical treatment of symptoms for long Covid. The second part of your question was about evaluation and patient experience. The adveriad funding—adveriad is the Welsh for recovery as in Covid recovery—that funding has been utilised to carry out an ongoing all Wales evaluation project, which includes use of a health-related quality of life questionnaire called the EQ5DL, as well as a collection of patient experience data, case studies and local data. Although it can be quite difficult to evaluate services because of the nature of long Covid, people have relapses and their symptoms can fluctuate over time, but the analysis suggests that quality of life scores collected from patients at the point of discharge was higher than those collected at the point of referral and that service user experience was generally positive throughout the data collection period. We also, within our service, collect real-time feedback, which includes patient experience and this is also predominantly positive, particularly in relation to the themes around feeling well supported, listened to and believed about their symptoms. That's so important. Okay, thanks very much. I think that David Strain would like to come back in, and then Dr White, I will. There was just one other element that I forgot to mention. One of the things that came from those with lived experience is that a single point of contact for every patient who has been referred was absolutely essential. Very often, patients end up experiencing multiple different specialties that might end up as a result of this being different people. One of the complexities, particularly for somebody who is struggling with post-exertional malaise or fatigue, ability or difficult focusing, is the complexities of navigating the health service and knowing whether they need to be seeing their cardiologist or respiratory team. One of the most important and the best feedback that we've got from was having every single patient through the system having a single named individual that is the call point of contact that almost acts as the liaison between those different specialties. On the most part, that's the therapist. The use of occupational therapists and physiotherapists is absolutely tremendous. They have been essential, they've been right at the core of our service, but that was the single most important step that we took for modifying our service to make sure that everybody had ease of access, and therefore that person also then became their advocate for other of the NVT meetings that we were hosting. I was just going to come back on the point about whether you have consultant-led services or community-based services and I don't think it needs to be in either or. There is a win-win, you need both, but the consultant input can be very efficient. For example, we fund four hours a week of cardiology time and that serves our population of 1.6 million, but the efficiency of that is that that individual is an expert at post-COVID cardiology and gives us all the safety and confidence to manage patients according to a consistent approach. I'm just putting in a plug for we don't have to leave specialists in hospitals with our ageing population, multimorbidity, complexity. We need to bring specialists into the community and you can do that in a lean and efficient way. I know that the witnesses have all said about tapping into other services and referring to other services, but could you tell me, is there specific funding that has been earmarked and brought in for post-COVID long Covid services? If so, is that funding going to be reoccurring? How available is that? We start with Dr Heitman. The £19 million funding each year is for the assessment and treatment, so the rehabilitation that we've been hearing about. In my system, for example, more than half the budget absolutely goes on on the rehabilitation. It's the key part of the proactive treatment of this condition, so absolutely the funding is for that. In terms of what the future looks like, obviously long Covid has been a really moving target and it's very difficult to know how much the world NHS finance should be investing each year and we don't have completely perfect data to guide decision making. Funding is renewed for 23-24, and from 2024 we want to see how commissioning could be transferred to integrated care boards alongside their business as usual approach. I think that the decision as to whether there will be additional funding continuing as part of that process is something that I don't have an answer on at the moment that has been worked through this year. I obviously hope that that's the case. I think that we've seen real benefits with having a dedicated model. Dr Strain, can I ask you about funding? I'm under exactly the same remit as Mel. We're in the same NHS when it comes to providing services, just how we've used our funding is slightly different. Like Mel, we've bought time from different places. The biggest problem that we're facing is a lack of staff in order to do it. The money is there, but the use of that money necessarily is going to be taken away from somewhere else. There aren't enough community rehabilitation teams, whether that be physios, OTs, the psychology support. We've recently lost our psychologists who went to another team. That's the biggest problem that we're facing, but the staffing model is rather than the funding. I mean, going forward, hopefully that will be recurring funding and we are able to establish it as an integrated community-based rehabilitation-focused service, but staff is the key element. I'm not going to reiterate much of what we are doing in the south-west. It's the same as the challenges that Mel faced in central London. From 2021, the Welsh Government provided a fixed-term £5 million package of support for the adveriad programme to expand the provision of the diagnosis treatment rehab and care for those suffering from the long-term effects of Covid. The health boards have been extremely pleased to hear that there has now been a commitment to recurring funding for health boards from the Welsh Government, and the Minister for Health and Social Care will shortly be making a written statement to announce that. The funding commitment will strengthen community-based services by allowing expansion of capacity, widening of the access model to people with other medical and long-term conditions, but with similar symptoms and needs to those with long Covid. We are looking to provide prudent healthcare, to share resources, and we want to help those patients who currently fall through the gaps and do not fit into any certain service that they can also access and benefit from the services that we have been able to provide. As Melissa and David have said, we had the same issue when the funding was not recurrent, that we weren't able to spend the money, we weren't able to recruit to temporary positions, it was a real challenge, and that has led to longer waiting times than we would like or are acceptable. We really hope that this recurrent funding is going to mitigate that, and we have certainly had more interesting posts that we have been advertising permanently, so I am confident that it is going to be successful in terms of recruitment. In terms of the sustainability of those services, I suppose that it is also because the NHS boards in Scotland are all reporting the recruitment issues, specialist posts, rehabilitation coordinators, operational therapists, physiotherapists, and all those areas. You have answered that, but I suppose that the question then is how sustainable is it to be able to say that we are going to offer those services, and what needs to happen if there is a recognition, because the numbers that are reported as having long Covid are really quite high, it must be putting massive pressure on the system. What is it that we need to do moving forward, Dr Heimann? Those people need care. They will access care, they will use the NHS, and they can either use it ineffectively with poorer outcomes, or we can give them access to a model of care that is efficient and gets the best outcomes and continues to learn about how to improve. As we have heard, there is definitely potential to align those services with other conditions where needs are overlapping. Given our workforce constraints, we have really got to look at the skills transference between individuals, and a lot of progress has been made in long Covid in that regard. We now have people case managed by either a physiotherapist or an occupational therapist, and we are bringing more nursing support into the workforce teams. I think that is something where transitioning it to an ICB level will actually be an opportunity, because they will be looking at the needs of their local population, taking a population health, health inequalities lens, and hopefully start to expand the rehab offer for people with other complex multi-system diseases. That might be a way that you can grow the sustainability, if you see what I mean. I have been surprised by the number of people who have written to me saying that I have been suffering from FME for years and that it has been really difficult. I have not been getting support. A lot of the conditions seem to be similar. The needs are overlapping. Dr Strain, have you got any points to make on how we tackle the sustainability question? The first comment is that we still do not have clarity in underlying causes and the natural history of this disease. However, as you highlight, the similarities with FME suggest that there is going to be a significant proportion of the population that is not going to get better without some additional interventions or additional support. This is going to be a long term need. It is very important to distinguish the patients who are suffering from these long-term diseases. In the pre-Covid world, I am a geriatrician. We are used to community working. We are used to providing holistic impact from an outset. However, to be blunt, when you are working as a geriatrician with the 70, 80 plus, you are working within a limited timeframe. If, through long Covid, we have created a whole generation of 20 and 30-year-olds who are suffering with this long-term disease, if we do not get it right rapidly, we are going to instill a long-term illness manifesto. That is going to put further increasing pressures on the health service not just for three or four years. We are looking at 20, 30 or 40 years that people will have increased access to it or need rather from the health service. It becomes a priority to get it right for our patients like this and, hopefully, people with other allied diseases or other conditions with a very similar natural history that we are seeing will also benefit from it so that we can have a healthier society and tackle some of the other issues that are going on out there. Thank you. I am clear still. I do not know if you have anything to add to that. Not too much, just that. I do feel that there is capacity in our system at least. We see so much duplication going on already within services that have existed for a long time, condition-specific services, things like cardiac rehab, pulmonary rehab, pain services, and so many patients where their needs are overlapping. If we can avoid that duplication through working smarter and working collaboratively and looking towards multimobility rehab models where patients are able to access the service, instead of going, you know, when you have got DOPD, you go to that service, but also you have got heart disease, so then you need to go to a separate service. Let's not duplicate it, let's work together, let's work smarter. There is a service in Scotland that has a very good model for multimobility, and I think that they have really been leading the way on that, and that is something that we would really like to replicate as an extension from this programme in Wales as well. David Delleron said about the single point of contact and how that has been beneficial. Has that also been beneficial for people with a variety of equality issues, whether it is people from the travel community, people with visual impairments, people with learning disabilities? How has that particular process worked? So the first thing to say is that Devon is not particularly an ethnically diverse community, and so when it comes to the different populations that we're serving, it actually tends to be a relatively, I mean, compared to the population Mel is serving, it's a relatively non-diversity, so we don't have so much issues around that facing. However, the single point of contact has been absolutely essential. Actually, we took that model from our ME service, particularly for those with learning disabilities, for those who may be differentially advantaged from the different socioeconomic status groups. That has been absolutely essential. Very often computer literacy, for example, hasn't been there, and therefore having the ability to do video consoles is just not available. Having a simple phone call to a person on the other end that would always be a person that they would be able to recognise and know that voice has been a key component. One of the difficulties has been establishing those boundaries, and we've managed to achieve it really effectively, but that does appear to be the way that we have addressed some of those issues. There will always be on-going problems. Actually, the travel community as a whole hasn't reached out into the long-term Covid services, but a big part of that is their engagement with the health service completely. We need to make our service far more accessible, not just for long Covid but for the general health service to those individuals. That is something that's on-going work. I don't think that's long Covid specific, though. I think that's a pure health service-wide failing that we need to be making it far more accessible on those grounds. A simple answer to the question is that the single point of contact with a familiar voice on the other end of it is doing far more than anything else that we've done in order to improve the satisfaction with the service. Thank you. Mel, on the other hand, what's the area that you cover? I work in north-central London. In that patch, you see patients from the most deprived backgrounds and the most wealthy, so there's a massive range. In our clinic cohort of 4,000, people from the most deprived postcodes are underrepresented. We've now got a live dashboard that allows us to do a bit of a deep dive into our local population, and you can see entire postcodes that are completely left out as in not diagnosed with long Covid and not referred. We're trying to map that against the local communities when there's massive ethnic diversity. We have a real problem, so I have never seen anybody from a prison. We see very few people with learning difficulties, and there are certain ethnicities in our local catchment population who are also not coming forward to clinic, so we need to engage with our community in a different way. This isn't just about a barrier in primary care. I don't believe that that's where the barrier is really. I think it's in individuals understanding what a long Covid illness is and that help is available, and also that that help will encourage their recovery, that the treatments that we offer do work. I think that's another really important message to get out to people, but this isn't a hopeless situation. That work on the ground is quite challenging for us to do from within the service. We've recruited GP leads in each borough to help us with the outreach program, and we've done a lot of training with the voluntary sector, but at the moment it hasn't really borne fruit, and I think that we need to keep thinking about how we can solve that problem. Would the single point of contact be something that would be useful for your area? We have that. We have two brilliant nurse navigators who are really important to patients in helping them understand what tests are happening next, what's the treatment plan at the moment. I think that what we're looking at now is self-referable from particular communities, so that we do that in a very focused way, managing the risk as best as possible. For most people the GP referral route is very important and works well and allows the GP to join up all their other elements of care, but I think that the self-referable option might need to be implemented in some communities. I can only echo what's been said. Again, we're in north Wales. It's not particularly ethnically diverse, but there are a wide range of marginalised groups. We've got a very large prison in north Wales. We've not seen a single referral from that, and that's an area that we're looking to target. We're thinking about accessibility for marginalised groups. That's certainly an area that's already presented itself as something that we need to develop further. We've seen very few patients accessing services from marginalised groups compared to what we might have expected to date. We have taken steps to initiate appropriate engagement with those groups and ensure that the services that are accessible works on-going. We've been communicating with a range of experts in the field of engagement with difficult-to-reach groups and stakeholders from our equality and inclusion team. We've got a huge variety of strategies that are proposed to promote those engagements. There's lots to explore, and it's obviously very important. The single point of contact would definitely support with this patient group. In the Scottish Parliament, I chaired the cross-party group on visual impairment of chair the noses 2011, and certainly without the Covid period, we would meet online. The issue of that level of contact came up a couple of times in some of the meetings. Just in terms of wider engagement, it might be worthwhile to engage with the likes of the third sector and some of the charities that deal with people with visual impairments and potential dislikes and other areas. It's highly likely that they will have a better opportunity to engage with the people that you need to engage with and then assist you to do what you need to do. A few months ago, you used the phrase of people saying that they are feeling supported. I think that's an answer to a question from Alex. I met up with some constituents from the local long Covid support group a few weeks ago, and that was an issue that came up, but particularly regarding the issue of employment. I'm not suggesting that any of the three of you should be going engaging with employers in the areas that you represent, but, in terms of the issue of people being worried about their employment, has that come up in terms of discussions by way of potentially creating additional worry and stress for individuals who actually do want to get back into work? I'll start off yourself first, Claire. Yes, definitely. It's a huge issue. Even thinking about our own staff within our own health board, it makes a huge proportion of our patients—people from the social services sector, people who work in public services. The support that people receive varies so much in terms of return to work and support in the workplace. Long Covid is still very poorly understood among employers, and that is another avenue that we are trying to explore. We have invested in appointment of a co-production lead, and that has allowed us to focus on that kind of issue to do that engagement work. We want to provide training for particularly the very large employers in our area. It could be public or private sector. Helping the employers understand the nature of the condition and that this is not the sort of condition where you can have a phased return or what we would think of as a standard phased return, where we can work if people are expected to gradually increase their hours or increase their duties. It needs to be flexible, it needs that flexible approach, and for the majority of patients that's just not possible. It's not being made possible by their employers. I know that it can be difficult, it depends on the employer, it depends on the nature of the business, but it should be more flexible, it should be a way around it. We've seen so many patients sadly lose their jobs on Covid, and it's absolutely heartbreaking to see the effect that that has when we think that there are strategies that can work, but it's really important to engage with employers as well. As you say, we can't tell people and employers what to do, but with that guidance they should be able to support their staff better than they are now in most cases. Mail has a clock, has it been issued? It's a huge issue, so two-thirds of the people we see are unable to work, and I would also say that 10 per cent of our patients are NHS staff, and that's been replicated in the national registry across many services in England. One of the rehab areas that we've really invested in is vocational rehab. It highlighted a real absence of vocational rehab for people of working age in our community, and they're getting really good results. They're getting 60 per cent of people they see backstarted on a phased return to work, so from an economic perspective it's really important that we do that well. We're trying to expand the vocational rehab programme in north-central London, and we've had some charity funding to develop a bespoke programme for NHS staff in London, because they need a particular focus on the phased return. We do a lot of negotiating with employers. It takes a lot of the team's time. I'm sure that Clare and David have the same experience. I'm not going to repeat what Clare and Mel have already said. We echo that, but I just want to put a viewpoint from the health service. Obviously, with my BMA role, I receive a lot of the comments from this, and healthcare workers have a much higher than the national average risk of contracting both Covid through their activities on the front line, and they've ended up with a far higher rates of long Covid than one we've anticipated, which we believe may be something to do with the pressure to return to work. The BMA did a wide-ranging survey. I stress that it is just a doctor's buy. I suspect that it will be a very similar image among nurses and therapists alike. It's suggested across England, Wales and Northern Ireland as well as Scotland that approximately 7.2 per cent of healthcare workers or doctors are suffering on-going symptoms of long Covid, and 5.3 per cent of them have had long Covid, but have managed to make sufficient recovery that have returned to work on their normal hours. Approximately 20 per cent of the people who responded to the survey had required to take sick leave at some point during their long Covid, and 10 per cent of them are still working reduced hours based on that. We've got a substantial number of doctors who have lost their jobs as a result of the loss of special Covid leave and the on-going problems with long Covid. You have already heard from Amy, who tells the very specific story of how this affected her, but she is not unique by any means. We've got literally hundreds of doctors and I'm absolutely sure hundreds of nurses and therapists who are suffering with this. There are further issues. The UK as a whole is out of step with the rest of Europe that we don't regard as an occupational disease, even though there was very clear occupational exposure. By not offering it as an occupational disease, there is no means but to offer any sort of compensation or, for that matter, even disability support for people who have lost their jobs going forward. This is something that needs to be addressed very soon, very rapidly. The pressure of not knowing whether you will be able to feed your family or pay the mortgage is an additional stress that people with long Covid can live without. It's going to be a barrier to them returning to the fruitful work that they wish to be doing. Everybody that I see in clinic with long Covid wants to return to normal, but the pressure of not knowing how that's even feasible from a pure practical point of view is one additional barrier to them getting better, and it does need to be addressed very, very rapidly. The problem with accessing the disability is that it requires a very specific test in order to receive that. That's not easy to achieve, particularly for somebody who's suffering with the brain fog, the fatigue and the symptoms that a lot of our patients are experiencing, and, therefore, to simplify some core routes that can actually get through this and help people to navigate those challenges will ease their mental burden on them and allow them purely to focus on their recovery. Mel has highlighted the degree of support that we can offer to healthcare workers, and I think that Claire perfectly highlighted the individualised approach that is absolutely essential. That then comes on to the educational aspect of the employees, and that is something that we can all be doing more to work on. I'm just conscious of time, and we've got two members to go through. Brian Whittle, would you like to come in, please? Thank you, convener. Good morning to panel. Thank you for coming and sharing your experiences. When we speak to long Covid sufferers, the theme that comes out is one of a long journey to get to a diagnosis and then a long journey to get through treatment. I think that the diversity of symptoms for long Covid is almost a process of elimination. You know, there's getting ECGs, MRIs, blood tests, all the things that we hear from long Covid sufferers. All the other conditions that put the NHS under pressure have not gone away. One of the things that strikes me is key to that almost streamlining and making efficient diagnosis and treatment of long Covid is how we gather data and how we use that data. To start off, I'd like to ask a question. How are we gathering data? Do we have an IT system that allows the deployment of that data? I'm looking at your responses, Dr Heitman, so I'm going to start with you. First to say, it's a clinical diagnosis. You get better at making it when you've got experience. That's why these services are important. You don't need to have all the tests back and exclude all other causes before you use the label. I think that's where we're going wrong. We can use it whilst we're excluding other causes. That's one thing. In terms of data, it's been very difficult to know how many people are affected by long Covid and to measure how well we're doing against that need. The ONS Covid Infections Survey has been the best source of information, which is where people are self-reporting along Covid illness. They estimate 3 per cent of the population who are affected. What we don't know is what proportion of those people need to access NHS care. We estimate that it's about a fifth of those people because that's the proportion who report that they're significantly affected. We've got that data source. Within the England clinics, we have to submit data returns at patient level every two weeks. We have a national registry of all the patients who've been seen. That's a hugely important learning resource because those are people with a clinically validated diagnosis, not just self-reported. We can start to look at questions about equity, of access and healthcare utilisation of those individuals. What we've learned in our system is that you've got to partner that with live information about who's been coded in your primary care practices and your referral rates by different GPs if you really want to dig down into the health inequality aspect. Coding is a very incomplete, imperfect process in primary care. I've only got the data that I need through being part of a research programme but it's been a massive enabler to help tackle the health inequality issue. I would love to have this dashboard for all the long-term conditions that I manage in our local system. It's another area where there has been some innovation and we should learn from where it's worked well. Generally, I would say no, we don't have the data that we need to know how to plan well. Can I ask Claire Jones the same question and give us your experience and wills? Yes, it's similar really about the difficulties with coding and diagnosis. In terms of recording it, there's something to be said about do we need a national registry for the patients attending these services? I think that that could potentially support things, help to record symptoms and prevalence and help around that diagnosis but I think that potentially as well it could exacerbate the risk of diagnostic overshadowing in relation to not investigating new symptoms that patients with a diagnosis of long Covid might present with because it's felt that their symptoms are explained by their long Covid diagnosis. For example, you could get somebody with a new onset of chest pain and speaking from experience we're having referrals rejected because well they've got long Covid so that explains it but it doesn't explain it. The number of people with long Covid, they're going to still have these kinds of conditions, they're going to have cardiac events, they're going to have serious health problems which will present themselves and that have symptoms that overlap with long Covid so I think raising public awareness about that and avoiding that is really really important in conjunction with recording this data and sharing it and you know if we were to have a database thinking about recording that information about long Covid. If I could just expand that a little bit to Dr Strain from a BMA perspective, where do you think in terms of data collection and deployment we could learn and improve the system? I'm going to answer it from a research point of view first before from the BMA's perspective so from a research point of view I'm engaged in one of the biggest primary care network research programmes in England, I want to apologise it's in England, it's got access to 25 million patient primary care records purely just on the codings on it and actually one of the biggest predictors of having a code for long Covid is your locality or your proximity to the nearest long Covid service and when we went back and retrospectively looked at that as new services set up, new diagnoses of long Covid suddenly started appearing in the primary care records and I think this basically lends itself to using the primary care records to try and predict where we need the service didn't quite work because people although they were recognising long Covid it may not have been using the appropriate coding the appropriate tools in order to put that because if you don't have any service and you don't have any ability to do something about it then actually putting a code in is just yet another task for a GP who is bog down with 101 other issues going forward. Broadly the British Medical Association wants to be using the healthcare records to improve healthcare planning and healthcare services going forward across the board across the whole of the UK. We have a tremendous resource that is sat there that just remains the ongoing concerns about who has access to that data, what the risks are of freeing up patient data and making sure that absolutely nothing comes and acts as a barrier between the trust that sits between a patient and their doctor or there's always the fear that particularly when there's been the thoughts of private companies managing the NHS private network that doctors and patients relationship might be broken down if they're worried that somebody American conglomerate has the potential to look even just at the coding of those things and that is something that has to be thought about with great care before we start moving forward to integrate a fully integrated centralised platform in order to do this. The potential is tremendous providing it stays in the control of the NHS itself rather than going to the external sources. Thank you. Can I just clarify a point that the reverse we met there, clarify a point that you said there? Are you suggesting Dr Strain that the ability to point to a long Covid service for the GP actually dictates where long Covid diagnosis are likely to spring up? So retrospectively, we looked back at the records on the coding in different regions before and after their long Covid service was set up. The symptomatology was there already. Patients were presenting with the feedback, presenting with the breathlessness, the shortness of breath. It's just that the code didn't make it onto the records. As soon as the long Covid service was available, the same symptoms would be there as the primary symptoms but also were suspected, presumed or considered long Covid or post-acute Covid syndrome as it was originally when it was there. Actually, the availability of a service to point to was the best predictor of actually having that one specific code. The reason I'm saying that is not suggesting that the diagnosis is suddenly rocked up around the service. It's just that GP's are incredibly busy dealing with the problem in front of them. Actually, getting a coding right, if it's something that they don't have anything to do about, is less important than dealing with the patient in front of them and their symptomatology there and then. The only way to say that is caution doing a big trawl of GP records and saying, well, Aberdeen has lots of cases of long Covid or Aberdeen has no cases of long Covid, therefore there's no point in putting a service there. Once the services are in place or once the ability to provide the right management is in place and I'm stressing the ability to provide the management rather than a service per se, that's where we think the diagnosis is. That's when the coding will improve. Historically, that's when it did improve in England. I'll ask the question then. In terms of development of long Covid clinics, the outcomes from that are not just about ability to diagnose and treat. Are long Covid clinics then therefore a conduit, if you like, to gathering that kind of really important data? I'll come to you, doctor. Yeah, absolutely. Often it's the clinic that's confirming the diagnosis so it's only after the patient's been to the clinic that the GP then assigns the code with confidence, so that might be partly what's going on. But the clinics are an absolutely key resource for understanding the epidemiology of the condition and for bringing patients access to research of trials of treatments and underlying mechanisms, which is really lacking at the moment, actually. We've only got one trial of treatments running in England at the moment, which is one that David and I are involved in looking at repurposed medicines, but we would love to be able to expand that platform. The void in the understanding about mechanisms and treatments is putting patients at risk in seeking miracle cures. They're travelling abroad to foreign clinics who are claiming benefits from certain treatments, which we haven't seen evidence of, but it's something that we're all very concerned about. I think that I'll just conclude my questions here. Just expanding on that and the collection of data, I'll go to Claire first around your ability to share the data that you have and collect data from not just around the UK but, as Dr Heimann said, potentially from internationally, given that this is a global pandemic. Are you thinking about, for the purposes of research now, or generally just data around long Covid? I think that what we're trying to get to here is a position where what is the efficient spot we possibly can in terms of diagnosis and treatment of long Covid. Presumably, the more data you can pull from a greater level of population globally, that would aid you. Yes, definitely. I think that pulling as much data as possible is going to support the research that we're talking about in terms of what treatments are working, what's not working, what interventions are different people providing, and that is going to contribute to that research basis to try and figure out what is going to be helpful in sharing and disseminating that data. The question then to Dr Strain is, do we have a system IT system that is capable of pulling that data and, usefully, using that data to develop these treatments and diagnosis? Dr Strain? I'm struggling with the mute words. The technology is there already. The system that I'm engaged with actually lists, codes, information that's anonymised, that's sourced. I can also track what's been trialled for those patients and track the records. I do think that Mel's comment about having a central source get into that data is absolutely essential. We know about people with long Covid once that diagnosis is confirmed and the network that's been set up around the Covid clinics, the long Covid clinics, has been absolutely key to getting it right in England. That's not the only route. If we can get the coding right in primary care network and actually track what has been trialled through the existing system and the infrastructure is in place that can do that, then that is another route for it. I think one of the key deficits at the moment remains that understanding of the mechanisms that goes on there. If we had a simple diagnostic test, so in diabetes we just check the sugar, we check the HBA1C, we have a diagnostic test, you've got diabetes, it becomes really easy to track. We don't yet have that in long Covid. People working on it, we're working on it as soon as we have it, I think it will be a transformational change and that has the look potential. I think that is actually the thing that is going to really determine the best treatments going forward once we understand and have the diagnostics there. I think we're just conscious of time and John Mason, just in fairness, we can go to 11 o'clock. That's right. Thanks very much, convener, and pleased to take part in this. My constituency for your interest is the east end of Glasgow, which would be generally seen as one of the poorer areas of Scotland. Building on some of the previous questions, GPs have been mentioned quite a lot and my theme that I've been given is shared learning or how we share learning. I get the impression certainly in Scotland that we've had one or two GPs who are really specialising in long Covid and really into it 100 per cent, and we have other GPs who are clearly less familiar with it. I'm interested if we start with GPs, we can move on to other things. If we start in London perhaps, how does that work in practice? Are GPs being given information top down or do they share it with each other? Is there a consistency in informing GPs? We had an enhanced service programme in the first year of the clinics where there was a small amount of funding to primary care to incentivise coding, case finding and referral, but we didn't hold practices to account on that, so you could argue that maybe we didn't reap all the benefits of that process. RCGP have done some really brilliant training webinars. The Royal College of General Practitioners training webinars on the e-learning content, but actually working within a system, I have seen that we need to invest in GP leadership in long Covid, so we use our post-Covid monies to appoint a GP leader in each borough. They know how to engage with primary care and then in partnership with that GP we deliver additional training. We've been going into practices and holding what we call virtual MDT meetings where GPs can bring patients for case discussion. That's very efficient. You can talk through 20 patients in a one-hour meeting and work out if somebody needs a referral or not. There's a number of options, but the GP is key to this pathway. They are under immense pressure. We've got to do everything we can to support them in terms of training and process. We've developed, for example, a template in their electronic health record that allows them to do a quick long Covid assessment, and it generates an automatic referral and electronic referral just to save them time and to encourage them to use the pathway. We need to feed back to them about what outcomes their patients are achieving through accessing this care, just to prove that it's worth referring to as well. Would the GPs then be more consistent maybe than we think in Scotland? Consistency about GPs is massive. The biggest problem around GPs is the workload that they're currently facing and the requirements of dealing not just with long Covid but with everything else. Like you highlighted, we have some absolutely fabulous GPs who've taken on this. We've got loads and loads of fabulous GPs, but when it comes to long Covid, we've got some who've really taken it on. They've upskilled themselves, and actually we are utilising their skill and their knowledge base when it comes to the management of our patients. They're interacting very, very closely with NDTs. We are also learning from them some of the things that they're trialling in the community, particularly in the far and more remote regions, and their engagement is there. I don't want to in any way minimise the GPs who haven't upskilled themselves from that, because the only way that some of the GPs have had the time and their capacity to do the upskilling is by almost passing some of their other responsibilities on to their partners, up to their colleagues in their practice. Not every GP needs to be an expert in everything. This whole concept of GPs knowing everything about everything, it cannot exist in today's medicine. It's not full specialist interest but having different degrees and flexible degrees of specialties but, importantly, networking among themselves so that they know that, well, actually I'm probably not the GP to look after you while you see that GP, and it almost is generating a degree of specialism within GP for want of a better term. Yes, we are seeing the same as you and we are utilising it. When it comes to providing the educational package, we have regular across Devon. Every two months, all of the GPs get together for educational packages, some in person, some virtually, and long Covid has featured quite a lot in all of those. I've recently been in Devon to have a chat with some of our specialists there. I'm doing lots of our local education package. We are getting the message out there. All having the words of it, some are getting specialist interest in it. Ms Jones, in Wales, is there also this kind of idea of a network of GPs? Yes, just to echo as well, we do have a number of GPs with specialist interest in long Covid who are excellent. I think they link in with the network in England, if I'm right. There's a couple of GPs here in Wales that do that. I think there's a lot of variation generally here in most GP surgeries in terms of awareness. I think that there's a good level of knowledge about long Covid and the services available, but I think that most GPs know that there's some way to refer to it. They may not necessarily know what we do in our service and what we're able to provide. I don't think that there's certainly further work to do here in terms of engagement and raising awareness. We do engage with GPs through attendance at cluster meetings, for example, to try and raise that awareness. We do still have patients that come to us possibly via another route who say that they've seen their GP who told them that they didn't know our service existed, even though we've been up and running for a long time now. We provide guidance to GPs about how to refer and tests that we might suggest to them may be needed depending on the symptoms presenting before referral, but I think that we need to focus on sharing information about what we do and what is possible within our service. Another point is that we want to avoid patients being given unhelpful information, because the GPs are usually the first contact for those people. Sharing education about what works but also what is unhelpful. The prime example is graded exercise. It's not the answer to everything. Being told to just go and get on with it and push through it could be so damaging for patients with long Covid and similar conditions. We don't want patients that to be the start of the patient's experience that they feel that they're not believed or they're given unhelpful information. I think that there's definitely a lot more work to be done there. Okay, that's all very helpful. Thanks. If we can widen it out a bit, then, and again, I'll start with Dr Heitman, if that's possible. I mean, how about sharing between, say, the universities, your university, Scottish universities, even Germany, America? Is there a lot of international networking going on around long Covid? We've got some brilliant national network, an allowed healthcare professional network, which runs across the country and NHSC supports a clinical network, but we see a real need for a UK clinical society so that we can have a home for sharing this learning and sharing the research in this field. At the moment, we have to tag on to other societies, and we're not always very popular with them, so we need our own grouping and we're hoping that this is something that we can stimulate as part of the transition planning so that we're not siloed between England, Wales and Scotland, which does seem very odd. In terms of internationally, WHO have done some brilliant work on long Covid, and many of the UK clinicians are very involved in that. We've done a lot of research linking up with the US who have invested heavily in long Covid research, but in some ways they're further behind than when we are because they don't have an established clinical pathway. To actually do good quality research, you have to have a functioning clinical pathway so that you know you're studying the right patients. So there's so much more that we need to achieve in this, but I think the first step could be that UK clinical society, which we're trying to find a way to fund and resource and build enthusiasm for. Who would take the lead on setting that up then? How's that the question? The jury's out. NHS England are trying to support that process, so we've been speaking to the Royal Colleges. It's a matter of how we fund it. At the moment we don't have any pharma funding, we don't have charity funding because this is a new condition, so we might need to be a bit innovative about that to start the society and then make it more of a sustainable process, but you already have a network of massively engaged clinicians across the UK who I think would be very enthusiastic about this grouping. We need a lead, David. I'll let the other two come in as well if they want. My final question was just really going to be what is there anything else you think we should be looking at that we haven't asked you about today, so maybe I'll come to you, Dr Strain. Just to go back to the networking, as Mel says, there are tremendous informal networks that are being brought together. As Mel highlights, there's a whole range of different specialties that are involved in this. I'm a geriatrician, Mel's respiratory consultant, and we work with cardiologists. We've got rehab specialties, and because we come from so much different backgrounds, there isn't one natural home for us, the formalisation of that. Again, as soon as we start getting treatments going forward, that's where the pharma funding will start to come from, which can provide the back-end support for that. We would be very keen to establish the long Covid society for one to a better term, providing that the network can be provided. Going forward, the only other thing to say is that Covid isn't over. People are still contracting Covid, and people contracting Covid, even in a post-vaccine world, are developing long Covid. We've recently just lost one of our registrar who contracted Covid, and it's now four months down the line, she still hasn't been able to return to work. Due to Covid, despite being fully vaccinated, there's not enough highlighting that Covid is still a risk going on to make sure that this doesn't become an on-going long-term problem. At the beginning, it could almost be excused that we didn't realise the extent of this. Today there is just no excuse for the lack of messaging that's going on, that this is still a problem. In some places of the country, the prevalence of Covid today is actually higher than it was when we went into lockdown, and yet it's just being accepted. We fully appreciate that Covid isn't causing those tragic deaths, the ITU admissions, all of the other bits that were going on, but it is still triggering long Covid, and the only way we can avoid long Covid is not getting Covid in the first place. Okay, thank you. Ms Jones, any final word just briefly? I'm just going back to the sharing information. Nothing additional to add apart from just agreeing that I think it could be really helpful for the devolved nations to work more closely together to optimise that sharing at best practice and learning opportunities. In terms of anything else to add, I just wanted to stress the importance of early intervention with long Covid patients. Just going back to the difficulties that we've had with recruitment, which hopefully we'll be able to rectify with this recurrent funding and filling posts, but it ultimately has led to much longer waits than we would like or are definitely not acceptable. The sooner we can offer the support, the better. There's been longer waits than we would like for people, partly due to the staffing problems, but also the delay in establishing the clinics. We could have seen patients faster by offering shorter clinic appointments, but we feel that it's more important to ensure that patients are given adequate time in clinic to allow for a full assessment of their experience, their needs and their concerns, and to address them fully. Early intervention is so vital to prevent long Covid becoming an entrenched long-term condition where possible, as we have seen in other similar conditions. We need to learn from that with conditions such as ME-CFS, where, if you are lucky enough to have a dedicated CFS service in your area, access to this often comes much further down the pathway, where it's more difficult to support issues that have become more severe and entrenched. So we hope that we will be able to overcome those barriers to allow us to reduce those waiting times, and we really feel that that's crucially early intervention. That's great. Thanks very much, and final word briefly, Dr Heitman. I agree about prevention. Vaccination does reduce the risk. Most of our patients were unvaccinated at the time they were infected. We mustn't forget about that. We've got to standardise our rehab programmes and start measuring the outcomes from those so that we know what good looks like at the moment they're too variable, and early access absolutely agree. This is a treatable condition. The sooner we see people, the better. Thank you. Great. Thank you. Can I thank the witnesses this morning for giving us your time? If witnesses would like to raise any further evidence with the committee, they can do so in writing, and the clerks will be happy to liaise with you about how to do that. The committee's next meeting will be on 9 March, where we will continue our long Covid inquiry by looking at study and research. That concludes the public part of our meeting this morning. I suspend the meeting to allow the witness to leave, and the meeting to move into private. Thank you.