Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Right. Thank you very much. Um So there will be no dance music in this video. It's probably my biggest those of you who came to Newport will remember some overly loud music in the the pin sinus er to they gave so I wouldn't repeat that because there's still people complaining about it. My other thing is is what Brian Justin said. I think I was at the first one of these so it's really nice to be back the end as well. So I'm gonna talk about this, this is a title I and I think this is a title I given if I thought of this title and II probably a bit tired or had a head injury or something to think of it as a title, but we're just gonna go through this and these are things I'm just gonna cover in the talk. I just put my stopwatch on. Um so do we need to save surgical training for the future? Who's gonna do it? What's the NHS gonna do? And what are we gonna do to save surgical? And I say we cos it's an earth problem. You and me and everybody in the room, all surgeons are involved in this. And I think that's, that's the takeaway point right at the start. So do we need to save surgical training? Well, how we actually doing what we're supposed to do? So JST, we have quality indicators, say what your average working week should be your job plan. And then we collect data through our annual trainee survey, a trainer survey as well to see how we're doing against those Q and other things as well. And you can see that we're nowhere near. So it's a relatively modest thing. So you look at theater, it's three supervised sessions, 3.5 days a week, you can see for every specialty there. So we're not allowed in general surgery, but no more than 60%. It's slightly better than last year. And for core, core training, it's even worse. So trusts are not delivering the, the access to theater that they're supposed to. Uh, we can see this again in clinic. You're supposed to go to two supervised clinics a week and you can see where it's better in clinic. Uh, general surgery is probably the worst performing out of all specialties apart from vascular. And in, if you're a core trainee, you're really, I don't know what you're doing, but you're not getting to do what you should, should do. Emergency theater are even still not achieving that. Only one supervised session a week on average, still nowhere near and informal teaching it's really sound, it's only two hours a week of formal teaching is supposed to have and you can see that in general surgery again when they were here. Hopefully we're gonna roll out, well, we are going to roll out the, er, national online training, uh, program that we've done in core, er, to all specialties. And so I think that's starting in, in, uh, next month for general surgery and that means you don't have to travel anywhere. You'll get national experts talking about the subject's map to the syllabus and hopefully that will be improved, but it's still about getting access to that two hours a week. Don't want anybody having to do this in their own time. So, the Paul Smith Gram here shows how we've done since 2019. Remember in 2020 we had this thing called COVID and it's had a massive impact on training. You can see general surgeries on the, on the left of all those diagrams. And if we take the activity that appeared in the log book in 2019 as one and everything else relative to that, you can see that we're still a long way behind the pace. Some specialists work effective than others. If you're a cardiographic surgeon, things have actually got worse and all this is lost experience, experience that you're never gonna get back and that runs into several millions of cases across surgery. So there's a huge deficit in your training there. Look at some numbers. Now, if you extrapolate 2019 to 2023 you can see that there's just thousands and thousands of cases that haven't had a trainee involved that would have done, had we not had COVID and other things happened. So there's a big impact, a big reduction in access to operations. And of course, it's about all operations. It's about, it's about clinic, it's about supervised ward round, it's about endoscopy and all kinds of things. If you look at emergency laparotomies, they obviously didn't change very much. There was a little bit of a dip in the very early weeks of COVID where we weren't quite sure how high risk things were, but they pretty much emergencies pretty much returned to normal quite quickly. And again, it's, it's relative to 2019. So the dotted red lines 2019 and we can see this that the message that even in emergency laparotomy, we're having trainees are exposed to fewer emergency laparotomies than they used to be. And you can see for assisting supervision. Thank goodness, is about the same as 2019 levels that performed a lot fewer relative to 2019 segmental colectomy. I think probably because of the pressure to catch up with cancers, et cetera that we did get a lot of exposure to that and assisting one right up. But then so did supervision as well. So I think this is the one area probably across all of surgery that we're doing ok in. But again, if you're a core trainee and this is very worrying, you can't really, you need to be able to walk before you can run. And we are not getting people walking less access to. This is because day case lists without access to trainees and the advent of off site um off site centers to do this and these things happening in the independent sector. So that's because cystectomy as well. Another index procedure that you need to be able to do for, you can see that just well below where we should be relative to 2019. It was hard enough in 2019. It's getting very, very difficult. Now, this is some data from TNO. We did some work with GFT. So looking at his data, we found the total number of cases performed in these index procedures for in t for general surgery while I'm showing you this and these are things that trainees need to do to get to. The blue shows the total number of procedures that happened in England and Wales and the green involving trainees. The maximum proportion was 18 per cent of all the cases done. And this will be something when we look at the figures, I'm sure of repeated in, in uh in general surgery. And of course, all this adds up people get towards the end of training and haven't got to where they need to be to be a safe to practice day one consultant and we've seen these are the COVID outcomes and of course, they stopped being issued last October and they've virtually gone to zero. This is up to, to June 24. But we can see is those outcome threes have more than doubled cross surgery. And that's about eight or 9% of surgical trainees are having their training extension on average about a year. So it's a big problem for trainees. It's a big problem for pipeline delivery of workforce. And it's a big problem for and also a problem for people trying to come in to train because numbers remain occupied. The other thing, we've heard a lot from asset about the non financial costs of training. I'm not going to go into to all their data. But what I thought I'd see is just see finding the data on how hard is surgical career compared to other careers. So I thought I compare it to other medical specialties. Quite a doss, I think being a physician and then also some comparable other professions that are law and finance. I think you see that, you know, finance worked pretty hard. But if you look at all those things, that surgery seems to be pretty hard, take quite a hard toll on people. So people are working hard. If we look at just burn out alone, there's a massive excess of burnout. I don't not saying to depress you, but it just shows that training is in trouble and you can see that, you know, surgical trainees seem to have a harder time of it than comparable other professions or even within the medical profession. Ok. So it looks like we do need to save the future of surgery, you know, er, surgical training uh about performance, about delivery, about access, but also about the quality of uh, of the training as well, both in terms of what we deliver, but also the environment and the experience who's gonna, who's gonna do this? Well, there are, there is some bad news that the cavalry are not coming or we are the cavalry. Er, in fact, if I had some music now it would be John Louis. Um but no one's coming, no one's coming to rescue us and it's really, really disappointing and I have, you know, we are trying so hard for this, those of you cast your mind back to two days ago or remember the DAS report coming out if you do the fantastic command f function and type and training. Finally 11 mentions the word training 167 pages, not one of them is training relating to anything to do with medical specialties at all. Er SEK Starmer er, gave a, gave a big talk on this and uh you can, you can find the transcript of your speech online as you can with all the, all of them. There are zero mention of training. So we're gonna save the NHS, but only for today and not for tomorrow. There's no investment er, in this at all. Ok. So that's the government. Um, what's the NHS gonna do to save training? Well, there's a lots of things about that working environment that I said and there's lots and lots of things coming through that, uh that uh non surgical cost of trading work that Aet did. Um, this came out from NHS England in April this year and they're gonna do something to help with the quality. They're gonna try and fix the rotor a little bit, give you a bit of notice and try to make sure that you're paid properly when you start a new trust. So thanks very much. Um Nothing's happened so far, by the way, he with a dying breath before they were absorbed into N HSE, put out this really quite useful document about how to put some. So you're back into being a trainer. One of the big problems we have is disengagement of my consultant, colleagues or the people, you know, or consultants that you will be in a very short time as well. And there's all sorts of other pressures and people are pulling back from training for some of the reasons we'll go into in a minute. So what he decided to do was put together what is quite a sensible document. If you look around those things there, the educated workforce must be a key consideration in workforce planning establish an educated time and resources, ring fenced and career frameworks for educators supporting the well being of educator. You can look around those. They're all very, very sensible suggestions. It was reissued by only a few weeks ago in August and I'm talking to them next week about this. But there is precisely no action on this and there is no money behind any of these things at all. So fine words, no action. OK. So what can we do? The, the, again, the emphasis is really on we, it's, it's, it's for all of us to sort this out. So, the first thing I think we need to do is we become some of the misconceptions around training, which I think is sort of three main groups. It's training isn't safe, training takes ages and so it has pressure on our, on our list and there's no money. Why should I do it? Because I don't get paid to be a trainer. So it, it, it's, um, it's quite hard to find decent studies, er, on, er, on complications, but this is from 2012 and it's the big, the national North American, er, NS Quip database. Er, and, er, showed, well, you can see there 60 61,000 cases, there was a, there was a slightly higher complication if rated trainees have been involved in the case, but it was things like superficial wound infection. It really wasn't anything. So, and the conclusion is that, er, resident involving surgical prisons is safe and it continued to be safe and if it's not safe, it means you're not being supervised and trained properly. Um, it wouldn't be a talk unless I could sign myself. So, uh, here's, here's us looking at emergencies in the UK from, from nearly nearly 90,000 patients and we found that there was no increased risk of death or return to the, if trainees, the operating surgeon. So you can say, oh, it's not very safe and it's difficult so. Well, actually, the data doesn't support that. We're all like data driven, right. Evidence based there is, and it's quite hard to find a decent size study. But this one's got, er, three quarters of a million cases in or, or nearly, and this from Canada um shows that training does take a bit longer. I always thought it was a cyst but it turns out it might be something to do with the trainee doing the case under supervision. And you can see there's an average of about 20% extra time if the trainees, the, the main operator and that's absolutely fine as we get better, we get a bit quicker and people operate in different spaces. I guess most of you won't operate as slowly as some of my colleagues. There's a huge, there's a huge range here, but we need to be aware of that. I think there is a cost, a financial, an opportunity cost to training because it displaces some of this. So one of the things I've been trying to do is to persuade to, to attach a best practice tariff to training, involving cases where trainees involved in doing the case to compensate for that extra time taken for training to happen so far. And it's been a bit disappointing because the people in charge of this money and elective recovery have been people very much involved in training in the past and seem to have left it all behind. It's fallen deaf ears so far. The other thing, it's like you guys pay loads to, uh, to train, you know, you know, well, you'll know that a lot better than me. And this is it. I just sort of get some comparators to other countries and you can see that you put a lot more into your own training compared to people in other countries in the Republic of Ireland. The government pays for their training fee, for instance, which I think is pretty much a difference there. And, uh, and the USA it's mainly travel costs rather than costs for courses, et cetera. What do we put into surgical training from central? That goes to trusts quite a lot in the UK. You get most of your elective salary paid for plus a supplement of about 12.5 1000 lbs for each of you. For every single trainee in the hospital goes to their hospital. Very, very little of that. Makes it to the shop floor, makes it to anywhere to support your trainer. Uh In that it all just disappears into the general budget. If you ask your DM E med medication, where's the budget? They probably won't know. It just gets, it just gets filtered off by the CFO but some money does make it through to support posts in training. And again, I've done some international comparisons there. UK It's not very much, some but not all ass will get about 0.25 of a pa per trainee program directors will get about one pa for general surgery and heads of school will get 2 to 3 pas depending on their thing. So there's a bit of money that goes in there to support that, but really not very much at all. How much do you, how much are you in debt by the time you get to CCT? And I think that's an international comparison but you can see, I I've totally upper the debt salary ratio. So if you're in America, you might do a bit more, but there's a pot of gold waiting for you when you arrive. I'm not sure what's the pot of when you arrive as a consultant surgeon probably shouldn't say in public. But you can see that, you know, your your debt salary ratio is pretty high, but don't forget that you generate a lot of income. You see a lot of patients, you do a lot of things that the trust, uh, then bill for. So this is, you know, I just tossed up some figures, uh, sort of, you know, proper back of a beer kind of thing. I don't smoke so we can't be back in a fact, p 20 patients you see emergency weak and you can see the figures are a pretty modest week I'd have thought. And you can see, depending on the complexity the patients treated, there is a massive er, income generated by your work. Uh If you take off some reasonably safe assumptions about what the overheads might be involved in that, there's still a pretty high profit made from you, your activity as a trainee per year in return for uh for the trust your out of hours salary. Only the other thing we need to do is put some prestige back into training. It's the proper Cinderella, er, thing to be as a, as a trainer when you and it is partly, you know, the fault of specialty associations in that when you go to ACP or something, it's all a glamorous but it is the robot, this and a robot, all those things. And nobody says, hey, here someone does some great training. It's very, very rare to see that. So there needs to be some prestige back and also needs to be better practice tariff actual time and job plans for doing the training as opposed to just being the, and for surgical tutors. Who are representatives of schools in the hospital in your units to actually get those JCT quality indicators implemented. So you're doing what you're supposed to do rather than not getting access to all those training opportunities we need to, we're getting colleges on board to highlight, promote training and you know, and, and sort of other rewards. Well, one of the things that's happened is that with the demise of Clinical Excellence Awards and and other reward schemes is is that there's, there's no mention of training and training wasn't featured very highly in that anyway. So there's no real prestige, no emphasis to do that. And then, you know, everyone's been trained. I was trained quite a lot of it in my generation was self directed. But we had, you know, people let me be self directed and taught me some, some things to make me safe to be self directed. But you have to remind people that they were trained and they said duty and privilege and pleasure to give back that training. So training is fabulous. It's a really, really good thing to do if you don't train. It's a bit like saying, well, I've had kids but I'm not going to look after them at all. And you know, so like you were a trainer, you were a kid once. So why do you know, why don't you look after your kids? And it's exactly the same thing. So it's great to give back, you learn loads. It's great for on. And it's also an investment not only for your own healthcare in the future, I place a couple of years ago, really pleased that we had a former trainee and he was very good and, but it's great to help people. See people can't be anything more rewarding. You benefit generations of surgical surgeons after that because you, that thing keeps passing on and then think of the tens and tens of thousands of patients care that you influence through that training. It's a great feeling. What are you gonna do when you, when you're doing it? Well, get training at central list. Bring it up, bring it up, er, objectively, this is Poppy Redman's er surgical checklist. You, you can download it just to type in Poppy Poppy Redman's surgery education checklist, put this up in theater, put this up in the changing room and then start the conversation at the who briefing? What am I gonna do? And then everyone's aware about what's gonna be training. You can agree stuff beforehand. Grateful to Joe Norton who is a vascular trainee in Edinburgh doing a phd on this and this gaps framework, goal, autonomy preparation strategy. If you run through that and again, you can download the gaps framework, an internet search decreases the cognitive load of the trainer. They don't have to stress about what they're going to let you do. It reminds them and it allows some space to train and is evidence based in improving things, was trying to do about a month ago or so to, to do some more. So I managed to get the, er, colleges to introduce uh, appraisal which wasn't happening for, for surgical tutors so that they can then be judged against the impact they're having in their trust and the quality indicators we've circulated and allowed access to specific units, performance in the E log book. So TDS can see which units are doing, who's training, who's not training and then have a word of people to see what the barriers are and to stop those barriers we are developing. We're gonna do very shortly, a snapshot of activity performed by trainees with as it. So if it comes to you, please fill it in, what do you do on that day or that? We haven't quite signed the protocol yet and then we can show just how much money you are generating for the NHS and some of that needs to come back to you. Uh We're gonna put an foi request to trusts to see where that money goes, that goes from the Deanery, see what actually happens to it. And, and then, and then uh publicize that and then put a, put a campaign on over the autumn just to get training going again to get people doing it. We all college presidents are constantly reminded by me to whether they meet with ministers to put training very high on the agenda, they do that. I'm not sure that the ministers listen very much, right. The other thing and probably my last thing is that uh we are, I'm a trainer now or you may be a trainer now, people in the room, but you will be trainers in the future. So this is just a thing, you know, you will be doing that. And I would ask everybody here to remember that you're sitting here being trainees, you need to train the next generation of people when you become trainers yourselves and you become consultants. If there's only one thing you remember from today, remember that? And um it's really fun. You can read all the things there and this the most self evident hashtag in history, completely ignored so far by everybody need to keep getting the message out there. Thank you very much. Thank you, Professor Lungs. Anyone have any questions before Professor L runs away, it's always running away because of the question. And you want.