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Wonderful surgeon working in the wild in Birmingham in um tumor surgery, as well as revision, sleep. Great work in the IC hearing where tumors out there. I think it's something you see out there a challenging and would like to have some answers to how to deal with them. So hopefully it will get here today. Thank you. Hi, Ross. Um Thank you very much for the, for the invite to come for today. Uh So really, I'm, I'm not um an offshoot, a um census meeting which we organized up in Birmingham in January of this year. Um And I was predominantly looking at chondrosarcomas and ea joint infections in megaprosthesis. And the offshoot of that was we wanted to see sarcoma care was like it worldwide, essentially globally and middle income countries and access to sarcoma um work work done by, by Lee Jays and his daughter Charlotte as long uh as well as er Eduardo J uh Eduardo and uh Jian Tata in India. And so just a little bit about boom, the boom meeting was a consensus meeting that ran along the Delphi principles, um started in January and it ran over two days first day was looking at chondrosarcoma management and the second day was looking at management of parasitic joint, uh infections in megaprosthesis. And we had a global audience and it's the first oncological meeting, first consensus meeting that's ever been held in orthopedic oncology. Uh So it was a world first for that. We had delegates more on the globe of 300. It's in all scientific panel um and scientific committee uh from each region of the er world. The leaders in that prospective region were on that scientific committee questions were formulated but then uh then researched the evidence behind those questions and fed back those questions for debate on the day. So uh so why did, why did we do it January? Why did we do the boom um process? Uh Chondrosarcoma is a global problem. Infections is of a global problem and that's gonna only increase with megaprosthesis, increase megaprosthesis use. Uh These are just some of the photos that we get sent on whatsapp groups saying we do this. Um and these are coming from all over the place. So a lot of unanswered questions in Chondrosarcoma uh management there. But uh the the and there's still a lack of unified treatment policy for chondrosarcoma doing it slightly different. Um We wanted to try to unify that approach to get a more systematic way of managing this. You look in the literature, these number of papers that are being produced and there's ever increasing amount of research that's now coming out, um, and being published, which is fine but you have everything with everything you need to sort of keep in the chaff, really don't you? And often when you look at these papers, they're not comparing apples and apples and oranges and oranges and sometimes they're merging the two. and we all know that things are very different. We want homogeneity with research, not heterogeneity. Uh Most of orthopedic research, I don't know if everyone's an orthopedic surgeon in the room, but all into one of these camps, our camp is the orange one. So we've got a big database and we say our papers are the best because we've got the best database and then, and then other people have good registry and most other papers fall somewhere in, in between. So we wanted a a unified approach to it. So why the access pole? Um This was a global meeting. We had the opportunity to canvass um opinions and we canvass the real state of health care in, in respective countries throughout the world. We are lucky and fortunate in this country to be working in the, in the NHS, which provides pretty much free, really free health care for, for, for everyone in it. And we don't really have to worry too much about costs, but that's not the same for everyone as this audience will well know. Um um So we wanted to try to find out what the situation what the, what the current um lie of the land was throughout the rest of the world. We had delegates from all over the globe. We were underrepresented in Africa. Unfortunately, we had a lot of uh we had South Africa, but we didn't have much by way of central and North Africa. We tried to make that consensus meeting which was held in Birmingham as um affordable as possible 200 lbs to attend to the big meeting which is happening in October in, in Australia, which is 1000 lbs. Um We subsidized people coming from uh lower income countries cos they obviously can't afford to make it there. And we wanted to include them as much as possible. So we tried our best to get everyone. Unfortunately, we were underrepresented in Africa. So I want with all of that slide, but there, so the human rights issue. So, um the Universal Declaration of Human Rights, they, um that first came into effect and then there was this next act and this next article, this article basically said anyone's signing up all of this and you are committing to try to improve care for you to live in your country and going if you don't have the means at the moment, you are trying to improve the situation down the line ongoing. Ok? And the, the these are all the attending countries we have and in red they, these are all the countries which we class as a lower middle income country, well trust um levels. Anyway, so we had good representation with all um the demographics. Um This is again, just a, just a, a global schematic of the attendees that we had survey itself. Um He developed it, there was a mix up exposed and open questions. So um it went out on a survey monkey type format within an open dialogue box. Um At the end of it, um this was sent out to every, to all those members of the scientific community or scientific committee, should I say? Um this was the pure, pure numbers um of uh attendees distributed across. So, a good uh number from Europe, as you would expect, it's a lot easier to get to Birmingham from Europe uh than it is from, say Africa. Um But we had a reasonable representation from uh South America and Asia, some of these questions and I'll run through them um broadly, we're looking at the access to Sarcoma care in their respective country. And you can see just on that uh color diagram where the areas are, which had the most difficulty with access to Sarcoma care, predominantly Southeast Asia and uh bits of South America as well. So this is uh some of some of the questions that we'd uh we asked at that time. So um we asked, how easy is it for basically for, for every region in the country to get access to oncology care. Um And the results were reasonably good. 64% said yes, we've got easy access to it, but quite a large amount, 36% if you think about, you know, the whole population of these countries we're talking about did, did not have easy access to sarcoma care. Um For those who aren't aware, sarcoma, uh, outcomes are markedly better when they're, uh, managed at a dedicated Sarcoma unit with dedicated sarcoma surgeons. Um, and there is some intra country variability as well. Free, free text comment there from the, what the South African contingent said. Even within South Africa, the amount of access we have varies and it certainly better on the western, er, cape than it is in some other aspects of so, uh, areas of South America as well. They reckon I have very huge disparities, um, access to investigations again, specifically for oncological, uh, investigations, pet CT scans, uh, immunohistochemistry, proton beam therapy and translocation studies. And that varied, uh, a lot. And you can see that even in countries which are not classed as low or middle income such as, uh, Australasia, um, they have virtually no access to proton beam therapy in that country. Um, and that's, um, something which they are looking at about how to get access to that. So there is an enormous variation. Um, it's the good thing if you look at the basic oncological um, er, investigations such as immunohistochemistry, nearly everyone is gonna have access to that, which is So who pays for the treatment? Again? The NHS were very fortunate, largely state paying. Um And but 25% of people had to pay for some or all of their treatment. So when we're talking about mega prostheses, for example, or chemotherapy treatment, that's tens of thousands of pounds. Um And if chemotherapy treatment is even, uh and this was asking really how much of that percentage, how much would they say of the percentage of their population was covered by state of all private healthcare insurance. Um So lots of companies did, lots of countries did have some aspects of their care covered by their state or their insurance. But there was a significant number of people who still had to pay for some aspect of it up. Um um Specific to the question about access to a specialist Sarcoma center bearing in mind that the outcomes are worse when you don't get uh treated at a Sarcoma center. The numbers looked fairly good. Um 38% said over 90% of the time of the patients will have access to a specialist Sarcoma center, but that still leaves the other 40% in the in the section below. Um which which didn't, so there's still a very large number who potentially doesn't have access. Now, why is that a lot of information from these free text boxes which why we put them in? Um For example, Indonesia, logistically, it's very difficult for patients to get from Ireland to Ireland to a specialist unit where there may only be two or three sarcoma surgeons to sort of a massive population. So that was one aspect, other aspect is funding for patients to be able to do that because they have to be self funded for their travel treatment. So the treatment would be offered locally at a local hospital rather than a patient being able to travel to a specialized center. How often do they think that their treatment was compromised? Um Because if someone else has had um a goer treating a sarcoma, which ones? And so if someone has an attempt at treating a sarcoma, uh and then they'd get end up in a specialist center, we have to do a different surgery, a more radical surgery to make up for the initial attempt. Um And for 60% said not, not often, which implies that 60% of the time those patients are coming to a specialized unit and they're, they're receiving the correct treatment. On the other hand, but the rest that means that there's quite a significant number of patients who are, are receiving suboptimal treatment with best interest in mind. Of course, it's still suboptimal treatment according to what we would say, w what we would say was our, our gold standard of treatment. OK. Reconstruction, compromise again, feeds very heavily into funding and, and budget and whether patients can pay for what they need to have a megaprosthesis is upwards of 15,000 lbs in this country. Um And I know in South uh Southeast Asia, uh India, patients have to pay for these implants themselves. So that means that a lot of patients may not have limb reconstruction or limb salvage, that may end up with amputations or variation of them and end up with rotation plasties. Um And that gold standard is a, is a compromise and then we looked at results within countries. So the intra intra country uh disparity. Um and you can see that er India, the, the care, the provision of care and the access to care differs amongst the, in the country itself. And that's also the same for Mexico and also the same for Egypt. So different areas are getting different levels of treatment. So it's the the global equivalent of the postcode lottery. Um That's kind of difficult to read but the more colors, the more go. So Mexico um high discrepancy, Indonesia and India, high discrepancy, Austin did they think that there was a treatment delay to the lack of resources um regularly, 10%. So that's good. Um Not often 52 I think uh in the N HSI, don't know what we'd say. There's a lack you asked that question. Is there a lack of resources to be able to treat a patient? How many of us would say I can't treat the patient? Cos I've got a lack of resources. Not that often. I would thought treatment time. So ideally, our treatment times you're seeing some within two weeks uh having a biopsy. Um and we've got a referral to treatment targets and our 28 day faster diagnosis targets for, for sarcomas. And we all know about referral to treatment times. And so we have some certain standards that we think that we should, we should achieve. Ok, see, across the public and private sector, there is a disparity certainly within the first uh two week referral, it's probably at least sort of as you would expect. You can end up getting a treatment that bit, that bit quicker does then pass on down to when you're looking at 2 to 4 weeks and 4 to 12 week mark as well. So in summary, we had 100 and 92 people completed that survey, um vast majority. So the vast majority majority of patients um respondents practices uh they were covered by private or public insurance, but in 18% of the to, so that's, that means that patient is self funding. Um Most were treated in a, in a public hospital and there's a um 25% of those um out of pocket payments for implants or treatment. So, yeah, only 40% of the respondents in globally when we looked at all the numbers uh across all areas of the world were, were treated in the Sarcoma Center, which is worrying worryingly low. Um because it's a very specific type of treatment that is offered uh by a sarcoma surgeon. And uh that is a very, very uh low number. Um and often that's financial constraints which is affecting uh people's access to healthcare. And the type of healthcare that is delivered was marked in regions with lower income areas. We know that high density population are often found in, in poorer economies and sarcomas are population based incidents. So population higher instance of sarcoma um and found in poorer economies. So it's allowed us to have a look at that on a global Yeah, there's publications coming out and get statistics around the answer if they're statistically significant to that as well. Um It allowed us to highlight the intracountry variation to those attendees um more. So this isn't just a paper to churn out. This is this is feedback for the people who attended that conference who actually put data into this to be able to take that data away. Have a look at it themselves, use it to influence people in terms of funding in influence gov governments and lobby uh governments to try to improve or standardize the care in the country. So, so the publication results, what we're going to do next um That data was is available for anyone who attended and it's available for anyone at all. You just go onto the the website which is at the end log in and a username and you can download all the data to use it for, um, you want really? But certainly our aim would be to use it for lobbying to try to improve standard of care in treatment. Hi Web on. By the way, we access the data, I thought that was amazing. Like to get all those people in one place. Yeah, basically it was a really good idea to actually do that to get mobs of people online. So how did you get everyone to, to, to come? We um we largely so that it, it all came about through a chat when, when I don't know if you know Lee J, but he's frequently flying around the world and he knows he's very good friends with most of the Sarco units in the world. Um And on these talks, it's very evident and even when you do them in in the UK that there's a lack of um concrete evidence behind the treatment being issued. Sarcomas. So, and that's always a source of debate at any of the meetings you come to and someone puts their hand and says, oh, I wouldn't have done it like this or I would have done it like this. Um And that over time has generated a, a sort of a groundswell of, well, we need a way of managing this. So a lot of it was buy in from the they want, they want to have some guidance, they want to have some system to manage these conditions um that is ratified by the community that does deal with those conditions. So a lot of it was buy in um and then whats apps and a lot of emails and yeah, once when it came together, it was trying to make it as affordable as possible. So we raised over a 250,000 lbs from sponsorship um in order to do that and that was industry all industry. Um and the roh and we have a charity as well for that. So without that, we do have to work hand in hand with industry to make this stuff happen because we don't have that money, do we? So did they do they pay for their travel? We didn't pay for their attendance or something like that? Yeah. Yeah. So we, we tried to sub, if they had to long way to pay for the travel, then we try and subsidize their health. Um but it got, it got it difficult. So we tried to, we, we did a very nice, yeah, we had, we were using clockwork me medical. I don't mind them. They were fantastic. And we used them to negotiate with the hotel we had in Birmingham. Right. We don't think they have to hold it out. So would you do it again for other problems? Yeah. So that's the plan. So the original plan was to then have it as part of the, the alumni of fellowships from fellows who come through Birmingham. So the next one is in South Africa in two years time, a different set of questions. I didn't include any outcomes from the sarcoma and the infections. I didn't think it was relevant to me, but um we're doing it, let's not focus on what you did. But have you got any explanation as to why there was so little take up within one third continent? And have you got any plans for how you can increase that engagement in the future? Yeah. No, that's a good, that's a good point. I do. We don't know why we got such poor uptake from Africa and North Africa. Um We're hoping that the next one in South Africa will be more, will be easier because so the travel is easier. Well, it's not that much easier not to go down to uh down to South Africa, but it, it be local s but um there's more, maybe more buying. Um I think it's a bit more fragmented. I think that's, that's probably the difficulty that there is no that there are, there are no tumor surgeons. Yes. No, they or every piece of tumor surgeon. A little, a little, a little bit of that, I think because there's so many countries within massive continent that potentially the differences in their healthcare systems means that there is. And as you say, one, a nominated sarcoma surgeon, but I know there are sarcoma surgeons in um in, in North Africa. Sorry guys can slightly answer question. So I comment on a few countries in Africa. I can't comment on the whole continent, but generally speaking there, there just aren't any geo surgeons as, as you know, I think, I think that's the, the issue. So in terms of how do you, we get, that's probably the next step. What could you start? It'd be cool just to say like you could get one individual from every country on, on you wouldn't have to attend. They just have to be virtual. Yeah. Yeah, that would be amazing. I think you could do that. You got like, yeah, so many people. Yeah. And we did have a uh that option to try and do it if required, but I just didn't get that by. And so, but yeah, that would be the next day. Try and get everyone. We got a good amount. One of the things, sorry. Um Just one of the ways of reaching out. I'm not quite sure how you managed to, to, to survey and get your, your back. But um we've used the of the colleges wax CASS all the pan Africans on but going to the whatsapp group of the trainees in those colleges, I agree to be very effective. So, getting a course. Have you done courses? And when we went through COVID with the webinars that we did a BB first in this age and if you're going through the cassettes, a trainee, what's that group letting you get a very, very quick response. So you could reach a lot of the hospitals. I don't know which, how, how you, you, you uh surveyed Africa, but that's the way, that way, we, we had a, we had a lead for each region and in a bigger region, we had maybe two leads on that scientific committee. So we had a, we had a couple um and then they would then disseminated, but thank you very much. It's a stimulating for your follow up on that. Yeah. Um So our next uh two speakers are representing the P SSH uh here today with some um which was uh partly uh um spoken about last year and it's really nice to for you the SSH to come back and give us an, an update on, on this. So we've got Jonathan Jones uh from Peterborough and Martin Wood also. Sorry, I didn't quite get details. Uh So, yeah, well, after we do just Yes. Ok. Yeah. And good afternoon. Good afternoon. Can you hear me? Alright. And uh are we OK, we, we still have an online audience as well, so. Ok. Um So we're going from boom um to Lyon. Um I don't know if there's a connection there. Um But there is a sarcoma case in this, this talk. So stay awake for the oncology bit. Uh So we're doing a bit of a double act and um Martin will pick up the bits that I the balls that I've dropped and, and, um, yeah, he's, he's the graphite rod in the nuclear reactor. So he, uh, just check everything through. Um, so this is an update on the line project. That's the Lung Institute of Orthopedics and neos surgery. Um, and, uh, but there will be a little bit of a reboot for those of you who might not know how the line project started. Sorry, there's gonna be some overlap on previous Malawi slides, but uh it is a beautiful country. Um So let's see if that goes in it, that's going backwards. So let's go forward. Ok. So we know where Malawi is. The only thing I'd pick up on that on, on the additional bit about the Malawi. Um is that um it costs about 1000 lbs to fly to Malawi. So when we're comparing overseas trips and how much it costs and to get a faculty there and we talk about carbon footprints and we've been talking about the environment today. Um Just something to bear in mind. It is expensive to get down there. So we try to make the trips, um people to stay for longer if they can and it takes um at least sort of, it's about a day travel by the time you've gone there. So, so it's, it's a week if you're gonna go, go for a bit longer, Charles and Mercy, these are the uh the staff in the house just by the way, but they represent the warm heart, the heart of Africa, uh spending a couple of weeks with them is just gold dust. So if you go for nothing else, go and meet these uh Charles and Mercy. Um and uh it's, those are just the usual demograph graphics that we've already seen, but actually we're talking about one doctor to 65,000 people that's in Malawi in the UK. It's 1 to 330. And how many people do you come across to say they can't get to see a doctor? So imagine what that's like. Um And uh so yeah, that's all very nice. And yes, it's a beautiful country with beautiful wildlife and this is for anybody who's on the audience who's dialing in, who might be thinking, I quite like to go and work in the line unit. I have got hand and up limb experience. And would I bring my family out at the end of it and go for a little trip around at Malawi then yes, please do. So if that just nudges you over to just say, say you're gonna come, then please do come and it's safe even though there's hippos and lines there. Um And the lake is stunningly beautiful, the lake of stars. Um So we're very lucky with the NHS. It's uh and there is this concept of global equity and, and it's been fascinating having the comparison with the reusable and throwaway drinks. So there it is it's a huge contrast, isn't it? And then bed sharing um and kit and lots of instrument sets with lots of jumped up instruments um and hands are important and feet are very important. You can't get from A to b uh your feet, but you need your hands to do things. Where would we be without our, without our hands? Um Once you've got to be, you need your hands. Yeah, you need it. So hands, hands are for life. Um, and uh the business offers an interface specialty. It's one of the few interface organizations. So there, there are both plastics and orthopedic surgeons within that. Um, er, so, and, and you need an orthoplastic approach to uh to hand surgery. Um, as you do with a lot of orthopedic, er, problems. Um, um, by the way, I forgot to say it's nice to be back with work as I do, I haven't been a member of work for about 30 years now and it's also been nice to be back at Sheffield University where I was a medical student. Um, so I tell her that I've come home today but I started off as an orthopedic surgeon in work. His man's and, and Martin's very, very walker heavy person. In fact, his father was big and what he was indeed, Martin will tell you about his father. Um, so general burden of, of, of trauma leads to the fact that the hands are often left behind as we know in this country sometimes you'll just wait until the end of the day until so and so has done their nailing and so, and so has done their ankle fractures. So, well, I'll come in and do a couple of 10 repairs or a few, no repairs. So, you know, we remain the poorer sisters in the orthopedic world. Um, uh, yeah, very high rate of trauma. Um, and in fact, um, yeah, so they mentioned about the link between deaths and then obviously the injuries that, um, that go along with that, which has been in any situation. Um, road traffic absence. This is no surprise. These are all, you, you're very familiar with this. There's, there's some very experienced overseas surgeons there who've been in, in, um, you know, these sorts of settings for long periods of time longer than I have. Um, my experience has been for the last sort of, um, 15 years or so, but I've been in the military and gone overseas for different reasons. Um, but in terms of the, this is, uh from one of the, the, er, Linda Banza who's from the Lyon Hospital, he did this study which has shown that that's, that's the increase in trauma that's coming over the, as you've probably seen this picture, but it's a bit scary, isn't it? I mean, already they're overburdened with trauma and it's just going up and up and up. Um, so, uh moving on Sustainable Development goals yes, open fractures, we've touched on this in other, in other talks and hand fractures of which compro um, comprise about 20% or, or so, or, or, uh, it, it's probably a higher than 15% of, of hand and wrist and upper limb injuries. So, um, there's a lot of open fractures in there. Um, and, and the management of hand injuries makes a real difference. Um, you can get long term disability, imagine your hands, if they're stiff or they've got wounds, you can't use them. And if your someone in your family also has got a has got injured hands, they can't do anything. Um So if your, if your wife can't look after the Children you have, can't work et cetera. So all the disability that goes with um having hands that don't work. Um Our, the, the line project really kind of started. Um If you like of the seeds of it when uh the we were invited by wo no less in 2015, um via Steve Mannion, uh via Lin to coa who wanted to get some of the uh hand surgeons to come and teach the orthopedic clinical office. So that's where it all started. So thank you Wok. Um So way back in 2015, um for inviting us to go, go to Malawi. So we went and taught on the Mangochi, the orthopedic Clinical Officer course at the um annual uh conference for the orthopedic Clinical officers. So there's Bo Verson. Um and there's uh masters ea he was the president of the Malawian. You probably know some of these guys. I, I'm sure you've met these folks and then we carried on visiting, uh doing other courses and then we widened it to include trainees and residents. Um So that we were teaching some of the registrars and you'll see a interesting picture later on showing some of the, the trainees. So, in fact, this is one of our trainees from uh 2017 and we recognize him for those of you who've been to Malawi a lot. Yeah. The Soil Banda. Yeah. And he's a line consultant now. So there he is, he's been short hand, he's been uh examining um hands in Blanca. We didn't know these guys, but now we realize that actually, obviously they're not there. They're not in the line because of us now, but it's nice to be in part of their journey. Um Lida in Blanca, she had this dream cos we said to her, what do you really want in Milan? She said, well, uh what I want is a special hand in, in, in uh well, in, in Blanca that she wanted um and I want you to help us to heal the hands of the working hands of Malawi. Um And, and she wanted the referral pathways. So she wanted orthopedical to refer cases when they needed to be referred. We had lots of presidential interest uh by the way, I don't know if you recognize that. So there's um that's Martin putting a, a bone graft in from the, in a scaphoid and I just um wall up to the IAC Crest. So I provided the bone grafts. So we were just a bit of a bit of reconstruction there. Um And then this is where it says it's mentoring, it's teaching and sharing ideas and um experience. We had presidential input from the B SSH and see love. He was very interested in the overseas work and said to us during our time um on the overseas committee, he said, why don't you um build a hand unit in um or rather do a pop up hand unit in a low resource country. Um So she gave us the, the I was the president, I was the chairman of the BSH Overseas Committee at the time. And I thought, well, that's great. That sounds like a good idea. And let's take it away and have a chat. So we put it all together and we thought we went to do a pop up unit. We'll integrate with local people and we'll go to Blantyre because we have our partners there. And let's see if Blan will actually respond. So we chatted to them for about six months. And then after a while, Jeff Bates who's mentioned, the name has been mentioned already phoned me up and rather agitated, said, look, it's not gonna work in Blantyre. They're not ready for it. It's gonna take too much energy and resource and everything else there. Why don't you phone? Um Yeah. Uh there's a man in, in uh in who is uh who has got, who's building a new hospital called the line unit. And if you give him a ring, um he might be interested. So I phoned him up and it was like he just, he spoke to me like a long lost friend. He said, you couldn't have phoned at the mo at the more opportune time. This is just what we need. So we thought hand unit the long way line spend work aboard. So that was what it was. That's the lego picture of it. Um community central hospital. That's, that's the place by line. Um So that was built in the 19 seventies. So that's what existed before the line. Um And uh there's, there's a population, these have already been mentioned, but they need hand surgeons, they need hand surgeons. Um And the orthopedic clinical office says everybody knows what they do. So I'll race through these slides cos most of these are fairly straightforward. There's been a lot of progress since 2012. This is Boston mentally sequence, all this going through trying to make something work, all these agreements and so on and the negotiations, it takes time, it takes years. Um So we come in really at the end of that. Um And uh so that was the lion hospital in 2019. So it looks like a, a Roman archaeological dig, doesn't it really um, you trying to work out what's, what um, in comes the BSS age and very quickly over, over literally about three or four months, we had a memorandum of understanding. We're gonna come as a hand surgery team, a consultant, a trainee and a therapist and we're gonna be on the ground for a continual presence offering hand surgery services to the hospital and that's what the line hospital is now. Well, that was in September and it's getting bigger and bigger all the time. Um, age has got a, a house in L, um, which is in area 43. So that's not far from the vice president's household. So it's a reason we say part, part of town. Um, and that's our car. It's called the Red Line. Um, Martin and I bought this about two years ago or 18 months ago and a great duress with lots of dollars in our pocket. And, uh it was very scary. But anyway, getting a, a car is quite an interesting experience. So that's how the team gets to the hospital. And then last year, January we started out with two of us. Uh, there's, there's ST three plastics, Hanin and myself outside Community Center Hospital. By then, the line hadn't actually been open. The line only started, um, in basically July last year. Um, Ben Martin ditched up and Abby Shaw from Oxford and then Meryl hand therapist. So, going through last year, that was, that was the, the work that was the workplace really at Casa Central Hospital. Um, before we moved across into the line. And in fact, in, in retrospect, we realized that it was a good idea to basically work with the orthopedic department bolted onto them and then move with them into the line. Uh, obviously could, we have waited until we moved into the line. But in fact, you know, it worked out very well, but actually we got to know them and worked with them and there's Sean Walsh, um, who's, um, er, who's actually just coming back today. In fact, he's just done 11 weeks out there and his wife just joined him and there's Tom Bot from East Anglia. Um, so, yeah, lots of fun. Uh, trying to make up handsets and trying to remake up handsets. I think we've probably gone through about 25 different handsets. A lot of them go missing. Um, but we're trying to get the kit that we need, introducing link magnification. Um, and then keeping well, well, the team are keeping us happy really. So gave us a mini C arm, er, for free. It was 20 years old and we flew it out there and it's been very useful. Um, so having AC arm is very useful. This is one of my favorite slides and this is Abby Shaw from Oxford. So, er, and Cher Precious Kita, um who's one of the senior trainees doing his exams this year. Um And they are just working out what to write in the operation note and what to put in the patient record. So to me, I think if nothing else, I'm seeing the best of the best of trainees in our country, trainees in Malawi and this is the future. So we just clap and say this is brilliant. This is, this is the future, a little a bit of teaching going on. We have a weekly teaching program which I won't go into now. But um I think, see, I might have mentioned that on the last one, but really before the line, this is what it looks like. This is the corridor, there shouldn't be any beds in here. This is the physiotherapy department, there's lots of swollen hands around. Um And in fact, physiotherapists, you know, honestly, they need to go as the vanguard, they need to go as the f as the forward party to basically get all the hands working before you actually come and operate. Um This was the very first case that was referred to us in the line last year. It was from the Physiotherapy Department. This hand's a bit stiff. Can you come and have a look at it? So hang a second. Listen. Now this is from physio. Um So there's a soft tissue problem and then obviously, you know, we had to work out what to do. We have a weekly MDT, which is the virtual DT. So people can, can phone in and uh and, and we can have sort of live arrangements. And so we put a skin graft on uh try and see if that would take and just to recover. Uh it needed something more definitive. Um But this seemed to, to be the debridement and uh and the skin cover. And then about six weeks later, this plastic surgeon did an epi epigastric um flap and that seemed to be ok. So this guy's hand would have been amputated. So we're trying to save hands for function. But obviously, there's a lot of stiffness to be and and those joints were wired as well. So the MTB joints were wired cos otherwise, if they're like that, the hand can't work. So this is the line today. Um It's got 160 bed wall. Please note there are 100 and 20 patients in the hospital, 160 bed ward. So community Central hospital has now moved orthopedics to the line. We still got people in the corridor and they still got people sharing beds. And so the challenge is there, but it's, it's a moving um and the line has not finished. So there's gonna be a ward for women and Children. There's gonna be an ICU which has been built yet, there's gonna be a guardian's ward and there will be an education center. So, but it's, it's promising things are, things are going, things are going in the right direction. So, before I hand over to Martin, uh, just a, a little bit cos he's been there recently. Um, this is, this is the team BOFA and Ashton were talking about, you know, doing a BOFA sort of, but, er, Lion link, it takes a lot of work. It's literally every day sometimes, you know, in, through the evenings we're getting calls from the team. So Cushion is the A B CS global, who's the global partnership? The SSH chair is, is on our exec. So there's myself um Martin and, and Sarah were on the exec and then Sean Walsh, he's instrument lead, all that kit stuff, you know, should I bring this? Should I bring that as a, as a trainee link? His trainee and Matt, he runs the, the MDT. Um and Kate S is running a very fine educational program which is fully set up with modules, running through a whole diploma, well, not diploma, a whole international certificate and hand surgery uh program over to over two years. Um So including workshops and, and all the rest of it this then and there's Boston mentally chap. He used to be a consultant in Mizui and, and a hospital director, a water man, he can do anything and he will always help you whatever situation you are in. Um he's a pivotal person in the team and that's our spheres of influence. We operate like a board. We all have our areas of, of experience and we uh finance there, Martin Wood and they say, and we try and meet, well, we meet, meet, we meet monthly um and, and we try and solve all the problems as we go, we have to be pragmatic and uh and it, and generally it's been quite a lot of fun but there's been some struggles. We need partnerships, don't we, We need collaboration f to see all the slides of previous talks where, you know, you can see the kind of thing we want. Er, so we got the, the British high commissioner. Um, so health commissioner from Long Amy Potter. So she's involved, the president visited um the line and opened it last year. So he's met the team. Um and, and then we've got, we brought Boston mentally over to Swansea, so we gave him a little bit of a fellowship in Leeds. Um And we've got fundraising talks at schools and we've got industry involved. Um, you know, there's lots going on and the lines international, not nothing to do with the line, but lines international. Fundraising is hard work. Um But we'll talk about this. So a couple of slides about what the team are doing. So this is what the team would have been doing. Uh Today they were in clinic, there was a, there was a hand clinic on a Monday and a Friday. There's the waiting room, it looks quite good, isn't? It looks quite nice inside. Um, there's some treatment rooms. This is our fellow, we've got a B ssh line fellow who's Gladys Gondo and she's in the army. She's one of the top commanders in the Malawian military lady. She's the third highest. Um, unfortunately she wasn't, didn't get her visa today. She hasn't come over on her two week traveling fellowship to Derby, which was supposed to happen on Monday. She hasn't got a visa. Nevertheless, she has been with us for coming up to six months. We're hoping that she is gonna be a local champion. She, they're building a hospital for her. Um, and so she's learning all about how to treat your hands and then she is operating with one of our trainees, our senior trainees, um, under, uh, well, surgery. So lots of local anesthetic surgery. Three lists a week. Um, two of them are under local anesthetic and this is in the physiotherapy department. Um, this is the rehab unit. So that's good. It's nice and clean. There's lots of kit, um, and there's the 500 miles prosthetics, which is a really good organization for the, uh, the oncology, er, for the, er, the, yeah, for the, the tumor treatment. Um, and they've got spines, they've got spinal surgeons there. So you've got, they've got the, all, you know, the, the full spec of, er, um, specialists and there's some pictures of active therapy going and we do have high quality therapists who come with us. We, there's a hand therapist there all the time and the therapy department on the line is really super, very high quality. In fact, they've just poached Dustin from Blanca who's really, who's super keen. So there, there's a lot of very good rehab going on. That's the therapy timetable there. Um And yeah, the future for therapy is bright. They're trying to retain staff and to make sure that they keep staff and that's the surgical team. I'm gonna hand over to Martin there. So that's the surgical timetable. Anybody who's thinking of going, it's a very full week, but it's good fun. And you've got a lot of very, um, good human friendly surgeons to work with Monday will be, every day starts with a trauma meeting at 730 then you do your ward reviews. You go into a steaming hand clinic for Monday and then in the afternoon, Tuesday, you're doing well, hand surgery of hand trauma that's in the emergency department treatment room. So this is outside main things and then Wednesday's uh, main theater. Then Thursday is again, well and surgery in the Ed Minor ops theater. Um, and then Friday is another hand clinic. So I'm going to pass you over to Martin for a recent experience. Is that why you're coming in? Yeah, he's going to talk to you about a little bit what we're seeing and some of the cases. So I came back, um, about a month ago and, um, I'm just gonna go through a few sort of what cases, just so, you know what we were getting up to about now. So, one little correction that was our first case that we put up after that was, uh, a groin flap that Abbey Shaw and I put on after he left. Yeah. Oh, that is it with me. Right. Right. So we, a lot of this will, will raise, um, links with a lot of the other talks that have happened today. That's why I, I've been a member of Walk for a long time as well, actually. But it's been fascinating to come to your meeting and see how much relevance there is between each talk and each one, what a lot of and particularly, uh go back to what, how we were saying right at the beginning, we started this project by going out doing teaching first for the OC Os and the registrars. And then one of the fundamental things about the line project is we sort of wanted to provide fellowship level training for their trainees, but without taking their trainees away from the everyday job. So we're going out doing that. So that's the sort of progression um where we feel line is a sort of step forward. Anyway, this is the list of sort of things that you probably see all around the world. We certainly in line, there's a good share of those Johnson says working in KC H for a month or two first before we move to line. Certainly those of us who have been in both places, we feel very privileged to be in line and suddenly hearing some of the um, what courses you have to deal with in other parts of the world. We are actually quite privileged in line. Um, and we appreciate it. Right. So thi this is a, a typical case. Um Anger injury, a pan is a a machete if anyone doesn't know. And you can see this has nearly sliced the hand off and you can't help but thinking if we weren't there, someone interested, wasn't there, they'd just finish the job off and do a nice there. Um But we thought they offered to us, we like to do better. So we didn't have very many plates at the time. We had four metacarpal fractures. So and a box full of assorted rusty wires. We picked a few nice on that one, put them all together and then Abby and I started doing most of the extensors and most of the flexors having a extensor tendon lose. I mentioned how important rehab is. So, uh rehabbing extensor and flex attendance all at the same time, the same injury is particularly challenging. This again brings up a point about follow up and um patients coming back, which is uh we mentioned before, we put these wires in, I never saw him again. Told you he did come back and the wires had come out, but I'm not sure, you know, a hand looked like a hand afterwards and he certainly started going when he was still in the hospital. And so follow up it and uh, since record is a problem, but I'm back. So I can consider that. Um, this is another typical panga injury. Um This one can't quite see by the, um, there, um, if you see the X ray, he nearly took his thumb off. So by stabilizing the thumb that then gives you um a fe skeleton that we can do breast, the soft tissue repair around. And again, this sort of illustrates a few. Um and the, the injury, once you start debriding it and getting into it is much bigger than you think. We, we do have some quite nice kit that we've taken out with us. So we do have little screws and things a lot of it we can do under local anesthetics. This is what we used to do after a while, we make a big bottle of local anesthetic and adrenaline and use that throughout the day and you quite well, Jonathan, and that'll be doing that. OK. The operations at the end, I'm sure a lot of you have come across these tumors just keep coming up. And so this was in, in K th they actually have quite a, a nice tumor center. So Oncology center, but as you said no surgeons specifically dedicated to tumor surgery, but they do have, um, oncology physicians. So this were, we were asked to see this, asked if we could do anything about it. This was a, an isolated lady who'd been sitting on this for quite a long time. Yeah. Yeah. She, she has a, a lot of chemotherapy. So we saw the x rays and got excited and can we, can we maintain some function here? Can we sort of ice some of the hands and maintain her at least a pinch grip. Um We ended up being sensible and pragmatic and took the hand off and the 500 miles charity, which I think is a Scottish charity. Um They provide a very good service. So we actually took her to the prosthetic people beforehand. And so she was happy about the amputation. It's actually slightly more, more than it seems to be given up. Yeah, that wasn't, that wasn't, that was he was happy at the end of it. So we ended up with a smiling patient, which is usually a good sign. So as I said, um we started this project, we possibly naively said we'd do it for five years and at the end of that, we'd have a, a functioning hand unit. Um And therapy has been really, really important um and very successful about getting volunteers having a trainee out there, just seeing the practical peer to peer learning of the UK trainee and the Malawian trainees has been really gratifying, working as a team with people out there so very much. We're, we're trying not to be there doing it all for them. We definitely are trying to work with their and just help them to improve what they're doing and do more. Possibly, we'll be leaving after five years. Ideally, we might leave after five years and send the project to another country and do it again. Thanks in terms of reviewing what we've done. I'll read all of that. But um there are themes coming through which is essentially what I've just been saying about sort of training and work collaboratively. But these are all comments from all the our volunteers that have been out there over the last 18 months. Um These are all the positive comments I have to call the challenges and risk essentially money like everyone's mentioned. And also as Jonathan's mentioned, getting the getting volunteers, a continuous stream of volunteers is actually quite a hard ask. So I know not all of you are hand surgeons in this room, but you're all by definition of being here, things about global surgery and I'm sure you have colleagues who are hand surgeons may not be members of PSHH and is already do ask them please. It costs a lot. Uh Johnson's figure of 500,000 million is probably a little overestimated. II would go with five right? As much money as we can really gave me that. I think it was supposed to be half a million, wasn't it really? 96,000 lbs a year is what it costs. And our, our year one budget, it cost us 96,000. It was 86 to 96. So we've already breached our budget but the time and uh yeah, that's what we've been doing. Um interesting discussion before the break about data um modestly trying to. But first thing we'll do is just do a simple description of what, what that is, what we're doing after that, if there's enough data. And Jonathan said, we, we are recording data, but it's within the line. Hope we're making a difference. Certainly, our colleagues out there as sure us, they feel we're making a difference doing it with the help of a lot of, a lot of partners. We said we started with the teaching project. We've over the years had contact with quite a few people. I was gonna go through some of these just to point out two. Yeah. II think um I was asked that last slide question about how do you measure success? Which is probably something you should ask. We ask ourselves every time we do one of our trips is how do we measure success? And it, it was by a Swiss surgeon who's thinking of coming out next year, you know, just success. And I went, hm, well, basically, we leave a hand unit behind him and we, it's all fine. But actually he was talking about how do we measure it as we go along and when do we know when we're there? So that's challenged us. We're looking at, we are recording all our data, all our operations. We're looking at how many trainees we're, we're teaching and we're looking at how many progress and, and do our things. But basically, probably one of the things is whether someone as an orthopedic surgeon with an interesting hand surgery, that's probably one mark of success. But if anybody's got any thoughts about how we will measure, we've got research um in the audience, then please do, let us know. But um one of our things that we're measuring of success is what's the success of the Malawi project? Well, I presented, we presented this photograph when Boston came across to um the fundraising, um Christmas, um Osteo osteo osteo funding have contributed significantly. We, they are, we are their main charity. And so I stood up in front of everyone else and Boston Mali had come over been to leeds and I was saying to him and look, we've got all these people here. I mentioned Jeremy Stanton from Colchester and Chiku who was a Cassa trainee that was back in 2017. She, she's one of the senior surgeons at Blantyre, Milani, she's a, a surgeon at Blantyre. Um You know, but Banda, you know, all these people, we didn't know who they were at that stage I actually, no, it was in the UK at that stage. But all these people that come across, they, they are the lead, they're the lead players in Malawi in orthopedics at the moment. Um And, uh, so we, we've contributed on a hand surgery at least in the meeting with him, but the partnership's gone since then. And then Boston came back to me and said, I'm in the middle and there he is, he was actually the guy right in the middle. So he's, he's the, the hospital director of the line, which is the lead trauma receiving center in Malawi. Um And he's still um perky and full of energy and he's, he's uh he's, he's blazing a trail. Um And there's a few other people that I know some guys from Zambia and Zimbabwe there as well. So all these tricks and these courses that BFAs do and walk do and so on. Just imagine the little things that you might be doing. You may be just inspiring someone a later on seeds. So it's, it's really collaborative, keep chipping away and keep persevering. So, thank you very much for listening. Um I always love the trees in Malawi and so there's a tree there and the Children just beguile you don't know, they're always just so happy. Um And uh yeah, help us. Um You know, we, we, we enjoy the collaboration. We're great to be a partner with, with work. Um So do do help us to heal the hands of Malawi. We'll help you to do all the other orthopedic stuff with a huge amount. But this is our local hand world. Um And there's the line uh logo, there's the, the therapy, um that's the British Association with hand therapy. So it's very much a hand surgery and hand therapy project. Um And our, our sort of strap line cos we're all told we have to have strap lines, don't we? But we thought the three es educate, but that's education of both ways cos we're learning by being there enabling, we're helping them to get on and do things and we're empowering. So that's kind of keeps us with our focus is that's what we're gonna do. The three years educate, enable and empower and hopefully the LAA will continue to flourish and you're welcome to visit the line and come and uh meet us there, whoever the team is and elaborate, put mental ideas or whatever else in the future. Thank you very much indeed. And burning crosses because I'm I'm slightly naive with hand surgery. If, if you were to have like a top three hand problems in that setting, what would, what would they be tendon injury, infection, infection, neglected infection sort of, um, you know, um from that and I think, I think really just tendon, soft tissue injury, tendon, you know, delayed machete injuries. Um don't see much burns, burns a little bit. Yeah, sunburns, not as much as we thought, but we had, we had um some of the burns obviously go to Grand. So we do see sunburns, but pretty much most of the time from the kidney, you do get to clears in to clear. The thing is going to um neglected wrist fractures. A fair few of those wrist fractures, poster carpal injuries, lots of peri in uh carpal injuries, tendon injuries and infection. That's sweet. Uh the one list is it mainly hands or do you do wrist stuff in the w we do stretch to the wrist, uh, with the one. Yeah, we'll do, we'll do um, extensor and flexor um up to same or then five, it, it's a little bit dependent on this, the experience of the, of the surgeons of some people out there who are absolutely wild wizards and wouldn't do anything under one others. Um, we do have access to a regional blocker. Um, and we can put them in advance so they can do so. They have got a couple of blockers. Yeah. Are you doing any work in terms of prevention? Some of the worst injuries we would see were kind of work related. Um, we're working on that with, um, with the Hand Injury Prevention Society that's um, arm of this stage. You've got hand injury prevention, that's a fair sort of um uh body of people. Um, and we're thinking of it would be good to do a audit and uh, maybe some research on hand injury prevention. Um, that's a big, big area, obviously, commercial industry, safety, health and safety, which is challenging and obviously, and it's a very good, it's important part. We're thinking about hand injury prevention. Thank you, implants wise. Do you have sustainable supply of plans and screws? Um, no, we have quite a few plates and we don't have as many screws, but we're sean is very good at, um, talking to industry and supplies. Um, the, the Norwegians work out there. They seem to have quite a good supply of secondhand plates that didn't happy to donate and Malawians are happy for so it's a bit sort of today where you're going and so it's not secure. But there are med artist have been very, very generous. We've taken out wrist sets and handsets for med artist and their can screw sets. I would say it's been really helpful. Still. I decide I take a bit more time. No worries. Mhm. We've heard, we've heard a lot already today about, um, trainees and surgeons coming from other parts of the world and joining UK units. And, uh, this has been something that many surgeons have struggled to actually make happen. And, uh, you know, we, we hear about it episodically, you've had some success. A lot of people haven't had any success. We've got two people in the room here who've actually done that and we'd like them to come and talk to us about it. We've got Abraham chairman elect of, er, world to be concerned. Uh, recon surgeon at, um, Leicester, er, University Hospital and Sanjay Gupta from Glasgow, who is also on the walk committee. Uh, if you like to come first, I'm not sure. That's funny. So, yeah, I guess there's been a lot of interest about how we can go abroad but I guess ultimately, uh, particularly in my line of work of oncology to have a kind of sustained model, we need to train and you can't really train in a week to do the sort of reconstructive work. So we want you to explore how do we get people to come to us? So, while we have background a little bit about what we've done, why would they want to come to Glasgow or indeed why would they want to come to your unit in the UK? Uh Why on college in particular? And are there any kind of subtle differences in terms of what we see between the UK and elsewhere in the world? And then very briefly in conjunction with our current fellow, just a sort of short guide as to how people can actually come from abroad to your unit to hopefully have a, have a fellowship with them. So in the last I've been a consultant now for eight years and in the last eight years, we've had fellows from all of these countries for uh between a year and two years. I have to say anecdotally for oncology. I would certainly say you need a minimum of one year. I would actually say that there's probably not much value in having a fell over to train and then go back to, um, their hopefully home country for any less than a year. So, Glasgow and, and in particular, why you, why should they come to you? Well, I mean, we all have this classic image. This is my hospital and that's on a bright day. So, yeah, it is a dark gloomy city. However, it's a very, it's a very busy city. It's a very fun city. But why do people want to come to the UK? Well, I think the first thing, sorry, in particular Glasgow, the first thing you have to have is a bit of insight. Maybe they're just coming for a visa if they are. It's ok, we can question motivation as to why someone comes over. But I think our job is to find people that are interested and know that people might be coming with different aspirations to what we would like them to have. But that's all right. Maybe they're coming because of your research reputation and the fact that you put yourself out there or maybe they're just coming because you've got the greatest football derby in the world. But why would they come for M SK Oncology? People have classically shown in some of their slides today that the cases are more advanced they're different. Well, in my experience, there's not a big difference actually in the soft tissue sarcomas that we see in the UK. To those that we see abroad. I made a comment about what we call a whoops type incision. So someone's already had a go at hacking something out. So you see that in the UK? What's the difference? Probably the FR CS exam in orthopedics, I think scares people in the UK sufficiently so that we don't tend to get oops procedures performed by orthopedic surgeons. And I would still say, I don't know if a guy would agree with me, but you still see them from general surgeons and from plastic surgeons that have had a go. So, um I would say that practice is probably similar if you're in different bits of Africa or elsewhere, this may be a more general part of your practice in terms of that delayed presentation, the fungating tumor. Um I probably see up to about 10, a year, between six and 10 a year in my practice. Uh And we cover about 33.3 million in the west of Scotland. So I think you do see them more often in, in uh countries and you know, why is that? Well, of course, it'll be a combination of surgeon education as well as public education, you know, to have that addressed. So, is there a difference if you're coming from abroad? It's an international fellow. Is there a difference in the practice there is, but I don't think there's actually that big a difference other than the delayed presentation component, then there's the big thing that obviously everyone associates with orthopedic oncology. So big implants and yes, for funding reasons, big implants are typically not available in many parts of the world that we go and visit. Um However, I think it's important if an international fellow comes over that they are educated on some of the potential reconstructive options and then they can go back and modify these and improvise. Um I certainly remember one of my fellows saying that in oncology, because the situations are often unusual, you do have to be able to make things up. And I think it's about learning the skills to be able to adapt that to any practice. A surgical perspective. I would say the biggest difference for me between an international kind of practice and then a UK practice was blood products and then higher level HD ICU care. I said this very clearly to one of our first fellows that came home from Ethiopia for a couple of years. I said to him or I advised, please do not do a pelvis resection in your first year when you go back because in my hands and I'm I'm not saying I'm the world's best, but the patient will be in ICU for at least a couple of weeks, but we need several units of blood. So the last thing you want to do is go back to your home unit, do a big clever resection and then the patient dies because that won't help your confidence as the first person to go back and help, you know, your local population and it won't help the confidence of anyone who is going to refer to you. But in terms of what will they learn? Well, I think the single most important thing, the MDT component and I only have snippets of exposure to different African countries. But I have not seen an established MGT wherever I've been. And I think we always talk about MGT working in the NHS which and I think it's of importance everywhere, but I think it's particularly important in an oncology practice where you need to have the input of the radiologist, the pathologist and the oncologist as to what are the latest treatments available. So that was sort of a very brief overview of my interpretation of what a fellow can hopefully gain coming from abroad to a UK unit for oncological training. The second bit of it is, it was really a bit of AQ and a that I had with my current fellow who is from India. And I thought, well, I can read a little bit about it from different websites about the process to come from abroad to the UK. But it was better than me. He's got friends and colleagues that have been doing it for much longer. And I had a sort of mini interview with him and I've just highlighted the kind of the key features that I took from little notes from my discussions with them. Why do people want to come? What was quite interesting is, well, we talked about the visa thing earlier on, but do they actually want to do the thing that you want them to do and take it back? So some will come with the motivation of perhaps not even staying in orthopedics or going down a UK residency route. Um And again, I'm trying to read that out an interview because my personal interest and passion is for that person to go back to their country. Um But so far, what I would say is all of the eight fellows that we've had since I've been in post seven, have gone back and are delivering care at local hospital and one person is going down a sort of caesar route for the UK. What are they mentioned to the UK? So when we're all a little bit doom and gloom sometimes about how frustrating NHS is, it's really good to have the feedback of. Well, the UK is still rated as one of the best places to train in the world. I have large public sector hospitals, we have a good cultural training. Um And what was really important for him with a, with a young family is that you can bring dependence, which is not always the option particularly in in North America in terms of the GMC process, I'm sure many of you will be aware of this. But the common pathway is for international medical graduate is to have the job offer and then to get sponsorship and that sponsorship route certainly for us needs to be approved by either the English or Scottish Colleges. Um and that not all jobs being sponsored, I think, I mean, we were having a conversation earlier on about what different hospitals and trusts will value. Obviously, I can't comment on every trust across the land, but certainly in our trusts, they will sponsor posts from abroad and they will welcome values from abroad as long as they have been deemed a point as part of that job fellowship hunt. Obviously, there are the usual websites that we'll all be aware of both Scottish and English and elsewhere, but in terms of English proficiency, one thing that I was not aware of certainly until I had this chat is that there are two exams that the candidates can or need to pass at one of two. The IE TSI believe is more difficult but it's cheaper and the oe is easier but more expensive. So there are the two options available if you're advising colleagues from abroad in terms of certificate sponsorship. Um, obviously, it's needed as we know to, to have GMT registration to get that visa. But in terms of the visa process, specifically, there are tier two visas that are available for health and social care um and also tier five, but for a tier five visa, which I was certainly not aware of, you have to go back home within two years and reregister before you can come back again. So depending on how long the individual was planning to stay on tier five, they will have to return. One thing that I've learned from bitter experience is if you want to have fellows from abroad, that you want to train to hopefully make a difference back home, it will take them at least 3 to 4 months to come minimum. Um So that means for our August posting, we set out our advertisements in my opinion for too late. We advertised an interview in April. Um and that's led to a delayed start. We're not going to have our fellow for August. He, he's going to be coming in September at the earliest, but this is with experience, it still takes time. So just to wrap up because I know I'm gonna have plenty to add. Um from my perspective, you have to give people a reason to come to us. So we all work in different bits of the UK. So you have to have your own USP as to what's going to inspire people to come to you. And I think we need to put ourselves out there a little bit. Um I think North Americans are much better at publicity and advertising and, and sort of taglines. Um and I think the UK, we're typically a little bit shy in doing so, but it's important for us to advertise our presence and that we are a viable and good training option. And we are still regarded as one of the best training options in the world um to be as available and as helpful as you can. We will talk about whatsapp groups that I know will all be part of in terms of giving that advice about different cases. And please please please do not rely on your hr department to know. Um That is a really important thing because again, we can't all be experts in everything, but we need to work with them and they are helpful, but they will not always know the process. And sometimes we have to be a little bit ahead of the curve if we want to attract these fellows. And I have to say personally having had UK fellows and fellows from abroad visits are amazing and I love doing visits to different parts of the world. Um just with my own circumstances, I can never go for longer than kind of 10 days at a time. Um But in oncology terms, I think the biggest impact is on getting someone over uh for the same period of time because that is the only way they will learn hopefully the skills to take back the difference. I have got this on my laptop as well. But we thought it was useful to have some QR codes of all of the kind of services that a fellow will require. Um, if they're applying from abroad, between the language, the GMC, the different college sponsors and the various websites and if you can download, I appreciate there are lots of QR codes up there. I've got it on my laptop as well and I'm happy to share that slide if that's of any use. Ok. Mhm. It was a great question to you while is loading up that up. Would you encourage um um trainees to come into tier five visa event? So, you know, they have to then disappear and go. And I think that's a fair question in perspective. So what I've not established and I've tried to ask a few different people whether it's easier to have a tier two or tier 55 is easier, five easier. So, thank you. So if tier five is easier, I don't think it's my right to choose what visa the person wants to come on. So I'm not going to try and tell them what they should or should not take. But I guess my practical point of view, they will have to go back after two years. And therefore, if you're thinking you want to deliver care back home and perhaps yes to avoid. Ok, folks, I know we're, we're running a bit late so I, I'll be, I won't be long it'll be short and sweet and there will be a few contradictions uh with um sun. Uh But just, just a show of hands, please. How many of you have managed to get a fellow into an NHS post, a paid post with patient contact, almost like a registrar on a road. So how a show of hands. How many of you? So, so, OK, a number of you. So of the, of the folk who have got people in, can I ask you what s what, what method did you use? Just your hr or did you use a, a college or? Yeah uh through hr hr So your, so your own sponsoring your college, college for yourself doing it ourselves? And OK, so this was gonna be an interactive slide with, with a QR code but it's not working. So we'll just quickly go through it through it. Um um So if you want someone else to do the, the groundwork, then the way to do it is to use either the MTI S scheme or the I PD scheme. If I will, I'll come to another way that you can do it like like fucking Birmingham. But D but if you want someone else to do the work, someone else to do the, these application and processes and more importantly, someone to take on the mantle of supervising a doctor in the UK with all the GMC GMC permutations that, that come with a doctor working in the UK, then you have to give that whole process to a different organization. So, the organization classically is either the MTI, I'm a member of the Edinburgh College. So I've used the I PD and the IP DS are, are, I think a little bit more straightforward than the MTI. It's a smaller office. They know who you are. The emails are much more. Um Should we say prompt communication is a lot better and, and they can classically get you uh a fellow over within 3 to 4 months. Uh So, so you can use something like the I PD and the I PD. Uh it's a fairly straight forward um flow chart. So you can either choose someone from a pool of preselected clinicians or you can say, well, I've got this girl who was in India or who's in Pakistan or somewhere in Africa and I want to bring him over. So you can have one of the two routes. So the training group number one is that they have a pool of people who they've vetted. Uh training route two is that you have someone who you identify, but that person has to be vetted by the college. So the, the application has to be filled by, the applicant has to be filled by you. You have to provide a job description. You have to provide a contract to say I will be the educational supervisor and you have to commit to a process which is very similar to having a trace, but that still has to be vetted by someone from the college. And then, and then every six months, you have to do a report almost like a learning agreement. And at the end of two years and you, and you get a tier five with this process, so they cannot stay on, they have to leave the country. That is, that is that you want a tier five to. So um just a few examples, we use the I PD. Uh Dan was a uh a, an associate professor in CMC. For long. Many of you will know it, it's a established uh institution in the south of India, very academic institution. And you can see that he's a fairly academic uh uh clinician and his, his interest was to come to the UK to experience a different culture and make have a different uh type of uh work environment. Um Apart from him, we had another two people, uh the uh person at the top that's who we have now. Uh uh Alvin VNA studying with Raj Sakar who many of you will know uh from the GA Institute. Uh The third person I'm not allowed to show you cos is the left colonel of the Indian army and the Indian army being so bureaucratic will not allow me to show his photograph in, in fatigues. But anyone uh a little bit of trivia, anyone want to know where that, where that might be in, in battlefield setting. This is the highest battle team in the world 20,000 ft altitude. A pointless war between India and Pakistan over a glacier called the Siachen Glacier. And Naveen was stationed there as part of his uh attachment and, and he came again to experience what it is like to work in a, a very different setting to get CPD. And you know, we, we take CPD um for granted in, in our system, many people work in isolation in one hospital for the whole of their life. They never get to rotate. You know, the nearest other hospital might be 5, 600 miles away. They might never have weekly meetings, let, let along well, they might never have annual meetings, let alone weekly and so on. So, you know, for them coming to, to a system to, to learn how we, how we grow as professionals, it's, you know, it's a fantastic experience for them. So a little bit about the alternate system which I told you about. And if you are a sponsoring body, uh and there is a list of sponsoring bodies, uh you are allowed to bypass, uh you're allowed to bypass um colleges, you're allowed to apply for a visa through your hr So the list of, of organizations who are classed as sponsoring body are on the, on that website there. So if you, if you go to the GMC licensing organization, sponsoring bodies, you'll see if your name appears on there. So University Hospital of Birmingham is on there. Uh University Hospital of Leicester is on there and there's several other uh institutions which are on there, which means that you can apply for a tier two visa, not a tier five visa, a tier two visa makes it much more flexible. You can extend it if you wish. Um And then if you know, for whatever reason, if people wanna stay up to those two years, then it does become a little bit easier because after five years, you can apply for what's called an IR. Right. Right. Uh and leave to remain. So, uh apart from a few uh university Hospital trusts, there are individual departments. So for instance, um there's a gynecology uh unit in Belfast, there's an anesthetic uh department at older, hey, these, these departments have individually got approval to be a sponsoring body so they can sponsor someone getting a, a tier two Visa. So that's the way to find out whether you know the way to do it is to find out whether you're a sponsoring body or not. And in, if you are a sponsoring body, you can interview that person, you are taking the responsibility that you will supervise that person, that you will maintain standards to that expected of the GMC. And you are bypassing. That's a really straightforward way. Instead of 3 to 4 months, this will take six weeks to get someone in F so that's uh what we've managed to achieve in Leicester er with these three people. Uh we interview them locally. Uh We send them an offer letter and the visa, er the visa and the registration with the GMC is running in parallel. So our, our HR they process the GMC registration and you can see the application on a portal so you can see how quickly it's being processed at the same time, the visa is being processed by the HR and that applicant can also see the the status of their visa. So it's it's relatively straightforward uh compared to any other system that exists. So there's a sponsorship registration certificate. Uh The doctor applies for provisional registration certificate of sponsorship to the home office and you have to pro provide certain uh certain details as part of the application. So just a a very quick, quick uh recap of of one person in particular Alvin Vino's with us now, uh he's a very experienced surgeon who does pelvic aceta reconstructions pro that kind of stuff. And he just wanted AAA break from his regular uh work to experience what it was like to grow. And the other thing that a lot of them realize is that, you know, orthopedics in the UK is, is like 1015 years down the line, they don't have the subspecialist exposure, you know, the foot and ankle exposure, the oncology show them. But uh they, they don't have it over there. Well, I experience it here. They like the fact that they can rotate through, you know, four or five firms and it's, it's nice for them to see the, the challenges of working it up healthcare system. So, uh by all means, please see if you are, if your uh employer is a sponsoring body. Because if, if, if they are, that means getting someone here a whole lot easier. Thank you very much. I'm aware everybody wants to kind of hit the road a little bit. So can I just invite one question for each of the speakers? Uh And then we'll move on to the next talk. If anybody has any questions, deep breath, those are really, really good talks. And thank you. But in what we've discussed this in the past, is it by doing the fellowships? You are essentially investing in an individual. What do you think about that as opposed to if you go and teach you, you tend to invest in a department or a, or a hospital that said, I think that's a rhetorical question. Uh No, but II think your point is taken that um in terms of value for money, in terms of uh expense and it is much, much more cost effective for us to go there than, than the other way around. But I think there are some unique individuals who will grow, are coming across. So I think um so I think it is justified in that in that sense, it grows by coming over. But I just wonder how many people take those skills back. But so deep, I have kind of a personal snapshot out of 87. So II mean, I think there's a degree of screening because all the people I've I says publicly, but I basically have an unofficial rule. If you're not going back to use it, you won't be coming now and you 100% predict that. Of course, you can't, however you can, you can get a pretty good idea their references from going to visit them from whoever their bosses are and that they've got them lined up to take on an extra job when they come back, you get a good sort of idea of what they want to do afterwards. And I, I can only come from my own experience. I don't think you can do enough or two to teach oncology. It's kind of slightly so. So I think if, if we don't come over and yes, it is an individual, but it's an individual who then hopefully be employing a partner and training and colleagues, et cetera and that's what they have done so far. But, but I think, I think the point you make is, is a valuable, there will be some people who choose to remain and that is a risk you take. Oh, sorry. Just have one more question. Ae e used to have a funded uh fellowship kind of scheme. Since he was uh malation into it seems to have disappeared. If any of you ever used that route, you know what's happened to it? I was not aware that there was one. So, so they, they would actually pay you. So, so instead of your hospital having fun, hey, the trainee who's coming across? NHS England was supposed to pay, which makes it very attractive for the hospital existed in Scotland that I'm aware of the O DA. The old O DA was just to the sponsor, individuals from focused countries. I think that's on the way of API and the IDP. So this is coming to the last bit of our um meeting today. It's aptly named the F LP Roadshow. Just a bit of introduction to the F LP. This is a Future Leaders program which is run on a yearly basis now by the B OA. Uh but ba there, there are many ways of actually getting sponsorship to do that program. It's a one year program which really is an intensive training into a leadership role within the NHS and wider beyond um an alum that program. So one of the routes uh that is open to applicants is to request sponsorship for work. We have uh since uh 2020 one, I think, been sponsoring one or two fellows a year and this is open for anyone from er SD eight to I think, first three years of er consultancy. So we've had two fellows in the last year. One is James Berin and one is, uh, who is present here. We've got two people on the program. One of them is a prerecorded talk and one of them will be presenting live, I think. Look at, looking at the time we've had a fairly busy, you know, and, and full on, er, day to day, we'll probably skip the, er, the prerecorded session and go straight to Kla. Hela is a hand surgeon at, um, North Manchester General Hospital, which is where I started my hair a little bit as an, uh, um, hand over to her. Um, hi. Yeah. So I'm, um, actually I just want to talk about perhaps a different approach you can take to doing overseas work or being involved in it and I was already involved in doing certain things before I actually went on the LP. Um, so I was a world of be concerned fellow. I was funded by B OA, uh, in 2022. So, uh, end of 2021 20 to 2022. So why did I decide to go on a, be a Future Leaders program? So, just a bit of, uh, background, um, in med school, I did uh, a few things but then when I started working as a doctor, uh, I actually never managed to get an opportunity to do all this work. I'm not sure why. But, um, I had a lot of rejections and, um, I sort of never managed to engage with individuals or to, to do what I wanted to do until 2016. And then, um I became um, like a founding member of a committee member of Northwest Orthopedic Trauma Alliance for Africa trying to get in. Um Oh, yeah. Yeah. Um, and I was a trainee representative at the time. I was also involved with work and I have a lot and no, and walk for, because I had bursaries, I had a Bursary from work. Uh I had trust uh fun and I went quite a few times out concentrating most of my efforts in Ethiopia. But what those trips, uh those physical trips let me do was actually form very, very strong connections with my colleagues over there, which has served uh very well in future work uh from that time. But it was on my second visit. Actually that the trainees over there said to me, um can you help us with developing research and audit? And that was, that seemed like a, a big, big task at the, at the time. And I was in an environment with sort of training program at the time where no one really did it, maybe someone was doing aid work. Um You know, and so I thought about it. So mainly my aim, our aim to improve patient care or help them in ha was a set up an orthopedic department. They started in 2016, um set up a department and build the orthopedic service um and that they need to look at their outcomes to improve their patient care. So, audit and research was a way to do that. When I speak, spoke to my colleagues about how um how they can help. Majority said, you know, it was not the right time for them to travel, they had young families, um things like that. So I actually um I actually then thought of an idea and set up the Residence Day. So the Residence Day is a collaboration. Um We started in 2017, multiple times. We've done four until 2021. So 2017, 2021 what we did was um we, we um we have a period of where there's an online collaboration between UK Registrars and Ethiopian trainees or any trainee who wants to join. Um And then they produce work, but the work is based on what the, so the, the trainee from the low middle income country wants not what we, we want them to do because it's their setting. We, so the trainees sort of work together. They learn the UK trainees learn a bit about overseas work. And then um what happens is they produce some work, uh either a poster presentation, oral presentation. And when we, we have a special day like a research day and they present the work, it's judged, they win prizes. Um the prices, we're very strict. We don't give any finance. Uh we books or we fund someone to uh to present a project in a, in a conference that they've, they've got a space there. So I think one of them went to Rwanda to present his, his work and we paid for that. Um So, and the trainees in the UK, on both sides, actually, they had approval from their program directors so they could use that audit to come towards their CCT or the or and, and the UK uh trainees could present it wherever they wanted to, they could write it belonged to the trainees. Initially, the idea was I must say to the wider, probably a group, not very popular, but since COVID uh probably a bit more popular, the Fourth Residence Day was completely online. And by the time it reached the fourth Residence Day, there was very li uh less support that the Ethiopian trainees needed from UK trainees. And that was all right. And the winning, like the winning um uh project was by Alpha Sifu. I think she's logged on actually. So she's now in Sheffield. Um She couldn't come today because she has uh something uh to do with her supervisor, but she's doing a master's at the moment. And her project was actually for the first time they had a Dexa scan in Ethiopia and she did uh values for um bone density in the black population, your debt level by by then, um but the thing is I really didn't, was not able to successfully succession plan or get more people involved. So I then decided to come on the F LP to get some help. And this picture was taken in the work meeting in 2022. And by, by then I had spoken to a lot of people um to, to sort of uh get assistance. Now, one of the things I'm not sure and it's very controversial, but I'm going to say it anyway. I'm not sure if people are aware, but if you are doing overseas work, so you go to um uh low middle income country and you look like the population there, but you are not originally from that country, you are not treated as well and I'm not sure if anyone ever has noted this but because I was also at uh B ABI R Diversity R champion. Um These are the things that people tell me and very often I do not know what to say what to, how to deal with these issues. And I think that some of that actually stops train from here, going out for fellowships in certain countries because they might not be treated um treated as well or maybe they do not uh gain as much. So, one of things in the F LP is they tell you about finding out why. So why do you wanna do this? So if I had no one around me or very little of my colleagues doing it. Why, why do I spend so much of energy to do it? And for me, I I've mentioned I am from a developing country. My aim was I feel like I can't, I don't want people to probably experience inequality in health much. I think it is unfair that in one country you can have such inequalities. And that was my motivation. Um So um sorry, yeah, so my ambition in practice was um the ambition in practice was basically um something they tell us to do. So the work that we do and that moving forward that I did. And with uh not a, I always thought it has to be something that is sustainable. So it was always education based because if we are doing civilian sort of overseas work and we don't have a sustainability plan or education, then it's kind of sort of questionable why, why, why we're doing it, you know, the whole aim is to help our colleagues and to encourage them to maintain sort of um education and clinical. The first thing I did again was I actually uh in our registrar meeting. So I was uh training in the Northwest uh the the sector. So that's the Manchester side. I gave them an ultimatum. I said I'm coming to the end of my training. If nobody takes over uh my post and the projects I am going to give it to the Northwest, that's like and that sort of the problem. There were quite a few people who, who, um, who came on, they were, uh, very good trainees, I think, uh, a few sort of dropped out but two of them, there's someone who has taken over, who has recently been to Ethiopia as well. Sophie. But I could not progress. I didn't hand over that project because I was, it was too much of work and we needed a team and I had no support. So that was one thing I did. And, and in 2022 we have II collaborated with B SSH and Harvard Global orthopedic Collaborative. So that's Iran uh right on the top here. Um And he is a very powerful ally to have and a very helpful ally. Um We held the first research methods course that was um tailored to sort of LM IC requirements. Um It was a lot of work but it was very successful help over two days, completely free for any kid need to join. I also need to add that our residents, they uh to join to do most of projects. Everything is completely free. So all the speakers that was on this research methods course, um we relied on the complete charity to present um and do things, but it was all online. We had breakout rooms there for ideas and discussions as well. Um So, um we, these are all our collaborators at the time, quite a lot. So this was the research method. The first one that was held, uh we had very good feedback um at the time um following this uh in 2023 early 2023 we used presentations and also some of the speakers offer live presentations. And uh we collaborated, collaborated with B SSH for um education sessions for the West African College uh through the West African College of Surgeons. So some of this um um is uh sorry, some of the educational events are also sort of recorded and we're supposed to put it online, but that's still in discussion at the moment. Um Because so this, this is a example of one that was done in writing that we recorded, uh if you know, miss this, Miss Walker, um doing some dissections with uh consent, you want to put it on the online platform for not up. But the problem is at the moment we haven't. Uh although I created a website, uh we haven't successfully recruited, um we need to, to um sort of update the website. So things are in discussion at the moment. This is some pictures from, these are some pictures from the last visit that was in uh Dinota with the place on the uh with um he went to Haa in Ais, was in uh November last year. So from the F LP, what I sort of gained or loss is basically I understand now completely why I did, I did what I did why I am interested in um helping my colleagues abroad or them uh or learning from them. I think networking and collaboration is very powerful. I think we managed to run. Um We ran so we've run uh two research courses. We ran one last year as well. I think there was some problems last year, but we are going to improve on, on that. Um I got some quite a lot of skills for leadership roles and I wasn't, I didn't feel as guilty about, you know, what I was doing anymore. And also there are certain things that I can control and some I can't. Um I want to thank ba and Walk for uh the F LB and for all the support throughout since I started doing the um uh working with no uh since 2016. Thank you. Say that. Now I'm also joining from this month, I'll be joining the SSH and the partnership partnership. Mm Thank you very much. That was really nice to see where all that uh work is going and all that support from uh Walker with the LP er program. And it certainly, uh you know, being effectively uh any questions from the audience, from potentially future F LP applicants looking this way is right. Um We've kind of decided getting to be nearly five o'clock now and uh we've got a prerecorded session from James Berin, er, from his experience again in Ethiopia with its former system, we um probably was going that to the ba session in uh in uh September and he might be there himself and, and give his person. Uh because I think everybody's attention span has probably dropped off a little bit and thinking about the drive home. Thank you very much all for staying to the bitter end and for all your participation, it's made this meeting really, really engaging. Actually, just everybody chipping in and, and asking all these questions. I find it extremely stimulating. Thank you to all our speakers for giving up their time uh for coming here at their own expense. Um Thank you to our sponsors from the be Academy for this wonderful facility, a brilliant lunch, excellent support with the it and getting all the communication on our behalf, we couldn't have done this just with our own little team. You know, all these emails you've been sending me all the live links you've created and this has been, yeah, a fairly uh well run uh event to be able to combine live and then we've got an international audience or a virtual audience and stuff. So I think, yeah, we, we really thank you uh thankful to you for that. And um thank you to me, all who are actually also um you know, uh sharing this platform online separately to, to our wider audience. Hopefully, like last year, we might get a, a recorded version of it and we can point people who missed today to, to go like myself last year. Actually, I was not present. So I actually watched a lot of the uh sessions uh delayed. Thank you very much, Alberto for all the work that's gone into it in setting this up and, and you know, mainly be such a success. Um We've not talked about getting a feedback form or anything like that, but we will probably ask a medal to email everyone a a feedback form so you can get your certificate because that's all that was a model that was done last year. So it'd be grateful if you could all in all your honest feedback and any questions you haven't asked, maybe you can put that in there and we'll see if we can answer that. So uh I'll leave I to just to add to thanks really important. Thanks Michael. Pardon, who leads us here and he give me very supportive. Uh And this is financial input but, you know, he just gives the orders and it AINS does all the work and there's a huge amount of work in the background uh at five o'clock this morning and other times. Uh So it's, it's done by a lot of people in the background, Chris, who's it, that's been brought in by academia uh to help us out as well. And then in the background, Phil who is maybe listening in uh for me, huge amount of work him and sue. So thanks to the people in the background that do it, uh even up in the background, poor rose to chase people. But thanks very much for coming. Thanks for the input from all the speakers, which has been absolutely excellent. And uh please everybody in person and virtual uh from all over the world. Uh Thanks for coming and thanks for the feedback, you're going to give us because we can only build in the feedback. Thank you very much. Indeed. Hi. One last thing, can we just have a little proto if uh if possible at all, please? Yeah. Should we all come to stand it then? Yeah, we'll all come and stand here the other one. Just.