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Oh, Automatic silence. Fantastic. Um, hello and welcome to our next session. Uh, what? We've entitled presidential address because we're lucky enough today to have two fantastic president's and or present and vicepresidente. Um, firstly, I'd like to introduce the presidente of our association of what we are the specialty that we are part of. Um I'm proud to call her my Presidente because she's also a key member of our region. Uh, person I've known for many years, Um, Professor Deborah Eastwood. Um, she's also a trainer, uh, training of the year in our region. Um, and she's a fantastic surgeon trainer person. Um, you know, and she's going to be a fantastic presidente over the next 12 months as we go into the b o a Congress next year. So I'm proud to introduce her and have her as a guest at boats congress this year. Uh, and then and then we have, um, Mr Tim Graham, who is a cardio, uh, cardiothoracic surgeon and is the vice president's of the r. C s N number at the moment. So it means that he will be presidente. That's correct with the presidential line. Oh, is that, uh, apologies? uh, I I apologize. I do apologize. Um, but he is. He's a prominent figure in the RCs Edinburgh, um, and and works actually in England, so Yeah. Yeah. Um, so we're honored to have you, uh, to represent RCs. Anybody who has been our principal sponsor for our congress this year, Uh, and has made, uh, effectively came in at the last minute to make our Congress cost neutral. Uh, and we will be going to Edinburgh next year. So we'll be seeing you next year, Mr. Graham, uh, up up in Edinburgh for our next Congress. So without further a do I introduce, uh, eastward? Yeah. Fantastic. Thank you very much. I'm deeply honored to be invited here and even more deeply honored to be here as your b o a presidente. I have an opportunity to wear my bling, have bling, will travel. So I'm ready and waiting to talk anywhere anytime. Especially if there's a social engagement at the end of it. The b o a. And Botha working together. So where shall I start? I'm going to start back in the day with Tony Clasen engagement and myself before you get the wrong end of the picture. No, he didn't ask. And so I didn't have to say yes or no. But he was the presidente of Botha and I was the honorary secretary of Botha at that time. And at that time, relationships between Botha and the B O. A were fractious, to say the least. And so Tony, myself and the Botha committee at that time felt that this was an untenable situation and that we needed to work together rather than be, uh, antagonizing each other. Also, it seemed so. I'd like to think that somewhere along the line that sort of wish to engage and be part of each other's associations and work together with you has borne fruit and will stave, uh, for the future. The B o A. As I hope you know, is a membership organization. It's also a charitable trust we like to believe, and I believe we do provide national leadership and a unifying focus so that we can care for patients' support our colleagues, our surgeons and therefore transform the lives of our patient's focusing, Of course, in on excellence in the way we run our professional practice in training and education and research and we'd like you to be members of our association for the princely sum of almost two cups of posh copy Posh coffee per week. You can be a member of the B o A. Where did my recent be away journey start? Well, it started in 2018 at the Congress, where we were celebrating 100 years of the B o. A. We were also celebrating 100 years at the end of World War One and also 100 years of women getting the vote in the UK because we're a bit late in the UK In that year, there were some council elections for new members, all good men and true. And they all represented one demographic so hashtag I looked like a surgeon for the B o. A. Council in 2019 looked like this. It included myself and the patient representative, but also Ananda Nano as our president's at the time. Okay, If we look for change, incremental change is good. In the 19 nineties, when I was appointed as a consultant orthopaedic surgeon, it made no difference to me that I was female and most of my colleagues were male and over my career time, the percentage women consultant surgeons has increased from 3% to 13.2%. And there's been incremental change year on year, which I think is to be, uh, accepted and welcomed. But we all know that if I look at the figures of the percentage women consultant, surgeons and trauma and orthopedics, we are the worst of the worst, and we still are. But it is changing. The NHS workforce data for last year showed that we had 100 and 91 female consultant surgeons and on the pie chart that looks pathetically small, I do agree. I was saying last year that in order to go from 7% to 8% it took an additional 26 consultant appointments that would go to women can't female candidates. But we did have that number of trainees coming off the top, so that should be possible. So it is changing. And in the NHS in 2022 we have over 200 female consultant surgeons in trauma and orthopedics, so we have only gone from 7.2 to 7.8%. I had so wanted it to hit that 8% but it hasn't. But we have had an additional 25 appointments who are consultants who are female. We've had some female retirements, but last year in England and Wales, 19% of consultant appointments went to women. So we are getting better. Things are changing. And if you look at the consultant membership, there's a big bunch in that in that orange pie chart in that orange bar. So a lot of the female consultants are early stage consultants, not old fogeys like me. So we're looking at step by step change, and if we look at court trainees, worryingly, they're going up and down a little bit. But the S P R numbers have steadily got better, and the intake last year at ST three level was 30% female. So that's got to be a good thing if you believe in diversity. And again, whilst the bar chart bar charts for the consultants have too many oranges for the registrars or trainees, there is at least a semblance of a a nice big blue bar as well. And of course, it's not just gender diversity, and I do get slightly cross that we're always talking about gender diversity when it should be talking about all are protected characteristics. So Kim Chi and of course, your own Presidente Oliver have both been trainees on our unit recently the ethnicity data through the UK medical student system and over the last decade has changed significantly. The orange bars have gone down and the blue bars have gone up, and that's great to see. But if you subdivide that that bar, then you see that those who would call themselves, uh, black, uh, English, English, Caribbean origin or African origin. That's a very small percentage compared to our British Asian colleagues. So you can't be. What you can't see is often leveled at the female gender, but I think there's a lot else that it could be addressed, too. So if you look at the changing face of trauma and orthopedics, if we look at the 2022 data by ethnicity, the consultants are yes, largely in that blue pie chart on your left, uh, white British. But if you look at the trainees by ethnicity, it's a much more mixed pie chart, and that can only be for the good. So it is a changing face of trauma and orthopedics back in 2020 the B o a. Launched It's diversion and inclusion, strategy and action plan with the vision to attract the best into our profession and to lead the profession, to challenge the status quo and to stimulate change. We had five priority areas, too, which we were, for which we were accountable to our membership and those were they. We used a carrot rather than a stick philosophy, and over the last two years we have strengthened the diversity of our leadership. We have increased the diversity of those who teach and train at educational and scientific meetings, and we believe we have increased the awareness of trauma and orthopedics as a rewarding career. There's lots more work to do, but I think we have changed and I think the pendulum has swung and that's good. The following year, with the help of a lot of Botha members, we develop the parental leave documents giving advice and guidance regarding the particular difficulties of being a female surgical trainee. We wanted to encourage flexibility not only in thought but actually in the practice of developing flexible training programs. And of course, we've worked with the Royal College of Surgeons in England with their support program for those returning to training or returning to work, not just after parental leave, but after your PhD research after caring for a colleague. Sorry, a colleague or a family member who needed you with them. We're advocating a lot more take up of the keeping and training and the split parental leave training days as well. And on the back of that, as you well aware at the B o. A Congress Just a few months ago, there was some concern raised about the increased incidents of breast cancer in female trainees due to the lack of appropriate lead gowns. So there is work going on. That and there were will be articles in the J, T. O and additional guidance on our website very shortly to help, uh, to help reassure those affected that we are have their interests at heart and we're doing some practical changes to ensure that our risks are kept to a minimum. The parental leave documents had some statement of expectations, not only for the trainees but for some of my colleagues as trainers who might be a little bit behind the times and not understanding what the means is by flexibility and training doesn't just mean coming in at 7. 30 instead of eight in the morning. It actually means a little bit more than that. So for trainees, trainers and the program directors, we need to work together to ensure that there is flexibility for all of us Trainee s, A s and consultant levels in how we train and how we work. And this flexibility is going to have to be a key part of the workforce planning going forward. Otherwise, we will have no workforce to deliver care. And then last year, this year Sorry. This year it's not 23 yet, is it? This year we appointed the culture and diversity champions and they have been excellent, uh, recruits to our governance system, if you like. And by being representative on many of the training education, uh, staffing committees around the regions, they are bringing about cultural change. And that's been delightful to see. But we need to work together. These are are B o A. Botha combined champions. There's a lot of research work going on, led by our cultural diversity champions so much that I'm not always sure where it's going. Not that I need. That's not my problem particularly. But if we're going off in all different directions, it would be sensible to remember that we should be working together and so that some research projects are not being duplicated. So we need to work together to make sure we get the best bang for our buck, so to speak. If we're championing change, that's more than just the written word. And so the last, uh, but one episode, uh, addition of the J. T. O had articles written by you by Botha members and by members of the B O. A. Looking at the barriers to flexible training and how inclusive we are. And, of course, hot off the press last night, one of your team, one of your orthopedic registrars with a disability or someone who is less able than others has been recruited to the European Space Agency is one of our potential astronauts, and his article makes good reading in that issue of the J. T. O. I'm going to ask you to challenge your perceptions, and some of you will have seen this slide before because I've used it quite a lot. Tim and I are colleagues, friends and exactly the same age. At the time we entered training, Tim was classical. I was atypical in many ways. If I show you this pie chart which admittedly is from 18 months ago, looking at the, uh, members of one of the particular training programs might not surprise you to see that their 19% of our trainees were female of all ethnicities in this particular London training program. It might surprise you to know the same pie chart represents that 19% of trainees are white males. So Tim is no longer your average orthopod in the sector of London. Uh, and I'm not yet average, but I'm getting closer to it. So we are a much more diverse society, and I wonder if that means that we're more We're more challenging to the rest of our colleagues. For some, I think their world has changed upside down. They could cope when it was just me as one single oddity because I could be ignored or included, and it didn't really change the way they're world spun about its axis. Now that there are so much there's so much diversity, I just wonder whether that put some of our colleagues on the edge of their comfort zone because back in the day I thought I was part of an inclusive, open, non threatening environment. But when I hear about all those tales about bullying, harassment, sexual harassment and almost sexual, definitely sexual assault, I don't truly recognize that world that we're living in at the moment. And I would wish that we were a kinder generation, and that's what I think we have to work towards. And of course, there's a balance, as we were just discussing between the storms on social media of which I am apart and the facts. But the storms on social media encourage us to look for and identify the facts. So, for example, when it was said that lots of women were leaving surgical training and lots of people of ethnic diversities were leaving surgical training, it was embarrassing to say that we hadn't really got the data because of G. D. P are there to protect us. But they're also means that some data is hidden behind a wall and that we can't get at. So Rob Gregory and it's going to be deeper bows now. They've been looking for the last 18 months that those that have left training. So we've had 16 levers, mainly, uh, mail, Uh, quite a few females. And the proportion of the 1200 trainees who have left does suggest that more women are leaving than men. This is not true in the 1st 12 months of this data collection, when the reverse was true. But it's changed, which just goes to show you must not take a snapshot. You must be collecting the data and having a look at it. So what we need to know is why we know what they've told their training program directors. But we also know that that may not represent the truth, the whole truth and nothing but the truth. So is that there is the lost project, the leaving orthopedic surgical training, which has begun doing the qualitative interviews for all, not just females, but all trainees who have left the program to try and work out why that is The Scottish Trauma and Orthopaedics Equality Project has just finished collecting data due to the hard work of the culture and diversity champions. Up in Scotland, we had a 70% response rate to that survey, which is pretty impressive. The final report has just pinned in, but I haven't had a chance to read it, and it's embargoed until the January meeting. But the idea had been that we would then roll that out, tweak it and then roll it out to the rest of the UK. But I know other, uh, surveys have gone out recently, so we just need to make sure that we're not duplicating things too much. Because, of course, if we have no training today, we have no surgeons tomorrow. But we do need to find new ways to train. As we went to the B o a last year, we had this graph that I showed, which shows that there are a lot of people waiting for trauma and orthopedic care that means in outpatients or on the surgery list. The orange box shows that the actual waiting list did go down because no one was referred in during that first wave, and from then on everything went bad again. So before the pandemic hit, this was a failing system with 500,000 trauma and orthopedic patient's awaiting care or investigation from ourselves, despite the fact that we wondered in the B O a. 2021 when we're all excited in Aberdeen to be seeing each other. We thought that life would get better because I'm forever an eternal optimist. But look, it's no better at all. Is it 800,000 now on that waiting list? So that means that 60,000 waiting more than 12 months, a 53% increase in our workload and around 240,000 patient's waiting for our surgical input, the government said, quite pleasingly, that we had got rid of the two year wait. Well, the Orange Line may be small, but the percentage I mean the scale means that there are 1000 trauma. Orthopedic patient's still waiting over two years for investigational treatment. That's just not acceptable in this day and age. If we take just one procedure, I'm not saying it's the common one. I don't want to have done one in my life, and that's about it. But if we look at the two, it went well just before you ask. She sends. She sends me a Christmas card every year. She must be about 95 anyway, Uh, if we look at the incidents of that procedure from the NJ are over the last two years, it's gone down significantly. This is just one, uh, procedure of many. And this is taken from Rob Gregory, who I know is chatting to you tomorrow. So how do we train you? Rob's figures from the S A. C and the log books say there are 50,000 potential training opportunities that you and I have lost over the last two years. So you just not have had neither of us have had access to them, so I haven't been able to do them, and I haven't been able to train you on those cases. But the most important thing is that in the optimism of the b o a last year, we had thought that that training gap between what has been normally the blue line jiggling along at the training opportunities every month we had thought that Orange Line would get to match the blue line. But it hasn't. It hasn't changed a jot, so we can no longer keep calm and carry on because that's just not working. We're going to have to think differently and Tim Briggs, of course, always wants us to think differently and work harder. I we ought to think differently and work differently. I mean, as does Tim. And we know the G M C training survey showed that a lot of people were feeling the consequences of the lack of training that they had received and that trauma and orthopaedics had the highest rate of Covid, UH, 10.1 or 10.2 outcomes. I know that Rob Gregory will probably talk to you about this tomorrow, but he was worried that the people who perceived that they would need an extension to training was not matched by the number who are actually getting an extension to training. And whether you know the truth is probably halfway between. I'm not sure that not everyone who perceives that they need more training actually does need it. I say that as an older colleague who's trained many a trainee, so I don't think all of you do need the extra time, but you feel you do, and that's important. We've got to address that. There was some work done recently showed that the MRCS examination pass rate there was differential attainment the boys do better than the girls. The whites do better than non whites. If you're younger, when you do the exam, you do better than if you're older. Okay, we can say some of that's due to exam technique, but all the differences were greater in the face to face assessment, and that is, frankly, quite disappointing and worrying. So there is a short life working group at the moment that some of you are involved in, uh, and some of the bor involved in to sort of direct which projects we think that we should do and to coordinate initiatives to try and work out what the problems are between differential attainment. We have had access via rob and deeper to a large amount. And I mean a really phenomenal amount of UK med data covering absolutely everything about our trainees. Progress from core training up to, uh, my level of concern, uh, two consultant level. So we do have lots of studies in progress. We want some low hanging fruit, and then some more tricky, difficult projects to do. If you have an idea of what you think we should be looking at, please let us know If you want to be involved, please let us know. Or more particularly, will be Robin deeper who are coordinating this. But we've got amazing amount of data and we need people to help look at it properly and one step at a time. We're going to challenge the norm. You know those red bars? We have not got enough staff in the UK system, so we're going to look at where we work the British Society for surgery. The hand have reminded us that not every hand operation needs to be done in theater. It can be done in a clean treatment room. We've got to look at how we work in terms of getting our patient's fit and well and getting them rehab quickly afterwards. And we need to involve you in all of this project and service redesign. We have to make the best of what we've got and look for the chances to change and to guide our professional growth because make no way, two ways about it, all of us have got to change. Even an old fogey like me knows that I cannot continue practicing the way I did pre covid. I have to do it differently. And of course, it used to be wife before night for night before why and so that just needs to change, doesn't life. And this goes back to what I was saying before, we have to have much more flexibility. We have to be kind to ourselves, and we will then be kind to our patient's. So until we address this balance of life and work with going to be a problem, we all remember when covid hit, we had to take a leap into the somewhat frightening dark but clinically led innovative practices came out of nowhere, and some of them were great. Some of them were good. Some of them weren't worth the paper they were written on. I agree. But that doesn't mean to say that we have to go back to all those detailed plans and taking five years to come up with a plan to build the dams, that you can change something. Maybe you have that brilliant idea and the Archimedes screw principal comes to you and you get water uphill very quickly. So, yes, we've got to have governance in what we do. But please, let's not go back to the stalemate of nothing. Nothing. Nothing is happening when we've got 800,000 Patient's waiting to see us. So I've never been a planner. Those of you've had the misfortune to work with me, know that I'm not planning, really. But I do believe in persistence, overcoming resistance. So no matter how good your umbrella is in a rainstorm, you will eventually get wet. A ripple. A raindrop on a pool will have a ripple effect, and those ripple effects do make a difference. And that dripping tap, well, you could turn it off. Or you could just collect the water and throw it over a manager who's or a clinician who's annoying. You don't quote me on that one. That's not probably right. So what else does the B O a do? Well, we've done our standards because one step at a time we have to improve the care for our patient's. We have to do some service design and re delivery, and we have to work to the best standards that we can. We've come up with some guidance because our patient's were frankly worried that whilst they were waiting for their hip replacement, some attractive website said. For the princely sum of just just 1000 lbs, you can have something injected into you that will make a world of difference. Well, it might make a world of difference up here, but it may not make a scrap of difference to your Oh, a hip. So he came out with some guidance. For that, we contribute always to the nice guidance to the best M S K pathways to the patient initiated, follow shared decision making tools. There's lots of little words that you have to learn some of it's great, and some of it's really going back to just putting more processes in place. So we have to work with them. Otherwise we're gonna be taken over by it. And of course, we have Congress, and that's well attended. And we, well, I enjoy it. And the content and the contributions from the specialist societies like yourselves, like the elbow and shoulder surgeons like the knee surgeon's is essential to the running of our association. And as I sort of said in my presidential address, yes, we are all different parts, but we are parts of the same body, the same association, so we do need you to keep together within the overarching umbrella of the be away, and that umbrella will keep you dry. I'm sure if we want to develop sustainable systems, then we have to work with the greener surgery projects. There's no doubt about it. We waste far too much packaging and everything. I mean that goes without saying so less waste will be may lead to more efficiency. And sometimes it's like pushing a rock uphill. And sometimes just a light feather touch can bring about change. Yeah, Why do I need a suction device for every blessed percutaneous to Not a me I'm doing, I don't so don't get it out of the packet ing. Don't throw it away at the end of the case, untouched, unused. So there are simple changes that we have to make, so there is going to be a president's prize. Details to follow in January that will bring about a project will bring about a sustainable system. Change be in staffing of your fracture clinic, be in how you train, be it in a greener agenda in theaters or anywhere you like, And the only provider will be that the change that you are promoting has a reasonable chance of transferring to other trusts with the in the NHS within the NHS so that we don't keep repeating the wheel. We run courses, as do you. We have well being pages. We have online educational tools. We have fellowships and the ones I want to highlight. I think, yes, are the traveling fellowships? I agree there was some problems this year, partly because of the covid that we got. The timing's wrong, and the interpretation of the rules meant that if you were just about to go on a fellowship, it was considered that you couldn't apply for the grant to go on that fellowship because the grant was for next year. So I apologize profusely on the B. O s behalf for not thinking that through, and that will change. If you fancy a week in Athens in the summer, then there's one going free as long as you apply for the forte traveling fellowship. And I think you do have to go and do a little bit of work while you're there. But it's all great fun. We do research activities. You heard about those in the dragon's den, and we will and are encouraging, flexible working for our research fellows of a minimum of 0.5 full time equivalent. So if you're interested in these research activities, do be in touch with us. And there are research opportunities going. And there are, of course, fundraising opportunities. And John Skinner's son did the London Marathon with this lightweight tree of Andre strapped to his back. I can promise you I will be making know similar contribution to next year's marathon. I will be in a local public house cheering you on if you want to join it. But we do fundraise a lot and Mark Bowditch and I believe a trainee just sitting over there to my left has offered to help organize. Maybe a sponsored cycle ride at the B O. A in Liverpool was certainly having a fun run like you've had today so that we are doing. And if you have any, if you'd like to be involved in helping us organize it, then that would be great, too, because we said, with Covid, there is clinically led, innovative, uh, projects came out from Covid. I do remember going as the Ukraine War came out, I went to the Royal College of Surgeons of England meeting where we said, What can we do to help? And the College of Surgeons of England said nothing at the moment, nothing. So I went back and reported that to the B O. A. And we looked at each other and thought, Well, we can't do nothing. So a quick response turned into a valuable resource with the support for Ukraine Webinar series between the B. O. A. Capra's and the Society of Surgery. The hand. We want to know whether we can widen its reach and we have anonymous used all of those webinars taken everything that is referring to war in Ukraine and aggressors and non aggressors. We've taken all of that out carefully edited, so it is now available for other areas. Should they wish to access that, should we be doing more well, myself and the people in what think we should? But our membership, sadly when we surveyed them said it wasn't a high priority. So maybe we can just scrub what the membership think about what we do and carry on. Regardless, I didn't say that either. It's widespread engagement. I want us to be engaged more You know that your culture and diversity champions have been working with some of the b o a. People as well looking at diversity in design, looking at why so many of the panels for the industry have traditionally been Meinel man ALS and mail only panels. And a bit by bit, all of that is changing to you. Can't registration is open for those who need to know we've had the photo competition with designing surgical hats. If you've got any ideas for merchant merchandizing for the Botha or for us to just let us know we want to be involved and then lastly. But most importantly, we do have to lobby government around properly. Resourcing elective care. We've supported Scott. We've gone to Northern Ireland. We've been to Wales to promote the health of our patient's. And there's all of those things with the best M S K initiative, which is now under the auspices of Goofed and now under the auspices of Tim Briggs, as as the leader of elective recovery through the country. So there's a lot to be done there, and the challenges, of course, remain about the capacity for elective recovery and the fact that the workforce is not there. We had 1200 people reply to our retirement survey, and the news is not good for the consultant body and for delivering the work. It's great if you're a trainee and looking forward to some consultant opportunities because it looks like there will be a lot and that looks like there'll be more opportunities. Then there are trainees to fill them, so that's got to be looked into as well. We've got to look at the fact that, uh, international medical graduates, the S A S. Doctors are going to form a significant part of our workforce. So we can either put our head in the sand or we can embrace that and help train them and bring them up to the same standard if they aren't at it. But make sure that everyone is at the same standard. I'm not good with money, so I'm not talking about tariffs here. The big problems are the medical device registries. So can we fund registries not just for joint replacement, but for ligament reconstruction for the baby infant hit hit that I operate on? We are losing implants because of the device regulation and it costs the companies too much to get the device approved here. So we are losing implants and were stifling innovation in this country, and that is a huge problem. So if you think change doesn't occur well, there is no patient representative, so that's a bad thing. But there's no patient representative on this photograph. But I think the diversity is better and we are changing the rules to allow more of you to stand and more of you to vote in our council and committee elections. George Bernard Shaw said. The single biggest problem in communication is the illusion that it's taken place. So I think I've communicated something about what the B o A means to me should mean to you and does mean to our patient's. But if I haven't communicated it properly, then join us and tell us change is tiring and we can't do it on our own. So if we don't work together, this change that has to happen won't happen, or it will be driven by those at the top, meaning management rather than those of us who care about our patient's. So we're going to keep people moving by engaging with a diverse group of colleagues, so work with us to develop, deliver some sustainable systems. And those, of course, are my themes for the B O A. In Liverpool next year. So you better be there or be square. Thank you very much. Mhm.