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And what I'd love to do is I'd love to be able to welcome to the stage, our final presenter, our final speaker again, joining us all the way from over in Canada's. We've got Professor Eastward Presidente of the British Orthopaedic Association. Um I will let you have a chat with us today. Thank you very much for joining us. Thanks. Thanks Fran. Let's hope my slide on so last, uh and maybe least I want to give you a little bit of a broader view on sustainability from a bo a point of view. I think we've heard so many brilliant tips and tricks and ideas and plans and projects that are in various stages of completion that we are in a very exciting part of uh life really in terms of what we can achieve. But it is true that in some ways we have to look back to look forward. So it's 75 years ago that the NHS was formed, it had three core principles. And as an NHS fan, I do still adhere to all of those top three principles. What I have perhaps forgotten is that one of the core principles as well was that we should be promoting good health and by promoting good health, we could perhaps vanquish sickness seems a little bit of a naive idea. But one, we're thinking about a few summers ago, the NHS turned 70 the three principles have become seven. We had those horrible words of accountability and partnerships and organizational this, that and the other. But they did want us to be efficient and they did bring in the phrase sustainability. But they also highlighted the fact that we've got limited resources and they considered that some procedures were of limited clinical value and that we should think before we do things. And I think that's right. But when a hip replacement was a procedure of limited clinical value, then you have to say no, that can't be right. So we must keep questioning what comes up before us. And when I look around us now, it doesn't take much to open my eyes and decide that the NHS which I love and support is an organization in crisis in terms of simple terms and conditions of service. We're not very good at recruiting and, or retaining our staff at the moment, we're not as efficient and certainly not as effective as we could and should be. So as the NHS turns 75 next month, the question is now, is it fit for purpose? Is the organizational sustainable or not? Is it time for a root and branch change? Should the NHS retire and maybe like consultants. If it retired, maybe it could return in a different format uh in a different way. It's a good reminder that we have as orthopedic and trauma surgeons. Three groups of patient's. We have those who could be any one of us who are involved in a car accident or fall over and fracture our neck of fema. We have to be admitted for surgical and, or social care. There's another group who are the walking wounded, essentially fit but injured people that could be you or I or our Children, we can go home, but we will need to come back again for treatment. And then there are the elective but not optional care cases. And again, that could be any one of us with a bad arthritic hip which can be cured completely quickly and a great improvement of our quality of life with a hip replacement. 2 to 3 years ago, in fact, three years ago, now, the Royal College of Surgeons brought out a 12 point plan for a new deal for surgery. So I'm just going to highlight three of those in order to make the system sustainable. We were to adopt a surgical hub multiple across England. We would enable and ensure that our surgical trainees caught up on the missed opportunities from the COVID uh pandemic. And as Fran had mentioned, we must look after our staff well being because retention is that forefront of plans at that stage trauma and orthopaedics owned 92,000 on the waiting list who've been waiting for more than 12 months. Well, the sustainable NHS is not sustainable when we look at these figures, these are the trauma and orthopedic waiting list figures for last month. So the bottom blue line of 500,000 shows that before the pandemic hit the system was not sustainable, there were too many incomplete pathways and this graph is measuring the incomplete pathways. We are now up to 800,000 with the recent spate of uh industrial Axion and bank holidays tipping. That figure over the 800,000 mark, 52,000 are waiting more than 12 months for their pathway to be completed. We've had a 60% increase in our overall workload over the last 2 to 3 years since the pandemic and there are approximately 250,000 waiting for surgery. So something does have to change and it has to change. Now, a couple of weekends ago, I did a straw poll on behalf of all of us to see what the clinical directors of the different departments thought about where they were in terms of the waiting list or the elective work getting back to normal. So as you can see, it was a 50 50 split as to whether most units were anywhere near working at pre pandemic level and buy anywhere near, we meant above 80 to 85%. So there were some who said it's a very fragile. Yes. Our theater time and our resources are very limited. Staffing is very limited. And there were a few in the no column who said we're nowhere near, nowhere near people who have not done any joint arthroplasty for four months of this year. We're supposed to have access to surgical hubs now, but most people do not. They do have some ring fenced beds, but those beds are being broached all the time. And there are some who are worried that the system is now becoming unsustainable in terms of becoming a two tier system with some hubs only taking S A one or two patient's. So that again may solve one problem that causes another problem. That's for the elective work. Many of you will have taken part in the orthopod study earlier this year which showed that 17 hospitals around the UK had more than 30 patient's waiting for surgery each Monday morning trauma cases. That is not a sustainable system. There was a huge variation in business from one hospital to another. The longest waiting times were for those cases, which don't have a target on them. So a neck of femur fracture will be done promptly. But the same fracture at the bottom end of the femur will not be dealt with promptly. Me and my ankle fracture will go home and we may or may not come back in the next day or two or three. And if I am brought in from home as a fit and well person with an ankle fracture, only 5% of those cases come in to a dedicated day case list. And if there's a hospital two miles down the road, which has capacity, I will not be transferred to that hospital. We are not using our networks efficiently nor moving patient's let alone surgeons around. And if we don't look after our trauma, well, then we will have a huge knock on effect on our elective bed base. And again, that's problems for a sustainable system in the future. My sort of hashtag last year 2022 was no training today, know surgeons tomorrow. And many of you have heard me talk about the fact that there were 50,000 potential training opportunities lost over the last two years for total knee replacement alone, again, not sustainable in terms of teaching and training. But the good news is that as trauma and orthopedic surgeons, we are up for the challenge. So the red lines on those bar charts show that the UK is bottom and next to bottom or close to bottom in terms of the number of doctors and nurses around per 1000 population. So we are going to have to change and we are not afraid to change. We do adopt new practices. You've heard a lot about those today. We want to highlight efficiency and effectiveness and as many speakers have said, do the right procedure in the right place with the right hand's doing it. You've heard also the fact that as a profession, we like to protect our elective orthopedic environment so that we can be efficient and effective and deliver a sustainable system for our arthroplasty, the British Society for Surgery of the Hands, as you, as you heard has developed these hubs and we are encouraging, operating outside the main theater environment. So doing cases maybe in the clinic room, maybe in an anesthetic room, maybe in a separate area that you have made clean and safe for doing minor surgery. And if it's good enough for hands, then surely it could be good enough for feet. And if we have a trainee with us to do a simple operation, maybe we don't need to scrub nurse, not because I don't value the nursing staff, but because I think we should all do the jobs that we are good at. And if by doing a simple case, someplace else, I can free up the nursing staff to do the bigger cases elsewhere, that's a more sustainable system. I hope you're all aware of the boasts the boa standards. If you follow these different standards, we can and are doing things more effectively and more efficiently. We are doing less wasteful imaging, we're doing less investigations, we're getting the right patient in the right place at the right time. And if we look at the early management of pediatric forearm fracture, that was shown that was very acceptable to patient's and two parents, if you can have your child's fracture treated in the A and E department and be home for tea time, that has to be better. And as this paper said, instead of being admitted for two days or having the whole process take two days, it's come down to two hours. That's a really good opportunity to challenge for change. And this has gradually taken off at various or in fact, most hospitals around the UK on a slightly different than maybe similar note. We're looking at whether all the biologics or indeed, um uh sorry, not virtual reality. Um uh computer assisted robotic consisted surgery has its place. And where do we find that place in this brave new world? If we're going to be efficient and effective, we have to think outside the box. So the Knighting Haas Nightingale Hospital in Exeter has been repurposed and it is now a high turnover uh day case hip and knee arthroplasty unit with the facility to stay overnight. If have to, I've always believed in individualized care. I like the holistic approach. I like to die direct my treatment to the patient in front of me. They're all individuals I thought but going to visit a unit like this and seeing how if you consider the similarities of each patient that most patient's wanting a hip replacement are joined by their similarities more than their differences. So if you have a very protocal eyes driven pathway, making sure that preoperatively patient's are prepared per operatively. Everything goes according to a protocol, which means that you eat until really you're starting to go to sleep. It means you eat the minute you wake up again. It means that your pain relief is well controlled. It means that you hardly ever become ill, injured or unwell. And if you hardly notice that you've had an operation, you will get better, quicker, more effectively and more efficiently. It is difficult as Fran and others have said to bring about sustainable change. And I've used this slide a lot this year as I've gone around talking to people, but persistence will overcome resistance. And I know Fran felt that it was difficult if you're only a trainee in a department for a little while, but you put a raindrop on that puddle and it will have ripples and the next trainee in will drop a similar, it'll stone into that puddle and there will be a knock on effect that's bringing about perhaps sustainable change in how we practice. But we also need to bring about sustainable change in how, why and where we train, we have to be much more flexible, we have to allow our workforce to be able to live a, have a better work life balance. And that's for you as trainees, us as trainers, we need to make things better for all of us. And I do believe that working together with the BBO A and the Boat A culture and diversity champions. We are beginning to bring about a sustainable change in how we think in each of our training regions, in each of our hospital setting things in each of our teams. By working together, we can bring about a little bit of change which makes our quality of life better. And if we work together better as a team, we are more efficient and more effective and then that's more sustainable. So it's a nice little circle, challenging for change is tiring, it is difficult. So you have to be prepared to muck in and shame some people from inaction to Axion. So they can't keep saying I don't want to use reusable gowns. I don't want to use an alcohol based handrub. You've got to shame these people interaction because there is an open door and it is opening further. And if we carry on pushing through it, we will bring about change. But we have to take someone else by the hand and bring them through that door to. And then gradually they'll be more through the door than there are left behind and they'll feel left out and they'll want to come and join us in that room. We have to look after our workforce. We know that sadly up till last year, we had 16 levers from orthopedic training, but we do have 1200 trainees. So that wasn't perhaps a big percentage, but more women, percentage wise than men left. We're trying to find out why we've looked at the Scottish Step study. We're rolling that out nationally. There's the lost study which is looking also the reasons why people leave orthopedic surgical training and those results will be out next, uh in August. So we have to identify what it is that is not sustainable for our trainees. What means that they can't see a future in trauma and orthopedics. We have to look after our staff whilst it's mandatory training to understand our patient's are different that they are individuals and may have different needs. It is not yet mandatory that we understand each other, that we understand that we don't all learn in the same way that we don't all act in the same way. So we do need to have to work to work together better here as well. And you know, as well as I do that, the culture and diversity champions day next month is going to look at this in more detail and the bo a will be running symposium at it's Congress and there will be a webinar on this subject just prior to Congress to we have to celebrate who we are and accept that we need to work with people who have similar ethics viewpoints views on life. As we do, we have to have a workforce who feel safe if you want them to stay in trauma and orthopedics. So with the radiation exposure that has occupied quite a lot of our time. We have to be careful. We have to keep our arms down, stand back, reduce the number of shots that you take of the bone in question. And we must not wear gowns that it expose the whole of our axilla and the breast tissue to damaging radiation. So we could and should put that gown on much more tightly and or find a gown that fits better. We absolutely need a workforce who feel safe in terms of sexual harassment and bullying. Uh and banter and these two articles were implied that this was a hashtag me too moment for the NHS and a survey by Botha suggested that when this sort of event happened, people did not know who to report it to. Well, that's unexcusable as well. So call me, call a friend, find a friend, call somewhat, but you must report this sort of behavior otherwise it will carry on. So overall, you might not think that what I've talked about is about sustainability, but we have to keep an eye on that bigger picture and remember the importance of each piece of our working life and our social life if we're going to make the future sustainable for all of us. So 2022 is no training today. Know surgeons tomorrow 2023 must be something different. Maintaining the training issues, of course, but it has to be something different and something sustainable. And many of you will have heard my trite phrase that I've been saying that we need to sow the seeds and plant those seeds, look after them and grow some green shoots of a more sustainable future. And maybe if we look after it, that little sapling will turn out into a nutri of Andre and we can work forward to a more sustainable healthier system for ourselves and for our patient's, what we are doing at the moment is simply not acceptable and not sustainable. You've heard how much the NHS is responsible for in terms of carbon footprint for road travel. We are a hugely single use society. We ask for something, the nurses run and get it. We open it up and then we don't use it anyway. That is unacceptable behavior and it's not sustainable whether we use reusable or not and we should use reusable. We do not need 2 to 3 layers of drapes for every two centimeter incision. If I'm doing it in an anesthetic room or a clinic procedure room, I do not need to drape the whole patient. We have to think differently and we must use reusable gowns. I could go on and on about the green agenda, but there is no point unless we make change happen. And I know Frank quite rightly said it isn't all about reducing reusing and recycling, but we do have to work together to reduce some of the unwanted waste. We do have to reuse some pieces, equipment and we have to, as we heard with the Splints, find out ways of recycling, uh, some of our equipment, a lot of what it comes down to can be described in terms of car journeys from here to Timbuktu and back again. But you know what most of what we've been talking about is pure and simple, common sense. And if it is just common sense, then common sense says that we should, we should do it now, but we need to look after ourselves and then for we can then have a more sustainable system in which to work. Thank you very much. Thank you so much for that brilliant presentation, Professor Easter. That was really enjoyable. Um I really liked what you're saying at the end about sowing the seeds and that we actually just need to use a common sense approach. I know we've been saying lots of very fancy, exciting things all day today. But actually, you're right. It, it's common sense. What can we do? What are the simple things that we can change that, that will make a difference in the long term. And I think you're right, Fran and we're building up gradually a bit of a groundswell and it will change things and the old fogeys like me will have to learn to change as well. Professor Eastward. Thank you very much for your inspirational presentation slices. If it, I think I've got a comment here from, from within the chat and just highlighting the issues regarding um retention and recruitment is evident that there's a lack of, but there's also a lack of clear opportunities and guidance that's keeping our eye. MGS are international medical graduates away from, from training posts. Do you think that there's a way that we can be opening up our, our doors so that we can keep our home graduates as well as international graduates um in training programs? And I wonder if there's a difference in rates of drop out or retention there? Yes, I mean that, that is a huge big issue which we are trying to tackle. Um, Joanna Higgins down in the Wessex area is, is running a program for the international Medical graduates. We're trying to see from the BO A whether we can link in a program with the international medical graduates, link in with the SAS projects as well. We are actively recruiting at the moment for an SAS, a member of Council and I know there is a difference between the IM GS and the SAS grades, but there are some similarities as well and I totally agree there is a lack of clear guidance and opportunities there. So we do need to work with you if you are one of those and that group to try and make them Linkin better to our training at the moment. Thank you. Uh Just, just another question. I, I just wonder where do you see sustainability going with the British Orthopaedic Association? I know that your tenure as Presidente is going to be coming to an end in September, what's going to be going forwards and how can we maintain this, um, with regard to the next group that come in, um, to help run the bo A? Yeah. So I, they can't get rid of me. I'm staying on as past Presidente, of course. And I've, you know, one of my jobs is I've revamped that role a bit so that I can carry on interfering a little bit longer. Um But the, the whole of the BO A is behind this. So I think if we make it uh just an inherent part of our day to day life, then that will be helpful. And I think we're not going to persuade the joint arthroplasty surgeons at the moment to change overnight because infection, infection, infection, but we can do it around the edges. You know, the hand surgeons are breaking the rules. The happily the foot surgeons are pediatric surgeons would sort of bend and break the rules. So as you were saying, hearing earlier from uh Mr Mango, there are lots of things we can do and we don't have to get everyone to change everything all at once, but we do need to start the process of change. And I think that that's where our SOS survey is going to be very interesting and we'll be able to delineate what the different subgroups within orthopedics, trainees, more senior colleagues, different subspecialties, what everyone's thoughts and opinions are and actually how we can then support those different groups. Um So when that comes out, we are going to have to get people to fill it in. And I think, um as Fran nose, but maybe other people don't know when the first round of that survey comes back. That will, as you say, Fran, it will highlight some people who may well then get a follow up questionnaire or a follow up discussion to see how their ideas can be brought forward into practice. It will be interesting. Absolutely. Thank you very much for your time. I really appreciate it and knowing that you're all the way over in, um, over in Candida and the time difference was a bit challenging. Thank you very much. That's a pleasure from pleasure. Um.