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So continue on the theme of developing for the future. Um In some of our work in Malawi were very aware of the lack of specialist training, especially for the young consultants are coming up. And uh one of the recent projects is a Lion Hospital in uh a long way funded by the Norwegian government and philanthropists. And there's a link there again with going back to the past with the B S S H has actually started an program of long term support and development of a hand surgery and upper limb service. And the Sioux fully love who I first met back in the nineties in Zambia is now going to talk about the work of the B S S H and maybe try and recruit some of the enthusiasts out there. Sue. Thank you very much. Thank you very much Alberto for inviting me to present to walk today. It's a great honor and it's lovely to return to the annual walk meeting. After a very long absence of two decades, I do have history with walk uh as a registrar, I was sponsored by World orthopedic Concern. UK to spend six months working in Zambia alongside Professor John Jealous, who you've just heard from. And then I took over as leader the Ethiopia project from Jeffrey Walker. And I ran that for a few years before. Unfortunately, the pressures of NHS consultant work and a young family forced me to step down. But more recently, I've resumed overseas work and today I'm here representing the British Society for uh surgery of the hand, the B S S H. So Alberto has asked me to speak to the title. Long term. Always best. And I'm afraid that I'm not going to be able to prove to you today that that is the case. However, it is my strong belief that the most valuable work that we can do in low and middle income countries is that which seeks to be sustainable in the long term for the host unit and not continually dependent on external input of skills and resources. So I would like to tell you about the hand surgery unit that we're setting up in Malawi. And my hope is that in five years time, I might be able to come back here and prove that long term is always best. So first of all, a little bit about the British Society for Surgery of the Hand. Who are we? And what do we do? We're a medical charity, supporting hand patient's where a professional membership organization of UK, hand surgeons and associated professionals and most hand surgeons in the UK are members of our society, we have approximately 1000 members um comprised mostly of either consultants or trainee hand surgeons. And finally, we're uh internationally recognized and one of the world leading hand societies. So what do we do for our patient's and for public benefit, produce patient information about hand conditions and treatment. We measure surgical outcomes in hand surgery and we use that information to improve treatments for hand surgery. We run quality improvement programs to improve how we deliver treatment to patient's. And we decide on areas where research in hand surgery will be most useful. We involve members of the public and patient's routinely in our society to help us make the best decisions about what we do. We run injury prevention campaigns. We work with NHS England to agree the best standards of care for different hand conditions and we right national clinical pathways to guide healthcare professionals in delivering these standards. What do we do for our members? We run educational courses and scientific mean eatings. We offer travel bursaries and fellowships to help surgeons get additional training and experience in particular areas of hand surgery. We run a diploma and a master's degree in hand surgery and specialist training fellowships in the UK. We run competitions and offer prizes for good work in hand surgery. We run a mentoring program to support our senior trainees and junior consultants. We support, organize and help fund research projects in hand surgery. We train the emerging clinical leaders in hand surgery. And we recognize excellence in our field. And finally, what do we do at an international level? We work with our global partners to participate in or run international hand surgery meetings. We fund international traveling hand fellows from both developed and from low and middle income countries to visit UK units and attend our scientific meetings. We produce the most red hand surgery journal in the world. Members of the British Society for Surgery of the Hand are active on councils and committees in both the European and international hand surgery societies. And we already have a long history of supporting units in low and middle income countries and running educational programs for them. So what next in 2021 be Ssh Council agreed a proposal to step up its global outreach work up until then. We'd used a very traditional model for our global partnership work. Uh We offer remote support to 10 low income units and we send a surgical team out there. Uh of surgeons, often nurses and Ethan tests and therapists uh out to visit those units approximately 10 days to two weeks every year uh to offer treatment for a few selected patient's and provide some teaching for the local staff. But we've now gone on to develop a very ambitious new model for delivering global hand surgery. And our aspiration is to create a permanent hand unit in a low resource country. Is one of the project involves identifying a suitable host unit and agreeing a collaboration which we completed in 2022 is two of the project is to provide continuous volunteers who will deliver service, training and support in hand surgery and therapy for approximately five years. And we are now approaching halfway through our first year of that support and stage uh phase three of project will be to stage a gradual withdrawal, leaving a self sufficient hand unit for this project, we chose Malawi uh because be ssh already have strong links. There is one of our current partner units. Uh It's a country of great need. We chose the long way because it was the perfect of venue uh to help us meet that need. So you're probably all aware that Malawi is one of the poorest countries in the world and it has one of the highest rates of road traffic injuries and deaths in the world. For every death, there are 25 injuries causing permanent disability. And of course in countries like Malawi, one person with a permanent disability often pushes an entire family into poverty. There's a vast burden of general trauma in Malawi with very few resources to manage it. And only a tiny minority of any hand injury in Malawi will get any treatment at all, let alone surgery. The long ways, the political capital of Malawi with a population of uh about a million. And it's also the tertiary referral unit for 43% of the entire Malawian population. So a further eight million people, Kamuzu Central hospital is the main state hospital there and it's long had insufficient capacity, but they are a very progressive hospital and they used to working with donors and all around the perimeter of the hospital. You'll find satellite donor units covering different specialties. So they have a pediatric ward, a maternity unit and I infirmary Infectious Diseases unit. And so on three years ago, the hospital was pledged a new build orthopedic and neurosurgery unit. It's called the Lilongwe Institute of Orthopedics and neurosurgery or the Lion unit. And it's on the main hospital site and its mission statement is to create a Malawi free from preventable musculoskeletal and neurosurgical disability, the local orthopedic department, they're currently has six consultant orthopedic surgeons and up to 10 trainees on a five year training program and they're very keen to populate their new unit with both general and subspecialty orthopedics. This picture shows the architects, drawings of the building and we've watched it develop over the last uh year or two uh from that uh from this building site here uh to the actual reality of the unit. And the building was officially opened by the Presidente of Malawi last month and is just being completed. So last year, a small team from the B S S H and the Hand Therapy Society made escaping visit to the hospital in Lilongwe. We watched how the local surgeons, nurses and therapists worked, we discussed with them what they wanted and needed from us and we agreed a memorandum of understanding between the British Society of Surgery of the Hand, the British Association of Hand Therapists and the Lion Unit for five years. Uh starting this year, we've undertaken to provide a continuous rotation of volunteers to set up and staff hand unit. We will be treating large numbers of Malawian patient's with hand problems and injuries, but always with the emphasis on teaching and training the local surgeons, therapists and nurses to do the same. And our mutual goal with the Malawian team is for the local staff to become sufficiently skilled at the end of the five years uh that they can run the hand unit autonomously with the local lead allowing be ssh to withdraw to a baseline level of support. We've developed strong leadership teams on both the B S S H and the Lion side with the full support of the hospital. In the long way. Our principal partners in Malawi are the medical director and the chief executive officer, the Lion unit, both of whom are orthopedic consultants in Malawi. So once the project had been given the green light, we um set to work recruiting volunteers and setting up a base for them. In the long way. We've been really thrilled by the response we've had and we've already populated the consultant and the hand therapy timetables into 2024 the trainee program is already pretty much full until the end of 2025. Obviously, as a charitable endeavor, it won't be an extravagant project, but we do recognize the importance of our volunteers being comfortable and safe. And we've rented a very pleasant five bedroom bungalow in a safe area of the long way for the team to live in. Uh, it's looked after by a local housekeeper and Gardner and we have a night security guard. We bought a car for the team to use for transport around a long way. Our first volunteers went out this January uh to make ready the accommodation and start building bridges with the local team. And by um February are full compliment of volunteers was out there in clinical work began in earnest from the very start, they were able to integrate with the local teams. Start taking their place for the queue in the key for the emergency theaters. And we were made very welcome by our hosts. This is what the hand unit team looks like. Now, this is the weekly timetable. The caseload has surprised us somewhat. Um Whilst of course, there is the usual bread and butter of hand surgery, flex tendon injuries, two carbons tina side of itis carpal tunnel syndrome and so on. We're seeing much higher volumes of severe and complex trauma than we anticipated. Unsalvageable cases of infection and malignancy requiring simple ablative procedures are relatively straightforward to deal with. But there are many Ortho plastic cases that are a significant challenge, especially as our consultant, volunteer will either be an orthopedic consultant or a plastics consultant. But not both. We have uh put in place very good remote M D T and whatsapp support for our volunteer team so that they can readily seek advice. But ideally, these cases would be managed by an Ortho plastic team. And we're now looking at the possibilities of having both orthopedic and plastic hand consultants out there together intermittently, this is our budget approximately 100,000 lbs per year, giving a total bill of about half million pounds for the whole five year project. The British Society of Surgery of the Hand have generously donated 100,000 lbs towards the project. And our aim is to fundraise the rest. If anyone's feeling generous, we would welcome any contributions more about the project if you're interested can be found on the B S S H website. So if you just Google the British Society of Surgery of the Hand and in the search bar, if you put a lien, um you'll find the correct page and that's got more about donating, volunteering and more about the project. If you are interested in volunteering, you can find the links on that page or you can use this QR code to complete a Surveymonkey. Uh and then we'll be in touch with you. So thank you very much for listening at this stage. Uh I can't prove I'm afraid that long term is always best, but I certainly believe that this is a good, a good model of sustainability for, for global health care. Maybe in another five years, you might like to invite one of the project team back to, uh, to tell you how the project went. Thank you very much, Sue. Thank you very much for that. Well, I think it's incredibly exciting future. Hopefully bringing the best of British orthopedics and hand surgery to, uh, place I dearly love. Um, are there any questions for Sue? Yep. Matthew. Hi. Thanks for that. I was really, really, really interesting. I was just wondering how easy is it for trainees to be released to come and do a prolonged period of work? Is it something that you guys have found relatively easy? Um, yes. So we've had, uh, we've had trainees volunteer using various systems that I'm talking about. UK trainees here. Uh, so some are taking out of program, uh, experience periods and I think you're allowed up to 12 months in your whole six years of orthopedic training. Uh, so we've got quite a few of our trainee volunteers coming for periods of three or six months. Um, other people who are coming for sure, two visits, uh, and we, uh, discourage trainees to come for anything less than six weeks, but for sure to visit some, some trainees are coming, using a combination of, um, annual leave. Uh, and, um, sometimes they're trust might match them with study leave. I would say also that there are some trainees who, who are coming, who got who've taken periods out of training for various reasons or who were at the end of training in between fellowships before they take up hand consultant posts. Thank you. Any other questions? Right. So, thank you very much. Indeed. As I say, we'll keep an eye on the project and come visit you when we're next in Allawi. Thanks very much. Thank you.