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Yes. Um Yeah. Right. Um Welcome back. Um I hope you've had AAA good break and a pleasant lunch, found something to eat and refreshed with coffee and uh desserts. Uh We're back now to our afternoon part of the today, which is basically entitled, a Surgical Team of the Future. We have several speakers later on this afternoon and we have a session where there will be a panel discussion and um obviously questions from the audience uh invited uh because I did choose this topic as it's quite timely controversial and hopefully, we will, you know, invite more discussion and varying views to really open up this discussion that has been happening in various walks of life, media, social media, politics, government Department of Health, and really the role of the court of examiners within all this debate is not really very visible. And will there be a role or not? And um how are we going to be part and parcel of quality and standard setting for a future surgical team which, which seems to be varyingly shaped by nonmedical actors as it were. But um II won't take much of your time. We're starting our talk today with the snippets of surgical life, which will be um presented by Sir Barry. Barry has been uh president of the Royal College of Surgeons of England, president of the Royal Society of Medicine, president of the Association of Surgeons of Great Britain and Ireland. Uh he was an elected member to the General Medical Council, civilian consultant surgeon to the Army and he was a member of the consultant staff at Saint Thomas Hospital, London for over 30 years specializing in gastroenteral surgery. We are really honored to have him here today to speak to us and I understand it's a very entertaining, thoughtful talk. Yeah. Right. Ok. Yeah. Right. Yeah. Good afternoon. Can I first check that the microphone is working and everyone can hear me. Good. Thank you very much. Well, um, I'm the light relief in a way after your morning of intense discussion about the future of, uh, s surgical exams and this afternoon's discussion. Um, but I think I've probably been invited because I can take you back as to how things were to some extent in the past and how quite wrong they were in the past when I was myself an examiner and a trainee and a member of council of this college. But it all starts, uh, in a different way. How on earth did I achieve what I've managed to achieve? Uh, over the years, it begins with my geography master. I was not a very good student at this grammar school in East London. Uh I did not do very well academically. I came from a, a non academic family. Uh I failed geography O level but even so my geography teacher was the person that I ascribe. The fact that I'm standing here before you today, the reason he was the careers master. Uh, and when I was 16 I expected to leave to go out to work as most of the school did at that time, very small sixth form. The we are going back to days not very long after the Second World War. Um He noted that my best subject at school was science. And so he looked in his book of reference for something scientific that a 16 year old could do and clearly it was not medicine, but he found something called surgical technology in his book. He didn't know what that was, but he said, well, this looks interesting and I knew nothing about it and he gave me an address to go to uh and through a series of events which I don't need to go into in detail. I found myself a couple of months, three months later at the age of 16 years and one month working in this building here, which is number 92 to 94 borough, High Street in the borough. Uh Now it is an estate agent as you can see Fox's. But in those days, it was the headquarters of a firm that made surgical instruments called Down Brothers, then called Down Brothers, Mayor and Phelps. And I worked there for two years and became absolutely fascinated with surgical instruments, how they were used, what the history of them was, what all these names meant. The first book that I bought was this, which sits on my library shelves today, it was designed and written for nurses. But I found it incredibly useful because it told me all about the various instruments that nurses used and how they were used for my Christmas present. That year, age 16 years and three months or four months. I asked my father to get pi's surgical handicraft as my Christmas present from him, which again sits on my shelf today and which I used to pour through, looking at all these things that surgeons used to do in their handicraft. But of course, I didn't do so I worked there for two years and in those days, there was national service and I was called up at the age of 18 for national service. Uh And uh I was to the best thing in my life, a turning point, in fact was that I was posted to the Middle East to serve nearly 18 months, more than 18 months for Her Majesty in the Royal Air Force. I did not apply to go to the Middle East. I wanted to uh stay in England as close to home as I possibly could being a rather a home loving child, but I was sent out to the Middle East and that was the making of me because a it got me away from parental p uh uh purse strings for the first time. It took me to stand on my own feet because you had to do that or you just went under in national service in those days. And I also more importantly, met a whole lot of people out there, many of whom were going to go to medical school when they came out of national service, having got their A levels to get into medical school, but wanted to get national service out of the way before they did medicine as a as a as an undergraduate. I decided rather bravely, I think that I should write home to my parents and say that what I really wanted to do when I came out rather than go back to down brothers where I had a job waiting for me was to go back to school and to try and study four A levels in physics, chemistry, zoology, and botany, which would give me on paper entrance to a medical school if I could pass those in London. Because the universities out of London, the medical schools out of London in those days required an O level in Latin which you did not need uh in London. So uh I much to my pleasure and, and they surprised uh they accepted my request and using the money that, um, I had saved, uh, in the Middle East having nothing to spend it on out there except beer. Uh, I came home and went back to school to study and I did those four A levels and got a number of O levels along the way to boost my CV. And then started applying for medical school. There were 12 in London at that time, I applied to all 12 because there was no ac A it was all applying directly. I applied to 12. I was turned down moly without an interview, but just turned down by 11 of the 12 medical schools that I applied for the one medical school that did not turn me down outright was this one now no longer called the Westminster Medical School. Uh As I say, it was a 1 to 1 interview with the Dean of the Medical School and he saw perhaps something of me and he said, well, we'd like to hear more of you when you've got your a level results. If you pass them, we'll reconsider you. Uh And so I was given what they called a reserve place that entitled me to sit their entrance exam, a a closed entrance exam for Westminster Medical School students either accepted or on the reserve list of which there were several like me. Well, I took the exam and passed it with on the scholarship. And so I ended up as a scholar at Westminster Medical School. Much to my delight. I had a fantastic time there. It was a wonderful, small medical school firms were three or four not like today at uh well, there are 100s of schools, 100s of um students. And uh I did my second MB at King's College in the strand and then came here for clinical work and passed and with good academic results and found myself as house surgeon to the surgical unit. During my six months as a house surgeon, I performed the list of operations personally that you see on the on the board there, mostly of course with a registrar assisting me. But some of these small ones, the minors I did unassisted by myself in the theater with no no assistance. I wonder how many house surgeons get that operative experience in their first six months today? Some of you might have. But I gather from what I hear students today do not. There is this historic photograph which some of you have seen before. I'm quite sure of Professor Harold Ellis, someone whose name will be known to all of you even though he's 96 years old now or 90 approaching 97 in the center, thanked by Roy KN of uh renal transplant fame. Uh Norman brows became president of this college on uh his right the right as you look at it, Professor Chris Rotel at the back who was the registrar on the firm at the time me as the house surgeon and then the sho tall di with glasses went into obstetrics and gynecology and the, the name won't be known to you, but it's quite a, quite a powerful surgical unit. I think the uh, um, six months in 1963 I then had to face, I decided quite clearly that I wanted to be a surgeon and you'll realize that, I mean, I enjoyed pathology. I enjoyed physiology. Uh I enjoyed all the things that I taught, learned as a medical student, but I really wanted to be a surgeon. So primary fellowship comes along. Now in those days, it was the primary fellowship followed by the final fellowship. They were nothing to do with intercollegiate. They were quite separate with this college and with the Edinburgh College and with the Glasgow College and with the Irish College, they all ran their own exams. There was no intercollegiate at all. There was no M CQ. They MC QS had not been invented. At that time. There were essay questions, no choice. And Survivor in each of those three subjects that you can see with a very low pass rate. As you can also see, thankfully having worked very hard, I took time off in fact, to study for this. Uh and I managed to pass, I remember only one of the questions that was compulsory that I was, had to answer and that was in applied physiology. And the question was two words discuss pain and stop full essay question. Yeah. Can you wonder that the pass rate was fairly low? So, uh, after primary fellowship, I went to Saint James Hospital Balam, uh, for six months, which was a very important formative part of my career cos I worked as an sho there in general surgery and I was given quite a lot of responsibility both operative and clinically. But then I had to apply for the next post. Uh and I had to do a special subject for uh the entrance requirements for final fellowship. And I had a choice of being, doing a job in cardiothoracic surgery or a job in orthopedic surgery. Now, orthopedics had no appeal to me, whatever. I'm afraid to the orthopedic surgeons in the room. I'm sure there are several of you. Um It was what I saw at that time as being carpentry and rather bloody carpentry and nothing much else. So I went for the cardiothoracic job thinking, uh that I was going to be a maybe a cardiac surgeon, uh that did not transpire uh by a two jobs, came up. The job that I expected to go to, which was part of the Westminster Circuit was to the Brompton Hospital. And at the same time in the journals, there was a job advertised at this hospital which is Saint Thomas's Hospital, the old Saint Thomas's Hospital in London. And so I applied for them both. Um II thought I um wrote off. Saint Thomas's sent me back an application form that I had to fill in and it was so obviously geared to Saint Thomas's graduates that I nearly tore it up and put it in the waste bin and just relied on trying to get in at the Brompton because a they wanted a photograph of you at the top right hand corner so they could remember who you were. Secondly, the questions were such things as what prizes did you win in the medical school? They didn't ask which medical school we went to. It was assumed that it was at Saint Thomas's. There was no space for referees on the application form. I phoned up the medical staffing office at Thomas's from Saint James Bum where I was working and I said, I've had this form, you know, I'd be interested in applying for the job, but there's no space for referees. Uh Where, what, what like she said, oh, she said, uh I should just have to ask someone. She said, just hold on. So she disappeared for, for quite a bit of time and came back and said, I've been told to tell you that if you put the names of your referees on the back of the form, that might be useful. What words to that effect? So I put the names of Professor Harold Ellis and Professor Roy kn who uh who was my first two chiefs. I thought they would be pretty good. Referees actually sent it in. And the next thing I knew I had a, uh, I think it was a phone call. It might have been a letter. It was a long time ago saying I'd got the job without interview. I II, a fantastic bird in the hand worth two in the bush. So, uh, I withdrew my application from the Brompton. I'd been invited for an interview but never attended the interview. I withdrew, went to Thomas's uh and found once I'd been there for uh a short while that neither of my two referees have been consulted. What had happened was that one of the chiefs that I was working for, knew one of the Westminster consultants whom I uh had not worked for, but I knew I'd been on his firm as a medical student and phoned him up and got a verbal reference as when I was a medical student on the firm and had done quite well on that firm. I have to say academically and, and other in other ways and gave me a good reference and on that verbal reference without reference to either or I can, I was appointed at Saint Thomas's. Could that happen today? And it happened regularly? That sort of thing. The telephone call for interviews, not only at house officer level, but at consultant level was commonplace. And some of you, the more senior members of you will remember those days when you'll get a private telephone call saying, well, no matter what the CV looks like and no matter well how he interviews, uh I suggest you look elsewhere or vice versa despite his rather weak academic ability, uh he's very good clinically. He's got green fingers as a surgeon who should uh appoint him. And that, that happened that I had experience of that. So what happens? Then I go to Saint Thomas's and the first thing I do, I have to report to an office to get my charge as you can see up there charge for housemen. And it was a long sheet telling you what my duties were and it ended up at the bottom the last paragraph. If if at any time we receive anything lacking in your department will report it to the appropriate resident and not further middle there in it was written in that sort of language I was then given at the same time, the general rules for the medical staff of ST Thomas's at the bottom. Resident staff may not share their room with friends or relatives, including wives. And I was married with a small son at that time. Of course, that rule was discreetly ignored and provided you got on with the porter staff and the nursing staff, nothing was ever said. But if you upset some of those, you might find it quite different. And Ron Hole's grinning over there as a former Westminster uh student himself may remember one quite well known Westminster surgeon F for and was sacked as a consequence of having his, his girlfriend in his room. So it also had its own lingo, its own private world R. Esra P blue room M and so major week firm gal lighter pinkies hospital scooter Lydia. I didn't know what any of these meant at all. I discovered resident assistant surgeon, resident assistant physician blue room was the night nurses, uh night sisters, not nurses. The night sisters sitting room M NSO was the medical and surgical Officers committee which ran the hospital, not the ma not the managers. The M Nso ran the hospital major week was when the firm was on call for the entire week. They took it in turns. Each firm firm gal lighter was the head medical student who bossed the medical students around pinkies were the cleaners. They wore pink uniform and so they were called pinkies at the hospital. That was the hospital chaplain Scutari was the department of Psychiatry. And Lydia was the department of the neurology that II survived six months there as an sho uh and then we did the Thomson's final fellowship course, which was a very in those days, it was eight weeks uh which was quite extensive, took the final fellowship as you see here again, no MC Qs, no choice in the written exams. Uh And with a rather better pass rate than the primary as you might imagine being clinical as well. Uh And uh I managed to pass and so moved on to register dropper um the registrar appointment with another turning point in my life, which I'm not gonna go into because of lack of time. I see that time is going on. I want to get on to college matters. Uh But I was appointed consultant surgeon at Saint Thomas's. As you've heard, this is the modern Saint Thomas's it with a modern block there, 22 blocks in the old part. Uh And for 30 years, uh I was in busy consultant practice there initially as a general surgeon. But quite quickly, a specialization came on uh going into get the gastrointestinal upper and lower and pancreas and liver. I did all of that in great numbers. And then when we merged with guys, they had a very big esophagogastric unit at guys and I stopped doing the esophagogastric work, let guys do that. And then when we, the medical school merged with Kings, I stopped doing the liver surgery because they had a big liver unit at Kings. Uh And uh that left me with uh the lower bowel. And so for the latter part of my career, I was almost entirely colorectal. During that time, I saw all these introduced colonoscopy, initially diagnostic but then therapeutic. And I think I was appointed at Saint Thomas's because I could, I had been to Germany to learn colonoscopy and could set up the first colonoscopy unit at Saint Thomas's, I think that got me the job. I many improved diagnostics. Of course, all the scanning drug treatments, the H two blockers, amongst many others, minimal invasive surgery. The uh first uh called laser cholecystectomy. Um, it was called, um, before we realized that lasers were not necessary to do a minimal access cholecystectomy. He could use diathermy, uh the morbidity of mortality meetings and audit short stay and see the rest. That's all happened during my lifetime. Concurrently with the loss of all these surgical operations, which I had been doing in abundance for many, many years, but one by one, they all stopped. And so there was huge change clinically during my 30 years as a consultant. And so we then come to my activities with the college. Um, you may think that like most of you, II guess my first association with the college was with the examinations, the primary exam in my case. And then the final in your case, probably the, er, what's now replaced those as interco exams, the fellowship, the membership and, and then the specialty fellowship, but not at all. My first association uh with the uh college was with the welcome Museum of Anatomy during my second MB at Kings. And I heard on the grapevine that there was a wonderful anatomy museum of dissected specimens, including some amazing corrosion casts as you see on the right here um in an, er, an anatomy museum here at the college and on Saturday mornings, um quite often I used to come over uh to the college uh together with a fellow student. And we used to quit each other on anatomy. Because anatomy, there was an enormous emphasis on anatomy as a medical student, a huge huge amount of emphasis on anatomy weekly vs uh in anatomy. And then quite a tough exam. At the end of course, we now realize completely inappropriate for 95% of the students that are going to uh graduate. But in those days, very important. Hi. And quite soon after my uh visits to the uh anatomy Museum, I discovered the Hunter Museum in its first guise after the war, many of you won't remember this but some may. Um, it opened in 1963 and then was supplanted uh during later years with this um iteration, which was the pre forerunner of the one that we have now. And I never dreamt at that time that I would become a Hunterian trustee for more than 20 years and be responsible largely for successive iterations of the colleges, sharing the Hunter Board of Hunterian Trustees of the Hunterian Collection. But that's another story. And then the examiners, um I was advised that uh I could apply as an examiner for primary fellowship. I applied for Anatomy in the first instance because I thought I was quite good at Anatomy, but I was not elected. And so the next year I applied again. And this time I applied for as a pathology examiner and uh was uh uh appointed the um a pathology, the um exam. The primary fellowship in those days consisted of pairs of surgeons with an anatomist, professional anatomist, a surgeon with a professional physiologist and a surgeon with a professional pathologist. I had used water in Israel's General Pathology. This book here as my Bible when I was working for my own final fellowship and primary fellowship. Uh And so I swatted that up and turned up my first day as a primary examiner. Uh and I knew some of the other members of the examining body but not many. Uh and waited for my co examiner and it was a strong trepidation because I found that I had paired with, um Martin Israel of, of Walter in Israel's book and I thought my God, you know, this man, he knows absolutely everything, you know. And I sat there and before, before the exam started, we all used to, um, be provided with jam donuts, uh and cups of coffee and had a jam donut and cups of coffee and talked about me and went to your table and I sat there and the bell rang and my co examiner had not turned up and I had no idea how to conduct the exam. There was no briefing. I'd had no uh briefing as to what I did or what I, you know, I was, I was relying on my co examiner to lead off and tell me how the thing worked, but not a bit. Anyway, the will went and the first, the candidate, first candidate came to my table and as he came to the table following him behind him was Martin Israel who I'd never met before. He came down and sat next to me and said you start just like that. And I was, had to go on for, I think it was 10 minutes each or something like that. Uh And uh, so we went on and I found Martin Israel a very interesting man. Um, much misunderstood a very tough examiner, a hawk rather than a dove, but very fair. And if somebody really knew their pathology, he would give them very high marks. Um, but otherwise fail, fail, fail all the time. Um But uh I like to think that uh although I was impaired with him every time, but most of the time I was with him, uh II learned a lot from him and, uh I think I learned to be a reasonably kind examiner and not a not too much of a hawk. And then after six years of that, I didn't mention the core group because, uh which was on the previous slide. Um The core group, I don't know if it still exists. Does it exist now the core group for CQ SA panel? Well, there was something called the core group in those days, MC Qs had come in in the time sometime, I don't sure when, between, when I took the fellowship exam and when I was an examiner, both for primary and for final fellowship. Uh and there was a group called the core group which were six people and a chairman um who were responsible for providing the questions for the M CQ bank. And within quite a short time, uh I was elected as the pathology surgeon representative on that group, chaired by Mike Hosley, uh from the Middlesex who was the chairman and we used to spend um a long time writing questions. We used to go on away weekends into a country pub in Oxfordshire and rent a room and spend all day with cups of coffee coming in to us writing M CQ questions and then an assistant from the college would put them up on a screen and then they would be pulled apart by the rest of the, the five. And you really got to know what were good questions and what were not. So that was the core group final fellowship. Look at this all white one woman uh here that's Phyllis George who was uh a council member and also an examiner. She was the sole female examiner until Avril. Mansfield was elected as well at the uh soon. Well, some time after Phyllis Phyllis was very senior. Avril came on as a junior examiner, but all the rest are white male. Look at the candidates the same all night, all male. Uh I did six years of final fellowship examining, moving uh around to various centers. Initially, they were all held at the examination center in Queen Square, but then that closed. And so much of it was moved in house here, the old at the college, but not this college, but the college that preceded this new building. Uh and then we also had final fellowship exams in examiners home centers around the country. And they were responsible for providing the patients for the clinicals of the two experiences. The primary and the final, I much preferred the primary. I found extremely stimulating. Whereas the finals, I thought there was a lot of questions asked by my co examiners that were completely unfair to um expecting detailed knowledge of certain fairly rare and obscure er subjects which you wouldn't have imagined uh a youngster would really know. But even so that was how it was in those days. I was uh after I'd finished my term as uh an examiner, I was elected to council. Uh And uh here I am on council on the same time as Peter Morris, late, late, he succeeded me as president here who was elected in the same group as myself. Uh And here's Avril Mansfield who was elected the year before and over there is Bill Heal who had been elected the year before Mansfield. So there were, this is uh sir Stanley Pitt who was a physician, a very distinguished physician at Saint Mary's uh uh who was uh chairman of the Hunter Institute, which was the research arm at that time of the college. All the research that the college provided was in house here at the college. Uh And uh this is the first council meeting that I attended when one of the uh council members took photographs of various groups around the table. And that's the one that I kept, of course. And uh that was my introduction to the council again. During that my time as co on on the council, I saw dramatic changes. The Hunter Institute was abolished. Uh research centers in academic departments up and down the country were introduced and funded in part by the research board who attracted huge sums of money largely through the good offices of Martin Coomer. Who some of you will remember here as a member of staff who was fantastic fundraiser for research. Um I was closely involved even then with the heritage of the college because of my interest in surgical history and my uh knowledge that went back some years dating from my early days, uh the examinations board and the examinations changed during my years, the primary was abolished and something called the A BS Applied Basic Science came on in its place, but there were still two exams A BS and final fellowship before the new membership was introduced just um as I was coming off council. So that's part of uh the examination process that I was not personally involved with. But there was quite a lot of change. And then I was elected president. Much to my surprise, I did not expect to be elected president. There were other candidates that I thought were more worthy of it than me and senior to me. But anyway, I was elected and I thought mistakenly that I would spend my time here as president looking after exams and training supervis, you know, overseeing trains, examining and of course fraternizing with other royal colleges both in this country and abroad. Did that happen? Not a bit of it? Two weeks before I assumed office at the July meeting in 19 6, 1998 the Bristol Babies affair hit the headlines and some of you will remember others may not know too much about it was that there was shown to be substandard performance by two cardiac surgeons in Bristol, pediatric uh cardiac surgeons in Bristol. Uh one of whom was struck off the register, the other one was put on limited duties and a medically qualified manager who was stuck off the register even though he was not a practicing uh physician. There was and shortly after that, um Bristol here, two weeks before I started uh shortly after I started this chap who was a rogue gynecologist was found to have created terrible, terrible mayhem amongst many of his female patients and was again struck off the register and it became a national scandal. I show you some newspaper headlines, this relates to the Bristol Babies. These are the national press in this country. You can see arrogance, surgeons failed, arrogant, secrecy, killing fields, baby killers club of death tragedy of Bristol. And it all reflected on this college because the surgeons in question were fellows of this college. And I had to face the media flack which was enormous newspaper interviews by the score, television interviews. And as soon as we sort of thought the calm had collapsed after Bristol, uh then the gyne gynecologist came on stream and then we got incompetent surgeons struck off in June, the Guardian, 100 and 10 women maimed by surgeons mistakes, greater accountability will bring the certain gods back to earth. These are the natural newspapers, doctors in the dock, this is the Guardian stop. The butcher surgeons says MP and so on and such like and again, I was faced with enormous media exposure because of these from the press, particularly on television as well. The uh medical profession generally not just surgeons, but generally were accused. As you can see on the slide, I'm not gonna go through it. It was just a most amazing experience and very difficult to cope with. But we coped somehow we assured them that the college was doing good work. We had a surgical skills laboratory which we'd got established uh under the new academic educational arrangements within the college. Uh that was very active and doing w and doing a lot of work, the GMC as you can see, were said to be blind, deaf and vocally uh unable to speak. And that was what led me to stand for election to the General Medical Council so that I could try and offset some of the criticism or if that criticism was justified of the G MCI would uh be able to perhaps influence in a small way and try and improve matters. But that's another story which I'm not going to go into uh as a consequence of all this incredible media exposure, I had inevitably dealings with the government because the Secretary of State for Health uh was wanted to know what the hell was going on at this college and other colleges as well, I might say. Uh and um I invited the college, uh the uh Secretary of State for Health who was a Milburn. Some of you remember him who was not a friend of the surgical profession. Generally, I have to say to come here and see what it looked like, what we, what we were doing here. Um The day before he was due to come, he accepted my invitation. Uh someone phoned up and said um yes Mr Milburn's coming tomorrow, whatever time it was. But the Prime Minister would also like to come with him to see for himself what's going on. And so w I had Tony Blair who was then Prime Minister and Milburn come to inspect the college, what we were doing and also meet on a 1 to 1 basis. For a discussion. Here is Tony Blair visiting an atl s uh patient so called. Of course, it was all mock. And there he is talking with him on the doorsteps of the college as he was leaving, we got on. Well, he was clearly very impressed. He was very approachable uh somewhat to my surprise cos it was the first time I'd met him. Uh And um the consequence of that meeting perhaps was that uh and also the fact that the uh government was being criticized in a major way. Uh by the press for the underfunding, that was then clearly the case in the National Health Service, the Prime Minister decided without reference to his Chancellor Gordon Brown to, to put in an enormous amount of money into the National Health Service and set up a group of professionals within the health service to try and sort the problems of the National Health Service out. And so the next thing I knew I was called into the cabinet room as you see here and asked if I would be prepared as president of this college together with presidents of the Royal College of Physicians, the president of the Royal College of Gynecologists and General Practitioners, president of the Royal College of Nursing and the trade union, medical trade unions, unison and various other groups, whether they would all cooperate with the government to try and improve the National Health Service. And so for the next several months, I was involved with uh broad issues relating to the entire NHS, not just surgery to try and improve matters. We all said yes, of course, because we were all dedicated to an improved NHS. And so I wrote this extraordinary newsletter, telling the fellows and members what was going on. I wrote three of these special ones which are mailed to them all quite apart from my regular monthly uh president briefing in the bulletin. Uh And during that time, of course, I got a considerable flack uh from the press for, for some of the things I said, I was called an enemy of the people by the Sunday Times as you can see here. Uh I was, it was given an extremely hostile interview by the new statesman. Uh and they put this uh car caricature of me on the cover, but ever any anyway, des despite that, at the end of the day, we came up this group of 100 and 50 people involved in work to produce the NHS plan. In, as you can see here, the date is July 2000 huge amount of work. The principles of which were well 10 in, in number uh some of which I did not agree with, but most of which I did agree with. And that was the case with many of the other signatories to the NHS plan. They didn't agree with all of it, but they agree, agreed with considerable parts of it and so were willing to sign up for the principles rather than some of the detail. Um I have to say my counsel here at the college were not very happy with me. They thought I was um some of them thought I might have been a pawn in the hands of government, but I managed to assure them that that was not the case. And after initial skirmishes, we got a United Council support for the NHS plan, but it was not all doom and gloom. It was not all Bristol, it was not all um NHS politics. We had the bicentenary of this college, the 2/100 anniversary of the college during my time as president. And apart from a wonderful uh service of celebration in Saint Paul's Cathedral, which was attended by a huge number of people including representatives all over the world. Um College and surgical representatives, many countries were involved. Uh We also had inhouse events and one of the in house events which I'm rather pleased with is me planting the sapling oak tree in October 2000 in Lincoln's in fields opposite Nuffield College as you can see here, not opposite my office which was in Nuffield. Uh and that oak which was I was told may not survive because oaks are very difficult to propagate. I'm pleased to say that there. It is 20 years later, still going strong. So at the end of my time on council at the college, uh, I retired from college act important college activities and from the NHS, which I'd done, I was 65 and, um, at that time, 65 you compulsorily retired from the N HSI. Also retired from the private practice. I had a small private practice. Not a big one that I retired because I didn't feel I could carry on if I wasn't doing things regularly, I'd rather become deskilled as a consequence of a three years as college president. So I reverted to my first love, which was surgical history. Uh And one of those things that I did was to take over the pla lives of the collars and, and we became chairman of Pla Lives Committee, uh wrote many obituaries of of uh D CS surgeons. Uh II think I've written over 80 obituaries, Sus Lives. Uh The I looked after the college possessions that took an interest. This is the earliest piece of silver we've got in the college. It dates from 1745 which was the year the surgeons broke away from the barbers in 1745 to found the company of surgeons. Before in 1800 the company of surgeons became the Royal College of Surgeons in London and later of England. Um My favorite piece was John Hunter's Tank. As you can see here. It used to come out regularly in front of the president of the time for all college dinners, formal dinners. Buxton Brown, um Hunterian banquet Diplomate days and such like, and you would sit on the table and it's inscribed as you can see here. And I like to think that John Hunter's lips might have drank some beer or whatever his tipple was from it. At one of the Diplomate days. The person sitting on my right. Uh a lady, I can't remember who she was, but she was someone quite important. And she was on the top table and said, you know, what's this? And I showed her and she said, well, don't you drink from it? And I said, oh, Missus Hunter's Tanker, you wouldn't drink from it. She said, oh, I think you should drink from it. I uh got up, stood up my feet and uh, I had a microphone attached and I said to the assembled throng of the Diplomate and their parents. I said, you know, this is Hunter's Tanker and I said a bit about Hunter and I've been asked by my uh colleague on my right that uh, whether I should drink from it and I'm a bit sure. Do you think I should drink from it? And immediately the whole remote said, yes. So, uh there is me drinking from John Hunter's Tankard, which gives me quite a thrill. You've already heard that I was associated with the Royal Society of Medicine, particularly Association of coloproctology. That is the uh uh uh there it is. That's the president's badge of the of the section of coloproctology at the Royal Society of Medicine. And then I later became president, the Association of Surgeons, which II hugely enjoyed and be was very privileged to host the 75th anniversary meeting of the Association of Surgeons in London. The uh reference to the army services as a civilian consult has already been mentioned. I've not mentioned the royal side. Fortunately, time doesn't in al to go into that. But I was for some years surgeon of the royal household and then sergeant surgeon to Queen Elizabeth, the second sergeant surgeon means serving surgeon. That's from the Latin Servis. And what does it entail? Well, it entails um an largely an advisory role. It's unsalaried, but the perks are an annual invitation to a garden party. I've been to so many garden parties cos you never like to say no, it was, it was a royal command you see to anyway. And also an annual invitation to Royal Ascot. And we called that the works outing because it was the only time that the medical household in the south of England. Uh got together as a as a group uh for a picnic in the stables at Royal Ascot. Uh and we would the wives would bring um salmon, fret, smoked salmon and strawberries and various things. So we would have a works outing picnic before we all trooped across the road to ask us and lost our money on the tote, uh, in the race meeting. So that's 45 minutes of my life or parts of it because there's a lot more that I haven't mentioned. But throughout it all, I could not have done what I've done without Sheila, my wife of 61 years who supported me through thick and thin throughout. Thank you all very much. Indeed. Questions are not appropriate, I think and I've exceeded my time by one minute. Oh, no, that's completely. OK. Um Thank you very much for such an insightful, thoughtful inspirational talk and it just shows how much commitment um you can give and how much change and improvement to the future and shaping the future. Thank you very much and thank you for being here uh serious discussions now. Not for me. Thank you once again this evening. Next, we have the beginning of the workforce report of 2023 and we are privileged to have Kirk Sowell who is head of Intelligence and Insight of the General Medical Council. He also strategic insight specialist, passionate about evidence, informed debate and promoted promoting sharing and use of intelligence and data. You, you also lead the strategic insight function, producing analytic products like the state of medical education and practice and a range of other collaborative intelligence and data sharing initiatives. Thank you very much for agreeing. Thank you. Um Just to check my microphone is working. Yes. Um Thank you for the great introduction. Thank you for the invite to speak as well. If I just page forward, will it get to me? Wonderful, wonderful. So I essentially, I manage a team of researchers and insight specialists and I'm gonna come here and just talk about one strand of our work, state of medical education and practice workforce report. Um I wanted to start really with just why, why do we do it and, and start there and, and once you see why we do it, then the findings start to make a certain sense in context and I'll, I'll try to keep, keep us to time on the agenda as well. So why do we do it? The GMC S corporate strategy has four strands. We're gonna ignore half of these for today, enabling professionals to provide safe care, developing a sustainable medical workforce. Absolutely two of four core priorities for the GMC. And so the question is, how do we achieve that? And, and one way is just by sharing our data, we have a huge amount of information, digital records and so forth at the GMC, the Medical register, demographics of doctors qualifications, complaints about doctors who is complaining when and where about what revalidation data, where are doctors being deferred? Where are doctors struggling with this process? And all of our surveys, research and monitoring the national trainee survey, which I know everyone here will, will have an awareness of. So I don't need to sort of labor any of this. One of the reasons I share, you know, what is the range of data we hold is that I don't really see pres presentations, discussions like this as the, the start or end of the conversation. Anyone can contact us, my team, me or the GMC. The email address will be in these slides which I'm sure will get sent round afterward. Um You know, just with questions, with ideas, comments, thoughts. Um So with all of this data that, that the GMC sits astride, we publish it on our website, we create insight reports, working papers, discussion papers, we do outreach and engagement activity, things like this. We do a collaborative analysis. We join together with other organizations to jointly research things and we do a lot of ad hoc and bespoke work as well as questions come up, we try to answer them. So one strand of our research found what we call our vicious cycle. This is why this is one of the reasons why we're so interested in supporting the workforce and supporting the profession. When a workplace is under pressure, the doctors in it choose to reduce their clinical hours to manage their own wellbeing. They may choose to leave the profession, move to a non clinical role and around the vicious cycle. These doctors in these circumstances are high risk of burn out high risk of moral injury, other workplace difficulties, the decisions to reduce clinical hours leave those teams slightly under service, exacerbating these pressures and the vicious cycle goes around and, and this isn't just a concept. We have survey data running for a number of years. Really eiden in this, it's beyond controversial. It's, it's not a debate anymore. It's the evidence is clear that this is real. And as the GMC and, and us here in this room, we have a sort of obligation to, to act on that. So that's not just it though. There's multiple reasons why we're interested in supporting the workforce around improving retention of doctors and and increasing the capacity um to provide care. There's an equality and diversity strand to this doctors who declare a disability report significantly worse workplace experiences, higher risk of burnout, less able to cope with workloads and more likely to be planning to leave as a result. Also long term workforce plan in England is about to increase the number of UK training posts. But trainers report worse workplace experiences than their peers. They are under more workplace pressure, they struggle to find the time to train and just across so many metrics. Trainers less well off in the workplace than their peers. And the final strand of why we're interested patient care. This chart here shows how many doctors over the last year at the point of the survey found it difficult to provide the sufficient level of care that a patient needs that increased from 2021 to 2022. So significantly and all of this correlates in the data with those teams and those pockets of the profession that are struggling with our workloads. So I said it was the last reason why we were interested. I lied. Doctors tell us what they see the barriers to patient care as being. And those are things like inadequate staffing, pressure on workloads, delays to treatment and so forth. And all of this, we have a AAA solid evidence base of that's why we publish reports like the state of medical education and practice to share the data. We have targeted to these discussions. So the workforce report publishes every year in autumn round about October. But please don't quote me on that. It looks at the medical register who is joining, where do they come from? What qualifications do they have? Who is leaving? What reason do they give for leaving? Is it geographically varied? Is it, is it people retiring early or not? And tries to myth bust some of the common, common er sort of troops of discussion out there? So, into the report itself, which I'm here to speak about just to go through some of its key findings. This is a waterfall chart here. Oh, here we have who's leaving and who's joining each year over the years twice as many doctors are joining them leaving the proportion that are leaving is not increasing and yet these workplace pressures persist. A puzzle perhaps. Um It is interesting for all of the media noise that doctors are not increasingly leaving with the sort of growth of UK training imminent from the long term workforce plan. There is a question of, does that change the composition of the workforce? And what does that mean for us collectively? So we did project forward what the workforce looks like of all doctors overall. This isn't limited to surgery and here we've got the UK trained people. So that's the primary medical qualification in the UK International or from the European area for the foreseeable future. Even with the increases in UK training will continue to be reliant on the international workforce. So these are all doctors who move here from somewhere else, adapt to UK practice and then remain here for, for sizable careers. So given it's growing so much, what are these doctors doing? GPS 2018 to 2022 have grown 8% specialists. 11%. I think the the rate for for surgeons is uh round about the 11% mark 9%. I believe doctors in training have grown 17%. But actually it's the nontraining non consultant posts that have grown 46%. More than four times the growth of specialists that is doctors on the specialist register consultants. So it's interesting of these nontraining non consultant posts. The growth here, the blue line that's the locally employed contract type. So not SAS doctors, these are highly varied locally determined contracts often, often fixed term. So what else is changing? This looks like a radical change to me really rapid change in the composition of the workforce. One of the other things that's changing, changing and it's been acknowledged, I think a number of times already is the gender balance. The proportion of the overall workforce that's male is coming down. The proportion that's female is coming up. 39% of the specialist register were female in 2022. 16% of surgical specialists though were female so much lower. But, uh, I'm sure everybody here knows these facts. I'm not gonna be sort of breaking any news to you and people will say, ah, but it's improving, it's trending up. So this is the proportion of surgery specialists that are female, but that's all the other specialists specialties. So the gap is quite, quite wide and also the general trend is just mirrored in surgery. The gap isn't narrowing. So, um, obviously people will say, ah, but those in training, obviously those in training, they will be more female and they are significantly more female coming in through the UK training pipeline. But it's true everywhere. So over a third, about 36% of surgery trainees were female in 2022 which is up from 25% in 2012. So that's, that's a shift, but it's a shift seen across the wider spectrum. Um, surgery in this latest bit here, you do see the percentage of a female cross over with intensive care. So it's no longer um the lowest line in a sense, we expect those trends to continue as well. We have no evidence that, that they're shifting. So I've covered a few things that feel almost slightly random perhaps. Um So what I'd just like to do is recap what I think some of the challenges are that all of this data, I've just shown you pause for us, us collectively. So the workforce supply is shifting, it's going to shift from an international inward migration to a UK trained group. But even in that scenario, we still need to have the international doctors well supported, brought into inclusive and supportive teams w supported to adapt to the UK as well. That's not going to disappear. It's just we will also have as well a UK trained cohort and that early career UK graduate doctors will rise sharply increasing a demand for, for training and support in workplaces. Um I think NHS England will be hot on the case of working out the detail of what that looks like as well. I'm sure a number of others also, doctors aren't working as consultants, they aren't going into formal training posts. And so you have this locally employed cohort with this slightly unknown map of skills in surgery and, and how exactly do we understand that? Can you predict the number of surgeons of the future in that scenario? Um another challenge, female surgeons, surgeons with a declared disability, female surgeons, an untapped source of future talent and skill and resource in the profession. Surgeons with a disability, are they getting reasonable adjustments in the workplace? Are those possible to make and can more be done to better support those doctors to help them operate at the top of their license, retain them. So they're not planning to leave creating that vicious cycle. And the final challenge I think is a slightly more subtle one that all of this growth in doctor head count hasn't yet translated into a reduction of workplace pressure. There is COVID, there's all sorts of other factors but actually twice as many join as leave for the last decade. This is a big growth. And so the productivity puzzle as some are calling it the question of how can these workplace pressures be reduced if the increased head count has not yet done, it will become increasingly focused on uh potentially at a political level and being prepared for that, I think will be important. And so my final slide and again, I poses questions, not because I think I have the answers, but cos if you cut me out, I bleed data analysts. That's my history. I love posing things as questions and I will always have more questions. Um So I almost pose the question so people see my starting point and can challenge out and find the common ground that we both have around. Are these our questions to answer collectively or does somebody else need to be answering these questions? So what does the growing locally employed cohort mean? Are there more innovative ways surgical teams can use them or recognize them? Are there better ways to understand their capabilities? I don't know. Um And are there any issues from this cohort being less well supported, perhaps having less of a sort of governed career plan through a training pipeline? Um And a lot of these locally employed doctors will be newly arrived international doctors. How do we recognize their skills and help them to operate at the top of their capability? Then how do we actually build the future workforce? Is the capacity of trainers ready for the UK increase in training? Um Can time to train be better protected? Can the c can the sort of burn out risk and the difficulties in the workplace of trainers be somehow better governed or sort of helped? Um And I think I will probably stop with my list of questions there because as I say, I do sort of generally ask questions forever, but I hope just by pausing these, it, it turns some cogs and sparked some thoughts and that is my starting point and that really is all I wanted to achieve today. You will of course have to read the full report yourself. Um If you want to see all of the detail and all of the other sort of data underpinning some of this. Um So on that, I think I will stop. Oh, uh Thank you very much. Um It's very interesting to see the what we all perceive to be happening in black and white. So the locally employed doctor cohort is mushrooming out of control and it's mainly to feel a service commitment which has been uh vacated by the trainees or the lack of funding for more training positions. Um So that just shows that the unrealistic expectation from NHS England um and it translating in the workforce is, is not really meshing in. So they still need to be locally employing the doctors instead of actually increasing productivity or restructuring the surgical firms to take account of reduced trainee numbers. So it is interesting, but thank you very much for a very stimulating thought. Any uh questions before KT, thank you very much for that. Um I think these are, I guess maybe more comments than questions specifically, but the real sort of life impact of the growing locally employed court that we're seeing is while I completely understand and appreciate the need to have more doctors. What this is directly causing is significant pressure on the training application process. What we've seen in the last 34 years is specialty training ratios have double tripled in some specialties, which again then impacts because whilst they appreciate we can try and figure out innovative ways of using locally employed doctors currently the process for doctors in the N is you're a foundation trainee as a registrar consultant. And the other thing I think is the question around the productivity paradox that you mention we have more doctors, the pressures aren't decreasing. But I think the problem with raising that is that doctors aren't one unit. NF one versus a sta who is about to become a consultant are two very different things. It's much better to phrase this as how many senior decision makers do you have? Because actually they are the ones who will be dealing with the productivity, who will be helping improve waiting lists. So whilst it looks great and I'm not saying this is, it looks great for NHS England to say we've recruited 10,000 more doctors. Actually, how many of those doctors are senior decision makers that will make things progress along? So I guess there are more comments than questions to yourself. Yeah, and I would say on the uh competition for Training point. Uh I mean, there, there's a lot of mismatch between the structures that are out there and and the solutions to these problems in a sense. Um Obviously the locally employed group is a high proportion of international doctors who've arrived here will be looking to firm up the next steps of their career, which may involve training as well. So there is sort of multiple sources of competition for these posts as well, which is growing. Thank you very interesting talk, but you use the term head count and that concerns me because that does not reflect reality. If you look 1015, 20 years ago, all consultants were first time consultants. If you look at what's happening now, consultants and GPS, a substantial number of them are even half time, not only part time, half time, and one of my colleagues has gone to two sessions only and that's becoming very common. So the head count if, if that's what I understood what you're doing, the head count by itself is very, very misleading. And if you start from that, that doesn't reflect the true reality of what's happening at the moment in our workforce. And that would also explain why I've got a vicious circle because you, you've got less actually physical sessions by consultants even if the numbers are increased. But each one is being burnt out. And in addition, you've got much less, the training scheme is so different. But that's another story. Let's take you back to females and training. You chose to split off ophthalmology from surgery. What was the rationale for? That is a great question. And I think this split is not necessarily about the deployment of skills and their differentiation, but about having groups of a size that are analytically viable. So you can do trend analysis and statistical testing with it, that skis, that graft, it does it. Yeah. Yeah. Yeah. It could narrow the gap a bit. Uh but still there's a gap. Yeah. Yeah. There's a, yeah, I'll, I'll take that, I'll accept that, readjust it. Yeah. Yeah. One last question maybe. Yeah. Yeah. I mean, there's a huge problem with burnout, um, with training doctors but there's a huge problem with burnout with generation Z anyway. I mean, how do we, it's a problem throughout the workforce. It's not just doctors, is it? Uh, I would be keen to see the evidence of that. Yeah. II mean, there's generationally, it's all been the same. Uh the same thoughts that senior surgeons think about junior surgeons have been generationally exactly the same and unchangeable. I don't think there's one cohort of, you know, juniors that is getting, you know, the, the challenge is having longitudinal perspective on it as in, is it worsening now, the intergenerational perspective than historically? And I think there are sort of records of home are writing down about how the younger group drank too much wine and was unfit to fulfill the roles of an adult in the workplace. And, you know, II think being able to separate signal from noise in this is very important. It's not been mentioned so much. I'm not so much about now, not talking so much about doctors now, but there seems to be more of a problem across workforce in general. Yeah. Oh, ok. Um Shall we move on? Um Thanks very much, Kirk Cheers. You. Uh it's built uh next uh uh talk on on the same topic as Mr Bill Allen, who is an R CS England council member, chair of R CS England Workforce and Training Committee, also a consultant surgeon at the Royal Marsden and a visiting professor at Kent and Medway. He's also a former chair of the J CSD and he's worked with the GMC and Academy of the Medical Royal Colleges and, and Health Education England Bill. You're welcome. Thanks. Yes, sir. I'll give you a talk, Kirk. Is that all right? The front, is it coming? It stopped. So we'll just move forward. I don't have to go. Lovely, thanks very much. Well, good afternoon, everybody. It's quite a pleasure to be back in the members of the court having been here some years ago. Um Thank you guys, a very, very kind introduction. And what I want to do is to take you through the, the report that we published in January following the census that we undertook last year. It's not the first time the college, the English college has done a census Bob Grax who many of you will know did it in 2010 and 2011. One of the problems for not continuing it because in those days it was done for consultants in England, Wales and Northern Ireland only was resource. What's been gratifying now and allow us to do what we've done is the college has put some finance behind it and have introduced what's called the Business Intelligence Unit. Which has been staffed by an extremely good uh individual who knows an awful lot about data handling. And we've got project managers who have allowed us to do this process. And as you can see, it's cosponsored by the other two sister colleges and also the Federation of Surgical Specialty Associations. When this was done 10 or 12 years ago, it did focus, as I say on consultants. But as we've already heard, there's changes ongoing with regard to the surgical team. So we want, we wanted to do was to understand the challenges facing the whole of the surgical team across the whole of the UK. And so that's not just consultants, but it's also trainees those in SAS and locally employed positions. Uh and also those in what we've termed the extended surgical team. And it's been done to look at the current state of play so effectively a snapshot of where things were last year, but also to pick up on the challenges facing the surgical workforce. Uh as best we could, it was questionnaire based and there were binary answers, drop down answers and plenty of free text. It was run during May and June last year and to put it into context, that's just as the various industrial actions were getting and going. And we were able to use some very sophisticated software which allows you to actually not only interrogate the data you're recording, but go a lot further than that because of the nature of what this software called Power Bi I allows you to do, you can get information that you hadn't thought you wanted to know about. It's that sophisticated talks or the, the way we've done it is based upon three principal topics, the workforce itself in terms of the demographics, the detail of what people are doing with regard to their job plans and then their wellbeing and conditions of work. We had just over 6700 responses which was really very gratifying cos we worked it out. It's approximately 25% of the whole surgical workforce. As you can see. Uh we've broken it down from, from this particular slide. The top right is the grade of responders. 54% were consultants, 25% were trainees, combination of core and higher. Quite a good representation from L EDS and SAS doctors with 15% and a small proportion of those in the extended surgical team. We've heard a little bit about gender from Kirk already. Uh and then the responders, that's all the responders, two thirds of men and one third of women. And also as was touched on just we found quite a small proportion, working less than full time because less than full time, both in terms of training and also working at a consultant remains a challenge. So just over 10% reported that they are working less than full time. And I think that's something that needs to be focused upon age and gender top bars are consultants. What you'd expect with the majority, 41% in the middle years of their career, 45 to 54 years of age. Um And that contrast with the trainees, again, what you'd expect, two thirds were in the under 34 age group. There's quite a number older than that because for a variety of reasons, they've come into training late, they've done other things, family commitments uh for, for all these sort of straightforward, obvious reasons. But it does mean you've got to bear that in mind as you plan your workforce bearing in mind, the age of the cohort moving forward slightly different to the slide that Kurt showed you, although 25% of the consultant responders are female, but the gender balance is on the shift so that you can see that 42% of the trainees that responded were female. So there is potentially move towards parity. However, one can debate if parity is appropriate for all 10 specialties. And I'll leave that one with you to think about specialty breakdown largely as you expect. Big two general surgery intern orthopedics making up over 50% of the responders and then a good spectrum across the other specialty areas. Um as you'd expect knowing the numbers of specialists in those respected specialties. So we think we got a pretty representative sample uh across all specialties. So what are they up to on the left block. You've got consultants in S ast in terms of their contracted PA s, what they're contracted to do. And as you can see, 52% are working more than 11 PA s per week. Bob Great's work 10 years ago, that figure was 13%. The SPS has always been a challenge. And as you know, the, a variety of, since the principles of PAS and S PA came into contracts, argument from various representative bodies of trying to get at least two sp But as you can see, it's less than that for both consultants and SAS surgeons, which does have a knock on effect on how individuals can spend their working week. We asked what they were doing in terms of their contract, 67% are frequently or always working beyond contract. And when you put that into the fact that at more than 11 or do more than uh 50% are doing more than 11 pa s, you can see that there's a very relatively simple calculation to say we're short despite the expansion of numbers as Kirk has described, why is that 50% of the time that they're working beyond contract is down to administrative reasons. And those of you who are working with the electronic patient records will fully appreciate some of the challenges that we have to face. I don't know if anybody heard the Secretary of State this morning in an interview um on, on the today program. But her argument was that the money that the chancellor has put into A I et cetera should enable doctors to spend more, spend shorter time playing on their computers and then more time seeing the patient. And I can tell you from my experience with the current digital health record, we have we struggle. So that's a key issue to try and solve whether the A I et cetera will do it remains to be seen. But those of you, of my generation fully recognize we've lost secretarial support, et cetera. And it's made a huge impact on the way in which we function. And indeed in um maxillofacial surgery, for example, the president of uh of um maxillofacial surgeons told me that uh instead of seeing about 60 patients in a clinic, she now sees 10 because of this extra administrative workload. So that's what people are doing. We moved on to look at the key challenges, looking at wellbeing. And we gave the in the questionnaire, we posed 10 key challenges and asked them to rank them not really going without much surprise, burn out and stress across the whole piece accounted for 61% struggling. And the other big 1 56% couldn't get access to theater, 55% financial pay for the early years, ones pensions for the older ones, the challenges that we're facing. Don't forget this was done after the chancellor had had um presented the dis the the um uh details about lifetime allowance being scrapped. And Kirk showed this pre in his slide and what we labeled conflict between clinical and managerial priorities and the ability to look after patients. In the way you wish significant challenges contributing to the workforce burnout issue. Gone into this in considerable detail because this is where the qualitative information comes in. We've done the quantitative on the demographics and what we do quantitatively already has us. A proportion of the of individuals were considering leaving. And this is really quite striking. 40% hadn't taken their annual leave builds into your burn out and stress challenges. And some of the problems that are now ext were have been prevalent for some time, latterly have been expanded because of the work done by the sectional misconduct working party. 25% have experienced bullying and harassment and this is something when I was J CS two chair we looked at it's no different now than it was then five or six years ago because although it's on the agenda, it slips a little bit and we have to maintain these culture changes that are inherent with the way in which we, we work and train colleagues and half were struggling generally because their job plans and the way in which they were working with resources left a lot to be desired. The big problem with theater is because of a variety of reasons which you will well know it's the challenges of getting enough time to get to do the elective work. Now, the one of the problems I had when we constructed the questionnaire and got the results. This figure of 41% doing consultants doing two or fewer operating lists was as was the way the question was asked potentially had its limitations because it just reflect the scheduling on the contract. But there will be, there will be other operating lists that you're doing that are not necessarily scheduled in the in your 10 sessions contract, but actually take part and parcel such the sea pot list and what have you. And so when we do it again, we're going to slightly change that question. But this was the one that uh we got the most attention in the press when we, when we launched it, why is it surgeons are not getting into the operating theater? And I'll come to some of the solutions in a minute because what we have not wanted to do is to have this as a big whinge, we want to try and post some solutions. So what we are trying to do using this information with the statistics that we've got and to a certain extent, there's nothing new here. We've just got some facts to back it up to look at these three specific issues, obviously, post pandemic. We've got the big issues of wait waiting lists and hence the the the focus on productivity fits in with the colleges, a gender, particularly around things like surgical hubs. We have to make sure we have a sustainable workforce. We've already seen people wanting to leave, not happy with their jobs. We need to make sure that trainees still value working their way through the training program as we did to be able to work in independent practice. But at the moment, the circumstances leave a lot to be desired. And the third group is looking at the changes the way we work. Yes, the long term workforce plan is supposedly funded to increase the number of consultants. And I've shown you we're short, but I would also argue we're not working as best as we could. I think the efficiency of surgeons is is not great and some of that's at the at the administrative door and so there could should be ways in which we change through different what approaches the systems and the way we work. So challenges for productivity, workforce and theater capacity. Uh That's an state issue. Have we enough theaters? That's a number of surgeons issue are the surgeons available? That's a theater staff issue. And of course, it's an issue relating to our colleagues in anesthetics. We know that there are challenges with the clinics and the clinical c clinic capacity. Hence the waiting time to get patients into both elective and urgent clinic appointments. And one of the problems that's come out loud and clear from colleagues is scheduling for operating lists is totally inflexible. I don't know what, as many of you used to do. I used to have a diary which I filled it in. So I had complete control of what I was doing. So I was told I couldn't do it any longer. It took a long time to take it away, but it really was a challenge and we talked about the ait workload. So what are the solutions? We have got to get the capacity in place to meet this demand. And so that's focusing as the college has done with things like as I say, the surgical hubs and the the issue that we will always ask if you compare with O EC OECD equivalent economies, we're short on surgeons, we're down the bottom of the list and that needs to be addressed. Some of the work my colleague Stella Veg is doing um in terms of outpatient and work outpatient transfer is really to focus on different ways of running clinics, making sure that we see patients in a timely manner, they're not waiting ages before they get an appointment. And I think that there's an awful lot we can do in terms of the better ways of working our outpatient clinics. There is no doubt and this is a reflection on the change in gender of the workforce that flexible working has to be invested in. And that's that point about the head count. And when we gave some evidence towards the last of us, the long term workforce plan, we said, if you're going to promote f flexible working for 50% of your population of, of, of staff, you can do the maths. There's about a 50% increase in workforce to do that because they won't all be working whole time. And I've had me whinge about it. What about the sustainability of the workforce? And this is where the wellbeing and the working conditions comes in. Um And the issues around recruitment and retention don't have time to completely go into the retirement and return issues. But there's no doubt that retention is a key issue across the pa both in terms of trainees but also early years consultants and of course latter years consultants with retirement and we have got to invest in trainees. The responses from the trainees have clearly shown us a number of specific hot topics, competence versus confidence because of inactive difficulty getting access to theater, trainees are not getting the confidence that we have of experiential learning, Rotas and job plans. The core surgical trainees are the biggest group who are leaving early. They are the most cheesed off because they are treated purely as roto fodder and one of the proposed solutions working with the training organizations. And again, sorry chaps showing my age, the RSO senior registrar would run it and there's a lot of chat and a lot of discussion that actually we should use that model because not only will it help set up the rotors, but it will also set up the issues with regard to uh job planning and ensuring trainees at different levels. Get all the ex ee expertise or exposure to training that's necessary. The other big one from the trains point of view is cost. There remains the issue with regard to cost of exams continued um real thaw in our flesh, whether or not this will have some impact. And we led to believe it might in some of the negotiations over the current industrial action remains to be seen. And there has been a model suggesting first attempt at an exam should be paid for by the state. The other one is expensive courses, surgery is the most expensive training module that you come across it, discipline. Um And there could be ways and means of which we can address the the support for trainees paying for their training. And so we've argued in the report for policies on enhancing wellbeing. Those of you who've done sac visits would hold the respective employer to account. If there wasn't an office, there wasn't a canteen for food, there wasn't somewhere to rest, there wasn't access to the library, there wasn't access to the computer. Most of those are no longer available and we should be able to hold them to account for that. Still talked about flexibility, touched on the retention issue, which is I would argue that as you get over 50. You should be having a conversation with your clinical director within your department to understand how the department's going to evolve. When do you want to retire? Do you want to go less than full time? What would you like to do? Do you want to come back and do some elective lists? Do you want to come back and do some mentoring? So there's a sensible conversation rather than the face fitting to allow you to retire and return. And that bottom one I've proposed in the report that we take a leaf out of general practice and contract trainers to train. Not sure I get that one and then changing the ways of working. There is no doubt the practice has changed. Om fs oral medicine is a colossal amount of work outpatients, urology, significant amount of outpatient work ent the pandemic. Did this made us think about treating ent common conditions medically. So you don't need there's change in the way it should work. But the converse is you've got consultant delivered practice, huge amount of pressure of consultants on emergency duties to look after very complicated comorbidity and conditions themselves. And which suggests suggesting that there's an opportunity that if you look at the whole of a career of a consultant, one could introduce a concept of career phasing you're doing different things at different phases of your career, which enables you to play to the strengths of your workforce. Again, requires enlightened discussions with clinical directors, we talked a little bit about session job plans. And when we had the c the comments from the SAS and the led staff, they were among some of the most saddening comments. I've had the misfortune to read. They're not looked after they're not integrated. They don't have any career development, they don't have any proper uh professional development from the academic point of view. We have to look after them. You see how big the issue is and I put in another group, you may well be aware that the J JMC is looking at different routes to the register. There's a significant number of folk who come out of foundation who are not sure what they want to do, take on a trust job, don't want to move family are local and you could quite easily see how that model evolves. It might take me 12 years to get the specialist register, but I'm gonna be staying put, my family will be happy, the kids can go to school. I don't have to keep moving or applying for extra jobs. And you can see how that cohort could evolve. It doesn't mean it will substitute for conventional training cos everybody wants to do things slightly differently, but that group has to be looked after. So we've identified the challenges we're now in the process of developing a strategy that will inform college policy with those where we with the key stakeholders that we need to work with picking up on those three streams of productivity, sustainability and changing the way we work next year. Perhaps we can come back and tell you where we've got to. Thanks very much. Thank you. Thank you Bill. A very um insightful uh talk and um it generates, I'm sure a lot of questions we are pressed for time. But if there's any one or two brief questions for Bill, then can we just have that? Thank you very much in the penultimate slide. The bottom left hand side surgical team, I think that's a very, very important aspect. You didn't comment on the surgical team has been lost. And I personally believe that's where a lot of the issues have evolved from surgery has always been stressful. And I was a consultant for over 30 years and there was no time that I didn't feel under stress as a surgeon, whether it was when I was doing an extra operating list on a week when I was on annual leave or whether it was in a normal week. So if you're doing less work, I personally believe that you will still be doing stressful work. You cannot get away from surgery being stressful. So all these things that I see coming in, it is still going to be stressful. We have to accept that and in some people, it will lead to burn out others will cope with that stress and move on. That was a stressful day. And they move on to the next day, which is stressful day. But doing less of it doesn't make it less stressful. If you come up with a solution with more and more people, then you have this cog taken out and that one person is one person in a team, need lots of other people. So everyone taking out little cogs, the cogs no longer fit, it doesn't go round. You don't get more work done in an operating theater. If you've got your team, people that you've been working with people that you're aware of their abilities and their things that they don't like doing, you cope with it and you are more productive and if we have junior staff coming in and they would get the opportunity for training because everybody knows what's going on. So II, II could go on and II must stop it. Overall, those are my personal opinions. Um, time precluded me from taking too much on that. But it's, it's one of the themes in the, in the report that we have to make sure that the team functions, identifying the way in which the team is meant to work. And I'd refer, refer you to the future surgery document that Richard Kerr published five or six years ago, three or four years ago. Now, as we work our way through the strategy from the census, that's gonna be a key component of the way we put it all together, but you're Absolutely right. Um And a lot of this is actually um challenges of more than one surgeon or two surgeons operating together, appropriate cross cover, working out how you best use that team more efficiently. And I think we it's moving away from the not completely away away from the autonomous approach, but actually making sure that the the team ethic works throughout. Um That reference is not only for the medically qualified members but also the nonmedically qualified and I didn't want to get into that and spoil Franks Fund. Thank you very much. Bill. We do have a panel sort of discussion at the end. So if you don't mind waiting next, we do have Mr Frank Smith who's a professor of vascular surgery and surgical education at the University of Bristol. He's a member of Council for RCs England Surgical undergraduate lead for Bristol for 23 years. He's an external examiner and advisor for numerous universities in the UK and overseas surgical tutor and is a member of both the vascular and general sac. He is the National lead for vascular selection of core trainees and specialist training. He's chair was chair of I CPE and is examiner and assessor for the MRC and FRC S and the European Boards of Vascular Surgery. Yes, sir. Thank you very much indeed. And it's, it's nice to be here. It looks like a great day. I'm sorry, we weren't here this morning. Um I was just gonna say I'm sorry, he's left that it was a real pleasure to hear Sir Barry speak um, today because he actually was my examiner in Fr CS. And I can say this to a room full of examiners. He was a lot more cheerful today than he was the day he examined me. So, yeah, so, um, I've been asked, Yasser's, you know, done me no favors at all. He's asked me to talk about physician associates. It's one of the um most contentious issues that we seem to be facing. Nowadays, there's a college whatsapp group and just about half the correspondence is about um physician associates. The trainees are particularly worked up about physician associates. Uh And I'm just going to quickly go through the things I've been asked to do today. So, what are the roles that actually make up medical associate professions? These are the maps. Um And there are three medical associate professions that physician associates. Um The anesthesia associates previously known as physician assistants brackets, anesthesia and surgical care practitioners. And I've only been asked really to mention physician associates to today and anesthesia associates. And these are not to be confused with the other people. We work with advanced nurse practitioners. I work with six clinical nurse specialists who are invaluable to the vascular practice at South Hospital. Uh And some of us will be working with surgical first assistance, but they're not covered in this particular area. What's the background? Well, physician associates or physician assistants as they originally were, er, are not new, they were introduced, uh, when there a lot of people came back from the Vietnam War in 1967 with a great deal of battlefield medical experience and they were not to be wasted. Uh, and although they didn't have medical qualifications, they were introduced in the USA as physician associates. And, uh, the first ones came into, uh, into being in Duke University in 1967. And we've had physician associates or originally assistants. The term was changed in 2014 in the N NHS. Since 2003, they had their own association in 2005. They are part of a multidisciplinary team. Er, their existence is there to offload the work of doctors to help, er, doctors, er, and to free up doctors to spend time on other tasks. Er, the, the idea is that they have to work under supervision. Um, and as of September 23 there were approximately 4000 physician associates in this country uh on the physician on uh physician associates register, which is held by the Royal College of Physicians where they have a faculty and approximately 900 new pa is being recruited per year. And the excitement really about the whole situation has been exacerbated by the NHS long work, uh, long term work plan, uh which aims to increase the number of physician appro associates in this country to 10,000, uh, by 2036 37. This is the, er, NHS recruitment website for physician associates. And if you take a look at this, they're all very cheerful people. Um, but it's interesting, isn't it that if you were an elderly patient and you met one of these people on this photograph in i, in your clinic or in a, in a, in a theater, would you know what their role was if it wasn't described to you? Concisely, there's one chap there who isn't there above the elbows for a start and nobody's wearing a name badge. Er, and one of the areas of contention is the overlap and the difficulty patients have i in conceiving what the role of a physician associate is. So, what's the entry requirements if you wanted to become a physician associate, you would have to have a bioscience degree at, at grade uh 21. You would then go off and do a two year master's or a diploma course. And 50% of that course would be based in these clinical environments at the end of that to qualify, you'd have to pass the university assessment um for in the institution in which you were doing this course. Uh and a national examination for physician associates. And although I won't go through these in detail, you will all know the sort of tasks that physician associates are, are being asked to do. Um, they are not allowed to prescribe uh and they're not allowed to order ionizing radiation x-rays or ct scans. Uh And the faculty of physician Associates undertook a census in 2022. There are approximately 400 working in surgery. Er, and they're doing these sort of procedures. 70% may be doing arterial blood gasses. Um, somewhere down 11% might be doing a lumbar puncture or a paracentesis. Thoracentesis is down, 5% may be doing that. Uh And some in, in specialist units will even be uh removing lipomas, excising skin cancers and moles. What about anesthesia? Associates? Well, um they two are, are recruited in the same sort of way. They were introduced in 2004. Er, their role was overtaken and supervised by the Royal College of Anesthetists. They work in many NHS hospitals, er, but they have quite varied scopes within those hospitals and they have to work under the supervision of a consultant anesthetist or another autonomous practicing anesthetist. And again, to get into that role, you need a 21 Biosciences degree. First of all, or you could be, for instance, a registered health care professional, say a nurse with three years of experience or, or for instance, an O da uh you have to obtain a place on a tru in a trust or on a board in a hospital which has official training places uh for uh an anesthetic um associates. Er, and you would need to be assigned to a university offering a two year uh a a course. And there are only three of those at the moment i in the country. And again, these are their responsibilities. Uh Perhaps the most interesting one was the one at the very bottom, deputized for anesthetists in a variety of situations, requiring airway and venous cannulation skills. So that's quite a responsibility really. And as of an extraordinary general meeting at the Royal College of Anesthetists in October 2023 the college has recently taken a number of actions. Um like surgeons, they've been worried about training uh of, of their trainees and they have reaffirmed guidance that training for anesthetists in training should be prioritized over that of training for A as uh they have paused recruitment of new student a as er whilst the college um undertakes further work to look at the impact of the a a role and they pause development of enhanced roles until formal regulation is in place and the scope of practice is fully described and that's due to begin as from December this year. Now, II knew as much about physician associates as you did until about 11 or 12 o'clock last night. And, and then I went on to youtube, er, and there's this guy, Doctor Ollie and Doctor Ollie specializes in producing short youtube videos er for prospective medical students on top that may arise at interview in M mis multiple mini interviews. And one of his key topics for this year is the role of uh of um physician associates. It's such a key topic that it envisages that this will form AAA significant component part of medical student interviews. And he actually gave quite a balanced talk, uh outlining the reasons why junior doctors may not be at entirely at ease with the concept of physician associates and their legitimate gripes could be listed here. They do have concerns about patient safety and I will come back to a, a BMA uh re review and a questionnaire that was undertaken at, at the end of last year. When you hear about concerns of patient safety, you do keep hearing about the same cases which were brought up in the parliamentary debate. For instance, a patient with A DVT presented twice to the same physician associate who, who sent the patient away with cramps and the patient subsequently died uh of a fatal pulmonary embolus. So, and actually when one case is picked up, you find it reverberating through the literature and of course, er, people die under the care of doctors as well. There are concerns about the erosion of professional identity. Uh The concept is that the GMC will supervise er, physician associates in the same way as they do. Doctors, um the physician associates will have GMC numbers in the same way as doctors do. Uh And there has been a blurring of a distinction uh between a doctor's identity. The doctor er, has trained for five years, the physician associate in medicine for two years. And, and there's concern about uh the knowledge levels because of that junior doctors are also concerned about liability. Physician associates can't sign uh prescriptions, they can't order ionizing radiation. They do take care of patients, but they are responsible to the junior doctors above them. And when it comes to a medicolegal problem, where does the buck stop? And junior doctors are worried about that. Surgeons in particular are worried about the loss of training opportunities. They rotate through hospitals at a rate of knots as you well know, you, you know, you hardly see them 36 months, they'll be on a firm. But the physician associate who's there all the time has the ability to establish a bond with the surgical team and may get more opportunities for training and this is particularly important and detrimental in the wake of COVID when so many of our trainees are not achieving the index numbers they need. And then, although he puts it at the end of his list, of course, it is a significant gripe when you're an f one doctor having been in hospital for five years with a starting salary of 32,000 and a physician associate starts on a salary of 41,000, a 34% hike. Now, they may only finish at 55,000 at the top of the b they are. Er, but you can understand why doctors may be a little miffed uh at that concept. So the draft anesthesia, associates and physician associates uh uh order was debated in the House of Commons in on the 17th of January. Um It was subsequently passed in fact uh in the House of Lords on the 26th of February and Andrew Stevenson, the minister of health and secondary care set out the case and I won't go through it in detail. Uh but this is secondary legislation on the back of previously introduced legislation. Uh And the key um er finding here was that PA S and A as are to be brought into regulation by the GMC which has not met with universal approval. Um There, it's going to be a large program of informs, er, and there will be significant changes to the regulation of A as and PA S under a new legislative framework and this gives the GMC powers to register A as and PA S whom it assesses to be appropriately qualified and competent to set standards of practice, education and training and the requirement for continuing professional development. Er and it also er gives them er the power to operate fitness to practice procedures and to investigate concerns. So really all the policing being done by the GMC in the same way as they might do for doctors. Um and this fits in with the government's view of introducing a, a larger workforce to help cope with the current deficiencies and those deficiencies are set out here. Um We know that the government want to introduce 15,000 new medical places which would give us up to 60,000 new doctors uh by the RR round about mid two thirties. Er, and they're going to introduce more pa A S er up to 10,000 by that time as well. There were a number of concerns raised in that debate and these are all the concerns we've mentioned already the implications for patient safety training, opportunities for medical staff clarity for patients, particularly this has arisen on numerous occasions, er, when somebody introduces himself as a physician associate, wearing the same dress as a doctor with a stethoscope around their neck, er, really patients don't quite understand that. And indeed many think that, um, a, an associate or physician associate, I is a grander title. We had that debate, um, this morning in college that's happened in universities. You can now be an associate professor. Nobody knows what that is, but then nobody knew what a reader was either at the time. Um, and, but an associate to the public tends to imply a, a certain status. The real problem is knowledge of scope of the role of PA S, er, and what the GMC are going to do in and in terms of how they regulate, um, how they do things around the fitness to practice decisions. There has been concern that in some hospitals where there are, um, particular problems uh particularly in the front line workforce in terms of time, er that physician associates are working above their competence levels uh issues, for instance, where they've been found carrying the, the consultants bleeping, responding to consultant requests. We've mentioned liability and the BMA have been campaigning for a separate register uh to help distinguish pa from doctors and you will probably know some of you might have taken part in, in a survey at the end of 2023 18,000 doctors, 87% response rate, 2000 patients. Uh and the G GM er the BMA indicated severe concerns about the whole er prospect of this new legislation which has actually since been passed. Er They wanted changes in regulation, changes in professional titles to go back to physician assistants, er that's not going to happen, the government has indicated um and they wanted to stop recruitment and that has also not currently stopped. And if we look at um er just very three very quick graphs, this um shows that over 80% of the respondents to the questionnaire had concerns that PA was uh undertaking work beyond their competencies in this graph. Um There was an 80% plus response rate that PA S currently um potentially caused risk to patient safety within the NHS. And then this is perhaps most important to us as educators as a group. Um The red and orange bars indicate regions in which or areas in which respondents to the questionnaire felt training was compromised for medical students and for trainees. Now we're all surgeons. We read surgical papers. We've had to analyze papers. One might say this could just potentially be a skewed study and no, um, Turkey is going to vote for Christmas anyway. Um, so maybe these, you know, this doesn't reflect, um, what is really going on and that this, um, represents, er, er, some disgruntled responses nonetheless. Uh they, they're out there and it's ammunition for the B MJ. Um You will know that the, er chief ex um the president of the Royal College of Physicians responded um perhaps in advisedly on, on some misinformation from a questionnaire and saying that doctors were enthusiastically behind er, physician associates and that prompted a response from Steve Piss and the NHS England clearly outlining um the, the NHS England's position on the subject. So that just brings us to finish off with, where does the Royal College of Surgeons stand o on this particular um discussion? Er, they had a council discussion in February. Um and the themes that emerged were that physician associates must not replace surgeons or surgical trainees. There's an urgent need to define the scope of practice and training, curricula, training time for surgical trainees must be protected and enhanced and the role of our other colleagues, surgical care practitioners, er, first assistance and advanced urg er practitioners should also not be undermined. Um And we er, looked through Bill and his workforce committee at uh, a document provided by NHS England a, a, an initial draft on skills, uh uh in other words, a sort of curriculum, er, and, and the skills required for health, medical associate professions, er, and a career development framework. And that was comprehensively um disproved of, um, I'd like to say, uh, trashed through bills and auspices but, er, much less than that, it was comprehensively taken apart because of the vagueness of the criteria er, and areas of career development in which physician associates were given, uh for instance, clinical leadership roles with respect to research and training of other people without any clear indications of how they would get there or who would be training them or within what structure uh that would happen. So, the current steps are that the Royal College of Surgeons of England is working with the other surgical colleges, with the federation of surgical specialties, the training organizations with the M AP professional groups themselves, with patients and the confederation of post graduate schools of surgery cops to define the core scope of practice for PA S in the surgical team to ensure that NHS England doesn't permit individual trusts to escalate the roles of pas scope creep that's referred to uh and to discuss with GMC, er the regulation that is required um F for physician associates to perform properly and it's trying to communicate that to the fellows and members of the college and to summarize and conclusion, there was quite a balanced editorial um by uh Cameron Abbasi, who's the chief editor of the B NJ recently. Um And I think we do have to have some ground realities. Physician associates are going to be useful and necessary within the health service. They are professionals, they've done a biomedical degree, they've had training, they deserve to be treated with courtesy and respect. They are our colleagues. Um and the population has growing health needs which are unlikely to be met by doctors alone. So physician associates are here to stay. Um It's how we structure their careers and integrate them. That's important. And a AAA good phrase coming out of that editorial was the fact that we should respect our professional colleagues resist tribalism. Um but that any new professional group does need appropriate clear regulation. Uh terminology needs to be sorted out er and rushing into any disruptive er regulatory decisions at this stage, er would have been described as imprudent and fool Hardy. Er and, and the bottom line is that currently committed staff, both doctors and pa feel disenfranchised by the systemic failure to meet the core problems that I've been describing. So, thank you very much. Thank you very much, Frank for such a clear and comprehensive um talk about physician assistance. Now, I think for the first time ever on the annual Court of Examiners Day, we have two trainee representatives, Rylan Aftab who's currently in S D3 in plastic surgery rotation in Thames Valley Wessex and he's vice president of assets and has held previous roles in education in ICB and CP. And we also have this who is an ST four in trauma in orthopedic surgery and is the British Association orthopedic trainee association, Representative February. Lovely, lovely. Thank you very much for having us speak at your um, course of examiners. Um Thank you very much for the kind introduction. Um I think a lot of the points that I'm gonna be talking about have been made. So I'm gonna try and get through this very quickly. So as not to labor the point essentially today, it seems like it's gonna be a death by survey. So I have another survey to present to you. But essentially this is work that we undertook to try and understand what our members as the association of surgeons in training, what their thoughts and views are and to specifically give you a distilled view of what surgical trainees in the United Kingdom and the Republic of Ireland are currently feeling around this topic. I'm not gonna go into the background as we've already covered that in extensive detail. The queries and concerns that were being raised to um aci were essentially as listed over there. Uh There was very little clarity on the scope of practice, what impact this would have on our training, the lack of regulation and oversight and how will they be represented to public and patients. So therefore, we conducted a snapshot survey um in late October, early November to try and gain an understanding of what is the current experience of surgical trainees in the UK, working alongside physician associates. What impact do they have on surgical training and what impact do they have on patient care? So, we had 1978 responses of which 1200 just above 1200 were surgical doctors in training, which was around 21% of all surgical doctors in training in the United Kingdom. We had all grades of doctors um across all regions. And as you can see over there, we had all specialty represent uh specialty rep represented there in about the amount that we'd expect to find trainees in those specialties. Specifically, we asked them, what do you understand about the role and the majority of doctors said they had some understanding and were familiar with the role of physician associates. The there was exposure across all surgical specialties. Um U utilizing physician associates with general surgery being the largest specialty, utilizing them at the moment. And a significant proportion of trainees, I 34% had worked with them in multiple specialties. The way the survey was conducted was essentially if you had worked with APA, you were moved on to the other parts of the survey, describing your experiences of working with APA. If you hadn't worked with APA, you were taken right to the end of the survey where it was asked from your understanding of what you know, how do you see the future of this role? So specifically impact of training the majority of survey uh participants, 70 a half percent reported a negative impact on their training which is either strongly negative or somewhat negative looking into breaking it down further. So posit we asked for free text and we asked for, ok, if there's been a positive impact, please do tell us the general theme, positive impact was the fact that when physician associates were employed appropriately on wards, they helped with the administrative tasks, they helped ease the workload and they made the doctors more efficient allowing them to attend theater to access the training opportunities that they needed to progress on in their career. They found that the continuity of care that they provided on the wards was very useful, particularly given the rotational nature of our training. And then they found that by working with them, they were able to access the training opportunities. Before mentioned, the neg negative training experiences predominantly focused on the fact that there were reduced case numbers and reduced case opportunities for trainees in theater. They actually found that particularly when physician associates helped with um the on call or helped on the wards. Actually, it increased the workload on the doctors as previously mentioned by Professor Smith around the fact that they can't prescribe and they can't re request ionizing radiation. So actually, once you did the ward round and the job, so this was generated that still fell onto the doctors to execute because the PA S did not have the um appropriate um privileges to carry out the role. We then asked them about what surgical trainees thought the impact that they had on patient care. The majority of trainees responded that they had either a negative or strongly negative impact on patient care. When looking in, when looking into this further the positive aspects of patient care where the fact that they helped with continuity, they once w when they were supervised, they made appropriate clinical decisions. And a lot of it focused around working under direct supervision. They were appropriate for the tasks that they were given. The negative patient care aspect, predominantly focused on misrepresentation of the role to patients. The fact that certain procedures or interventions were performed without direct supervision or the fact that they were asked to request investigations or prescribe on behalf of the physician associates. The other big thing that came out of this was a lot of people did not fully understand exactly how they made things more efficient on the ward. Now, then we ask trainees. Ok. So how do you foresee this role moving into the future? So the majority of respondents believe the term is misleading. They believe that this causes confusion particularly amongst the public and patients. They believe that there is no role for um physician associates in surgical procedures and that they, they should be regulated by a professional body. We didn't specify or ask which professional body you thought and the majority of trainees as in 92.9% believe there should be a pause in further recruitment until we can come up with a clear scope and regulation. And also that trainees should be involved in defining the scope of practice for physician associates. So in summary, what are our recommendations? So our recommendations are that there needs to be a very clear, not vague scope of practice with responsibilities, surgical training needs to be prioritized for surgical trainees. So that there are surgeons tomorrow, there needs to be appropriate regulation and oversight that does not conflate the role of physician associates with that of doctors. And lastly, the there needs to be appropriate representation and patient education around these roles. Just before I finish, I'm gonna pass on to my colleague over here to give you the other training perspective as well. Hello, I'm I'm one of the SD four S in orthopedics. The Voter education representative, there is going to be a bit of repetition from what Rhian said. And there's been multiple surveys from SRT Royal College of Anesthetist B as UK, all of which show that trainees tend to have a negative impact. Well, not trainees pas have had a bit of a negative impact on training and from voters standpoint, we don't think there is any space for pas in theater. And that's our main stance that there is a gap in the workforce and that's predominantly on the wards. For example, yesterday was in a theater list, diabetic recon list. There were six of us, 61 fellow, one consultant, two registrars in training, two sos in training. So core trainees and a medical student, all of us in theater. And we all know that we don't need six people in theaters to do the cutting. There's already limited space in theaters. People are already kind of competing for training opportunities and desperate for training opportunities. We don't need an added personnel there. And again, in terms of the confusing terminology, we've got SAS surgeons, which we refer as specialty and associate specialists. Again, associate being, having physician associate is a grander title and it makes it seem as if they are at the similar working at the similar kind of level slash similar kind of sort of competencies as a doctor, an sho or a trainee. And it's something again, that was already mentioned that the assistant title won't come back. But again, there needs to be something that we can do to try and make these terms clearer. And as you know, a lot of things spread like wildfire and social media, there are adverts from some hospitals where they advertise physician associate roles as mid to senior level. And again, what is this mid to senior level are you expecting them to work as an so or a registrar? And there was one today for a renal transplant surgery firm asking for a pa to work at a mid to senior level. So again, pas should not be replacing doctors and there are already established pathways for um surgical first assistance, surgical care practitioners. So if a pa A does want to be coming into theaters, they should probably, you know, train it in those pathways and then come into theaters. And I think one thing that might be, might seem a bit slightly irrational is the familiarity concept. In terms of surgical trainees, we do rotate every sometimes four months, sometimes six months, every year. And a pa that has been in a hospital for about two plus years or three plus years, there is a concern that your consultant might ask the pa to supervise you doing a carpal tunnel, which might be a simple operation, but there are complications that can happen with that. And that is not something we want to ever experience. And we're just very, very strongly about the fact that we want our training to be protected. Most all of you have benefited from being trained. And again, we just want the same opportunities as you've all had and we want our training to be protected and not having to compete further these training opportunities. So in short, we're in agreement with a and our sister training organizations with regard to pas affecting trainees training. Thank you. Yeah. Well, uh thank you very much to both of you. Um It, it certainly is a, a very, um, well, hopefully not divisive topic, but it is a very topical um discussion and I just now want to invite both Frank and, but bill to come up and join the pan and Kirk. Uh Yeah, we need more chairs, please so that we can have an open discussion with our panel of speakers. Um And just my take on it really, um it's, it's raising sort of pretty repetitive themes uh which hover around basically the misleading nomenclature to the role. Um the misleading sort of scope of the role um the regulation of um that or the personnel who take up these roles. Also, how do we protect training for doctors and um you know, where is the college involvement and whether we should be involved or, or, you know, overseeing the training? Should we be inspecting these trusts that take on the training of ps um to see what impact it has on our trainees? Um or should we be involved in what the PA S get trained in? Um So there's quite a lot of threads there, but I don't want to take away from the um audiences participation. So I'll invite you to ask the panel what you feel is um e any questions? Thank you all for your comments and talks today. I just have a question actually about anesthetic associates because we potentially are going to be in a scenario where trusts will choose to have a cheaper anesthetic workforce and will have six anesthetic associates to one anesthetist. So you could turn up to your list potentially and be told here's your anesthetic associate ready to and he size your list. Um Now most of that work is being covered by the anesthetic colleges, but clearly, you know, the surgeon who is in charge of the patient, there are patients where does the college stand on, how it's going to manage that scenario? Because clearly there's a drive from government to implement this and that's what's going to happen. You know, those anesthetic associates, their job is to anest patients bill. Could you answer that? Yeah. Um unfortunately, I put my foot forward six months ago to be appointed as intercollegiate er extended surgical team board chair. The first piece of work that the colleges expected that board to do was partly to look at the career framework document uh for surgical care practitioners and also to look at the scope of practice. And this was last September in the asset survey. You will see that there was a request for a defined scope of practice document. That document is going to the joint cea colleagues meeting on Tuesday for the four presidents to review. We think we've got a fairly reasonable document to address the issues which have been flagged up another point in the asset survey was to have trainee representation on that task and finish group. We have had the president, she was vice president before now, President of British Orthopedic Training Association and the vice president, now president of asset on that group, apropos of anesthetists. Very difficult for us to make any impact on this because this is possibly one of the fastest moving things I've ever had to deal with. You will be aware that the Royal College of Anesthetists had an emergency general meeting about a month ago. They have been working on a scope of practice document which they are now having to revise. And in their response to a survey that was published on Tuesday, there is a likelihood of a pause of recruitment of A S into the training programs run by three higher education institutions in the country. No, the main concerns from the RCA membership was exactly the issues that Rayan has pointed out. And Frank pointed out in terms of the amount of invasive anesthetic administration. It remains to be seen what the RCO A recommend in terms of uh their scope of practice. But the point has been made in surgery about amount of access to theaters of PA S and that has been taken into consideration extremely carefully to respond to what the trainees I represented to that task and finish group. We have the surgical care practitioners that have been in place for 20 years initially starting out in cardiothoracic surgery. And during 2020 2021 we published the revised surgical care practitioner curriculum for the three and now two higher education institutes to train SE PS in the SE PS have a managed voluntary register and they have, you know, appreciate come from a nursing or an ODP background. So the college together with Edinburgh had a bipartisan colle the intercollegiate, the bipartisan group, that's bi collegiate group who set up the curricula, which we did and the managed volunteer which Edinburgh did that is in place as a form of governance. The big problem, the pas in surgery where it works and there's governance as the survey has shown they are helpful, particularly on the ward. Unfortunately, the vast majority of pa s working in institutions where they are lacking in governance and this is where you have come across the stuff that's published on social media about them doing all sorts of things and the concerns of the net effect that we'll have what the colleges are trying to do because it's now become an intercollegiate piece of work. As I say, I've got the misfortune of sharing it. Um is to clearly demonstrate that if as an employer, you feel there's a role for APA you should follow the recommendations that we hope to be able to publish probably sometime in June, which will clearly set a series of standards that are expected. Now, the push back is how on earth are going to police it. JC regulation role has been approved by government. There is no way that's going back. Although the charity commission has been approached by the Anesthetic Association um group to question whether the GMC is overstretching its charitable status, moving into an area other than doctors, it remains in the sea. What effect that can have as regards the way in which an individual trust decides to employ a PA A, they will have appropriate appraisal processes once they are regulated by the GMC. And although we cannot formally do anything, cos it's up to the trust up to the employer to do what they feel is appropriate. I suspect with the amount of noise coming out of NHS England and the C QC involvement that any trust allowing APA to work beyond the recommendations of the professional body will probably be in trouble. It remains to be seen how that pans out. There's a fair bit of water to go under a number of bridges, but the college is, have tried and I think we are not far away. It remains to be seen how much more push back there is on. This are defining what a pa in surgery should be doing. The big, big problem as well is the availability of trainers because we have insufficient trainers, as I've said, for surgical trainees, their opportunities have got to be protected to the hilt, but any of the any member of the surgical team and we as the bodies responsible for setting standards needs to be trained accordingly. And that's where the investment is required and it remains to be seen if NHS England will pick that one up. Yeah, thanks Bill. Um Just to follow up on that, I mean, it's, it's quite obvious that training opportunities are limited and we as a college are responsible for making sure the training in the trust is up to the standard that we say should be. So a trust that employs in a larger amounts of pa that limits the opportunities for the doctor trainees. So can we not then pull the trainees out of that trust? Uh They have limited the opportunities. Firstly, I think we have to wait to see the impact of what's being described on the way in which PA S are working as the asset survey has argued. Then no, and the boat have argued the most appropriate place appears to work is on the ward to support the team on the ward, not only from some clinical skills, but also we would argue administrative skills in terms of taking trainees out of training is not within the gift of the college that is dependent upon the way in which um NHS wte the workforce and training arm as was hee through their schools of surgery can monitor what is going on. And so some of the responsibility to be down to the schools of surgery, which although the heads of school going back in time were a joint appointment between the colleges and a ge that is no longer the case. And so, although we can report issues and it's down to individual trainers to report issues if they see it as such, we cannot formally take trainees out of a, out of a training post. Thank you. Any other questions? Um Esteban, so you've said that physicians, associates shouldn't be replacing surgeons, but they clearly are. And there are many physicians, associates who are undertaking regular independent endoscopy lists with various levels of supervisions. So what is the college going to do when that happens? Because it's an empty statement. Unless there's some follow up from that, it's all very well to say this shouldn't happen but where it does happen, what is the college going to do? Because otherwise it's just the just words, I'll refer you back to the days when, when nurse associates started doing endoscopy as an upper gi surgeon. I was horrified because of the fact that endoscopy quality assurance for picking up small lesions. Be it colorectal or upper gi was just not practical in terms of we knew there were fall down rates of the diagnosis of endoscopy. No, many endoscopy suites are now nurse practitioner led the statement that does it, which statements this, that was the statement that was released after the council discussion last February. So does that mean you don't agree with that or you do agree with that? No entirely agree with it. The trouble, the trouble is, it is very difficult for the college per se to stop a trust, employing a member of the workforce as they think fit what we're trying to do is to state very clearly what that skill set should be. And until that documents out, I can't really say a great deal more cos he's going through an awful lot of ramifications and changes at the moment. So it's a bit of watch this space, I'm afraid. Right? Uh run, I personally think there's a lot more to the surgery and surgical practice than just cutting and doing procedures as a responsible officer of clinical governance. The worst things I see is bad patient selection for surgery. Where do you see the roles of pa S in that? And how do our trainees get trained in patient selection for surgery? There is no role for a pa in selection of surgical procedures. No, that is what we're staying because the whole principle as is stated in, in the asset statement and also in the college statement is that PS should be supervised by a consultant. And that's back to my point about have we got enough consults to do that? Yeah. Um it will follow on on. Yeah. Yeah. Um and the other thing is that the other thing that asset is pushing at the moment is the J CSD quality indicators for all specialties that clearly state the necessary relevant clinic time to help develop trainees develop those skills in patient selection. And actually on ICP portfolio, you have one of it's one of the global proficiency is the ability to identify appropriate patients with surgery. So that's something that we're highlighting to all of our members to say, make sure you are getting your clinic opportunities because that is just as important as the operative side of things. This has been really interesting. I have very little experience of physicians, associates. I thought they came in because there were not enough doctors to do the work. And now there seems to be a bit of mission creep in that they're doing things the trust wants them to do because perhaps they're cheaper, perhaps they do more sessions than consultants do at your clinical work. But I must say I'm really concerned that with sounding like an old trade union and we're trying to protect doctors roles and we need to be very careful about that. We'll never have enough doctors to do everything. And I think the debate I hope is about the quality of training and supervision of these pas rather than about saying no, they don't have a role. And I must say I'm rather surprised by our both representatives to. So if you've got a physician associate who is a world expert in carpal tunnels, why wouldn't you want to go and be trained by her? Um why does it have to be medically qualified with that magical Doctor title. I think we've got to move away from this doctor title being special. I'm sorry to give her all a contrary view. But, uh, I think it's really important that we don't seem to be an old bastion of trade unionism here. Yes. I mean, I just respond to that. II, think you've raised a very good point. Uh, I mean, we've outlined some of the concerns that the profession has, But at the same time, we've got to recognize that it's inevitable. If you go into an operating theater in the United States, you, you accept that um a nurse, anesthetist will be given the anesthetic and the anesthesiologist will be roaming theaters uh covering those people and, and that's going to come, the practice has to change. So what we should be doing is not fighting it. Uh And I think that's the point you're making but harnessing it uh and directing the direction of travel, setting standards uh and ensuring quality and getting people to work in teams because that's going to be the most productive outcome of this. Yeah. Oh Rylan. Yeah. And II think the, the point that you raise is us, this mission statement is promoting surgical excellence. And as a training organization, our firm belief is surgical excellence is curated through five years of medical school, two years of foundation training, Mr CSF R CS. And that is the view that we hold that is those are the quality indicators that are present and attached and give you a certain level of confidence in the ability of that individual because that is the set criteria and pathway that we follow. And that's what we believe to be the quality indicator here in surgery. Yeah, I mean, just to play devil's advocate, um, I mean, why do we need to continue training doctors? I mean, there's gonna be a difference eventually between a pa a and a doctor trainee. And so the idea of, you know, one being not better than the other one or whatever doesn't really hold water. I love, I'm a surgeon. I see patients in clinic, I make decisions about operating. I do research, I do private practice. I even do a bit of medical legal work. I even have a bit of a social life as well. So that's sustainable. So be good robotically, you need to in theater three or four days a week to be trained up. And so the whole consultant model, I think radically needs to change, we cannot continue to have the plethora of activities that we all enjoy. And that's why we enjoy being consultant. Well, that's not sustainable. And that's, I think the elephant in the room that we never talk about because we don't want to change it because we enjoy our jobs. Yeah, that's true. And I was gonna come to the robotics issue because even though, you know, people are divided, whether there are four PS or not four PS. But the robotics is one of those that, you know, may suit apa role because you don't want to train doctor, trainees into the docking and undocking of a robotic procedure, but you want consistent staff all the time, but that's a different thing. And I don't want to monopolize the questions. Is there. Yes, sir. Thank you. And um just to count to some of the comments that have been made about the carpal tunnel. Uh world expert, the carpal tunnel, world expert could also be a doctor and for some trainee that's actually going through med school, having significant debt through med school for the tuition fees as well as accommodation coming out of that, going through exams and learning the same carpal tunnel and having a preferential way of the pa being taught how to do the carpal tunnel. There is a little debate to be had as to who deserves more. We are not the bastion and this is not uh this is not a union, but at the same time, doctors also have not the doctors, but the college are very clear that we have protected and we have encouraged extended surgical training. And this is what comes to when we have a ps that have worked extensively with the surgical team and they have blended it really well as uh as an endoscopy director. I know that clinical endoscopies are very important part of our workforce and quite a lot of them train junior trainees and they provide an excellent role. The specific question is about pas and their competencies before they actually are able to get to where our other members of the MDT are. So, it's not a question of us protecting a particular union or being, being slightly old fuddy duddies about what doctors can do. It's important to look after our trainees and that's essentially the point that I'm trying to make. Yeah, thank you. Any uh comments follow that. Yeah, I mean, the, the, the, the question begs itself, um why not put the funds into more training for doctors and rather directed into pa training which I'm sure will come up frank. I think the answer is the government is trying to do that and they're trying to reassure us that, that we're going to have 60,000 more doctors in the profession. Um by the mid two thirties, they haven't already increased the number of doctors training. But we know that if you put a doctor in it six years before they emerge as an F 1, uh 10 years before they're, you know, useful in terms of running a firm. So I think what the government see is uh a turnover to cover the perhaps the lesser work that requires a far shorter time input to, to, to bring out the finished product. The government will try and, and increase the number of doctors. 15,000 is the, is the target in the immediate future and we're at 9000 a year at the moment. Um, but, but it's just going to take time and, and the question we all ask and everybody in this room will ask is, is who's going to train those doctors cos where are the medical schools going to get the staff and the space to do that? Right. Yeah. Yeah, it's, it's exactly as you've said, I think, you know, doctors, 60,000 new doctors is a fantastic um you know, headline figure, but what the NHS long term workforce plan doesn't account for is how are we gonna give trainers the support that they need. As your workforce consensus report has said trainers are struggling across the board to train. They don't have the time, they don't have the resources, they don't have the space so you can create 60,000 new doctors. But how are you gonna get them to be the senior decision makers if the trainers aren't supported? So actually I would argue. Well, yes, you need more doctors but actually you need to support the trainers to deliver the training for these doctors. All right. Yeah. Um sorry, just um a couple of points on this. I do think it's important to recognize that training is not as linear as it was. People step off the training pipeline, have a fellowship post or portfolio careers in the long term workforce plan in England. The government is setting out plans to use apprenticeship models or other routes, shorter medical degrees and so forth. And I think the question very rapidly becomes, what are the windows of opportunity to feed into that plan as it manifests in its next layers of detail that will come out in the next year or, or two years? How does one make the evidence based case that supporting the current cohort of with the most opportunities and protecting that time gets you to those mature surgeons who get the waiting list down the fastest and in the most cost effective way. And I think in there somewhere is a lot of what we've seen today is the evidence base beginning to be regimented and, and I think it's important, we very quickly start to speak about exactly what, what the cost is of not doing this and quantifying that and using that to influence the imminent planning and debating of those plans. So, may I, may I just ask a question of the room then we're, we're talking about training more doctors and that being a major problem. But how many people in this room sit around on a big team? I'm, I'm in a team of 11 vascular surgeons. We've got two theaters a day. You know how many of us are sitting around not able to get to theater just because the rest of the infrastructure doesn't exist theaters, anesthesin the hospital beds to get your patients into it. It may not just be the numbers, for instance, of surgeons, but it's the entire infrastructure that needs to be increased if we're going to increase throughput. So do, does everybody get their patients in as they want to or who doesn't, uh, can you just raise your hands if you, if you don't or get as much time operating as you want? Ok. So. Ok. Yeah, the specialities. Thank you for certain special surgical specialities like mine, for example, ent and urologist and other where there's a bifurcation between a physician and a surgeon. So there is an ent physician and there's an ent surgeon. Is that something that the Royal College would look at? Because obviously there is endless pressure and it's only going to increase with the increase in population and the demands and then fit the ba into either pathway. I leave the surgical training for trainees. I am conventional in my thoughts. I really think that somebody who's been through medical college fought their way into a competitive training post has an understanding of anatomy, physiology certainly has an edge over someone who makes a somewhat lateral entry. So is that not possible to separate physicians from surgeons in some surgical specialties? Yeah. Yeah, that's certainly a, a very good point. Um, you know, having sort of, you know, like inpatient care being dealt with with physicians instead of surgeons as they do in other European countries. And obviously some specialities is quite clear cut. You know, the ent physician and a surgeon and so on. I mean, what, what do you think it was, it was one of the things that we got from the discussions with the relatively, with the relevant specialty associations, as I indicated, there's a complete different change in the way people are functioning in terms of the practice that they've got. And it's an evolutionary process is the best way of finding out whether you say, ok, well, this, it's back to the outpatient um transformation that the right people are doing the clinics in the right place for those specific set of conditions in your own specialty. The um uh one of the leaders from ENT UK was explaining that during the pandemic uh for GPS lost the skill to look after certain conditions and they sent them all up to the hospital that completely overloaded things. And that's why a lot of things are being managed medically. And so it's, it's trying to find the best way of getting that balance. Um It's down, I think really to the specialty associations deciding how that's gonna pan out. Um And advising on the workforce planning to see who works where we've got to wait until we've seen what happens with outpatient transformation. And the shift back to community clinics and what have you and that will change, I think, and you'll have a shift in emphasis for who's doing the more medical aspects of what is ostensively surgical specialty and those who are doing the more surgical aspects and this is all part and parcel of this change in the way in which we work, which we've picked up through the census. So just one thing. So clearly, you know, the workforce requires a wide variety of people to do different things. There are cost problems within our health service that require cheaper members of staff. We recognize that there are certain tasks that have been delegated to medical professionals in a variety of different terms such as endoscopy, for example. But what we're looking at is surgery and the whole remit of surgery going from assessing patients through to surgery. And surely we accept as a surgical community. The best operation that can be performed on the right patient is by a surgeon. So the concept that someone can say that the best carpal tunnel pro provider in the world is not a surgeon is factually inaccurate. Otherwise, we surely would not exist as a community. I mean, are we saying that, you know, somewhere in the world, the best person at doing this has not been a surgeon because that's, that sort of defeats the point of what we're doing, isn't it? Ii mean, unless we're saying that actually we should just disband with surgical training as it stands because there are better ways of doing it. And actually, you know, why are we here? I mean, that's not defensive of the profession that is, you've either got to have a standpoint that we have a way to train people that works and we want to optimize that or it's just not needed because actually you could do something else and you can get there. Yeah, any comments, I mean, uh I mean, my take on this whole debate is that it is a challenge to the profession to be thinking about what constitutes a surgical team because you would need people with different abilities, uh training and so on and so forth. And the traditional set up of a surgical team, we found very quickly that there is not maybe enough funds, there's not enough infrastructure to be rolling that out forever with increasing demand of health care and so on. And we very quickly we've run into problems. Um now and so as a person in the government, they'll be thinking about what happens over the next 20 years and how much demand there is for the healthcare. And so the team structure will have to change. And I think as a profession being on the table is a lot better than being heckling from the back. So, and that is really, I think the message and um unfortunately, um things as Bill said are, are happening so fast that engagement looks like it's missing from the equation. Um But you know, that's, that's what governments do. Um They perceive a problem and is politically hot potato and they rush it through. There is some engagement happening and there will be some thought. So, uh what I would, you know, hope is that everybody carries on contributing to this debate locally. And um you know, challenge what they feel should be challenged and accept what they feel is beneficial because at the end of the day, it's the patients at the other end who are receiving or not receiving the care and not everybody needs a heart transplant. Sometimes all they need is to be told to take one more tablet. And that is the reality of health care. And you can't have a consultant there to tell 40 people take one more tablet and them not then being able to do the heart transplant. So that's the reality of healthcare. I think people should, you know, have a different perspective and see both sides of the equation. Um Yes, Mark. Um you've, you've got to cooperate. I mean, look at orthopedic surgeons, foot surgeons, foot and ankle surgeons and podiatrists. When podiatrists first appeared, everybody was very much against them and the foot and ankle surgeons were very much against them. One of my colleagues looked heavily into this and there are undoubtedly some podiatrists who are damn sight better at doing a metatarsal osteotomy with the surgeon. So if you say the best person doing a carpal tunnel is going to be a surgeon, that's not just not true and you, you can't throw this out. You've got to cooperate. This is upon us and we have to cooperate and we have to um find a way forward. The four recommendations up there are perfectly reasonable. Nobody's going to agree with any of that whatsoever. But we've got to cooperate and we've got to come up with an agreement. We can't say that I don't agree with that statement. Surgeon is going to be an operation, the more complex the operation, obviously, the surgeon is going to be better at it. But there are more simple operations where a person who's not a doctor who is fully trained can do it just as well as a doctor. I just want to say one thing with podiatry, they have their own degree pathway that they do in their training. But pas they do a biomedical science degree for three years and then they do this two year degree where they do about 60 hours of surgical training within that. And then if they've done the same amount of qualifications as this expert consultant in carpal tunnel has done, then yes, maybe. But they, most of them haven't, they've just been in theaters for a very long time and they're given the opportunity because people are familiar with them in that hospital. And if they knew the background of anatomy, pathophysiology where all the complications are with that surgery and they knew that and they are training us then yes, that's a different story. But you know, for most of them, not most of them, sorry, that's a generalization. But there isn't any sort of exam that says they, they know this so, or qualification that they've got podiatrists and foot and ankle. I think that's a, I don't think that's a fair comparison to the pa situation. That's just an opinion. I mean, obviously for some surgical procedures you, you need to have everything that's required to do the operation but there are certain other, uh, simpler operations that can be done by a doctor. Uh Yeah, absolutely. Right. And I think the, the point sort of, you know, that struck me was when we were looking at a lecture of the snippets of surgical life and one they talked through, you know, the operations they did as an. So, um and you know, they had those 32 n operations that they did the majority of them, as you say, are very straightforward, simple procedures um that are technical operations as in once, you know, the technicality of doing the operation. But then that was done by a house officer at that time. And the, therefore that is the argument that we're pushing forward as a training organization. Yes, these are simple organization, uh simple operations, but these are the operations that very junior surgical trainees cut their teeth on. And if these are outsourced to other individuals and junior trainees don't have access to these, we then lose the surgical skills to then build that into the more complex operations. It is a stepping stone. So that's what we're arguing for. The simple operations are the ones we need as junior trainees to then progress on to the more complex operations. Uh On, on the same line, I think it is important to recognize a lot of what's been said today is about a sort of scarcity, a scarcity of opportunities for training. And then some of these debates spin out of the scarcity. It's not about a AP doctors. It's about can there be enough training opportunities that get us in the fastest possible way to the to those high performing rapid sort of getting things done that bring waiting lists down and see the most patients in time. And I think 11 of those sort of challenges is how do we evidence, how, how do we marshal the line of debate about training doc training doctors, surgeons versus these o other staff groups, you know, that that are there are many different staff groups. And I do think it has to be about what would bring those waiting lists down and have the most patients seen the most health benefit driven in the shortest possible time without sacrificing sort of a longer term picture. Um II just don't think we're there yet in being able to marshal that line of debate. Yeah, I mean, hopefully it's a work in progress even though there's been some major steps taken like the the act of Parliament to get the GMC to regulate and stuff. But we do hope it's a work in progress and more debater. Yeah. Yeah. Uh, frankly wanted to say, I mean, just in response to Mark, um, in our hospital, a clinical nurse specialist does all the radiofrequency varicose vein operations. I'm personally delighted that I don't have to do them. And she also, she trains the, the junior staff who want to do that and, and it's a very good relationship. She's invaluable to practice, But it's interesting that we're, we're complaining about semantics in terms of the nomenclature for the people who are doing it. Of course, I mean, I don't think it's possible to look after the patient without a nurse. I mean, they, they learn more about the patient on the ward. I don't know they have of teaching and training behind them for them to widen their role. I don't think with the same kind of resistance that the whole idea is that this is an entry graduate, entry biomedical science level to kind of come at some level at all with the nurse or the doctor. I have uh my mind is opened it for pa but the the point of of a pa is where I don't quite follow the argument. I mean, that's certainly been true. There's been some criticism that there is a nursing structure already. I mean, I had one of the very first nurse consultants in the UK in my practice on the colorectal team. So there is a structure already there, but it is what it is. Government has moved on. And so we have to be talking about what they've already done. Sorry, there was a question there. I was listening to the conversation about doing procedures, but I found being consultant consultant for more than a decade that uh most of my job is not just doing operation on doing procedures, it is decision making because that's where the um the experience of the learning of a senior doctor or a consultant, right? Specialist comes in rather than doing a procedure, of course, um an expertise is required for doing more complex procedures, which is obviously never going to be a pa or a jury doctor. But um important factor is about the decision making because that is where the most important argument should come where the role of a surgeon versus hopefully that will be outside their role. And I think so far, it doesn't look like they will be creeping into that role or there will be any such thoughts. Isn't that right? The fundamental difference is the whole six plus undergraduate years, then the upwards of eight plus postgraduate years to teach an individual to develop the skills you've just talked about, you cannot do that to an individual coming through a two year pa a training route. And that's fundamental to what we're doing that the whole skill set is that in the exam is tested as higher order thinking, it's the ability to, to look at the challenging problem and come up with a decision. The only person who can do that in surgery is a fully trained surgeon, but that's who's being trained in the processes that we have in place. And one of the problems with the argument we have is, as I said earlier on, unfortunately, these other members of the workforce have been a allowed to go and do things completely out with, of their remit. That's what we're trying to get round and stop. Well, that's very reassuring. I I'm mindful that time is moving on. So maybe one last question and then we can uh end the proceedings. Yeah. Can I just say that? Um this is a classic example of the road to hell being paved with good intentions. The government looked at this a while ago and saw there's a shortage coming and let's create um which would do basic administrative jobs help on the wards, free up the doctor's time to do more important things. But as happens, trusts have just had mission creep and the pa role has changed beyond all recognition um where everybody setting their own scope of practice. And unfortunately, consultants are also to blame in this because every pa is supposed to work under direct supervision of a consultant and therefore mission creep has occurred under the watch of the so called consultant who has agreed to it. And that's the elephant in the room which I don't think we are discussing enough as a college. I think it would be important for the college of surgeons to say that to its members. Yeah. And the physician assistants have changed themselves. They changed their name to physician associates, thereby, thereby leading to the confusion. Yeah, I mean, II don't think there's any sinister conspiracy or anything and I look back and, you know, over 2030 years ago there was the same discussions happening about international medical graduates coming to the UK and, and so on and so forth and look how the world changed the NHS would not function without international medical graduate. So there's positives and negatives, but from a politician perspective, it is actually the delivery of care and their requirement to their constituency. And from our perspective, we also are very mindful of our constituency as fellows and members of the college. So, II think, you know, on that note, we maybe should wrap up the proceedings and before you all go, we would need everyone to come up here to the front because they do want to take a photograph for the annual court day of all the attendees of obviously the online people, we miss that, but it's been, I hope it's been a very, you know, interactive, you know, debatable and as well raising a lot of thoughts in your mind, all the speakers contributions. And we've had very wonderful contribution with a very nice sort of insightful thought about what training was in the past from Sir Barry. We've had all sorts of discussions about the future business of the court of examiners. And we've had this very interactive session regarding workforce planning and physician assistance and how they fit in with our other roles in the NHS and how the college interacts with these changes. So, II hope you found it very useful and um a very fun and you know, educational day. And for those of you who are attending the court and council dinner, there will be drinks at reception at six pm. Uh down by the Hunter statue and dinner will start promptly at 630 pm. Uh in the Lumley in the library. Yeah, going back many years. So it'll be in the library and his black tie and you know, those who are there will obviously see you later on today. Um So thank you very much for our panel and thank you for all your contributions. And may I ask you to please come forward and then we can take a photograph panel included. Am I in this? Yeah, why not? Yeah, we're gonna find our way than the grill. We get the saying, it's a day. We want you three baby, you and the