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Dmitry Nepo Gordeyev, a public health registrar with a strong research track record. He's been part of the leadership team for COVID surge collaborative, a global research network that has informed surgical care during the pandemic and published 20 to peer reviewed research papers in journals including the lancet. Uh Yeah. Okay. Thank you very much for the invitation and it's a pleasure to be back at asset after some years. So um I originally did call surgical training after which I did a phd in global Surgery in Birmingham and now I'm a public health registrar but sort of keeping the interest in surgical research and surgical systems. So hoping today to talk about the elective back log. So first of all, just to start with what's the official data on the waiting list. So all this data is based in England. So sorry for anyone from outside of England. But um every month we publish how many patient's there are waiting for any kind of elective treatment, outpatients, cancer care, diagnostics and surgery. And at the moment where at a record 7.2 million people waiting on the waiting list for anything. However, our estimate is that of those, only, just under 900,000 are waiting for surgery and that's actually quite a small increase of just about 200,000 compared to pre pandemic. So the official data would suggest that maybe there isn't that much of a back log. Um, the government was very pleased when in the summer they claimed they had eliminated two year weights. Um, they were very happy with that. Excellent. Um, so what we wanted to do was to find out what is the hidden need because we actually think there's a lot more people who have missed the treatment that they needed during the pandemic. What we've done is we've looked at a routinely available NHS data that's online. Um And we've looked at elective procedures. So that includes endoscopy, ease, interventional cardiology, interventional radiology and surgery. And at a procedure level, we've looked at what's the gap between what we would have expected uh based on pre pandemic trends and what has actually been conducted to kind of work out, what is the backlog potentially? We've tried to be a lot more thorough than other people who've done this work by trying to counsel the population growth, population aging. And also actually the fact that some people who would have been waiting or potentially needed procedures would have died whilst they were waiting for that. So, uh if you go on that QR code, that's a link to a pre print, which has some of the methodology we've done used to use sorry some of the methodology to generate this data. Um but we've actually improved the methodology since then. So I've rerun this analysis with the most recent available data. So as of the first of December 2022 there were just under 4.5 million procedures we think needed in the English population. So that's a lot more than the 900,000 or so. That's on the official waiting list. The largest numbers of procedures are needed for endoscopy, ease, cataract surgery, hips, and knee replacements, and interventional radiology. So a few insights to share from this data. Um As you can see, this is a big difference between the number we're giving you 4.5 million procedures needed based on the gap between what was done during the pandemic period and, and what we think was needed. Uh and what's on the waiting list, that means that overall 80% of the need for elective procedures is hidden. We don't know who these patient's are because they're not on the waiting list. But there are these patient's are some more out there potentially uh waiting for, for someone to find them. Um The specialties were the biggest overall needs. Our general surgery with just under 1.5 million and orthopedics with just under a million procedures needed. But most of these are hidden and that's the case across the board. 85% of the procedures that are needed. We think are probably day case procedures or could be done as day case procedures. So that makes sense because during the pandemic, probably we did a good job of prioritising the patient's with life threatening conditions, cancers and so on. So most of the major surgery that was needed has been done. Um, the big gap is and day cases and when we try to look at what the age spread of the patient's who need these procedures is about half the patient's who need procedures are working age. And I think that's really significant because in this country, the moment we have a big workforce shortage, lots of reasons, but potentially for that. But one of them is the increasingly there are more and more people on long term sick leave potentially because they're not getting the elective treatments that they need, that they would normally have had. So to summarize the challenges, we've got a backlog of 4.5 million procedures, mainly day case mainly hidden. Um And that means that patient's are waiting a lot longer than the official statistics suggest because in official statistics, the clock starts when they're putting on the waiting list. But if we think about what actually, when did patient's need these procedures long before they join the waiting list, waiting times are, are much higher. What does this mean? Well, potentially because patients are waiting longer, they're not being properly triaged. That means there's an increasing progression of their disease, increasing disability impact on the quality of life, there will be knock on effects on primary care and acute services. There'll be an exacerbation of the workforce shortages that I've mentioned and also wider impacts. So even if people are not taking time off work, maybe it means they can't look after Children or elderly relatives, maybe means some people are dropping out of education. So there's a big societal impact. So actually how we manage the COVID backlog I think is the defining challenge for surgery this decade. Um So there's a lot we don't know. Um the reality is lots of people come out with their models and their solutions. Uh Very few of them have got really good evidence to back them up. And actually, there's a lot of wider questions that haven't really been addressed. So, training is what we're here to talk about. How do we use the recovery to deliver excellent training that develops a strong surgical workforce. Um I don't know that we've got those answers yet in terms of population health. So that's obviously more what I'm interested in. Um How do we identify the patient's with hidden need so that we don't have a lot of patient's who are deteriorating unseen and actually, we can get them the treatment they need as early as possible. How do we stop the recovery exacerbating all those inequalities in health that we already know about before the pandemic? How do we reduce these inequalities rather than seeing them widen. How do we prioritize patient's on the waiting list? So there's a big question about how should we be balancing clinical and social needs? Should we be prioritizing patient's who need to get their treatment to get back to work, for example, or to be able to look after loved ones? I know and he was going to talk later about the environmental impact. But I think that that as we scale surgery back up, we need to be thinking about how we target the carbon footprint of surgery. And also I think during the pandemic, there's been more and more focus on both air quality, water quality and water pollution. So how do we reduce the waste that we're putting out into the environment? Um So that we're not damaging future generations health. So just my final slide really, which is to say that um I think we are the solution here. Um We should all be embracing our roles as leaders. We need to be thinking not just about the individual patient's in front of us. So when I was a trainee, it was very much thinking about, you know, this patient has presented with right iliac fossa pain. We now need to be thinking much wider than that across the population who are the patient's out there in our local communities who need our help but are currently hidden from us. And we need to be thinking about how we strengthen our surgical systems so that we're resilient for future shocks because there will be future shocks. There will be a flu pandemic could be in a few years, could be in decades. We can't know, but we need to be ready for it. Um Antimicrobial resistance will be a huge pressure uh over the coming years. So how are we going to be prepared for that? And of course, economic recessions are inevitable. So how do we expand our thinking so that we're pivoting away from just thinking about individual disease is individual um surgical issues to thinking about how we use our audit, our research, our service development to tackle these really big questions, we can't tackle all of them. Um It's an entirely on our own, but we can build collaborations, multidisciplinary with academic partners without public health colleagues in the in the local authorities to try and start to address some of these problems. It's such a big challenge that actually the only way we can solve it is by everyone contributing. This can't be just about a few people who, you know, college president's or whatever. Um Coming out with some statements, this actually needs active participation from everyone in the surgical community to tackle this and surge uh surgical trainees are particularly well placed because I think a lot of us understand and we're passionate about these social issues that were sort of touching on. And I think there is a real drive to try and address them. What we need is for employers, trainers, colleges, to facilitate and empower trainees to take on that leadership role so that in the hospitals in their regions, nationally, trainees can start to affect change to address these problems. So I don't have the solutions for you today, I'm afraid, but I would be delighted to have the opportunity to work with some of you to try and address this. Thank you very much. Thank you very much for covering such an important topic today and I don't know about other people in the room, but I certainly always find it reassuring to hear about recovery and training in the same sentence.