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Our next speaker is a true friend of Asset MS Stella Vague is a consultant vascular surgeon in Croydon. Um She studied in Wales and did her research in ST George's. Um she's had multiple different educational rolls um from foundation program director um to those of the, the various committees, addressing court surgery, entire surgery training. Um J C S T chair for court surgery and a general surgery sec member. Um She was awarded the NHS Leadership Academy London mentor of the year in 2015. She's previously been named a woman of the Year um and Acid Silver scalpel winner. Um And we're very grateful to have you here and looking forward to your talk. Thank you very much, Dadri. Uh This is one of my favorite conferences. The dates go in the diary as soon as I leave one. Um And it's, it's a pleasure to be here. Um So I'd like to talk about training, but I'm going to talk about it in the context, Paul, as you say from NHS England. So I'm the National Clinical Director for Elective Care and we know we've got a problem, we've got a problem with training, but we also got a problem in delivering the care to our patient's. So let's just talk about the N H S. I was born in the NHS. The NHS has saved my life. I am here and I want the NHS to be here for my Children. And I know that all of you do too on numerous political polls from the King's Fund. The NHS continues to be the most pressured and treasured asset. But since 1948 to now, there have been great changes and the last five years, especially post COVID, the acceleration of video, digital technology, the technology that you have. I've got money in my handbag and I can't spend it because no one wants to take cash anymore. But when I qualified in 1991 MRI didn't exist. And if I wanted to ct scan, it had to be requested through the consultant and it certainly wasn't available in the evening or weekends. So what we are doing in the NHS is now accelerating at pace. And so this is no longer a conversation of there's a new consultant that needs to come in the trust. Let's find the empty theater list and the empty clinic and that's their job plan. This is now we need to take stock post COVID, take the NHS apart and put it back together again. And so my ask if all of you listening today is I want you to be disruptors and I'll tell you what I mean by that. So there's a huge change of, of expert expectations. So we know there's increased diversity. It's Gina doctor strikes are not new. Uh That's 1975 Brighton, but actually very different to the look that we have in the room, but also very different to the look that we have of the patient's that we serve and life expectancies are changing. There's a 10 year gap now from 1940 82,018. Um and those of you in the audience who is the same age as my son, who's 26 you are likely to live to 100 my God daughter who's five is likely to live to 100 and 12. So your longevity is changing and therefore your asks and wants of life are changing. So for us sitting on the, on the chair slightly older than you in the audience. Um and maybe 56 coming is 56. This year, I still feel 21 inside my body may not feel the same, but I'm certainly not thinking of retiring at 60. What am I going to do for the next 25 years? And for those of you sitting in the audience, you are not expecting to be working at the coalface in the NHS. For all of your years, the days of the triple phase of education, employment and retirement is completely different from you. So your ask are the stock and start. And my plea to all of you is do not stay in paid NHS employment for the rest of your lives. Make sure you take time out and do things differently and bring back that learning to the NHS. So there are other things that are coming through, however, that change the way that we think. So uh COVID hit, we all did COVID care, but actually we don't feel respected and valued post COVID. So the post COVID more moral injury is a live and living entity. And the cost of living crisis, we can't get away from that, but it's not just the cost of living crisis for you. We've got families who are saying I can't bring my child to their appointment because I can't afford the bus fare because it's too far away from payday. People are making very solid decisions about whether they come for their health care or whether they continue working, especially if they're on a zero hour contract. So we need to start different thinking differently. This behavioral change that happens in us, but behavioral change for our patient's as well. And the other thing of course is as I get older, I'm beginning to worry more and more about the planet. Have I left something that's sustainable uh for my Children and you are all sustainable sustainability champions. And there's a fantastic session yesterday. So when I ask you to be disruptors, I'm asking you to do things differently I mean, radically differently. So the conversation that's happening everywhere is we haven't got workforce and we're creating new workforce. We are creating new roles, but they're going to take time to come. But we follow rules in England and in Britain, we follow rules. We q the rest of the world doesn't do that. So what I need you to do is to think differently. So let me give you an example. So we have Stehf and a safe and appropriate staffing levels in this country and it doesn't matter where I go, I get a block that says that's not safe to do because these are the rules and I get handed the book, these are the rules that say this is how you do safe and appropriate staffing levels in England and in Britain. Well, okay. Well, I phone the rest of the world. I've talked to India, China, America, New Zealand, Australia, Singapore. I've talked to Germany and France. They also have safe staffing ratios, but they don't look like ours and they're not filled with the same kind of people. So if you speak to um the Mount Sinai Hospital chain in, in America, because degrees are expensive. What they do is they take people with aptitude cleaners off their shop floor who work in theaters, put them through a two year degree and they become uh scrub techs. If you speak to the Apollo Hospital chain um in Chennai, uh they're robotic theater, start at six o'clock because they do three session days because they're theater is the most expensive estate and the staffing ratios are very, very different. So we're pulling together a group now. Um, we're hoping to have a stakeholder engagement group um in May or June where we will invite everyone and present data to say, let's think about what rules we are entangling ourselves in that are causing difficulties. And that's the same conversation as the high intensity list, the parallel list. It's interesting how shutters come down, but the shutters need to go up again and you will see the training opportunities, you will see things that make the difference that we won't. And I say, I'm saying to all of you take time out, do something differently and bring it back. And I have pulled together now an elective training engagement forum where I'm hoping to harness all those ideas that's going to happen quarterly and be hosted by NHS England. But I want you to rethink patient pathways and training. You all love operating and the operative competence is important. The numbers are, are in our curricula that, that we have to deliver. But we think about it in a very narrow lens of surgeons. We think about elective and emergency in patient's outpatients and community. But let me just tell you about the problem that we have. So we've got 7.2 patient episodes of care waiting. And I know Dimitri gave a good presentation yesterday, we have tested those numbers. It is 7.2 million patient episodes and they're around about 6.5 million people waiting. Some of them are multiple pathways. But we do 100 million outpatients a year. We schedule 100 and 20 million and we move them around. But we do 100 million outpatients a year. And of those 100 million outpatients, there are 10 million that go to waste because the patient did not attend and it's not, they didn't attend. There's a missed opportunity where a patient and you are not in the same room together and therefore there episode of care is not moved on. So we've got 10 million empty slots and we've got 7.2 million people waiting for 7.26, some 0.2 million episodes of care. About 6.2 million people waiting and about five million people waiting for an outpatient appointment. So if we cut our DNA rates by half, we would solve the problem overnight without asking you to work harder and we cannot keep asking people to work harder and harder. We have to transform, we have to do things differently. So surgeons, we've got capabilities in practice, but we need to test what they actually mean. So surgeons need to have prevention strategies. You need to know about wearables and how they affect what you do. You need to discuss social prescribing. It's not all about patient's coming to the surgeon's hand and secondary care, our job should be to make sure patient stay away from us. And if you talk about sustainability that in your training, we need to think about the NHS carbon footprint, the largest provider of that is surgery. So therefore, if you stop operations from happening and operate on the right people, you are contributing to sustainability of the planet and we need to consider and it needs to be part of our consent process. Are we doing things under a local anesthetic? A block or general anesthetic? Have you spoken to the patient about the carbon footprint that they're generating because of having it under a general anesthetic? And we start talking about training. I want you to think about the last time you stopped at the end of an outpatient consultation and said to the patient, how would you like to come back to clinic or I think your scans are likely to be normal? I don't think you do need to come back. I will write to you as a result. Easiest thing is to give a three month appointment that's contributing to the carbon footprint. But also it means that patient's don't come because they can't afford to come. So we need to start thinking differently. The behavioral insight needs to be different. We need to use virtual wards. So we've got a pilot going on at the moment looking at diverticulitis. Why do admit all those patients' for overnight antibiotics and you know, stop the meeting and drinking. They can do that at home with someone going out to see them, they can wear wearables, we can do things differently. So our scope, your scope, the world that you live in is going to be very, very different and automated intelligence. Artificial intelligence is gonna be part of your everyday practice. It isn't mine. I don't understand it. It will be for you. We've got three D printing, we've got simulators sitting with people not using them in all our hospitals. We've got simulator training, assisted training, group learning. And then we've got the and I'm followed by fantastic Sassen ammunition. I'm not going to discuss it in detail, but the elective hubs, the community diagnostic centers and we need robotic training centers, but we need a one stop shop. We need patient's to come and have their entirety of care in a single episode. If we can, you need to show us where some of the opportunities are that we are missing. But when we train, we need to be seeing and ensuring that you understand where that lies as well. So what we know works, we know that if you focus on operative productivity and training, every case must be a training list that doesn't mean you start and finish the case as a trainee, but you do an element of that and we know that if you get it right, it works well and satin damaged I know we're going to show you that the high volume centers separating elective and emergency works. It allows you to train at the moment. We've got a 76% theater utilization rate, which is the same as PRE COVID. We can do more, but it still needs to be that we are teaching and training and those centers, we are just accrediting. Um Some of the city's eight pilots, what we can see is the accreditation process includes the training within the center and centers that are doing well. Have got the right culture and compassion Colin as you said earlier on. Um and the improved access to complex cases, the digital passport is alive and kicking, but it's not being used. There's a variable uptake across the community across the nation. We need to ensure that you all have digital passports and you go to where the work is happening and where the training is happening and the new technologies are coming in. But we need to give you time to understand and learn and see how they are applied. The bottom line for me is elective recovery. We are getting there. We've now got sustainable waiting list. The waiting list has not grown three months running. But if we've got elective recovery, that means we have training recovery. And for me, if we get that right, it means we've got excellence inpatient care, but you really are the future of the NHS and your thoughts and your disruption will make the difference. So please do get in touch and give me any hair brained ideas that you have. They won't be, they'll be fabulous. But thank you for listening. Thank you so much and Stella for that. A fantastic talk.