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2024 debate. My name is Martin King. I am the immediate past president and I will be chairing our house today. Thank you all for joining us. Um At this moment in our conference, I hope you've all had an enjoyable time over the last um couple of days here in Bournemouth. This obviously is what we constitute as one of the highlights of our weekend, whereby we get to have an interactive and constructive and respective conversation about something that has been important to us as trainees and also to the profession. And today's debate is um definitely in that category, I want to, first of all begin by welcoming both the proposers and the uh opposer of today's motion. I'm going to begin by introducing um the panel. Um First of all, with those that are proposing today's motion. Um So I'm gonna ask Val to introduce yourself. First of all, please. Hello, everyone. I'm Val. I'm the asset executive committee member, current Homes Officer, um and the plastic surgery uh trainee and then I am go carer. So I'm past as president and I'm current consultant surgeon down the coast in Brighton. Thank you to our opposing. Hi, I'm Lasha singer. I'm a vascular surgeon from just down the road in Bournemouth Hospital. And it's nice to see you all on a Sunday afternoon. Hello, Mister Davis. Hi, all, I'm George. I'm one of the Asset National Council member, surgical trainee from north of Scotland. So, thank you very much, um, panel um, for joining us for you in the audience and those at home here watching today's debate. You will have a QR code um on your seat. And also um you'll be able to have the pool um online, but also the question answer function. I'm going to explain some of the House Rose. Um Each um side of the house will have 15 minutes to put forward their arguments to the motion that this house believes that the expansion of the extended surgical team threatens undermines and risks surgical training. When the two teams have put forward their arguments, we will then open to the floor. Um Those of you both in the room will have one minute to ask your question and that will go to the respective um team for those of you online. And towards um after the 1st 10 minutes of questions on the floor, we will go to those online and then at the end, we will have our vote. So without further ado I'm going to ask um our proposers to state their arguments for today's motion and thereby I will hand over to Mr Cara and to Valdo, thank you very much. We've got a secret weapon with us today, we prepared some slides for a visual aid and hopefully you'll find having a visual as well useful. So today's debate is this house believes that expansion of extended surgical teams threatens undermines and risks surgical training as we all know, uh in terms of NHS long term workforce plan is for definition of the debate topic itself. The expansion of EST has been planned as a quite significant step. Um and how we defined threatens and undermine surgical training. We believe that it would have negative implications on surgical training across all grades and specialties, particularly focusing on theater training opportunities. In terms of the ST itself. We defined this as mainly focusing on the ST team members that particularly have heavy involvement in theater training opportunities. We all know that there is significant expansion planned uh already. Um And there has been significant increase in numbers over the last 18 months of the pa rolls in general. Our main arguments that EST expansion particularly pas would impact surgical training opportunities negatively. Are there there'll be deskilling of the surgeons of tomorrow that there will be addition uh that they're adding to the trainee burn out and there are certain levels of supervision challenges and also the impacts of the surgical care quality uh in the future. And that is at risk focusing on the uh first argument as we go through the evidence today, you'll see that the MA PS are prioritized. Sadly for surgical training courses, funding going to MA PS including training slots for surgical skills courses. PS are prioritized for surgical training opportunities in theater such as endoscopy lists parts of the procedures being done by the PA S rather than junior members of the team in order to progress their skills. And trainees are left to perform ward based jobs or service provision tasks instead of being trained to become the surgeons of tomorrow. Further to this taking in mind that there is significant bottleneck at certain levels of career progression throughout surgical training. As we see and the recruitment challenges, there will be a competition for certain jobs that pas may do instead of the trainees. And this is already happening with GPS who are struggling to get jobs and they're being employed. The PAS are being employed over GPS when they're already a qualified doctor focusing on the evidence specifically uh asset survey uh that was done this year and the report released has shown that 70 per cent of the respondents reported negative impact on their training opportunities and it was all across grades and specialties with more junior trainees being even more severely affected by this. So this is really important because these will be the higher surgical trainees, maybe they will not even want to progress throughout this career. If they have significant negative impact on their training opportunities, the way training opportunities were affected negatively were specifically in theater. There were decreased logbook numbers and decreased training opportunities in almost 80% of the cases. Over 70% of the cases. It also transpired that even across clinics, this also was impacted negatively and there was increased workload on the wards for the trainees. Looking at the open commentary that B and asset survey reports have shown that sadly trainees are not prioritized for the courses. There is lack of funding uh for the trainees to attend surgical courses and there is competition uh for learning opportunities and trainees as doctors, they are being asked to do lots of extradition tasks or re review the patients that the extended surgical team members have already reviewed and prescribed on their behalf or request radiation investigations, which is not ideal for the trainees because it adds to their workload, it adds additional admin tasks for them. Uh and it negatively negatively impacts their training. And uh obviously, there is the bottleneck argument if you look through the long term work for plan really closely. Yes, there is a planned expansion of all of these roles. It is important however, to have appropriate infrastructure to support this expansion. If we do increase slightly the number of medical students, what's going to happen at future steps because there's no increased uh specialty training numbers, so to speak. However, uh the pas would be consultant pa S uh interestingly um and as we can see the scope poses quite significant challenges because PA S are already working on the registrar or ho wrote us. So will there be further expansion on that? Going to our second argument that this is adding to trainee burnout and supervision challenge. There are certain supervision challenges. Currently, there is high levels of burnout and stress within surgery and there is increased requirements to supervise the rapidly expanding maps or in the surgical team members, which is an additional burden for more senior trainees as well as consultants. And it takes away the time that is really, really precious for training, more future surgeons. And of course, as I mentioned before, the trainees are being asked to prescribe, do tasks on behalf of the PA S which adds additional burden to their workload. Um Referring to the uh census that has been widely publicized, there's already a lack of time to train and mentor the trainees. So if there is no infrastructure to support this rapid expansion, we're gonna find ourselves in a very difficult position when there, there's more challenge for the trainees and the training opportunities are even worse and worse and worse. And uh it will have impact on how many people stay within the profession and it will pose significant challenges further to this um the working hours that the ma PS uh perform are significantly different to that of a doctor. However, it's not necessarily reflected in the pay that the PS or uh uh the doctors uh may be getting, which may, uh everyone has a good role uh in healthcare in general, everyone comes with a good intention. However, the challenges are uh that if doctors don't feel appreciated for the work that they do, um from the financial and the other perspectives is going to cost uh uh more cost with more stress and burnout within the profession. And um carrying on um in terms of the supervision argument. Uh interestingly, in asset survey, it was found that over 15% of the doctors were being supervised by the pa S uh more junior levels. However, some of them were high, higher surgical trainees in phase two of their training. And um it contradicts the surgical training practices as established through J CST and IP um where doctors should be the name supervisors in order to have high quality of standard of training and supervision. Further to this, uh as I mentioned before, lack of infrastructure for more senior uh doctors and consultants to supervise ps, which we're already doing as was revealed by the survey report will cause significant burden to the system and uh cause its collapse. And of course, the last argument, the quality of uh future surgical care being at risk. There has been quite significant instances of reported unsupervised practices, uh procedural or clinical and increased incidents affecting patient care negatively. And if we don't train the surgeons today, who's going to provide the high quality care or supervise those extended surgical team members tomorrow. So no training today, there's no surgeons tomorrow. Um As you can see, asset and BM surveys have revealed that there have been instances of negative impact on patient care. 87% of doctors uh who undertook the BMA survey said that um uh there is a risk of to patient safety with the way current practices are going and um never events as well as quite a significant topical issue that has come up. But you know, you could argue uh everyone makes mistakes. However, the equivalence of that, the hours of training that a doctor does is significantly much higher compared to that of a pa and limited experience will put you at the high risk of making those mistakes. And a investigation in Scotland has found that pas pay related never events were unproportional higher uh of those compared to a doctor. So to sum up uh my side of the speech is that uh by expanding unregulated by having unregulated expansion with a lack of infrastructure for pa or extended surgical uh um uh team. Um uh If we don't have the infrastructure, we don't have the the doctors that are willing to do it. We're skiing the surgeons of tomorrow. We're adding to trainee burn out. There are supervision challenges and the quality of future surgical care is at significant risk. Thank you, Val. Thank you, Val. Got a few more minutes left. Um Thank you, Panel Mister Media. Press president. So we should be concerned. We've got a record number of trainees who've answered our call to arms and have filled out this survey. The writing is on the wall. We've got a well meaning initiative, potentially having potentially catastrophic effect on our surgical training in the future. We're risking diluting training. We're risking absolute tsunami of never events. Potentially as a consultant, I'm expected to train um trainees, nontraining grades, uh medical students, the expansion of medical students numbers and also now potentially unknown number of pas the regulation is not set up yet. We are in its infancy. All of that needs to be set up, all of that needs to be discussed and every one of those bits are absolutely vital to create a way in which we can actually integrate these team members, make it safe for them to practice and make them useful for us as clinicians for our patients on the wards day to day in its current format, I feel and we strongly say that this is dangerous, dangerous for trainees, dangerous for patients being in. No doubt that in its current format unregulated, it does threaten, it does undermine and it does risk everything for our patients and for our training. So as a consultant, what can I do? So in principle, we would carry on, we are basically at the at the ground zero on the coalface, we would have to continue. We would we would support our colleagues we would do the training, we would, we would help for them as we can do as we would do with every single person who's on our, on our, on our team. That is creating a huge amount of stress for consultants. It's gonna be risking burnout, risking us, not operating and just spending time dealing in litigation, dealing in complaints, emails. If that tsunami of 31,000 never events does occur in an unregulated setting. This is gonna have a, a massive impact throughout all the grades. So I'm so so pleased that yesterday, all four college presidents and vice presidents were here. They hear our concerns, they hear our survey and I can't thank them strongly enough off the record and on the record, they are strongest advocates as well as the asset executive and asset committee are definitely fighting your cause. This is not something that managers or politicians understand enough to care about. It is not about votes is about core safety and core priorities for us as a training organization. And yeah, you should be alarmed and the number of record number of trainees who've, who've answered this survey shows that we are alarmed. Um we need to um have some regulation and yes, this ends our case. Thank you to um Val and to Goldie. Um and the proposers um I'm now going to ask Mr Vij and to give the opening arguments for the um oppo opposition. And obviously I am aware that the opposing team may have some questions to the proposition um today, but we will also do that after your statements. Thank you, Martin. Thank you, President and Committee of Asset for this kind invitation. I have no particular expertise in this area and I think you probably only asked me because you thought you could bribe me with a seat of the dinner last night. And it worked last weekend. I phoned my mother and I said, look, those nice people have asked you have asked me to come and speak on Sunday, Mother's Day. This is the debate. It's a bit, um, controversial. What should be my strategy? What should I do? And she said, huh? So you're gonna spend, er, mother's Day with a bunch of strangers rather than with me. Uh, the woman who carried you for nine months, washed and fed, you comforted you when you failed your Fr CS. Well, you're gonna lose the debate. Um, losing the debate might hurt, but reminding me I'd fail, the exam was even worse. Um, a few disclosures first. Uh, I'm a member of the College of Surgeons of England. Uh I'm also a consultant vascular surgeon here in Bournemouth. And I'm a visiting fellow at Bournemouth University where I lecture PS. And today I'm speaking in my own capacity and not representing any of those organizations. The motion. It's a little bit naughty, isn't it? Because it's asking us to conflate the extended surgical team with physicians, associates and it is concerns about the latter groups that caused all the anxiety, discomfort and turmoil amongst us with respect to pas Well, there have been clear instances of scope creep. They've been seeing treating and managing undifferentiated patients in primary care and the problems we're aware of. They've been prescribing illegally in some cases and requesting investigations using ionizing radiation and some have not been clear to patients that they're not doctors. And there have been accusations of training opportunities being taken away from our own trainees. Some of the comments from uh GMC N HSE and some Royal colleges and the government has only compounded the problem and the social media have amplified it. I'm sure you've read the results of the asset survey and especially the comments and the appendix. But these are directed really at PA S and not the extended surgical team as we understand it. So to the motion this house believes that the expansion of the extended surgical team threatens undermines risks surgical training. The simple reaction in response is yes, of course. Yes. Why would you ever think otherwise? But the more complex and less intuitive answer is no and I hope you might come to believe that no could bring surgeons and especially you and your successors a better and more fulfilling working life. It's worth revising how we've got. Here in the early two thousands, we saw a reduction in doctors working hours and the introduction of shift working. There was a reduction in the number of juniors working in surgery, especially at the most junior levels when a lot of foundation posts got taken away into primary care. Those juniors remaining in surgery were stretched to deliver service at the expense of training and to the detriment of patient care. The need for more specialist training brought an end to trainees covering multiple specialties when on call. So there were more gaps. The response of many surgical teams was to use the funding from these lost posts to employ non doctors. And these became the ex extended surgical team. They were then pilots of improving surgical training. I ST supported by assets. At that time, the pilot training program for general surgery started in 2018, followed soon by urology and vascular and then trauma orthopedics in 2020. And one of the pillars of this process was and I quote training and developing a workforce from other professions to support trainees to help deliver better patient care and free up their time for more training. Exactly what you want. Most surgical units chose to employ nurse practitioners rather than pa s. How are things for you? There is unhappiness about pay and conditions even without the insult of pas earning more. After less training and with lesser qualification, there's unhappiness about access to training in theater, endoscopy and other areas. There's unhappiness about the possible erosion of the surgical profession and threats not only from pas but from medical apprenticeships and the long term workforce plan that doesn't seem to increase trainee places, the, the demands of rotational training are also heavy, especially if you have a family to look after. None of these is the fault of the extended surgical team. Take pay. For example, pa S are paid on agenda for change. They have no influence over that. They're probably paid the right amount for their skills, but you are grossly underpaid and ps most of them would agree with this. The fault lies with successive governments previously, NHS England, the GMC and other medical leaders who have allowed this to run out with our control. What would you doctors in the surgical team need of the extended surgical team? Well, this depends very much on the stage. Obviously, if you're an F one, your needs are slightly different from an ST eight. But in general terms, you want someone to take all the dull, boring jobs that are not educational. This generally equals admin such as for an F one discharge forms, fluid and drug prescriptions, pharmacy queries, collecting audit data, recording notes on the ward rounds, chasing up investigations, that kind of thing. You've all done it specifically for higher trainees. These roles could cover tasks in and around theater such as booking cases, catheterization, the who checklist, prepping and draping harvesting vein for bypass, inserting ports, retracting, sign out, filling in histology and micro forms, closing wounds, completing databases such as the National Joint Registry and the Vascular Registry. Basically doing any tasks for the trainee in which that trainee has already achieved competence. None of this is new. We're already accustomed to members of the e carrying out these and many other tasks. So what then is the reason for this big debate and why are we getting ourselves in the lather about it? In simplest of terms, I see it as this and some of these answer the points that are made by the proposition in the vacuum left by the absence of poor regulation and scope of practice. NHS trusts, local surgical units and individual consultants have developed their ESS and formed them to fit the particular needs of their service rather than those of you, the trainees provision of service has trumped training and areas of bad and questionable practice have been allowed. So here, I'll remind you of the pillar of I ST that I quoted earlier on training and developing a workforce from other professions, the extended surgical team to support trainees to help deliver better patient care and free up their time for more training. Instead, we've developed the es and allowed it in some units in some hospitals and in some places to spread into areas that objectively hinder your training. The joint surgical Royal colleges, not including the Irish College produced a statement in October last year, addressing specifically the e recognizing their importance in surgical care. But acknowledging the lack of clear definition of scope of practice, assessment and governance, a task and finish group that included representatives of AIT and was set up to produce guidance, rcs England also published the surgical care team, a guidance framework describing clear principles of training, management, supervision and guidance on reading this. You'd be excused for screaming. If only people had followed this, we wouldn't be in such a mess. Then in February this year, the English College Council discussed the matter of pas and published its views. In summary, physician associates must not replace surgeons or surgical trainees. There is an urgent need to define a national scope of practice and training curricula and training time for surgical trainees must be protected and enhanced. Subsequently, the waters have been muddled by various statements from other organizations. Is everything going to be fine. Well, maybe there's no guarantee that a nationally defined scope of practice re specialty will be used by trusts to inform the parameters around the role of the physician associates. So therefore, RCs England will be talking with N and GMC on making sure that Pas don't carry out duties that should be performed by you. The trainees and how regulation will ensure scope of practice, revalidation and fitness to practice R. CS England also is talking to local consultants show that they're responsible for agreeing how PAS are used in surgical teams and will communicate with its members that this duty should be exercised responsibly and cautiously while national scope of practice and regulations are pending. In conclusion, est isn't going away, the es when deployed correctly has the power to work for us. And our patients consultants who lead EST S need to get their priorities right by putting trainees first, something they've failed to do and surgeon leaders, whatever organizations they serve need to remember that the well honed skills of people like you are, what the health of this nation depends on. And that when they were training, they too were eager to get their hands on every possible training case and educational experience. They could don't despair support the controlled expansion of the extended surgical team because with regulation, good governance and a strict scope of practice as in the USA, they do not threaten undermine or risk surgical training, but actually can enhance your working lives and improve access to training. So I implore you to vote against the motion. Thank you. Thank you. I'm going to ask our second um opposer um Mister Davis for the closing argument. Good afternoon Asset. It's no to speak for the topic. I've been listening to the whole of the Panelist. I'm just going to echo a few thoughts which Mr V has already said and I know the house is probably divided. But by the end of this panel discussion, we'll have something to take home. First of all, this is not a debate, this is a discussion, we are trying to get some wisdom, we are going to focus on that so that we can apply that in our small world to get big things done. The thing which I don't like is nobody is going to threaten us. So the threaten is a very strong word which has to be redefined. It's clear from all the discussions that extended surgical team had a, a very novel, very ideal thought which was to improve the surgical training. And now we are going to say that it's actually threatening the surgical training. That's not fair. Let me make this very clear. We are all surgeons. There's no doubt about that. We are all surgeons, we are all managers, we are all leaders. So there are in things which we can't do if we unite and plan things proper. So don't under underestimate the power of being a surgical doctor or a surgeon. There's no point of telling 100 million times what the problems are, but we can propose solutions and we have solutions blaming and getting panicked is not needed. Let's work together. That's exactly as it is done. We have done a national collaborative thanks to the team. I'm happy that I was part of that and we have actually brought up a few issues which needs to be highlighted. Let me ask you as a surgical trainee, you and me is our issue, the extended surgical training or just training as such. Are we all getting trained the way we expect it. Are we all safe and confident and competent to be a day one consultant after the training program or the curricula we have here? Probably not. I am not, at least probably the house is again divided on that. So the actual problem is not extended surgical team. The actual problem is fair. Just equal training opportunities. We were talking about burnout. So getting burned out was not because of external surgical team. We are already burned out, aren't we? We were all burned out for generations. So, external surgical team is not causing that probably a bit. I'm I'm not saying they are not doing it but it's not, it's not their fault. And I think the, the key is the surgical team. Do we have a proper surgical team? I imagine a world where there was no extended surgical teams. APA S or nurse practitioners or CPS or S NPS or whatever. Don't we still have problems in our units? Don't we have difficult different colleagues who steals cases from us? Operating chances, don't we have senior stubborn, senior colleagues, senior trainees who are refuse, who are still refusing to change. Don't we have difficult consultants who does not understand the the point of training us? I'm very proud that Aet is offering the prestigious awards like scalpel scissors and sutures. Some days when I work, II think back of my mind, we should also have a watch like for anastomotic leak like broken bones. These are probably for the bad trainers we have in every unit. I'm not saying my unit is bad or good, but we do have bad units. So we should also have these awards to pick those people up so that they including me and you and us. We should be good trainers. Mr We brought on extensive national collaborative detail in the evolution of the whole concept of extended surgical team. And I understand we have done a survey, there are units where it works bad, but I come from a unit where it works well. And let me tell you the journey was not easy. But as I said, we are surgeons, we are leaders and we lead the way and we get things done the way we need as long as I say for the patient and the team. So we did have a teaching and training committee manned by the fire up up from the CT S and ST S clinical leads, division leads and we sat down. So like we have before every single operating case, we should sit down and discuss the scope of practice and what we're going to do for each operating case or each each clinic list. So we sat down, we said this is what we need at different stages of training within our team and who's going to be making sure that happens. The consultant was responsible of the patient of the team altogether. So as a team in our hospital in our training center in our region. We make sure that everybody gets what they need to be getting. Last minute, Martin. Sorry about that. So what I was going to say is the idea of extended surgical team is basically built on the idea that we can have enhanced training, they can supplement us and they can help us do the things what we need to do, but there needs to be a change. So I propose we need to mold, we need to redefine, we need to break barriers and I'm talking this to the future surgeons. You and me are going to be the consultant in a decade, five years, 10 years time. If we act now together, if we have our minds clear what to be done, what should be done? Nothing is going to stop us. Thank you. So th some food for thought and some um interesting points made. So with tradition, um I'm going to ask do either of the um proposers or opposer have any points they wish to add from what they've heard from their teams. No, if I may I over the last few days, I've been in conversation with a lot of trainees. There was Thursday night at the college sponsored drinks, reception for a and then on Friday, the college visited my trust in Bournemouth and we met a whole range of trainees from f one level up to registrars and SS doctors as well as the consultants and then, um, last night at the dinner, I was, um, very happy to be able to speak to plenty. I hope some of you who are here today. And, uh, obviously the topic of pa s came up and I'm not sure what I was expecting, but I wasn't expecting that all of them would be saying to me. Look, I think this has just been so polarized that the voice of reason isn't being heard. And what they were saying to me is one chap actually was in the ro group. He said, look, I've been taught by a nurse endoscopist part of the extensive surgical team. She's done 1000 endoscopies. She taught me much better than the consultant who was my trainer. And that's one example of how the extended surgical team can be beneficial to you. But there were countless others I could recount. I didn't hear one example of someone saying a pa or a nurse practitioner is getting in the way of my training. Clearly that happens because it's been shown in the asset survey. But I just want to say that we can sometimes be um coerced by the feelings on Twitter and on the social media of thinking in a certain way when really there's a lot more outside Twitter is only a small percentage of world thought and surgical thought. So that's all I wanted to say. Some balance would be good to have. Thank you. So, over to the house? Would anyone wish to pose a question or point to either side if you do, please raise your hand? We've got our new elected Director of Education and someone's just behind you, Michael, who wishes to ask the question. So you've got less than one minute, please. Uh So my question is, um I've spoken to a few consultants. Uh and some of them are under the impression that it would be useful for them to have within their work schedule, dedicated supervision time for PA S as they normally have with their trainees. Um And my concern is that um have for consultants having dedicated supervision time for PA S in their departments along with their trainees would essentially detract finite time from trainees and especially when the PS are permanent members of the department. Whereas trainees rotate, um wouldn't this just give more incentive for a consultant to train their PA S? So essentially my question is, should p should consultants have dedicated time within their work schedules to supervise the PA S as they do their trainees? Thank you. Take that to the um opposition. Well, no one is saying you've got to have a pa in your department. My department works perfectly well without a pa, we've got three nurse practitioners. But if you, if you do have to have a PA, well, that goes back to what I was saying, it's the job of the consultant to make sure that he or she puts the surgical trainee first. So get their training done. If you've got spare time in your job plan, then by all means, put in something for training a pa but the surgical training has to come first. And that's why we're in this mess. Partly is that some of my colleagues perhaps have let things slip rather than keeping a tight control over what actually happens in their department. Can I respond? Yes. Um I think what you're actually expressing is inevitable and there is a finite time for consultants. And you know, if we looking at the errors that um you know, the extended team could um facilitate if not fully trained and supervised and looked after, I think it's quite scary. So in a finite time, it has to be that we protect our, our surgical trainees um and our doctors. So I think it's a really, really good question and it's inevitable that um this is gonna eat into valuable consultant time, um which there isn't any short comment if I can. Sorry Martin. Another thing to note, if we're looking at different system, uh different systems. So in the US, the trainees are not rotational bases. So it makes a very, very massive difference in terms of how the relationship between the supervisors pa s and the trainees works because they build the report, they, they come, they come to the unit, they work there, they're allowed to progress when we're rotating along. We're just someone who's passing by and it takes a lot of time to develop that report with your consultant. So dedicated time for ps uh poses a significant uh challenge for the trainees because if anything trainees need more time, they're already lacking time for good supervision and good progression. So it's a really challenging dynamic that we're in at the moment. So this is a really good opportunity for you to ask questions, but obviously we want to get to a outcome from today's to be a title, but we're going to spend another five more minutes exploring these issues. Does anyone else want to add a point of order or a question to the panel question just here if you had entered it? Oh, yeah, thanks. Er, I'm Alex Ortho ST three in eastern England. Um, I think your examples of what the extended team can do to supposedly help with the stuff that we don't want to do actually illustrates the training opportunities that they can be taking away. So, things like putting in ports and closing wounds. That's exactly the kind of thing that when I was in F one, I was wanting to do as how I start off in surgery and then going on to the nurse endoscopist. I mean, I don't know if there's any general surgery registrars here who can talk about the difficulty getting their endoscopy numbers. So I think you've, you've, you've shown there some of the problems that are in this So, yeah. Um Well, well, thank you. But um and that, that's a very well made point. Uh II would only say that those jobs that I mention like putting in ports. I did qualify that by saying that they would be something that the extended surgical team could do once the trainee had gained competence in those procedures, not that they should be done without the trainee having her go and learning and being trained on them. Um And the second point about procedures such as endoscopies that is in, I'm not a gi surgeon, say it's not part of my experience. But what I would say is that if there's a training goal that has to be achieved by a registrar, for example, then it is the job of their trainer, the surgeon to make sure that they are given the opportunities. Now, in most departments, I would say that that nurse endoscopist would be under the auspices of a of a unit, a clinical directorate. And therefore it is the job of the surgeons in that directorate to make sure that training opportunities are there for the trainee. The nurse endoscopist done thousands, they shouldn't have to do any more without letting the trainees to do so. Yeah, but by definition, those thousands of endoscopies that nurse has done has been thousands of missed opportunities where a surgical trainee could have done that in a supervised safe environment. So it's, it literally is a circular argument. You're doing that and actually putting trainees at risk, they're rotating, they're vulnerable. They haven't got the support network. They've gone nights, they're on multiple shift patterns. And yet you've got these embedded characters who were expecting them to be altruistic and to share and to train and yes, that may happen. And I'm, you know, pleased that you've got some excellent examples of that occurring. But in reality, with expanding training numbers, with the bottleneck that we've got for, you know, consultant numbers numbers, this is not something that we can give up. Unfortunately. So those thousands of endoscopies that your nurse endoscopist has done, unfortunately, I'd be very upset about that to respond. Well, I see your point. I think I would say that when I talk to my general surgery registrars in the unit, they say yes, they've got to do endoscopies, but they've also got to do laparoscopies and they've got to do this and that and the other, they cannot spend all week doing endoscopies. So there are clearly times when there are endoscopies that need to be done and there are no surgical trainees available to do them. And why shouldn't a nurse endoscopist who's capable of doing them, do them? II completely understand where the question came from because myself is a surgical, I'm not agreeing or disagreeing to it. But the whole, the point is we might have lost the battle or slipped the battle a tiny bit to start with. But now if we plan properly and respond, we can win the battle back again by making sure that all what we need we get and I'm sure the extended surgical team could not stand in front of us. If the trainer backs us up and if we have a supervisor, we have a training program director, we have curriculum. So if they back us up, nobody can stand in front of us. So it's us still leading the show. So as long as we as a team gel together, we can still get what we need. It's a challenge, but we should stick together to make sure that our needs are met before others are given a chance. It's difficult, but we should probably do it in a slightly more different way. Maybe just a food for thought. Thank you. And we're going to take a final question now from the house just here. Hello there. My name is Val. I'm one of the F ones. Um I can't speak to the higher levels of training. But um my experience has been that for example, pas if they were to be able to replace us in the ward scenario and the F one able to go to theater or whatever else that would work well. But specifically, the pas lack the ability to do the essential tasks, request the imaging, prescribe the appropriate drugs and medications. So in a sense, they're not really a replacement for the non training opportunities. They're actually competing for the training opportunities. Instead I go to the proposers if you want to respond to that. Well, that aspect, uh considering that aspect of things, where is the lack of staff, uh where do we lack people? Is it in theaters or is it in Ward setting? And when you go into theaters, even myself as a trainee, I've found myself in situations when you go in and there's eight people operating on a single patient, your training opportunities in that setting. Obviously, there are ways how you can manage it, but your training opportunities are very diluted other than having 1 to 1 ratio training. And it gets even worse when you're just left to deal with the ward work and all of the service provision jobs and uh someone else who's uh not a surgical trainee, not someone interested in surgery, uh not some well interested in surgery and liking, liking the field, but they're prioritized over someone who may become future surgeon consultant. They're prioritized to uh get the training opportunities is not great. It puts people puts people off even wanting to do a surgical training pathway. So I think, I think it's uh it's a problematic situation. I believe strongly that the extended surgical team can support the trainees on their rotational basis. In terms of getting a good understanding of how the certain services work, how the referral pathways work, supporting trainees in that way, supporting them with the, with the word work. However, we do have enough of people in theaters as it is and training opportunities are so, so limited. So it's, it's tough. Uh but we do have to find solutions moving forwards. And probably uh one of those things would be clearly defining what the scope of practice of the pas would be in the surgical setting and who takes on the supervisory roles of that, what they're meant to do. How far do we let them go in terms of performing the procedures? What sort of procedures or do we want them supporting the doctors as physician's assistant or associate in setting? Mr Thank you for your question. You're clearly here because you're interested in surgery and I'd encourage you to keep on and follow that. And if the college Surgeons of England can help you, please ask, that's my plug to answer your question. If you wanted to get to theater and at the moment, the tasks that you mention, like prescribing and ordering x rays you can't do. And I accept that those aspects are going to be addressed because prescribing roles are coming for pas, there are nurse prescribers already. Our nurse practitioners can prescribe. So our f ones if they desire, they could go to theater and the drugs can be sorted out by the nurses. Similarly, with request for x rays, there are protocols by which physiotherapists in the community, by which nurse practitioners and specialties can order certain types of X rays. So whatever your specialty is, those things can be arranged by discussion and going through the regular governance procedures of the trusts. So I don't think it's insurmountable that a APF one in your position could want to go to theater and leave a lot of the, the drudgery that you we we talked about earlier on to another member of the team. I hope that will be the case soon so that people like you can follow their um their dream and uh become surgeons. Thank you. Thank you for all of your questions and thank you for our panelists on the P proposition and the opposition on behalf of the of the council. Thank you for standing up and stating your arguments. This is something that's very important to the organization, but importantly to trainees and the future of the profession. What we do now is we will ask you to again scan via the QR code and our pool will be opened in regards of the motion. So again, the motion is this house believes that the expansion of extended surgical team threatens undermines risks surgical training. Following the announcement of the result of today's debate, we're going to make a short statement to explain why Asset Council felt that this was important and we're delighted the Asset Council is not just made up of surgical trainees but also are invited observers, those from the British Medical Association, other Royal College representatives and also representation. To the Academy of Training doctors group. So I'm gonna give one more minute and then if we can have on the main screen, the result. No. Yeah, that's good. Yes. So if we can now on the main screen have the vote closed, I don't see the result. I will see it with you. So on the main screen, we have 73% for the motion and 26 25% against. Therefore, the motion does carry and thank you to the proposition today for today's date. So on clo closing um today, on behalf of um sh our president, the executive in council and going to just read a short statement which will be public in the upcoming EST report. Asset is committed to the multidisciplinary team with respect for the contributions of all members to surgical care and the est pilot in its third year provides as examples of practice where health care services can be supported to deliver patient care safely. There is a considerable spectrum of health care professionals under the banner of the est with varying clarity as to the intended purpose of the rule. Some well established roles in surgical care such as surgical practitioners, advanced surgical nurse practitioners are regulated with a clear scope of practice that has been developed across many years. With the input and guidance of the Surgical Royal College. The specific role played by these professionals has enabled considerable support to trainees and surgeons in delivering patient care, other roles within the bracket of the est, lack that same clarity, absent externality and an evidence base to development with no clear scope to the practice. It is important for us to be specific in referencing these roles as there is differing remits and skill sets. And in doing so, we are better placed to understand how health care and surgical services may benefit from each of these roles. Respectful that the use of the term est does not inherently confer uniformity of practice. Notably, the recent long term workforce plan by the NHS brought to light the proposed expansion of rules within the est and particularly that of physician associates as it has been approached by multiple stakeholders from across health care and surgery, requesting that we adopt a position on these workforce changes and in particular, the role of PA S, we have always been conscious and consistent in the principles as the pan specialty, pan grade surgical training organization to the UK and Ireland to advocate based on the evidence and not anecdote. Our goals are to contribute to a thoughtful and constructive dialogue that is based on evidence, to inform and cultivate the solutions for the future surgical workforce. The asset report referred to here today is the largest survey in our history, reflecting the views from every surgical specialty grade and region that narrates the diverse spectrum of experiences and views on the roles of PA S in a modern surgical workforce it is essential to take all of these experiences into account to ensure the sustainability and cohesion of surgical services. As part of the long term strategy, the health care service must adopt to meet the demands and the utilization of all est rules to provide support to a workforce that isn't under immense strain, a healthcare service where training and expansion of surgeons and doctors is at the heart of a strategy with est roles, providing support in delivery of care, the evidence that has been documented within the report. And indeed, our pa a survey is an invitation to leaders of health care and ST stakeholders to shape the future of surgical health care with an awareness to the opportunities and challenges presented by the integration of various est rules in the surgical workforce. Thank you very much. Everyone that concludes the debate for us at 2024 and now we're going to pass over to our incoming President Mr Berger to deliver the closing remarks as well as our awards. So give us a few moments for that. Thank you, everyone.