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Um I'm very inspired by the title of the next talk. Um It's called Rise of the Phoenix. Um And very thankful to our two speakers who are going to do it as a joint presentation. Um Firstly, we've got Mr Sash Banerjee who's a consultant colorectal surgeon. He's the S A C liaison member and has additional responsibility for gi endoscopy. Um uh And, and does that through an endoscopy training to through the J C S T. Um He is a regional director for in Northeast London, um an examiner and the I S T P lead clinical lead. Um Mr Am a Lash is a consultant upper gi surgeon, Northeast London. He's the director of Surgery and Aesthetic and Critical Care Group embarking have a Ring Red Bird NHS Trust and he's the chair of the Surgical Optimization Group in North East London. Thank you both so much for joining us this morning. Thank you. Uh Just uh I'm um Lish, I've just got one question uh down for the organizers. We've got anesthetist sitting separately, surgeon, sitting separately. So if the date, oh thing, how it happens. Good morning, everybody. I'm sasp anergy and delighted to be here. Actually, it's afternoon. I was thinking it's still morning. Um Thank you for the invitation and congratulations to asset for organizing an absolutely fabulous conference. Uh, congratulations to Tamara and our Silver suture aboard winner as well. Um, between us, uh, and lunch you have 20 minutes and I'm gonna just bear with us because I'm going to talk to you about the mythological bird called the Phoenix, which has got origins in Greek and Egyptian mythology. And the magic about this bird is that it combusts or it dies and it regenerates. And over the next 20 minutes, we will talk to you about some of our past where we are currently and post some questions for the future just like Colin did so our Phoenix at our institution combusts and Parishes after the G M C does a risk based review in 2016 when we had a pretty unpleasant uh NTS results for our foundation trainees. And this was unprecedented because within a couple of weeks, we had 12 foundation trainees withdrawn from the trust whilst we had to continue running the same service. We had to take that feedback and think rebound with something positive. We came up with something called a transformation plan that completely revolutionized the way we provide trading to foundation trainees. We gave them access to theaters, we gave them access to clinics, it was rostered in and we encouraged them to be actively participating quality improvement projects and most importantly, contact time with supervisors built in into the job plan. This was then presented at the next acid conference as you can see in the poster, right? How are we going to go about? This is we're going to tell you a story, a story about a context of where we are working in, things have changed and what we're working in. What are the things that we did and what are the impact of this? And as I said, what do we think the future could hold when we look at it? So when we look into the context, this just didn't happen during the pandemic. Yeah, if you say that we're fooling ourselves, this is 2017 2018, you can see the things during winter. We were a seasonal elector was almost a seasonal operation that was happening the NHS during winter, we shut it. Yeah, we just concentrate an emergency. Uh Next slide, please. What happened during the pandemic was the waiting list. Just shot up. Yeah, for us or 52 weeks, we're almost virtually no pre pandemic and it just climbed and climbed the first. If you just keep climbing up for the few weeks, it's just patient's waiting for one year. So if you take that as a context and if you look into saying, you all know during the time of the pandemic were all thrown out trainees and everyone was going down to the independent sectors operating and all it meant was about 1.2 million fewer operations that trainees have been involved in since the time of the pandemic. That is a whopping large number, you know, catch up is going to be huge and endoscopy is absolutely similar. Excellent, please. This is our trust. I expect this to be potentially across the country. You look down at the tablet column below our emergency volume that we are doing currently has increased by about 10, somewhere between 10 to about 25%. What that meant was we are currently pre pandemic. We're giving six emergency Thetis for emergency activity. Currently we give eight emergency status. The taters that we have is fixed number which is meant that we had to take from elective to give for emergency resulting in a 14% reduction in capacity for elective work next time, please. So going back to the context as Amylase said, um Northeast London has got a population about two million. This lovely city of Liverpool we were checking at breakfast time has got population about 500,000. Uh North East London is one of the most deprived parts of the country. And with deprivation comes health inequalities in poor health. Now over the next five years, what we expect is our North East London population to grow by about 300,000. That's the entire volume of Newcastle moving into this area. What we couldn't do as the pandemic was shutting down, do the same things as we did before yet. For us, it was never an option. We cannot go back to the battle state of closing things during when opening things up, not knowing whether you can operate on somebody, not knowing who's going to do what it wasn't. Uh It wasn't an option for us. Uh We had two sites we serve personally. The trust serves a population of about a million population. We had to hospitals for us. We decided to move emergency completely out from one hospital to another another hospital site. We still have an acute idea at that hospital site uh but it was possible to do. Um So one site is dedicated for elective, another site is dedicated for emergency, but we also do some day case elective activity through the other site which is much more uh more emergency activity goes through. We now work on a model called as one team to sites everyone across the dream trainees, everyone not a single person works on both sides. I never used to work across one hospital at all to 2019 2020 before the pandemic I do is the visual surgeries, ideas, vitrectomies, gastric never used to step in. Now, neurosurgery, everyone works across both sides. Uh We currently worked up 30 beds less what the splittist meant is our bed based. We have, we are able to reduce it to about 30 beds, less the elective beds that we do are not specialty based. So our elected, what has everything, name it. You can have it. Yeah, urology, gynecology, neurosurgery, general surgery, colorectal. We have everything and we look after the patient. It gives a much more synergy in how we look after them. We have done some workforce transformation. We'll, we'll show you a little bit of that one element that we wanted to build into. This was our elective HD you stroke I T U hub within this site within the hub itself. So it's not separately in a different part of the I T U. But we have about seven beds, we can flex it up to 10, you can go up to level one if we need to, we can be Mr Pacu if we need to, we flex up and down with the workforce, it is part of the surgical team, we do it and as it is and critical care needs to cover it. So it really works well. Pre assessment is broken across the country. We cannot get a patient right from when we say, can this patient come to the hospital to the patient? Right on the table. So first thing we did was fixed that robotic surgery. We this the future has to be something different. You know, we can't re imagine a future where we were doing things before we now have two robots that we have Davinci. Uh We also got Makro robot for orthopedics were the first trust in the country to have robotic colonoscopy, which we just launched about four weeks ago, not admitted pathways are a huge strain for us which had to be tackled next slide, please. So the college also was very keen to have separation of emergency and elective. And with what we had as the hub, we were able to have the precedent visiting us. And he was very impressed with the vision that we were generating. One element that we tried to change was um I know uh broad college for surgical nurse practice. And for us, we felt we will want the wards to be supported. So we now have a training program for advanced nurse practitioners, advanced nurse practitioners cover the wards. What it does is it gives us two big benefit. One for our trainees, they can do the ward round and go to the status that they need to go to the ward work is covered by the nurse practice are fantastic. What it does for the consultants like me is if we go down there, there's one point of contact that we can ask, you know, sometimes people are different rotors. So it doesn't have the patient care is good. The nurses are happy, the trainees are happy, we are happy. Patient's are really appreciative of what we do is really transform how we work there. Next slide, please. So um we've, we've heard Jill although virtually, and we're really proud to be an extended surgical team um pilot site and and Paul's here as well. And what is quite important is in addition to the advanced nurse practitioners that analysts just mentioned, we have the concept of the doctor's assistance and there are usually banned three colleagues. They're fantastic because they do a lot of the work for the admin clerical work, sometimes getting a form across something also some conversations and they're brilliant asset. And here you can see a couple of pictures and um Jill is present virtually as well as on the slide here, international medical graduates. Now this is something that Colin raised the question. Uh and they're often now the forgotten tribe or the lost tribe as we used to call them. And the basic surgical training rotations that we had used to have in the past in my youth, when I was training, we created them with the new concept called the Academy of Surgery, gave them access to funded msc's gave them access to the I S C P and educational supervisors and encouraged them and they had the benefit of being able to visit different specialties, build a portfolio. Majority of them have gone on to acquire trading positions in either court or higher, either surgical or different specialties. And this was recognized by the Candida Report as an exemplar. I'm very proud to have the International Surgical Training program, trainees join us as well. They come from different healthcare environments and bring unique perspectives and what the Academy of Surgery trainees do as well as these colleagues do. They help with the Rotas becoming less intense and that helps everybody including our health education England trainees. Now, every um institution that wants to look after training has to develop in house courses apart from, depending on what the Dean Ary can offer. And here there's a list of couple uh what we offer. But I think there's some things that were quite proud of is we have recently become an endoscopy. So jag regional Training center and as you know, it's part of your curriculum. So we're able to offer gastroscopy and colonoscopy, basic surgical, basic courses. The other thing is of course a robotic surgery. We've just got ourselves a training console. And so the robotic surgical course is what we're going to launch. Now, this is what we have run ever since we had the transformation plan and it is run about three times a year and it's extremely successful. It's also accredited by the Royal College of Surgeons. And I think uh the feedback has been very good in all this. I think the critical bid is about healthcare and it starts from self care. So we have had sessions where we've been able to have safe spaces for people to have difficult discussion's poignant stories and healthcare. Health being uh sorry, well being checks are important. And I sort of refer to this poster which is downstairs by Robin that talks about the need for well being checks at every meeting with your, either your C S or A. Yes, this is something new because of the curriculum having changed. And what we have done is we've started immersion training. We've had a surgical fellow who's been able to spend two weeks in endoscopy doing every list and at the end of the two weeks had 60 colonoscopy procedures, dots and a progression along the learning curve. Ultimately, we're here for our patient's. Yeah, everything is goes back to how can we look after our patient's much more better are PTL is going big and what we feel we have this ethos, yeah, productivity is a side effect of focus. If you have everything is your focus, you do nothing, you know, until you want to become productive, you need to know what is it that you want to be tackling. So we focus on if we have an issue, we focus on it, try to get over it three weeks, four weeks. Currently, the bit about just pointing in the ent kids is currently, we have no ent pediatric patient waiting for zero. Uh Any first appointment's at all. It took 12 weeks. We changed the entire outpatient to just pediatric ent outpatients and we got that done impact hernia done by predominantly trainees 201st any appointments in the 11 day and we did the operation's over two weeks and about two weeks later with the train is completely involved in it. Um Stella mentioned about outpatients and D N A. So we recently launched something about for D N A. Somebody sits and just rings a patient. We saw a reduction in D N A rate of about 5 to 8%. Uh which in turn means about 100 new appointments in every, every week for just five specialties. Now, we're running it across 39 specialties. You can just see we can do things much more better. Next slide, please. So this is our model hospital data. The blue line on the top is our trust data and the black line is national data and the productivity is the left top left graph that is there our productively is about close to about 85%. Uh The lower one on the left is the number of cases that we can send through the blue line again is out trust and the black line is the national uh national average and the gray is appear average. The one that on the right top is the winter of 2021 Omicron crisis because of the separation. What happened was we were able to continue with the elective activity and the recent winter with all the pressures that we have uh again down there compared to nationally were able to continue. We did a bit of an audit on what was happening on the shop floor of every five surgical admission's that were having three of them were on a waiting list. These patient's were not being dealt with were coming back in through different forms. They were also clogging up the G P practices. GPS cannot see accu patient's, the patient's are coming to E D. This is a vicious cycle until you can deal with a backlog. You are going to be running your tail rounded next time, please. One part of update, improvement in efficiency. Just a snapshot. The green bars are the fellow sessions and the blue ones are the ones that we had 2019. Currently, we do not have fallow sessions come down significantly down the number of activity orthopedic activity last year. Just down below, we do about 10% more joint replacement competitive before with the less capacity compared to before. So previously, we, our capacities gone down by about 15% for orthopedic taters activity has gone up by about 10%. Uh These are entire waiting list. You can see how 52 weeks are coming down. We are one of the few trust where the actually the 52 weeks is coming down. Next slide, please. The government has launched a program called a Stiff where they've taken about 500 million and they're distributing across the country to see whether they can increase surgical capacity. We're building two theaters in there. Um Miss Weeks, talked about accreditation program. She came down for that. The team came down to have a look at it. Um One element of this is this is going to create new capacity and all this is going to be new training capacity that we have. Um And most of the things that we have done, in spite of all the things we haven't increased the workforce as much. We do think that if you take the admin and clerical and thinks a lot of clinicians and other people do a lot of work that can be done by others. And if you can move certain aspects of it down where you can actually increase productivity through it, next slide, please. So just a snapshot of what it means to be educational training, obsession. And here you can see that we have in our institution to Silver scalpel award winners. We've had to further nominees and commiserations to Richard. Uh We also can see that are majority of the consultants that work in the institution have been registrars within the region and specifically within the trust and effectively what it does. It shows that we are keen and we want to support training. And if you go back to what I said at the start about the feedings crashing and burning. And this is last year's G M C data. It shows that we have actually paid attention and not given up on uh what is the real thing to do, which is focused on are sort of the young generation as you can see the seventh uh sorry, the ninth in the country. I was just giving myself a bit of a extra leeway uh and the 12th in the country for overall in general surgical performance. And I have been educated that Paul and John are the authors of the hashtag no training today, know surgeons tomorrow. Definitely John, how do we how, what do we see, you know, the best way we can predict the future is to create it and nobody else is gonna come and create it. No one is going to come. We got to imagine it and we got to do it. We got to do it at pace. That is uh I keep saying it. There was if you can't do it personally, you know, in our trustee come down. If you can't do it in six weeks, you're never going to get done. People will wait for six months. I've been in it long enough. People talk and we don't move on stuff, we can talk, we look at data, we look at data, we look at data, we look at data. Yeah, we never move and sometimes you need to use a gut instinct to make a move. Um Team base structure. Currently, we are all firm based structure. We feel team based structures are the way forward. Uh We're happy to be corrected on it. Is that a way forward? I think we need to ask a question. Uh We were initially consultant led services uh consultant and now we become consultant delivered services. I think with all the pressures we will revert back to my feeling is consultant led services where the consultant will lead, there will be much more differential workforce below and it could be the same for also surgical doctors as well. Is it gonna be doctor delivered service or is it going to be doctor lead service? You know, these are questions for us to ask ourselves, the future is going to be, that is going to be suddenly from the surgical bed robotics, you know, 10 years, I can't see how we can run away from it. And we need to find ways that we can encourage you guys where where we can, we can make that change. You know, we cannot let that go with having a gap that is there technology and simulation. Um What do we do about it? How do we engage with this uh emerging um feel that it's happening? How do we get our training lined up towards this training? Focus, you know, trainees are the trainers of tomorrow. How do we get our trainees to focus on training? Um When the trainees come out, they should have a completely different mentality of to approach the training that they will be delivering compared to what they're doing now and we need to a cube them for it. Hubs and training, you know, hubs are going to be a national that that's happening. How do we then accommodate training into into the hubs environment that is there. You know, we call it for us. It's been easy because it's one trust. We call it as one team two sides and we, we never worked like this before. Yeah, just to put in all trainees, we're separate in those two sites now. Everyone works across. Thanks am Alicia. I think esteem colleague has said there's analogy of how we cut the cord when we have C C C C T. Um how do we encourage people like you not encourage you? How do we empower you to sort of know about to deal with complaints? How do we actually encourage you to know about what to do if you have a coroner's inquest to attend? How do we make you engage with managers with executives learn about to develop a strategic mind because I think the operative performance and the skills you will have, but it's the work that is done that is non clinical is a really difficult and that's something you need to learn during your process of training. Our DPTs need to think about whether the rotations need to be two years rather than train and move every year and leading to a little bit more stability. And how do we encourage our people coming from different shows to get apprenticeships within the NHS? How do we encourage young minds currently doing G C S E s and six forms to think about careers in surgery. So lots of questions to think about and I want to end with something that is just the key take home message that there's always been this theory that training and service are separated. But I think the theme that's come out of the recovery uh episode of COVID is that trading recovery is indelibly linked with service recovery and that leads to patient safety. Thank you very much. Thank you.