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OK. I think we're there. Um So, hello, welcome everyone um to this uh webinar uh hosted by Royal Surgeons of England on um sexual misconduct in surgery. Uh I'm Tamsin Cumming. I'm a colorectal surgeon and I'm chair of the Royal College of Surgeons of England Women in Surgery Forum. Uh I'm also a colea of the working party on sexual misconduct in surgery. Uh And I'd like to introduce um my uh cohost today uh Professor Ross, who is uh a professor of Human Resource Management and Organizational Psychology at the University of Glasgow and is uh also has taken up a role as adviser to the Royal College Surgeons of England on sexual misconduct. Uh So the plan is that we're going to uh present you some uh slides covering um the, the subjects over about the first half of the webinar. And then we're gonna open up uh for questions. So I will ask uh ros some questions and we will have a discussion and we'll uh see what questions there are in the chat. So, uh do please um put your chat, your questions in the chat as we go along? Thank you, Ross over to you. Pleasure. So, so thank you very much for this opportunity to and the Royal College for talking about the research that we've been doing. So, next slide, please. So what we're gonna be talking about is the um some work over a number of years uh drawing from that. So I just wanna recognize uh professional standards authority and also the National Institute for Healthcare for a recently funded work. Uh Next slide, please. So we thought it was important really to focus in terms of this research. What are we not talking about in this space? Uh Just to clarify completely. So what we're not talking about is being the front place. This is a very serious matter and a strategy used to deflect attention is often to say that is this about the flu police. Secondly, as Tamsin is going to be highlighting from the research that we've been doing together, but also the research that I've been doing with professional standards. This isn't just about women, this isn't just a women's issue, it's about men as well. And finally, this isn't a snowflake thing. So this is a very serious concern that is having dramatic consequences, not only for uh people within the profession and thank you for joining us tonight, but also for patients, for organizations um and for society as a whole. So what I'd like to do over the course of the next few minutes is just share some science. Uh and I appreciate that. That can have a strong impact on people. It can leave people feeling that this is a horrible thing that they don't want to talk about and they want to pull away and that's completely acceptable. It's a natural response to talking about this very difficult subject. Secondly, it can be something where people feel at last, somebody's talking about things that have been happening to me and they want to talk about it and engage with it. And finally, it can be something where people feel that this is a very difficult space for them and that they might feel that they have engaged in this behavior or they might have witnessed it and inadvertently um been part of the context we're talking about this because it's important to raise these concerns. So, on the next slide, I've got a series of quotes that come from my National Institute for Health Research project that's looking at witness to harm. So this is a doctor talking about their experiences. And as you can see here, these kind of highlight how people often feel about these experiences. So the idea that this might be an error of judgment, but also really the level of betrayal is highlighted here in terms of somebody that they trusted. Also, what we see here is their attempt to engage with this. Uh And this has been something that we've identified through a number of years. And then the third one is really showing the escalating pattern to behavior here. And I'll highlight this in the, the last one where we see other people being drawn inadvertently into this space through a range of different tactics that perpetrators can have. So I'm gonna now hand over to Tamsin and she's gonna be sharing with you the research that we've recently completed. Thank you, Tamsin. Thank you. So, um, this is just a recap for anyone who hasn't, um, sort of doesn't know the detail uh of what's, um, we um, published on the 12th of September and there was quite a lot of um uh of publicity around that. So I just wanted to go back a little bit briefly over this so we can put our research into context. So, uh we conducted a survey um uh between September and December 2022 supported by um the Surgical Royal Colleges uh of um Ireland Glasgow, uh uh Edinburgh and uh England. She not, um, and also supported by all college of anti uh and, and many other um groups uh were involved in uh in supporting this survey. Um So through the survey, it was, it was anonymous, there were no cookies, uh and it was therefore quite hard for us to work out who um, it had been sent to. So we didn't have um, a sort of denominator. Um, but we did work very hard to get this ethically approved. Um And there was a process as you went through the survey um of uh getting your consent and we specifically asked for consent for um uh quotations as well to be used anonymously. Um And although there are a number of questions asked, the thing that we uh focused on in terms of publications was uh looking at um events of the last five years. Um And that was because we've been told um that uh this used to happen, but it doesn't happen anymore. So we were particularly interested in finding out uh what has happened most recently. Uh And we wanted to know whether people had witnessed um uh certain events and also whether er, they consider themselves being the target. And we were very careful to give uh precise definitions next slide, please. So 1434 people completed um the survey and it was quite a long survey. Um, the vast majority were, er, doctors and the majority was, er, consultants even though we did send this out to um, uh hee as it was then. Um, and you can see that the distribution of specialties uh reflects um the proportions of people uh of specialties in surgery. The very small specialties we combine to them uh in order to preserve anonymity. Next slide, please. So the results that um uh this is, this is the result slide essentially. Um And you can see uh here that there were a number of rapes um uh reported in this survey that 30% of the women answering the survey and it was about 50% female, 50% male answers um had been targeted with sexual assault. Um There were far more women had witnessed assault, uh and far more women. Uh And almost two thirds of women had been targeted uh in uh with sexual harassment. Uh And almost everyone has uh witnessed sexual harassment uh in the last five years of the people answering the survey. Next slide, please. So, um this was the demographic. Um This was just the sort of visual aids that we, we put out. Uh And obviously we can't, although the headline that that hit the papers was one in three um female surgeons. It was one in three of the women who replied to the survey. Uh But we did do some work to match that. Uh as you'll see if you read the paper with um the expected replies when you look at the proportion of women in uh at least the NHS England population that we have data for. Um And it wasn't particularly skewed. So we believe this is uh approximately right. Um So some men uh have been um uh sexually assaulted but far more women. And if you uh sort of cast your eye to the left, you can see um the image on the left uh is in itself quite disturbing. Next slide, please. Um The other, uh there were a number of things that, that were reported, you get more details in the paper, but the top reasons for not reporting. So the vast majority of these incidents and none of the rapes had been reported uh was fear of being accused of overreacting damage to reputation. And this um not, not knowing how serious uh things are so potentially sort of not having normalized this um this behavior uh but also no faith that uh anything would be done uh as a result of these um these reports and indeed a fair number of people uh possibly rightly feared repercussion both from the perpetrators. Um And uh indeed, from the culture that they worked in. Next slide, please. This, I kept these two slides in just to give you an idea. Uh These are percentages, uh significant differences all the way down between female and male respondents. Um And there were very few non binary respondents and not enough for us to make a separate conclusion about that. But uh we do know that um intersectionality plays a part uh in this, but in terms of the data that we've got, you can see that we went into great detail uh with uh what constituted harassment. Um And 40% of women, for example, have had uninvited or inappropriate inappropriate comments about uh anatomy and body parts. Uh So this is all um very common next slide, please. Uh And these um uh we, we managed to get that 30% from this composite. Uh of a salt. But you can see here that um uh this being forced to partake in physical contact in exchange for training development was a significant proportion of those events. The next side please, I'm gonna hand back over to Ros. So thank you to in. So what you can see in this picture is we're trying to show the context in which this happens. So what our research to date has shown is that this disproportionately is likely to be enacted by a male doctor. Um And what we find is that there is a particular social context in which that happens, but there's a wider social context. So what we're seeing already within UK society is that there is a toleration of sexual violence against women and against those who are in minority sexual characteristics. LGBTQ plus. And so we can see this in terms of the GMC, where we get a low progression also in terms of from reporting levels all the way through to fitness, to practice cases. But our research in particular, from our witness to harm case is really showing that this is very much something that is in a GMC is in a doctor space relative to other regulatory groups. But it takes place within a context in which there is often a hierarchy and I'll explain a little bit more around that. But also we've shown from our PSA results that it's likely to take place in a space where there's already existing levels of violence. Next slide, please. So again, from the quotes that I started my session off with, you can see that there is an escalation over time often from what is happening in this space. So we see that the registrant of interest often pulls in other people into this space. And that can either be that they are increasing who is subject to sexual violence or they can be starting further escalation against their original target. But there are people who are brought in either through directly witnessing it or through secondary harm as things are spread through the organization. And in our case, we're particularly interested in that regulatory response. And we're seeing that fitness to practice in and of itself escalates that harm through the failure to gather proper evidence and through the drawn out process that is going on here. Next. Uh just press return, please. So what we would really like to identify this is actually sexual violence is a canary in of mine. They're telling you about lots of other things that are likely to be going on in this space that are a cause of concern. Next slide, please. So if I give you some background into how this actually happens, what we're seeing is that this type of behavior is a motivated type of behavior and one that regulation from a perpetrator perspective becomes harder and harder evidence, particularly looking at Australia, which has a dataset that's been able to look at how people's behavior changes over time because their regulatory system is slightly different, is really highlighted just how different sexual violence is in a workplace, particularly that it's subject to what's called recidivism. That's easy for me to say. And by that, I mean that once somebody starts the type of behavior, it's a goal setting behavior and they start to escalate. We also see that there is an interaction with the type of person so that they view themselves as outwit the rules, they view themselves as somewhat different. And in particular, the context plays a huge role both in terms of somebody specifically picking a context and a profession that allows them access to particular targets, but also particularly as they rise up an organization. And remember that earlier slide that I showed you with the yellow blob in terms of that hierarchy, what we're seeing is that these are often very senior people. So they actually get to control and create their environments, they decide who gets advancement, who does not. And through that they are able to again control and enable their behavior. Next slide, please. So what we see in particular and you can see the red um going around it is that there are ways that we can control and we can start to um change this behavior inhibit it. One of the key ways is around self evaluation and self reflection. But what we see within specifically sexual violence, this becomes harder and harder for the individual who's carrying out this behavior to see, they don't see their behaviors in, in the full context. And our work previously with professional standards, authority really showed particularly denial where people either said that they hadn't done something or that they were denying the injury that they were causing. They really didn't see that it was a problem. But in particular, around us, we also see that there is a decline of social sanctions. So people feel that they're allowed to behave in the ways that they will want to and that nobody is going to intervene. Nobody is going to check, nobody's going to call them out around this. So specifically, I would argue that those social sanction mechanisms are disabled in this context. And then thirdly this legal sanctions and again, the work that we did with professional standards, authority highlighted that in particular within medicine, there's a real issue whereby the sanctions for doctors who engage in this seem to be. And we found that they were significantly different from other professions. So in particular, we find that nurses and midwives, it's much clearer. If you do this, you're removed from the register and we're just not seeing the same within um a doctor context. So there's an ambiguity and in that ambiguity is where um problems arise because again, it feeds into that self reflection. Next slide, please. So actually what we are arguing through the research that we've been doing is that this event starts off as an interpersonal trust breach between an individual and either the trainer or a supervisor. It might be. But if that escalates so that they start to lose trust in the profession as a whole, they start to lose trust in the regulatory system as a whole. And this is a complete breakdown over time. Next slide, please. So just to recap what we're seeing is this is really a different type of behavior from the harrier. They have a different type of attitudes and beliefs and that then drives a particular action. It's much more likely as we said to be goal directed. People are doing this because of what it gives to them. But over time, they find that they start to escalate the risks associated with it because it no longer satisfies their needs is also likely to be undertaken because of an implicit misogyny. And that will impact not just on how they are treating colleagues around them, but also likely to affect how they are treating patients and other service users in this space, what we've identified. And again, looking at the literature, this is an an activity undertaken by people who are using sexual violence as a way of maintaining their own self, of self esteem and their own sense of themselves and their ego. And uh and it's used as a way of maintaining their dominance in the system. Next slide. So it's the sense of entitlement coming through. But we need to be fully aware of what are the consequences of this for the workplace. Next slide. So what we're seeing as I highlighted before is this tends to take place in a context where it's already fragile. In terms of bullying and harassment, there tend to be particular hotspots that are around private spaces but also dramatically public spaces. Again, the research both from nursing and from doctors is showing that operating theaters. So that very pride that very kind of public space where lots of people actually are an area where this is likely to be increased perpetrators because they are in control because they use their social relationships in a particular way, are actually insidiously changing their norms. So they're making this a much more accepted as Thomson said earlier within the slides from our study so that people are not seeing what's going on. And in particular, we've shown how humor is used to deflect, it's used to test out who is supporting you and who do you need to remove from a situation um by a perpetrator. But we think that this has a much bigger effect on the whole of the workforce. So it's reducing, if I can't tell you about the sexual violence, that's going on, what other things can I not raise with you that are real concerns. So it's going to reduce the safety, the quality of the service for both patients and staff. We're seeing particularly that there are key targets who are having dramatic impacts in terms of the great inroads that surgery in particular has made in terms of changing that demographic of adding new people, particularly female surgeons, who again, the studies are showing actually have much better health outcomes, have much less risky surgical interventions and from whom patients recover better. So again, it's really important to understand and to maintain this talent pipeline. But also, as we've highlighted with this, it's about improving standards. If we're not talking about sexual violence, what else are we not listening to that could be important areas for improvement. And finally, within this space, NDA S are not the solution. The only thing that a nondisclosure agreement does is that it fails to inform further victims about what is going on within a space. And I and I use that word victims because I think in this particularly NDA S are really highlighting that these are unnecessary things that are happening and they are avoiding facing some important issues within this workspace. Next slide. So again, all of this leads to fear which again is going to downplay what you talk about the areas, the things that matter within the health context. Next slide, please. So in terms of what we can do differently, we can start thinking about the professional environment and the professional cultures. We're already doing this within the NHS within a working party that I also sit on thinking about um domestic and sexual violence. We can start thinking about upstanding and particularly the role that we have to play from witnessing things and stepping forward and supporting both the targets in this space, but also to push back against individuals undertaking this. So understanding those toxic hotspots through um staff surveys are a really important resource. And again, our PSA work has highlighted this, but I think there are some important things that we can do with this top line of yellow things that are about understanding who are the likely targets for this and what can we do to support them both in terms of feeling that they can report things that they will be listened to, that they will be taken seriously when they raise concerns. Going back to thinking about what are the values for this profession, what are the uh equality, diversity and inclusion plays a critical role in this and understanding what are the self depleting spaces that are going on that are undermining particularly people um falling into this uh lack of self reflection and thinking about um how we report this and what are the sanctions and finally thinking about management education. I was speaking last week to the NHS Employers um conference and really highlighting actually using this slide about the role of managers in this space. So over to you, Tam, thank you Rose. That's so important to, to think around uh this subject. And it also just shows us how uh if we can influence anything here, it's going to make a massive difference to the culture of surgery. Uh and indeed across um healthcare. So, um I'm sure everyone who's joined has seen some of the uh uh some of the coverage that came out in September about this. Um And I think, you know, although necessarily some of it was uh you know, not detailed, um it has, it has really kind of helped speed through some of the, the sort of urgency to try and uh and improve matters uh for people who are, who are currently experiencing this next slide, please. Um So, uh just to say that the working party on sexual misconduct published a report, uh which you can access on um, the uh WP SMS website, which is WP sms.org dot UK. Um And in it, we had uh 15 recommendations which um uh very much, I mean, Ros was advising us at, at the time. Uh But there's a big group of us and um uh it really sort of covers some of the things that um uh Ross has just mentioned. So, um implementation of the recommendations, uh and this option for having um external independent investigation because a lot of people's attempts to report um have been uh silenced, they've been belittled. Uh and they have not got beyond sort of the first step at reporting. So there needs to be some way of getting around that. Um also a lot of um healthcare organizations uh do not have anything specific in their policies. And as Ross has, has laid out, this is a, a specific uh form, this is not the same as bullying and harassment and it needs to have its own specific uh policy and they need to be codes of conduct. So it's clear that when we're thinking about education and training, we're trying to move towards uh prevention uh of this and also allowing people to understand uh where um the culture has sort of normalized things that would be uh that are sexual harassment. Um And uh a lot of people are um are are not really aware or not sure of themselves. So that is something uh that needs to become widespread. Um And part of what is uh taken on at all stages of her career, but including early stages and we're hoping that this will in the end lead to culture change. Uh Culture change can be encouraged also uh with regulatory guidance, um We feel having an improved representation of women uh particularly in, in more powerful positions will um uh it, it isn't the, the only answer but it will help uh and it will help bring about this culture change. Um And also I think asking um for not only data collection but uh but transparency. So the opposite of the non disclosure agreements, but for every healthcare organization to be open that this is happening uh it's so prevalent, it will be happening in all healthcare organizations. Um And that by addressing it and being transparent about it um is going to be the very first step uh in addressing it next, please. Uh So things that have happened since uh since our research started. Um So um we had uh a meeting with um uh in May um with uh Royal Colleges and the GMC and uh uh people in NHS England amongst others. Um There's uh as a result of that amongst other things. Uh a new questions have been added to both the NHS uh survey and the GMC National Training Survey. Um The uh uh also this was being debated at the time, but um uh thankfully, the um GMC have added uh elements to good medical practice which have um which address this, which is really um fantastic that that's changed. There's also been an, an NHS uh Sexual Safety Charter. Uh And over 100 and 70 organizations have signed up to that. Um And uh work on um sort of speaking at the highest level in um in parliament has already started. Uh And the Royal College of Services of England has started a group um that both um Ross and I are involved in. Um but is led by Vivien Lees, our vice president um uh to make sure that we continue to press forward and push for culture change in this space. Next slide, please rose So these are uh just some of the publications that I've drawn upon uh in this talk with to. And so I think we can probably go to the questions maybe. Ok, great. Well, we wanted to leave a quite a lot of time uh for questions. Um And, uh I think one of the things now, now that this has come out, uh one of the things that, that we're asked most at the moment is how do we change it? And it's all very well to say things like education. Um But understanding uh sort of what is available, what could possibly um change and start leading to prevention um is something uh what, what's your view on that ros where are we with any interventions that have any evidence behind them that might change uh culture? That's a great question. I think there's a lot that can be done as you've highlighted around changing uh the demographics, particularly around leadership so that we see more women coming into leadership positions, uh more members from uh minority groups as well. I think there is also a lot more that can be done around um the use of staff surveys and paying particular attention to identifying those hotspots. We're just in the process of completing a piece of work that's trying to use a preventative medicine approach in terms of understanding primary secondary tertiary um and really highlighting different issues that are going on at different groups. But I think the issue for us going forward is to look at this in terms of the context. And as you've highlighted, uh NHS England in particular, have a, a lot are doing a lot of work at the moment through that charter, but also then unpicking the different dimensions to that charter. Uh I've seemed to spend at least three hours a week in those groups. I was seeing you in another one earlier to try and understand and build on the science in this area. So there's a lot that can be done. But the most important issue is I think around giving people access to a voice and believing them when they raise these concerns. And in particular, I think the importance of showing it's much more likely to be a senior person that somebody is reporting about and to, as I was trying to show in my slides, that kind of sense of entitlement that they feel they're, they're too big to be taken out of the picture. But actually, we need to redress that to show that actually the harm that they do if you're spending time thinking about how to sexually harass someone in an operating theater, are you actually focusing on the task in hand? Exactly. That's, that is so concerning when we think about it. Um, this happening, I think this is also one of the things that drove the, um, the media interest because, uh, you know, it's really quite a shocking thought that while you're under anesthetic this might be going on. Um I'm just gonna get to some of the er questions here. So um Linda de Coar, hello. Um uh start off with uh what is the age range of those involved? And I thought as you mentioned, senior um just a very quick answer to that rose. So I think there's two things going on here. It's funny, I was um talking to colleagues in Australia earlier around this. So what we're seeing is a social change whereby younger people coming in are starting. Um Mao uh and the influence of misogyny, particularly if you look at Andrew Tate and things like that uh where young men in particular are feeling that uh women are there to service them and in particular in medical school and in student populations, you know, I myself teach at a university. This is an important issue coming forward to highlight and to remove these people early on. But also we're seeing over time as somebody becomes more senior people, checking them people, uh calling them out around things becomes more and more remote and that their sense that they are powerful, becomes much stronger, they can control who advances, you know, medicine and particularly surgery is traditionally been a very competitive, very much a patronage so that if you upset God, God can have consequences on your career. And this is why we're really seeing people not step forward either as um or an ups standard to, to witness what's happened to somebody else and support them or in, in terms of speaking out about what's happening to them. And in particular, I think this is really important within the GMC. If they're looking at reducing the timeframe for reporting, we're going to argue you shouldn't be doing that because people want to be in a safe place before they can raise these kids concerns, which might explain why we had so many consultants reply and presumably a lot of trainees who didn't. Therefore, because even with a very anonymous survey, people don't feel safe to reply. So, um I sorry to interrupt you. But um, I, we've, we've got um a few, we've got some really interesting um, questions come in. So, um, Paul gimme gim, um, er, put brought up the subject of do certain surgical disciplines have a higher incidence than others. Uh And I was gonna say from, from our research, we don't, um uh we were so careful to try and avoid uh sort of drilling down into kind of, you know, the one cardiothoracic trainee in Wales, for example. And then the therefore being able to identify people that we were, um, we haven't published the specific uh surgical disciplines. Uh, but what I do know is that the dentist, which is very um uh female uh predominant and uh also pediatric surgery, which is as far more women in it, um, still have a problem. So this is still occurring even in, um, uh, in specialties with a, a higher proportion of women. Um, but, um, rose from your PSA work, did you find there was, it, was particularly skewed with the, with the those subspecialties of surgery where there are fewer women, for example, is there more of a problem or was that, is it not clear? It's, it's not clear. I mean, we see this, uh, as important in family medicine, obs and gynae psychiatry and surgery, right? So there's a big range in those, in those areas. Um And I think it's not safe to conclude that any one specialty is going to be free of this uh of this behavior. Um No, and I think it's actually quite dangerous to kind of put up, you know, our specialties be better than your specialty. And that's kind of reinforcing that competition within it. Any level of sexual violence is not good for anyone in that space. Is, is it? No, exactly. Now, um Julia Julia Shaban, um asked from a um who who graduated this year, asked from a student perspective, um the problems essentially of being a whistleblower um and getting published, uh punished. Um And that there is uh essential ritual undermining of the vic victims experience. Um And what can be done given that the student is often ignored in favor of the consultants. This is exactly what we've seen reported so many times disappointingly. Um What can a medical student do to support their student versus such powerful figures. I think a lot more can be done for trainees and to do a survey in each place that they are working. And so that if we are able to collect the data from those places, then people might feel more confident about stepping forward and that we can see over time patterns to this behavior. That's what they're doing in Australia and in New Zealand, and they're having some real success around it because from that, you can then start raising concerns about, well, do you want to place people in those spaces while there's such disparity in the results that they're getting? But I think universities can do a lot more around understanding what their student experiences are. And then, you know, questioning the value of those places if they're actually damaging students, I think that's really important, especially as, you know, if you think about the failure to report, it's difficult to report and then people get belittled exactly as this person says, what, what's happened in New Zealand and Australia. So they've got an anonymous system of reporting, haven't they? And then rather than saying, please name the perpetrator, they're just saying, where did this happen? And when, and then once you've built up a number of reports, you can say, uh there's a particular issue in this place. So that's the sort of data that you can have that doesn't potentially risk the student, uh or the trainee, it would be very useful to have that data. That's interesting. I think also, you know, the evidence is showing particularly ambitious women in this space seem to be likely to have more incidents of it. And whether that's a trade off in the sense that the perpetrator views them as you know, wanting to achieve things, so therefore they can target them or whether that's because the perpetrator is coming into contact more with this individual or which I think is more interesting from a psychological perspective, whether the perpetrator feels undermined by this capable young woman who's coming into their space and therefore they're using sexual violence because it's making them feel insecure. I think the more we can identify the perpetrators and show that their behavior is likely to be a defensive reaction because they are not that good of surgeons. And this is the concern that I think we need to be raising. Why are we protecting people who actually might not be very effective? Right. That, that's so powerful because we're looking at overall ways of improving overall safety, not just for staff, but also for patients. And this may, as you said, it might be a canarian coal mine, not only for the other people who get damaged in this sort of chain of harm. Um, but including patients as well, potentially certainly might be dysfunctional teams. Yeah, exactly. Yeah. Yeah, there was some, so there's been a, there's interest in, uh, so Pfizer sum, um, says that particularly, this seems to affect as far as she knows, uh, international medical graduates who may be afraid if they, uh, if they complain, um, of losing their job or, or even their visa. Um, so it's sort of more, you know, added fuel to the fire when it comes to the fear of reporting. I appreciate that. Yeah, that position. And this is something, uh, we've got a book that's coming out next year and we've got, I think 32 countries involved. And sadly, this is what they're saying. And sadly, it's often international visitors as part of their training who are being targeted in a UK space, right? And is that that is more likely to just having someone who is vulnerable, who is, who is less able to move jobs to, to, to escape that world? Is it the power? Do you think? I think it's the power? And I think it's the fear and that somebody feels that if they, they don't know who to report to um because there's a lack of clarity around who's there, particularly as they're doing different rotations. But I think it's a perpetrator deliberately targeting somebody who will keep quiet. I mean, that's uh that leads us to Susan Willis's question, which is simply how can we create standardized transparent reporting pathways in the NHS? That's something that is very much in hand. And I Catherine and her team from NHS England are really focusing on how can they do this in a way that it doesn't necessarily rely on each single trust that they can have a central system for reporting um that they can have standard systems and processes throughout. But I think it's about that transparency if people understand what constitutes this behavior and that's why it's great that the survey that we were reporting on earlier, so clearly shows what is this behavior but then that people feel that they can report and where to report. Yeah, absolutely. Um I want to come back to Portia but um H Sawyer has uh brought up the National Guardians Office. Um What is the role of the freedom to speak up guardians as a safe place uh to report? Do we need another different independent mechanism? So it's very clear from the NHS England work that we've been doing with the working party that the freedom to speak up. Guardians are part of that in terms of understanding what their role could be, but is their role where it should be. So I think that's an open space there. There's a lot moving in this reporting space here. Yeah. Yeah. Um So uh Porsha wanted to know what support does the college provide for? Witnesses? Um Now, uh and she says that having um been asked to give evidence at uh the GMC, uh there is no support for the Witnesses. Ross is question. Um And II can imagine that, that there isn't it? Certainly you've looked at the, the harm you go through while, while it being involved, either as a witness or as uh as an accuser. Um uh or even as the accused in this process, it, it seems to lead to and I don't know, as far as I know, there's no clear support offered from anyone. No, this is something I witnessed to harm. Uh NIH R study has been actively um highlighting across all regulators that there is really a paucity of support given here um from the get go when people are raising their concerns. Um So we were reporting back um in November around us to regulators and we have ongoing work that we're doing here raising this, but it is, it's not just the G MCI think there's a failure across the board in terms of supporting people to come forward and say very difficult things. And, you know, I think it's also, there's, there's no support for anyone is there. I think people who've been accused, it's also an extremely stressful process to go through. Um And you know, there have been some um uh very serious outcomes uh from people who have been involved in this. Um So, yeah, definitely working um with the regulators to, to make this whole process both speedier uh and more humane uh for everyone involved is a really important part of this work. Um So, um Amanda Duong um says if you see something inappropriate as a third party. How should you respond? Um, and that is, is, it's a small question but there's quite a lot to unpack in it. There's lots of ways that you can report that you can report this to the police. If this is a serious sexual offense, I think you can report it to the organization in which it occurs to hr, or you can report it if you know that the individual um involved as the instigator is a doctor, you could report it to the GMC. So there's lots of different doors that can be pushed against around this. I think the most critical thing is not staying silent. Um But also it is also I think very dependent on your own position. So it's very, you're in a very different position as say, a very junior trainee in a firm and it's a senior person and your, your whole future depends on that person's report. Um So what you say in that context compared to being a consultant and it's a consultant colleague. Um and your, you know, it's, you have to make sure that you look after your own safety, I think. Um And what I have done, I was talking about this with somebody else who, who received reports um of uh poor behavior, who said that even if you are not currently safe to report this yourself, uh you can support the person targeted. Uh and you can um make sure they make a contemporaneous report, you know, documentation of what has happened so that they can, even if they're not uh able to report it themselves at the moment, they could, they could in the future. Um And, you know, at the moment we do have a situation where you can be uh victimized yourself. Um If you report when there isn't the support for, for whistleblowers and for, um, people targeted that we would like at the moment. Um And so I'm loathe to, although I really want everyone to speak up and I want this, we want everything all at once. Um And at the moment, we don't have those supports that support in place. So think carefully, if it's safe, report, it, bring it to the attention of people and if not document it and wait until there is such a time when it's safe or, or you feel safe uh Is what I would say. Um Go Ross. Do you have something else to add to that? No, II think it's really important because I think there's a whole range of things that need to change in this space. But I think, I think recognizing and particularly if you're a witness to something, talking to the person involved and letting them know that you've seen them and that you support them. It's that social function piece that is really missing and broken in this space that needs attention and what we, we're hoping to do more work. And I'm just sort of, we've got a lot of great questions. I don't know if we, despite having left lots of time, whether we'll get through them all. So I'm just to give you ones that have got thumbs up now. Um, so uh if everyone else is interested in looking through, they can thumbs up the ones they want to discuss. So, um, Victoria Lane says within the NHS, many consultants are responding for are responsible for appointing both junior and uh consultant uh doctors, but we're not responsible for the firing or retraining of poorly performing or abusive doctors. Um What can be done to change this? It's very difficult to lose your job in the NHS and this protects the perpetrators. That's a great question, isn't it around? Yeah, that retraining space, I think it really. Yeah. Yeah. No, exactly. And, and again, these are discussions we've been having uh and it's really good to have this discussion um uh together about it, but you know, it is, it's hard. And what often happens is people want evidence. Um And that has been, we've seen examples of that being used against people who have attempted to come forward and report an incident uh and um victims being sort of taunted by perpetrators going. It's just your word against mine. I think within this context, I often describe it as frog boiling where people don't realize what's been happening to them and how they've been accepting things um as they go forward, certainly, the work we've been trying to do with NHS is to show them. Actually, your staff surveys are showing you really hotspots for this, that you could target far more effectively interventions and support because there's likely to be issues here. So I think there is some real important upstream work that could be done rather than waiting for somebody to report, to actually say, well, this is likely to be some space where bad stuff is going to be happening. And it was interesting that the first year we had those questions in the GMC uh trainee survey um that um a lot of them were not answered. So a lot of the new questions, people do not feel safe um to answer it. But even so of the people who did answer 10% are actively uh in this position at the moment. Um And so yes, you could use that uh to try and target interventions. What do you think about bystander trading that has come up? Um uh Shirley Chan um has uh noted that um the school of surgery is paying for trainees in T pds to have bystander training. Um Do we feel that bystander training is gonna be helpful in, in, in empowering people to speak out? I like to call it up standard training rather than bystander training so that people feel that they can feel confident about what to say I think it depends on the training in particular. It depends on the level of role plays and other things that give people a sense that they can practice and that they have skills to develop in terms of having difficult conversations with people. I think where you have a number of people together that are receiving that training, it makes it more effective. But also if you are able to target that training on people who are kind of role models that others listen to. We've all been in spaces where when somebody else has called something out, it actually then helps others to feel that they can do that. I think particularly senior people and senior men in this place really have a role to help and support other people. We all have a role of senior people, you know, to be role models and, and to show that we can have difficult conversations with people. But it, I think upstanding training is really important but it, it gives people the confidence to feel that they've done that, particularly in Bristol, they've been doing a lot of work and empowering people to, to say it's not OK, what you just said or did and helping people feel confident. Yeah, I think particularly on this uh the sort of level of sexual harassment that most people have witnessed um the jokes and the, you know, that, that culture, I remember you saying um that, that a, a sort of potential perpetrator might, might try out the, the field first with jokes and misogynistic comments and if that goes down well then might escalate their behavior. So there is, you know, potentially a role to get in there with. Everyone's had that training. They can get shut down at that point and make the whole atmosphere less conducive to this kind of behavior. Yeah. Banter is a really important way that you change norms over time. Yeah. Yeah. And I think uh everyone who's listened to this, who's experienced this might, it might recognize that um Karen Chewy um has asked um is the development of independent body for reporting and review of harassment cases, something that the search of England is looking into putting funds to support. Um And I think that we, we feel that having access to uh sort of an independent group of experts uh for um for reports on and issues with reporting is really important, but I don't know how far we've got in working out who might fund that and who might be in it. Um Do you know any more about that from your various um working parties? II think there, I wouldn't want to speak for the Royal College uh or for NHS England, as I said, I think there's a lot of movement uh around this space. So I think Karen there is work being done. II agree um with ros that we don't have it, it's unlikely to be funded by sort of separate colleges that every college would run their own. Um I think that um as um Laura Hamilton has put in the chart there is um a college of Surgeons of England helpline uh that you can phone, but in terms of getting a um independent um review body, um we want that to be accessible um to, to all specialties um across health care. Uh I don't know if we want too much. Um uh Certainly it will be interesting to see if uh this is something that could be supported by NHS England that would at least um sort of set a standard and a norm for um NHS trust in England. Um So, yeah, it is actively being discussed at the moment. It's part of our recommendations from the working party report, but there's nothing clear about how this um uh how this might come about. Um That doesn't mean that we haven't that uh you know, I it is clearly something that we need. It's just a matter of bringing it about. Um uh I'm just having a quick uh look for um any other sort of further uh comments because we're getting very near the end. Um Maybe Rose. I just ask you to sort of summarize for people who've um joined this about what really are we expecting over the next uh sort of six months in this space? I think there's going to be a lot of work done in this space around, making sure that people feel that they can have conversations, these are difficult topics to have and one where there can be a temptation to kind of pull away, particularly if they haven't affected you directly. But it's very clear that this is an important topic that's having an important impact on the pipeline, the talent pipeline. But also if we're not raising concerns of this nature, what other concerns are not being raised in a workspace? I think that the NHS past pandemic has gone through a very difficult time and all of that is compounding the pressures on it, which again, we know is likely to reduce the means of people's self reflection and self regulation. So actually, this is a very dangerous time. I think that's really interesting your work showing that this is a, this behavior is almost sort of an indicator for a service that's under stress. And we know that, you know, that the service is under stress and that this uh you know, a again, it's something that if we did have um uh reporting that was transparent, you know, perhaps that goes to the C QC. So that every trust and healthcare organization, you can see where, what work they are doing, what reports they've had. Um that might be an indicator itself for the, you know, that's why the C QC might find it helpful for, for the health of an organization. Um So we are as the working party going to have a, a further meeting, um to sort of follow up and try and make sure that our recommendations are implemented and also to sort of hear from and speak to groups that we haven't um uh that we, we didn't involve or for whatever reason, weren't able to involve for the first time around. Um And there's further, uh in fact, there's going to be a question asked about this in parliament on Wednesday. Um So, uh mps have been supportive and interested in trying to take this forward. Um So I think what we will do is close the webinar at this point. Um I would like to thank everybody for their questions. Uh really interesting and useful to have the debate and obviously, it's only one hour. Uh It's a really emotive and important subject. Um There are um uh Jane, I don't know if you listed. Uh But if anyone, obviously this sort of discussion can be very triggering for people. Uh And if it has uh upset you certainly on the working party uh website, there's a whole list of um uh of ways of uh sort of contacting sources of help and support. Um uh So I just would like to thank you for your interest. Thank you um Professor Sell for giving us uh your wisdom uh in this webinar. Um And we will keep everyone in touch uh uh with uh developments as they proceed. Uh uh as a result of this research and all the other work that's going on here. Thank you. Thank you everyone for joining.