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so I'd like to introduce Leslie Hunt. She's a consultant, colorectal and general surgeon here in Sunny Sheffield. Since 2013, she's been working on a surgical program in Sierra Leone and has undertaken 30 missions training in basic surgical skills, abdominal surgery and proctology. She's led the establishment of a comprehensive syllabus for general surgery training in West Africa and supervisors, a master's program and surgical education. We're delighted to have her today because she's delayed her trip to Sierra Leone to join us. So please, Leslie Hunt, thank you very much. Okay, Um, just before it comes before the slides appear, I was mindful of the audience, and my title is, What can the Sierra Leone program teach us, knowing that the audience was relatively junior surgeons and a lot of medical students have restricted myself to a couple of topics, which are the lessons I have learned about early years surgical training and also some issues related to morale of junior doctors. So be below, and Sheffield have been very good responses to the training program. We've also had materials from elemental Swan, Morton and Ethicon. The work that I'm going to present is largely uh, the knowledge has been gained when I've been working for Capital Care, a Norwegian NGO working in Sierra Leone. They've moved in a slightly different direction now. So although I'm still going to Sierra Leone, it's now direct with the Sierra Leone Association of Surgeons. And I'm also very pleased to say that in January I'm going to be starting with the surgical training program in Malawi with Physicians for Peace. So Sierra Leone is infamous for the child soldiers. They had a brutal rebel war in the 19 nineties which trashed healthcare and following the war. They're really starting from ground zero in terms of surgeons and surgical provisions. Lancet Commission 2015. 1 of its main objectives was to quantify unmet surgical need and what they did is produced data such as this. So along the Y axis, here we have a maternal survival. And along the x axis we have work force density in terms of surgical providers, that is surgeons, obstetricians and anesthetists. What you see is when you have very few surgical providers, you have a high maternal mortality. But very quickly, when you increase surgical providers, you get Oh no, you improve, uh, maternal survival, but also as it goes up, the graph quickly levels off. So the magic figure for the number of surgical providers we think we need across Africa is 20 and that's 20 per 100,000 of population. This shows that across the world in terms of colors and it's shown as a negative, so it's showing the shortfall of that 20. So in countries such as the UK shown in blue, there's no shortfall. We have all 20 providers per that 100,000 of population. But in countries shown in red at the bottom there, more than 19 of those 20 are missing. So they've got less than one surgical provider for 100,000 of population. And this little red spot on the west coast of Africa is Sierra Leone, So they were right down at rock bottom. Now, maternal health is very important in global surgery because it is low hanging fruit for making gains. But in terms of general surgery, the situation is a little bit more complicated. So this woman came to Sierra Leone from Mauritania. She crossed three countries because she had heard a story going around West Africa that there is a woman in Sierra Leone who can reverse stoners. Now Mauritania is this country here shown in blue. So on paper, they have got their 20 surgical providers, but still nobody who could reverse the stoma. I put this picture on there for you will because I thought you'd like the technology. Yeah, it's a petrol cap. Yeah. So over the last decade, we've been working with Kappa Care, and the program is a two year program to produce emergency general surgeons and obstetricians. So one guy does both specialties and we train them in two years. And when I first went out, I thought, There's no way you can do that within two years but it was wrong. We've actually been doing are glory Days of 2014, 2019 were absolutely churning out surgeons. It was a very successful program, and more than that, we were starting to train local trainers to make this truly sustainable. So this is Hindu, um, on his graduation day, I could tell when he was a student with us that he had got the training gene. So he was the first local trainer that came into the classroom with me and I love this photograph. I don't know how well it projects, but I think you can see in his face that he is checking understanding, and that is a really, really good trainer. The guy that is training here is a shocker when he was one of our trainees roll forward three years and this is my title slide, which is a shocker now acting as a trainer in the classroom. Officially, we are a task shifting program now tasked. Shifting is a big deal in global surgery, and the concept is that we are training non doctors to do tasks that are traditionally done by doctors. Um, now it's a little bit more complicated in countries such as Sierra Leone. So this class we've had for basic surgical skills Abdul and Abdulai, we're going. Abdul and Abdulai are both doctors. The rest of this class are health officers. Consistently top of the class was Shekou, who is one of the health officers closely followed by Joy, who was the best technician in the group and in terms of who is doing the training, obviously me, but also supported by Issiaka and um who are both health officers. So here it's not really task shifting is whoever's got the skills teaching whoever wants to know the skills. There are a lot of critics of shifting. People say that we're doing it down. It's not going to be so good. People may recognize the name here. Ben Lou is a colorectal surgeon in Wolverhampton. But when he was a trainee with us in Sheffield, we did a project and it was very, very carefully blinded. And what we did is we assessed surgical skill acquisition, comparing the surgical trainee in Sierra Leone who were 95% health officers versus the trainees in Sheffield by accident. The group that we had in Sheffield was slightly more experienced than the group that we had in Sierra Leone. Nevertheless, what we found is that the Sierra Leonean trainees outperformed the British trainees on all parameters. And to me, this is a bit of an indictment of how we deliver surgical training in in the UK, and I think we've got to step up. There may be some cultural differences in this, So a key step in surgical training is always verbalization of the steps, isn't it? Show me how to do it as if you're teaching me how to do it. The Sierra Leone's are an incredibly talkative community, and they just take two this like a doctor, water, blah, blah, blah, blah, blah, blah, blah, Whereas we're all a bit inhibited and shy in the UK In addition, the fact that these guys have got to learn to do this in two years really focuses the mind. There's a bit of fear there, and they hang onto your every word. However, we also have a different structure to the program, and one of the things that we have is a three week immersion, basic surgical skills course. And they are absolutely drilled on all the techniques. It's not just learning to tie a few knots, a few stitches. How do you like it that How is that done like that? How do you deal with the fragile vessel? And it's again and again and again, absolutely drilled into them. And to me, that course is worth it's weight in gold. Uh, sorry. There is this one here. If I have been No, this is West African creo, and if I've been no means God, if only I had known that and there are so many things I have found as I've gone through my surgical training and then my consultant career and I thought, Oh my God, I never knew that all these years I never knew that and I've tried very hard to eliminate that from the program in Sierra Leone. If there's something that's worth knowing, let's know it right at the beginning so you can use it all the way through. We do all the fairly standard things. So basic surgical skills. There's no OD peas in Sierra Leone. So if you're going to use a diathermy and quite a few hospitals do have diathermy, you need to know how to set it up out of trouble. Shooter, etcetera. We use video lectures. We use standard lectures. We use the sort of simulation equipment that surgical trainees will wreck. Recognize here, lots of not dying. And here we're using a medium fidelity hernia model, which is made of fabric, and it can't teach you how to dissect a sag, but it can teach you all of the steps of the hernia. So if you have all the hand techniques and you have the steps, you are really, really well, step set up when you go into the operating theater and you can see we're sharing one model here and everybody's videoing it on their mobile phone. And then we also in this three week course, take them into the operating theater. I would say from Day one, slight exaggeration, but definitely from Day three. So you will learn to make an incision on a pad in the skills lab, and the next day you will make an incision in somebody's going to start a hernia repair, and what we do to trainees in this country is we seem to deliberately hold you back. Just watch for a bit, see how it's done. Assist and we don't throw people in in the deep end, and we could do it perfectly safely. There's no nothing to suggest that you're any safer making incision six months into the program than than straight away in the program. We do a lot of repetition because repetition is very good for learning, and it forces recall. So I teach an abdominal course. We would teach it to Group A A and B, and then six months later, combine those two groups and bring them back again and then repeat the same material again in a wet lab. So we're really drilling home the essential messages. Okay, this is a World Cup qualifier, and it's England against Greece, and we are to one down in injury time. And if we lose, we are not going to the World Cup. Oh, there's no sound. It sounds good, actually. Yeah. Yeah. Okay. Even without the sound is good, isn't it? Yeah. Yeah. So I heard David Beckham speak about this particular goal, and when he was a teenager, he would practice free kicks for hours and hours and hours on end, and what he said was very, very insightful. He said every time I got it right, I learned nothing. And every time I got it wrong, I used to talk it through in my head, work out why I got it wrong and correct for it. And this is in surgical practice. It is what we call conscious practice. So if I just send you a way to practice something, you don't learn that much. But if we break it down and criticize it, you learn and you move forward very quickly and We've been very, very keen to use this in Sierra Leone. The verbalization they do naturally. We need to be a bit more open and a bit chatty. In this country. Repetition of the same task is very helpful. So if, as say, s t three, you do six hernia six, let's say not hernias. Let's say six hemorrhoidectomy in six months, you probably not very good at hemorrhoidectomy. If you do six hemorrhoidectomy in one day, you will probably be quite good at them by the end of the day. And then you can build on that going forward. And to my mind, as we come out of the pandemic, we've got huge waiting lists. There is an opportunity to set surgical training lists up in this manner and have real immersion and intensity in certain in certain certain operation, then move onto the next one. So what are the best operations in the world? So 2015 was this attempt to define essential surgery. So these are the operations that are the low hanging fruit in terms of preventing mortality and morbidity, and there are only two general surgery procedures on the list. They are laparotomy for peritonitis and groin hernia repair, including bowel resection. And those are what we are teaching in Sierra Leone, and it's important that the syllabus meets the local need. So 20 years ago, if somebody had told me that my training was didactic, that would be a criticism. But over the years, I've learned that didactic is not a dirty word. If I want to know what this Japanese says, I'm not going to do a problem based learning. I'm going to go and get some didactic teaching on Japanese, and my husband, who does speak Japanese, tells me that this says camera, So didactic teaching has got some really advantage is it is quick. It avoids wastage. So we all know a load of biochemistry that we're never going to use in our practical lives. And it is also safe because it means the whole of your training cohort get the essential training. So here's some didactic training from Sierra Leone. So anybody who doesn't know this is volvulus, where the sigmoid colon twists on its mesentry and cuts off its own blood supply. I didn't take that picture here from the UK textbook. I took it from a book, which is called Maurice King Tropical Surgery. And this is the kind of Bible for surgeons in Africa. Nevertheless, we do not teach this particular technique shown here, which is untwisting the volvulus in Sierra Leone. And the reason we don't teach it is the people who present with volvulus in Sierra Leone are healthy, fit young men in their twenties, and they present with Sorry, it's so sensitive they present with this sort of mess inside them, so a completely ischemic colon. And they also have this phenomenon called Ileocecal Notting, where the ileum gets wrapped around the sigmoid, so it's completely pointless to teach them to devolve it. We just teach them to go straight to theater and how to deal with it there. And then we also need to take it a step further. And what we do is work very closely with our trainees and graduates about what they actually face when they go out and, uh, into their postings. So this is a lecture on typhoid perforation, usual factual stuff that you'd expect there some how to recognize typhoid perforation, how to deal with it in the operating theater. But the Children that they're dealing with with typhoid are very malnourished and we have a high rate of complications. So we repair the bowel and it falls apart again. So they have to learn to make stones temporary stones to deal with this. Furthermore, the guys who come out of our program are the only really almost only trained surgeons in Sierra Leone, so they tend to get everybody else's complications as well. And there regularly dealing with a mess like this, which is a burst abdomen. So we need to teach them how to manage that as well. And then we need to train a few of them to sort out the long term consequences of this. How to deal with this fistula and repair this enormous hernia. Now, as I'm talking here, you can see this video. This patient has a very high respiratory rate, so there's no point in teaching them to deal with the surgery if we don't also teach them how to manage acidosis and look after the patient generally so very, very targeted training. And I don't think we do this very well in the UK. I have almost no idea what my houseman does all day. We are so separated from each other. We don't understand each other's roles in the way I feel I do in Sierra Leone now. People could criticize didactic training and saying yes, but what if they face something different? This one of the graduates had two weeks leave from his hospital, and he came back to find this woman, which is a complication of Cesarean section. You can't see it very well in the projection, but the small bowel contents coming out of here as well. I was in the UK So what's up to me? And then we had a conversation about what to do about it, and that evening he sent me this photograph, which is where he's got the bowel onto the surface very nicely. He's half closed the wound, and he's put a bucket, a bag over the lower part, and I think that's really impressive surgery, and he's never been taught for that scenario. But he's a clever guy, and he can use what he's been taught elsewhere. And this is the same woman. Just a few weeks later, Happy sheets. So at the end of this conference, you will judge me and I will look at it and hope it's all right. But we're also increasingly using happy sheets to assess training, and this is a dangerous thing to do, really, So I know I've just come from c T. One n c t. Two training in Sheffield this week. I can get probably excellent on everything on a happy sheet by giving a very clear talk, giving a nice practical session, starting and finishing on time and listening politely within complain about the car parking. Now that doesn't mean that my training is effective, and there is an argument that the more clear cut and simply you make your training, the more likely your trainees are to forget it because you've not challenged them. So medical students in the class will recognize this. This is problem based learning. So the idea behind Problem based learning is that it introduces something called desirable difficulty. So we make the training harder for you so that you remember it better, and it's a very sound theory. It improves recall, and it develops grits. You've got to be determined to get that knowledge. It insights curiosity, and it allows people to follow special interests. The problem is that if it's done well, it is enormously time consuming. So, uh, ideally, as the trainer, I should be reacting with every single one in this group. But I'm not going to because there isn't the time. And also problem based learning came into being before the information revolution. And of course, now all of us, if we have a problem, we don't go hard work seeking out. We just Google the answer. And so there isn't any real desirable difficulty or less desirable liberty left in problem based learning and also with the Internet, it's very easy to get deviated, so you learn all about something, and then the trainer says No, but you were supposed to be doing this. Are there any other ways that we can introduce desirable difficulty into surgical training without following something like problem based learning? Well, first up, if you're dealing with tough cases, it's inherently difficult, and we saw some enormous hernias before, but they only as a horrible in Africa. What can we do in the UK? Lots of things that we currently don't do. The first one is flipping, so I give a lecture and at the end of it, I give you a handout with the notes on. It's very easy. Just do it the other way around, which is what we do in Sierra Leone. Give them the materials first, let them study it and then come along with the lecture. Cost nothing. Forcing recall. We've already talked about that things like repetition and doing testing every single day. So force recall at the end of every day of teaching into leaving. So if I want to give 40 hours of teaching, I can give it during one week. Or I can give four hours of teaching every week for 10 weeks, and you will learn a lot more that way. But it's complicated to organize, So what you do with interweaving is you start with topic a move on to topic be. Tomorrow afternoon, we'll go back to Topic A, and we don't organize your training like this. In this country you have atopic, you finish it and we could be jumbling it all up. It makes quite a chaotic training program, but a much more effective training program and then clinical back and forth. So we are. We all believe that we are people, people, and if we have a case, we should study that subject because if we can hang it on a patient, we will remember it much better. We can introduce Jeopardy. So by necessity, these guys have got jeopardy in their program. At the end of two years, they're going out into a district hospital, where they will be the only surgical provider. They will learn it quick, but we also do things such as deliberately introducing competition into the classroom, which I think is not P. C. In this country. You'd probably have to get trainees to sign a consent form for that. And you can see around here going on about who did best. And it's obvious it's joy because he's got that smug smile on his face. Yeah, and we also have attrition. So at the end of the three week basic surgical skills course, if somebody is not going to make it, they have to leave. And that is also something that doesn't happen readily in the UK. So just a couple more minutes. I just want to speak about junior doctor morale because there is a huge problem in this country. I hope everybody has watched Adam Case this is going to hurt fantastic TV show, and these are obviously the cardinal symptoms of burn out. Now we can all understand why David not comes back from Aleppo and he's burnt out. But why are junior doctors burnt out? Some people would say You've never had it so good. Let's have a look at what motivates us in our workplace achievement recognition. Enjoying the work itself responsibility, we have removed that from a huge swath of junior doctors. What D motivates us? Things like salary and working conditions are not so important. And even if we have a good working conditions, I may be just working 40 48 hours a week. That is not enough to make people happy if you've taken away achievement, recognition, interesting work. There are lots of theories of burn out, but this one, the areas of work life seems to fit best with junior doctors. It's looking at things like your workload itself, but also the control you have, what reward you get for that workload, not in terms of money, but in terms of the pleasure you gain from it, the values that your organization has against your values and if there is a mismatch in this junior doctors will. Anybody, if there's a mismatch in this, will become burnt out. This guy here is six months into the surgical training program. He has just done a perforated peptic ulcer. I held the retractors and I did a lot of talking, but I did not put my hands otherwise on the operation. He did it and you can see the pride and almost the dopamine oozing out of him that makes him extremely happy in his work, even though he has a shit salary and poor working conditions. What do we do? Two doctors in the UK six months in the UK This is likely what you're going to be doing your sitting in front of a computer all day long and nobody signed up for that. There's a loss of patron interaction, and it also will take away decision making me come on the ward, give you a load of jobs and then leave. All of the focus on burnout in the UK is looking at shorter hours. Things like shorter hours is not working. We saw that even with good working conditions that cannot motivate people if the rest of their working environment is not good resilience. Resilience is nonsense because burnout is a structural problem within the organization. It is not the fault of the individual who's suffering from it and cognitive readjustment. This is awful. This is saying. Well, if you can't do the best job, just do a half job and be happy with it. No doctor is going to be happy with that. So another little one here, this guy is still a trainee. He's been on the program 18 months, so we're looking at CT one. Something like that. The baby arrives at the hospital. He operates on the baby. There's a, uh, infarcted intussusception he respects. It is a primary anastomosis. It doesn't let me know about it until the day the baby is going home. And then he lets me know. And it's just wonderful the pride that people have having done good work. And I feel that this is what we have taken away from a large swathes junior doctors in this country. So the final one, This is Hassan Hassan. These photographs have taken when he's five years out, so he's done two years in the program, and he's been qualified for three years, and he is doing operations such as he did this one. I assisted him, but he did it. Component separation enterocutaneous fistula really complicated surgery at five years and, well, we just ask the questions. I'll just play a video here, and the video is in the middle. And it is Hassan teaching a junior colleague how to close and abdomen. And I can think you can see how cocky and happy and comfortably feels with it. He's a really good surgeon, and he knows he's a really good surgeon. And it's a buzz talking in creo and he says, uh, do it nicely and it'll come really easily. And then he picks him up because the guy is not going to bury the not and he puts it in there. And he's also carrying on a bit of a flirtation with the theater nurse. At the same time, he is so relaxed and comfortable. And this is the equivalent of, uh, CT S t three or four, teaching an S h o and feeling that cool and that relaxed about it. It is doable. Thank you. Thank you so much. Leslie. That was inspiring and I think I can talk for everyone to say that we wish you were our training program director here. We would definitely love to have a bit more of that in the UK, so we're just going to do all the questions at the end, if that's okay. So next step, we got flu market. Still, she's the senior lead for Global Learning Opportunities in Global Health Partnerships Directory for Health Education, England. She focus on on developing opportunities for NHS staff to gain global learning opportunities. These programs are co developed with the overseas partners, and the schemes aim to have clear mutual benefits. She's got a background as a physiotherapist and has worked both clinically and in academia. So thank you very much for your kids off. Good morning, everyone. Nice to be here. I'm going to talk to you about some fellowship global learning opportunities that health education, England offers and health education. England is the organization. So, um, that, um, Leslie Hunt probably works for, um in terms of her training role. And, um, so health education. England is an arm's length body of the N h s, and its mission is to have the right numbers of healthcare staff with the right skills, Um, and with the values and behaviors. And as you know, in the UK at the moment in the NHS, that's a challenge for us. Um, but things are hopefully will get better as things do. What I want to talk about today is I'm part of a national team that offers some, as I say, global learning opportunities and the health education. England has only been in existence since 2013, and it was set up when the NHS was trying to make sure that money for education and workforce development was not raided for the provision of day today. Healthcare. So it's set up as an as a if you like, um, an arm's length body so it could do its workforce planning and, um, quality assured and plan the education and training for all the healthcare staff in England. So I am in England organization talking about, um, and that is what we attempt to do. You'll probably be aware that come April 2023 the N. H s various arm's length body is emerging back again to one overall arching organization called an HSS England and so all the all the bodies will be back together. One of the reasons for that is that it was felt that had become some separation between workforce planning, an actual the needs of the healthcare, um, provision of healthcare not only for uh, planning, but also for financial, um, commitment. So things change, Things go around in circles. I'm at the end of my career, um, and do to retire quite soon. And I've lived long enough to see many circles. Um, and, uh, that's good. That's good. Each circle solve some problems and create some new ones. And it keeps us interested. Um, as as we go forward, Um, but these fellowships, I'm going to talk about that. They came about back in 2007 when Nigel Crisp, who's a name you may know, in the field of global health. He was coming up to retire from the equivalent role as chief executive of the NHS in those days, and he wrote a very powerful and important document called healthcare Partnerships. And for the first time, it was a government sponsored of work for the first time. It said very clearly in a government sponsored piece of work, the mutual benefit gained from when stuff from the UK and by implication, other well educated Western world to if they went to work overseas. Whatever their motivation to go, often their motivation predominantly was altruism sharing, giving back wonderful, wonderful motives that actually they gained a huge amount, uh, themselves at a personal level. And sometimes that might have been recognized anecdotally but hadn't been recognized, if you like in that same way by the government. And, um, it enabled that the regional structure of the NHS at the time was strategic health authorities. I worked in one of those in the Workforce Development Team, and it enabled us to explore and get some funds for innovation and development. And so a group of us multi professional folks got together and decided Wouldn't it be great if we could set up some kind of a program that capitalized on the this report that said how beneficial it was? Two. Both parties, if you K healthcare workers spent some time off working with the UK with a partner overseas as well as at that time, we were looking again to try different ways to help NHS staff develop leadership skills and behaviors. And this wasn't just leadership skills for those in charge. This is the kind of leadership behaviors for anyone, anywhere in the system. And we talk about positional leadership, which is very clear if you're in charge and we also talk about personal leadership and the behaviors are the same. You just may emphasize different ones, depending where you sit in the system and what the context that you are in. But that is how these fellowships came about. So we we devised program in in a year, and we decided it at its heart must be upfront, this idea of mutual benefit and that that would signify partnerships. Always, if you've got an imbalance with one group feeling they're going to give back and to share and to do something good, that is wonderful. But it all it's intrinsically sets up perhaps an imbalance in partnership, and I think Leslie's example just now, just shoot a beautiful example of that is not the case. Your motivations can still be to share your skills and build, but there's a huge learning back, and I think Leslie alluded to that very well, as did keep Park. I think he talked very much about the mutuality that we've come to learn from these things that there isn't. There isn't a sort of a primary partner. Everybody brings different things to the table, and and everybody takes away different things. And that's what we were aiming to do from the start. Um, and the focus is on a bit about what we're bringing back to the NHS, because this is an NHS organization and these might be opportunities you might be interested in. But fundamentally, this is about mutual benefit. So we set up the scheme with one pilot partner in Cambodia, and, um, we had the first group we had were to GPS and to mid wives who went out and did fellowships. The important thing here, and I put it on many of the slides, is that this fellowship is does not provide any direct, clinical or patient care. And so I'm pleased. Don't think I'm against those things. It's just that this was a new thing. This was a gap. There are many other schemes that provide opportunities for people to provide a direct clinical patient care or clinical education, and this was just a different offer, so there's no inherent criticism of other offers just to give you a bit of an overview. We've got a number of fellowship opportunities. The first one we started is known as the I GH. Fellowship has the rather grand title of improving global health, which seemed a great idea back in 2007. Now it feels a little bit grand, so we use, but it's got quite a branding, so we use the I G H to to to cover that because a lot of people have heard about it and the things we've written, the evaluations we've done have got that branding. So that's what started off, and you can see the summary up there. I won't read it all through to you because hopefully you can read it. I presume you'll get the slides later, so if you're interested, you can read read up on it. But the model and I'll talk a bit about the model we use has enabled us to build on different types of fellowship. But the key thing for the i GH fellowship is that fellows on that who spend time working with an overseas partner, typically in a lower middle income country, typically in a resource poor setting or poor resetting that were used to in the N H s is that they work on a project. So the kind of thing you might do in your day to day life you work on a project on top of your day job. The idea of doing this instead of it being on top of your day job would be that you would learn how to do it really well. Uh, and you would have the time to do it really well. And you would have support from a menta to help you to do it really well. So it goes back to that some of those things that Leslie shared with us about satisfaction and challenge, Um, so but it's enabled us to open up opportunities. So the Thailand public health means that we can offer the same opportunity, the same model, but the vehicle, if you like. The thing that you do is public health research in Thailand. Um, and the only diagnostic diagnostic diagnostic imaging model again is the same thing. But it has a particular focus on diagnostic imaging. Unsurprisingly, um, so we are in developing a number of other fellowships at the moment. So one on planetary health, which we heard a bit about very passionately earlier this morning about the sustainability agenda, and it's a huge, huge topic. Um, we're working closely with Greener N H s, which is an organization I didn't know existed until earlier this year. So again, that's a quite a useful organization to get to know we're doing some work with the various diaspora networks in the country because we are very aware that we have many healthcare workers who's heritage is from overseas, many of whom may have been trained overseas. Or at least, um, done. Some have strong links with the country of heritage, and we're doing some work with various networks there to see if we can set up fellowships to help support people who want to find some way of still supporting the country of origin, the country of heritage, but in a dignified partnership way to do that. So that's an ongoing piece of work as well. We're looking at some fellowship digital again. We learned about that a bit. Mark mentioned that this idea of using technology enhanced learning, whether it's whether It's sort of augmented reality or whatever it is, but using that both in the UK but also with our global partners. So these are things that will come on stream subject to funding subject to nothing unexpected happening in the next couple of years. So I just tell you a little bit about the Oh, yes, if I just tell you a little bit about the fellowships. So again, you've got two people among you among your number today who are involved in this, uh, this program. So you've got John. If I may put you out sitting here on the front table, who did a fellowship back in 19 2020 I think just before the pandemic, working with a partner organization in Eastland and South Africa. And you got Hannah, who was the one who announced me who's doing a virtual part time fellowship with an organization in Zambia. And she's currently doing that alongside her NHS job with one day a week devoted to to that program of work. So typically and I'm talking typically, if there is such a thing as typically, but typically people on and I g h or GDP type fellowship as I say, work on a system strengthening project, and the key thing about that is the project is determined by the overseas partner. So we don't get we don't fall into the trap of saying We think we know what you need. The project is determined and owned by the overseas partner, and the role of the fellow is to convene and coordinate and be that wonderful person who's got the time, the energy, the enthusiasm and the requirement to coordinate and get that project moving. So it is not their work. They convene and make it happen, working collaboratively and then with the ti PHR, the Thailand Public Health Research. Obviously, that's about public health research and fellows, which is what we call people who we are able to recruit to. These programs develop skills in project planning or research and evaluation, um, quality improvement, cultural competence, which again, we can go into if you want, um, but probably don't have time today, but also this idea about thinking differently, that ability to pause and think differently. So what we offer fellows is it's a very managed program, so this will not suit people who are looking for a break from some of the bureaucracy. It's a very managed program. There are many requirements before you go, there are requirements while you're there. Um, but we give quite a bit of relatively speaking infrastructure and support for that, Um, and we are able to fund it. That's what again makes it unique. Were able to fund it because of the going back to the 2007 start because of the effect were able to show on the individuals and how they are then able to put that new thinking that new, learning those new behaviors into their role in the NHS on their return. That is why we're able to fund it. Uh, we fund it through, uh, we pay international travel. We pay for all the pre preparation, learning and development, and we pay a monthly local cost of living allowance. So if you're spending time overseas, for example, in Cambodia, we pay you a stipend that covers the cost of rent, food, um, Internet access, things you will need to live while you're there, so it will not keep up your mortgage payments in the UK while you're gone or your rent in the UK, but it does allow you to live overseas. If you're doing the part time virtual placement, as Henry is doing, we pay the equivalent of that to cover one day a week of your work. It's interesting the virtual placements came around because of Cove ID. Um, and as with many other areas of the NHS, enabled us to innovate more quickly and more, more effectively than perhaps we would have done had we not had that impetus to do so. Um, but now some of that is over, and I'm the video clip so early. So it's over. An international travel has opened up. The partners we work with are so keen to have fellows back out with them. So we have a small number of virtual fellowships which I know are very attractive and popular amongst the NHS workforce. But the overseas partner we currently work with overseas partners. We currently work with very much prefer having people there with them. If I can. Oh, brother, if I can give you some examples. These these are a list of examples of recent projects of the three fellowship types that I just talked about. Um, so you can read those, but hopefully that gives you an idea of the breadth of work, but also how clinically relevant they are. So you're not, as I say, providing direct patient care. But these are very clinically relevant. Um, um, projects the concept of mutual benefit which, as I said, is key. We've tried to be very clear about what the benefits are to the overseas partner as well as what the benefits are to the N. H s. And in health education, England's global strategy. We we layer it, talk about the benefit to the individual, the benefit to the N. H s as a system and also the benefit to the wider world. And so obviously we're concentrating on the benefit, if you like, from that perspective to the individual. But then those individuals themselves create a huge benefit to the NHS on their return. And the worldwide benefit is because, well, they're on the fellowship there, obviously contributing to global health in the work that they do. I mentioned earlier that we base this on the development model for the NHS fellows, which we do, and that feels important. The interesting thing before I share that model with you is that we developed it pretty much as it is. We have obviously improved it it in a regular way, as hopefully we do with all things over the years, as we learn more and understand more were able to to make improvements to it. But fundamentally, the model has remained. What it was back in 2007, Um, and in 2014 came across this work of somebody called Nick Petrie, and he described beautifully what we felt we were doing, and he had a great theory base underneath it. So isn't that lovely when you can? Actually, it's probably the wrong way around, but it's lovely when you can find a theoretical model to fit something you're doing in practice. But he talks about something called the Vertical Leadership Development Model, and he says it has to have three elements to it to make it an effective learning experience. There obviously loads of other ways of development, but this is the one that we base our work on, so you have to have something he describes as heat experience. It's an experienced way out of your comfort zone, Um, and in a very new and strange environment or when it's it's strange and it means strange. I mean new and, uh, you know, unusual for you. So as you can see, going overseas to a new healthcare system could very well fit that bill. It could just be moving hospital in the N h s. But you can see how it works for for global work and that again, going back to this concept, that is, it can remember how she phrased it now. But this idea, it has to be stretching. Um, but you need some support to help you that be a very positive learning experience rather than overwhelming where it might become a negative experience for you. So it's That's the kind of balance we're looking for. Um, and for that to be a useful learning experience, you have to have an open mind to to respond to that. And you have to be curious about this new place you're working in, why people do things the way they do, what the context is, what the culture is. And if you have all those elements that actually it's a very, very positive learning experience. He also talks about as a result of those new new experiences into context that your perspectives make allied your behaviors. Your values may collide with those of where you are. And again, that can be really good. If you're curious about that, rather than judgmental, Um, and then that's how you move and how you both benefit. Both all parties benefit, and then, finally, this ability to make sense of it. When we set up, we set up people, a mentor and the terms mentor and coach so varied in their understanding and interpretation. So we describe it as we have a mentor who uses a coaching approach to both support and of a challenge to fellows during the program, and that relationship is owned by the fellow. The conversations we, as the program organizers, know nothing about their confidential unless there's a safeguarding or any kind of issue. Then we will get involved with permission, but that is a private relationship between the fellow and his or her mentor, and that feels really important in terms of allowing that process or that magic to happen. Um, but it's also important that it is managed by the mentor, but by the sorry not by the mentor by the fellow. So the fellow, we give guidance about how often they should interact. But the fellow owns that and manages it. So it's not like a requirement. You got to talk this many times for this long on this topic, and that feels important as well, that people have the opportunity to own that and manage that, and some most take full advantage of it. Occasionally, people don't, um, and that just feels like a bit of a shame. But that's just one aspect. The model that we use to, if you like, frame the development. Using those three elements that I talked about early is the NHS healthcare leadership model. And again, this is a behavioral model designed for all healthcare staff. Doesn't matter whether you're got any kind of clinical background or if you're a manager or anything, any anyone who contributes to the healthcare, and it doesn't matter where you sit in the system. It is designed to be accessible and usable by anyone, so it's not positional dependent, Um, but it's a really useful tool, and we encourage people to use that and do some kind of self assessment pre and post and to use that to focus on some areas that they want to develop themselves, and then the other roles that we have. We have the fellows that we talk about and the volunteer roles, because even though we pay expenses, we don't pay salary. So the volunteer roles we have mentors and a lot of arm enters our alumni of the fellowship programs who come back trained to be as mentors and then offer that to new fellows. And we have a roll of a partnership link lead, which again tends to be for people who have been mentors for a number of years, understand the program and take on that role, which I can talk about another time. And if you're interested, we have a microcyte, um, there we can get more information. And, as I say, I think you'll get these slides, Um, and very happy to take questions if anybody's interested, The key thing is you have to finish for people. If you're all doctors, you have to have completed F two by the time you take up the fellowship, not at the time you apply, Um, and you have to be able to undertake these if It's an overseas experience unaccompanied. Um, So again, they will suit people at various times of your life. The bulk of the people who can who take up these opportunities are early career. But that can be anything, you know, early career. That's whatever you want it to mean. Um, although I'm not early career, so I'm very clearly outside of the scope. Um, but I hope that's useful to you. And I'm happy to take any questions. Thank you. Yeah, thank you all so much for such inspirational and fantastic talks. Um, if I could invite marksman, switch back up onto stage, we'll have, uh, magnesia back up on the screen. And if, uh, Leslie and for kids also stay here Great. Thank you. Um, so, um, all really, really interesting talks about global sustainable training, and I think our first question is from medal. So if anybody wants to add any more questions on to meddle, we'll try and get through as many as possible. But the first question is to mark. So how do you support training? Virtually? Is this from a mentoring or a training perspective? And is it a monthly or an ad hoc basis? um, that question is from Kathryn. How long medal Thanks for that. I think that's a really important question. And actually, it's a big challenge. I think throughout the coated pandemic to to do that. Actually, I think Magnesia is probably better suited to answer it, because what he has set up is a lot of virtual training and support through, um, digital media, for example, one of the challenges that we we're trying to overcome when I was talking about the Google glass project was is it feasibly possible to have somebody operating in another location and for us to be able to observe that but also provide feedback e in the glasses of all your incision is a little bit off or you want to go here? Do you know what this is? And we just didn't quite get to that. So to answer that question, I think we've supported the training in certain ways. But actually, I think it's probably a good question for magnesia if he's able to, uh, to answer that. What people? Because she did you hear us? Oh, um, So I guess the question was in, um, with regards to the virtual. Um training. Was this more of a mentoring or, um, uh, kind of training approach? Um, and Marks mentioned that, um, you, uh, were wondering about real time teaching in surgical settings. So, magnesia, do you want to just mention what you've done with the Netcare Foundation in terms of linking up with a number of sort of global tutorials, right. Thank you very much for the for the questions. I don't know if I get this correctly, but, uh, it's true that as Netcare Foundation, we are really working hard to make sure that we, uh we provide an opportunity for continuously surgical education, uh, for people and, uh, many times. You know, after graduation, many of us don't tend to go and up where they're level of knowledge. And therefore, we have a different menu, uh, different programs that we run around. And these are online platform, and you can get engaged. Uh, we have tried, uh, level best to engage some of our colleagues, including Mark, who has been part and parcel of the program during the teaching and trainings on how to best manage the, uh, the international standards. And because it has the African experience in a particular Tanzanian experience. He has been, um uh, so instrumental to make sure that we continue having some support lectures, diabetic lectures and some really state of the art technology that we're using there in the UK and exchange level of knowledge. I think with that, uh, it has really improved, uh, the understanding And, uh, to me, I consider that to me. I consider, uh, that, uh I consider that when you have the right knowledge, you have the ability to make the right decision. And when you have, uh, make the right decision, you're almost improving quality and gearing to manage your patients very correctly. Thank you very much. Thank you. Magnesia. Um, the next question is also from medal and, um, is directed towards Mark. Quite importantly, I think I need some clarification. Um, and it's specifically from Emmanuel Rider who just wanted to check. You heard right. Are mosquito nets actually used or is it a different material used but borrowing from the design of a mosquito net? Uh, so thank you. I think that's a really, really important question. And if I didn't make it clear, it is important to do that. This isn't just a standard mosquito net mesh. And the reason why that's particularly important is because they're impregnated with lots of chemicals. What this mesh is is that it's been manufactured in the same way, so even commercial meshes is produced in vast bolts of material. So what RAV a token I did is he's produced the PTFE mesh, which is produced in the manner of a mosquito net. And and literally, you've got huge roles of these things. So we take out a big bolt of mesh to Tanzania. Um, and it's repaired that way. So it is a very specific type of mosquito net mesh. It's not just something you buy in the shops, which would be a disaster to to try. Thank you very much for those. So just a few questions for Leslie, if that's all right. Um, certainly medal has blown up with praise for you. Everyone's very impressed with your talk, but one specific question I've got from Ryan Ellis. Um, he wanted to ask about the quality of the non physician trainees. Is there still such a need for the physician 20 target? Or are we focusing now more on the non physician training I have to confess my ignorance. I don't know the physician. 20 targets I'm sorry about Can somebody fill me in on that? Right? The same as we were looking at the surgical providers. Yeah, to to my mind you can they function at exactly the same level. Yeah. And as you saw from the slide, a lot of them. There's two bell curves and they intersect. So we have health officers who are outperforming doctors and vice versa. Yeah. Yeah. The reason you would become a health officer rather than a doctor in Sierra Leone is purely down to parental income. It is nothing to do with intellect or aptitude. If you kind of think of your cohort medical school, the top 10% who went to the poshest private schools would be doctors, and everybody else would be a health officer if they had been born into Sierra Leone. So, to me, we're not doing it down at all. Thank you. Um, one question I've got is so much of our training. Here is service provisions. And if you're condensing everything into such an intense surgical training program, who is providing that service provisions and how can we kind of shift that into our workforce. Yes. Not all the service provision we get you to do is of value, Is it? You spend hours and hours on a computer doing stuff that surely we can rationalize. So, you know, I don't see why it has to take an hour to write a t t o. Do you know t t o. Is that just Sheffield? Yeah. Tablets to take home. Yeah. So right in the patient's discharge summary when it used to take two or three minutes on hand. The technology is really, really letting us down in the UK, And that is what is bogging down lots and lots of the junior levels. The house officer level, et cetera. Um, increasingly, we're using other grades, aren't we Position Associates? A. M. P s. We've got them on awards so that we can free up the guys who want to go into surgical training to do the more valuable work. Thank you. Not the more valuable work. That's the wrong expression to do the more valuable for training work. Uh, thank you for that. And then a question for flu. This is one from medal from John Dalton. he'd like to ask. How do you find your partners? And how can you institutions join the program? Great question. We found the first partner serendipitously. Um, And then we got involved in a network again, Back in sort of 2008, 2010. There was a big United Nations program called the Millennium Villages Program. And we got known on that network and all the other partners we currently have found us. And these were overseas partners, found us and invited us to work with them. And that was at a time when we ran the program as a kind of a little, um, I don't know, a little fringe program on the end of all the more established programs. Since about 20 years now, 2022 we've been part of health education in Global Directorate, which was only formed in 2019. Now, we're part of that, and we have this expansion idea. I think there will be opportunities. As I said in terms of expanding that I know Mark is waiting to ask me some questions about that. Um and we have to link because we're now part of the government organization and funded very much by government organization through foreign Commonwealth Development Office priorities. Their priorities going forward are East and Southern Africa and the Endo Pacific Rim as well as UK overseas territories and dependencies. So there are the areas where are overseas partners for expanding and come from, and that we have to do it via There has to be some kind of link government level for us to expand. So I don't know if that helps in some ways, that feels like it puts barriers in the way, but it it will enable our program to be sustainable in and of itself. Whereas up into the point until we joined this team in, um, the global team in health education, England are funding was as precarious as any other global program. Um, basically, um, and then another question for flare. So this one's from Remember, she'd like to know. With so many discrepancies between different sceneries, how would you suggest trainees getting time out of training to do these fellowships? Yeah, another great question. And it is exactly as you described, and as you know, so we find so as it's a multi professional program. So anyone as I said earlier, who works in the healthcare? You any type of clinical roll or manager can apply. Um, we find the bulk of the people who do apply are doctors in training who have made their own decision to take an F three or a break after core training to do something else and fit it in that way. Um, absolutely as possible. And in the earlier days, we had many more doctors in training who would apply for and get an out of, um, an IUP. What does that stand for? Out of program experience? Yeah, and did it that way. They are increasingly difficult, which I think is behind the question because of numbers. Um, and Dina is having to do their best to populate rotors, but they are still possible in many deliveries, so it depends what route you want to take. But there are two ways of doing it. Currently, we do it on an individual application. There is talk about in the future whether we will do it through Dean Aries applications so that there's a bit more ownership, if you like at scenery level, Um, but again, as you can imagine and what's behind the question is, Dean's quite rightly have different contexts and different views. There's a huge amount of support for this type of work. Um, in many sectors, there is not universal support for this type of opportunity. Um, so there are differences, but I hope that helps to some degree. But at the moment it's individual application. And as I say for for people such as yourself, it's either you decide to take an actual break, which again you're generally won't like to hear, uh, talked off necessarily. Always, Um, but you will do it anyway, um, or apply for an out of program experience opportunity with the ordinary. So I hope that helps. Um, I'm definitely quoting a friend here, but I think it's interesting that we refer to as timeout when perhaps we should be thinking thinking of it as time in, um So, um, my question and having the stage and getting to, uh, this moment, I actually could direct this to any of you, but I think I'm going to direct it to magnesia. Um, a lot of these talks have been extremely positive and inspiring, but there must be huge barriers, and we've mentioned many throughout and I wanted to ask Magnesia if you can hear me whether or not there is a key barrier that you find inhibits training in your setting in Tanzania, we're just catching him in. Yeah, there are a couple of barriers. And, uh, this includes to the the unlimited really limited resources. Uh, we do not have the, uh, uh the number of a good number of training facilities and training institutions that can be trains doctors at the level of, uh, at the level of the surgical specialties we need, Uh, as you can see, if from the our data that we are having 0.3, uh, surgical providers 100,000, uh, to really go and, uh, improve our improve our capacity to manage this particular, uh, conditions that were experiencing We need to increase the trainings and, uh, the number, uh, trainers very severe trainees also is another barrier that it doesn't match always all the time. And having now the double, uh, pardon that we're experiencing here, and particularly in Tanzania, non communicable disease and communicable disease, all in the surgical particular, uh, surgical portfolio. And you'll find that the resources are so limited, and therefore you may not be able to achieve exactly, especially at the level of the governments are planning and, uh, policy. And, uh, these are the issues that we are trying to mitigate with what we're doing and give capacity, uh, employing colleagues from different parts. And the last point that I want to finish up as I as I'm reacting to the questions at hand is, uh, you know, we we we we have experienced the limitations. Uh, the limitations that we have seen is also in the technology, uh, in Tanzania we are We are We are now in the basic laparoscopic procedures while the globe is moving to robotic surgeries. And you can see we're doing a lot of conventional open methods and a few basic laparoscopic procedures, and, uh, that is limiting us, since the world is growing very fast into in terms of technology, and then, uh, we don't have the national data for, like, a log, uh, to always see our our patients book our patients at the national level. We have individualized XL. She needs a hard copy books and that we need all those things to be included so that At least we can have a platform. As I was talking about, resource, uh, at the level of the of the ministry, you find that that we are almost considering non, uh, noncommunicable now. But the dashboard that that that that informs the polish makers of the ministry level is is Leslie, including the the the surgical portfolio, and therefore, we need to create some dashboard so that they can give them They can inform the Polish makers and therefore include, uh, surgical plans in their in their in their in their in their in their working, uh, portfolios. And then stop has just come recently. It's two years now. We're implementing the NC program. Uh, it is a five year program, and we're looking forward to see if it will come out with some of the good, uh, outcomes to improve the number of surgical, uh, providers and the quality of care that we we want to see. Thank you very much. Thank you very much for that. So thanks all for a fantastic morning session. So we're breaking for lunch now. I just like to say during the lunch session, we've got a few announcements about some of our sponsors. So we've got a striker and die a medica. So strike will be talking about Neptune Waste management, Um, and man different systems and safe air. And Diane Medica is going to be talking about appropriate technology for L M I. C s and a personal view of current and emerging big issues. So we've got lunch now. We're starting the next session at two o'clock, so if everyone can make sure they're back here by two.