Simon Hodkinson Presidential Speech BOA Annual Congress 2023

At the beginning of this Congress, I suspect many of you wondered who on earth I was, and more importantly, how the hell did I get here?  It's a question I've been asking myself increasingly as the days have gone by. But here I am, and we've got a job to do, and I intend to do it to the best of my ability.

When Deborah introduced the Congress, she raised the issue of the problem that we all know is there.  Tim Briggs, in his talk earlier on today, talked about the vast volume of work that we do, but also the increasing volume of work that we need to do. The Government, on the 31st of August, produced a major conditions strategy. The interim report was published, as I said, on the 31st of August. This addresses the six major conditions that contribute to the burden of disease in the United Kingdom. They are, as you may imagine, the usual ones, but we're in there. Musculoskeletal disorders are in there. Musculoskeletal health and the lack of it is the leading contributor to the global burden of disease. In the UK, 20 million people live with a musculoskeletal condition, and it's said that 21% of the ever-increasingly economically inactive report a musculoskeletal condition. We're getting old, and I know it, becoming increasingly frail with age, so the workload is going to go up. But in a study that was produced by the Government looking at the future over the next 14 years, there's an estimated 260 to 360,000 shortfall in the workforce that Tim alluded to as being well over a million. UCAS today has announced a 12% fall in those people applying to study nursing, so we are not in a good position. All the while, the waiting list goes up.

Amanda Pritchard, in her letter introducing the long-term workforce plan just recently published, said that without the workforce, the NHS is nothing. Yet we're at the bottom of the league, virtually, for doctors per capita of population. Now, that's a subject that engenders a lot of discussion, and some agree with that. We agree to disagree whether that matters. But just to put some figures on it, there's roughly one orthopaedic surgeon per 25,000 population, and this was very similar to when I started out in training an awful long time ago. In the US, the worst state is estimated to have one in 18,000 per capita, and the best, one in 8,800. So we might have a way to go.

The NHS plan refers to train, retain, and reform. I didn't plagiarise this strapline that we're going to hear, and I've not included in mine reformation, but I'm quite aware that we have to think differently about how we deliver care, and that may be looking at a different form of workforce. This engenders a lot of controversy, but it's something that we must face, and we must never be afraid to challenge the status quo.

But I want to focus on recruitment, sustainability, following on from Deborah's theme, and retention. We need a sustainable workforce in the United Kingdom. We need to train our own doctors. Since 2017, there's been a 2% increase in the United Kingdom trained medical graduates, but 121% in overseas medical graduates. We have to be incredibly grateful to those individuals who come to this country, but what about their country? We all have a responsibility to support healthcare systems and their sustainability around the globe, and I think our current model is hardly contributing to everybody else's. So the plan starts off with a massive increase in recruitment into medical schools. That will bring with it numerous problems, and we're looking ultimately to double the number of medical students going to training. But at best, if that starts in 2025, that cohort of individuals is not going to be coming into the work stream for another five, six, or maybe longer years. And recent studies have suggested that the potential dropout of medical students is quite simply awful. We've known for a while that a lot of our young doctors disappear off to hotter climes or wetter climes, but a recent study in the BMJ only last week set out the results of the Ames Medical Student Survey, and it's depressing. They had 10,500 responses. That's only 25% of the student population, but pretty good. 50% said that they have no plans to enter specialty training, but the headline in the journals was that one-third reported that they planned to emigrate to work abroad at the finish of their F2 year, but only half of those intend to come back, which is a big change on what people had been assuming was happening. Worse still, 3% have no intention of carrying on in the medical profession, and even my maths can work out that that's roughly 300 million pounds down the swanee, and we haven't got that money to waste. So you have to ask the question why. Well, the answer might lie in the fact that only 17% said they were either satisfied or very satisfied with the prospects of a career in the NHS, which, of course, means even my maths can work out that over 80% are not. Now, in my day, I suspect we were ignorant and probably still are in many facts of life, but our younger colleagues are most certainly not, and that's a very worrying statistic.

A recent survey of medical students published in the Annals looked at why women aren't entering trauma and orthopaedic surgery, a subject dear to Deborah's heart and mine, as my programme, and I know some of them are here now, was the first one to ever have 50% women in my programme, and I'm very proud of that. One of the reasons, and you can all elucidate the reasons, I'm sure, yourself, but one of the reasons was inadequate undergraduate training, which I've been banging on about for ages. One of the conclusions was that we should improve the delivery of undergraduate training in T&O. Well, I will be controversial and say that I think it's about time we actually reintroduced it, because in many centres, there is none. So our youngsters have no concept of what really happens in our profession, and we need to get a hold of them.

I'm delighted that BOMSA, the Students Association, are here, I met them this morning, but these are, they are the chosen ones, they've obviously got sense, and they would want to come into trauma and orthopaedic surgeons, but we need to get more of them, and we need to infuse them and make sure that they stay in not only the medical profession, because those figures I elucidated earlier are awful, but obviously to come into our profession. And we need to sustain these individuals throughout their career, and obviously, the next stage, and I'm delighted that my son is joining the profession, is selection to become an orthopaedic surgeon. We probably have sufficient numbers wanting to be orthopaedic surgeons, but whether we're recruiting enough orthopaedic surgeons remains to be seen.

There was a very good article in The Bulletin of the College of Surgeons reflecting on the issues faced amongst our young colleagues with the lack of training numbers, and suggested that lack of training numbers were not keeping pace with the expanding workload, and Scarlett McNally alluded to this on Tuesday. There are various pros and cons to this argument, and I'm not going to go into those now, but clearly, trainees are concerned, and our colleagues are concerned. We aren't at the top of the list in terms of workforce. Training numbers may well go up, and my colleagues on the SAC know better than I, but they probably won't go up by as many as we may like to think we need, because there are huge competing interests from our other specialties. So we have to keep banging away at the people in power that we need to expand our workforce to deal with the ever-expanding workload. So, and I now make a plea, selection.

Many of us sitting in this audience, and I'm one of them, have been involved in selection, and want to keep face-to-face selection. For reasons which we might not agree with, the MDRS, or the Medical Dental Recruitment Service, has said that for the foreseeable future, it will be remote. Disappointing, but it's there, and we need to work with them, because we are letting our youngsters down if we don't, and I make a plea. Please support Cronin Kerin and his team and Deepa on the SAC to deliver this service, because we have to deliver it. No one else will, and God forbid anybody suggests that they will deliver it other than us. The BOA, and Deborah kindly has supported this, have written to NHS England, asking them to reissue this letter that some of you may be familiar with, some years ago, to our Chief Executives of the trust, saying please let your consultants go, and senior clinicians, to this process. It is essential. We've also written to the MDRS, expressing our concern at the decision, and we'll wait and see.

But we must also not forget a huge, untapped workforce, which we are, slowly but surely, probably too late, but we're getting there, beginning to realise, and that is our SAS and locally employed doctors workforce. We've had some excellent sessions, and there's some really informed, motivated individuals coming into the BOA, and we've, you know, one of their predecessors, Mamdouh, has been championing your cause for years. But we probably are not supporting and developing these individuals in the way that we should do. It's to the detriment of the NHS, and certainly to the detriment of the BOA that we are not, and I will say now that we will continue to do this, and to develop them, and allow them to develop, because a few weeks ago, when I was at the College of Physicians, talking about outpatients, and the need to reform how we do outpatients, as Tim said this morning, somebody from NHS England said that we need everybody in the workforce to work at the top of their game, and I would suggest that many of these individuals are not being allowed and supported to do so, so we will.

But what about what we've got? Well, there's the oldies, like me, and in November 22, the BOA, along with the Royal College of Surgeons of England, carried out a retirement survey, and I know people are sick to death of surveys, but actually getting accurate data on what the workforce is and wants to do is well nigh impossible, so we have to try. There were 1,200 respondents, about half of the current consultants in the United Kingdom, and I know that these workforce surveys are notoriously inaccurate, and probably filled in after a horrendous clinical swearing at that wheel going round on the computer screen, because it won't do what you want it to do. But they are worrying, and without going into details, and many of you can look at them if you want to, potentially we could lose 50% of the consultant workforce over the next five years. That is a large figure, it's 1,200 surgeons, and we don't recruit and retrain anywhere near that number. Now, if you apply the fudge factor of surveys, it's very unlikely to be that, but there's a kernel of truth in all these things, and then we must not ignore it. We must retain that group, and we must consider how we're getting the trainees, and are we getting enough trainees through. Health Education England told me that they're not worried because they work on the premise that we will lose 100 whole-time equivalents a year, but the majority of consultants that filled in the survey were working 10 to 12 PAs. They might reduce the work, or they may never come back. We don't know, but we do know, of course, that retirement return may be positively influenced by the recent pension changes. That remains to be seen.

The worry, of course, is that our trainees have been through an extremely rough time. In my own trust, in the first half of this year, virtually no primary arthroplasties were undertaken for elective, or as we would now like to call it from our Scottish colleagues who recommended this phrase, is planned essential care. It is not an optional form of care for these patients. We didn't operate for very reasonable reasons as far as people are concerned, but not the patients. Our trainees, therefore, got no exposure to primary arthroplasty during their four-month blocks. That takes recovering from. They don't have excess time in their training scheme, and we know that average numbers in trainees' logbooks are 24% down on pre-COVID levels. That's a massive amount, and we have accurate data due to Rob Gregory and Deepa Bose's work in gaining access to the logbook.

So T&O was also the largest user of the prefix 10 in front of their ARCB outcomes, and many of you know what that means. It was awarded for COVID reasons, but it's obvious we weren't doing elective surgery, and therefore, they're missing out on their training. And my own view is that the effects of COVID are yet to play out fully, and there may well be a huge problem. Deans are not aware of the actual figures, but my own dean in Wessex think there is a problem coming down the road. And I would plea to everybody involved in getting the restart going. There's an understandable need to get our numbers going. There's an understandable need to maximise service provision in our theatres. God knows we're fed up of sitting twiddling our thumbs and banging our heads against a brick wall, but in that rush and that drive, we mustn't forget the trainees because they are frequently forgotten, and I've seen it on so many occasions. We know that units can do it. Exeter in particular in their Nightingale Surgical Hub have shown you can provide service and training at a pace, and we must all do it because if we forget these individuals, we're in real trouble. I listened to the last survey. I fully appreciate the frustrations that are expressed, but as somebody said to me not so long ago, why do we give our trainees the best and the brightest, as Jo Maggs said, who've worked damned hard for these numbers, why do we say that you've got a six-year training scheme in T&O, but then we, in most cases, hand them over to trusts who offer them six-monthly or yearly contracts? And if you're on a six-monthly contract, you don't even qualify for the cycle to work scheme. I know it's not easy, but for heaven's sake, is that the way to treat them? I don't think it is.

It was 2016 that the Government produced a report on improving working lives of our young colleagues. Seven years later. So I have yet to see anything in my career that suggests we need now, or at least in the foreseeable future, less orthopaedic surgeons to deal with our patients. There is certainly no shortage of work. There's certainly no shortage of work now and in the foreseeable future. And as Amanda Pritchard said, we need a workforce to do that work which our patients demand. What that workforce is and what form it takes remains to be seen, but there is a real and present issue which we need to address. And my aim next year as president is to keep all parties focused on the issue of the current and future workforce involved in all aspects of T&O healthcare provision. We need to recruit, sustain, and retain us.

Thank you very much. 

Simon Hodkinson
BOA President 2023-2024