nicest day of the week, so it shows a real commitment on your part, so hopefully we'll make it worth your while. I'm Adrian James, I'm President of the Royal College of Psychiatrists in the UK, and I'm also a forensic psychiatrist, and it's my great pleasure to be chairing this session. We've got four great speakers, the best that we have in the Royal College of Psychiatrists, and I'm here to chair it as well. So we're going to be talking to you about getting serious about equality, diversity and inclusion, and it's our journey really in the last three years around this important topic. I think it's, if I look back on my presidency in the last three years, it's the thing that I'm most proud of, and I think it's the most important issue that we have looked at. And one thing I always say is that this is an issue for all of us, and if we can look at this and get it right, we all benefit, and particularly our patients benefit. And not only is it a moral and legal imperative, it's also about the performance of organisations. We know that when you address inequalities that organisations perform better. So it's a massive win, whatever way that you look at it. So we've got four speakers. First speaker is Dr. Lade Smith. Lade is at the moment the presidential lead on equality, diversity and inclusion, but she is also my successor. She will become president on the 11th of July. She's an amazing person, a forensic psychiatrist also, and she's done a huge amount of work over the years across government, across the Royal Colleges, across the Academy of Medical Royal Colleges, and a lot of work on the review of our Mental Health Act that had a strong theme around equality, diversity and inclusion. So Lade, we'll pass over to you and you're going to give us the context for this work. I'm actually going to go in the front row so I can see all the action. So over to you Lade. Okay, so thanks Adrian. In Britain we have, I think it's probably similar in America when it's fringe, you know it's fringe performances. If there are more people in the audience than there are speaking, then we go ahead. So we're all very, very pleased that there are double the numbers of people here than we are. So what I'm going to do is set the context so that you'll understand something about Britain and when we think about the UK, you know if you ask people about the UK, what they'll, they have, they think of, you know, the Queen, they think of, you know, villages with lovely greens and people playing cricket, things like that. And if you ask people in surveys what British people like, they'll say British people are fair, British people are honest and sincere, that in Britain you can actually get equality and that's why lots and lots of people want to come to Britain because they think things are fair and that it's an equal society. And one of the things that people say when you look at the qualities of British people, they essentially mirror the qualities of a true gentleman. And a true gentleman, if you look it up, if you google it, it will say something like someone who is honest, sincere, trustworthy, someone who thinks of the needs of others and someone who is fair in everything that they do. And so it means, because in a sense Britain is like a kind of a nation equivalent of a country gentleman, that in Britain because everything is done on the kind of gentleman's agreement, we don't actually have a constitution because we don't need one, because everyone is just generally fair and good to other people. Which is fine if you're a gentleman, you're like a gentleman, because a gentleman knows what gentlemen need. But what happens if you're not a gentleman, if you're not like a gentleman, if you are in fact you belong to a group that the gentleman has fairly negative ideas about, or the gentleman doesn't know about you at all, how then do your needs get met? So I'm going to tell you a little bit about modern Britain. So every 10 years we have a census, and our last census was actually in 2021 and the results are just out, it's hot off the press. So what I can tell you about modern Britain is that it's different to the way it was you know 100 years ago, the kind of you know Downton Abbey type Britain, it's a bit different. And we know that about, so everyone gets asked about themselves, and in Britain currently about 90% of people report that they are straight or heterosexual, about 3% of people report that they are lesbian, gay, bisexual, pansexual. Interestingly about 255,000 people identify as being transgender, very small number of people considering the enormous amount of press that said about them. When it comes to race and ethnicity, Britain is quite a different looking place to the way it was 50 odd years ago. So we know that about 80% of people in Britain are white, about 74% are white British, about 7.5% white other. Almost 10% of people are from South Asian backgrounds, so this is people mainly from the Indian subcontinent, and we have a few people who are Chinese or East Asian. About 4% of people are black, and about 2 to 3% of people are from mixed heritage. And what's important is that across Britain there is actually quite wide variation in terms of where people are, where people live. So if you've been to Britain, you've probably been to London, and London is incredibly diverse, it literally is a multicultural, multiethnic, multiracial city. And it is a city, people describe London as being like a country within a country. If you go outside of London, however, to the rest of the UK, if you go to Wales for example, less than 1% of the population are from a minoritised ethnic group. So you get really, very, very different kind of racial distributions depending on whereabouts you are in the country. And then about 17, 18% of people report having a disability, which is a lot, obviously. And interestingly, since the last census in 2011, a significant proportion of people report that they have no religion. Why is that important? It's important because actually, what we know is that if you are someone who is not like the norm, and the norm here is the majority white population who are straight, then you are much more likely to have a mental health problem in the UK. You are much more likely to, if you are from an LGBTQ plus background, you are much more likely to, you know, unfortunately die by suicide. Much more likely if you are transgender, we know that there are much higher rates of self-harm thoughts and self-harm attempts. And worryingly, we know that women have more mental health problems than men, but worryingly, and we know that men are more likely to die by suicide, but in the UK, the worrying thing is that over the years, over the last few years, suicide has been the commonest cause of death in younger women, and that's a real concern. We know that people with learning disabilities have more mental health problems, et cetera, et cetera, and the big thing here is this, that if you are poor, if you're rich in Britain, it doesn't protect you from having a mental health problem, but it definitely helps. If you are poor in Britain, then you are two to three times more likely to have a mental health problem than if you are richer. And we can see that people who sleep rough are very likely to have mental health problems, and we've seen a very similar thing in San Francisco. And this is the big one. If you are from any minoritized ethnic group in the UK, unlike your original first generation immigrant grandparents or parents or great-grandparents, you are much more likely to have to be detained involuntarily. You're much more likely to be detained under the Mental Health Act, and that's every single ethnic group, including white other, and if you are any kind of immigrant as well. And that's problematic, actually. It's particularly problematic for black people who are much more likely to be, to come in under, in crisis, be brought in with the help of the police. Much more, 40% of black people access mental health services through the police, with the help of the police or the criminal justice system. And it's even, we even see that involuntary detention for people from Asian backgrounds is still much higher than the white British population. So you would hope that when it comes to treatment, those people who are getting, having to access care in this involuntary way, get better treatment, more treatment. But if you look at psychological therapies, actually, to be honest with you, it's very hard to get psychological therapy in the UK. It doesn't matter who you are. But if you are from a white British background, you are twice as likely to get access to psychological therapy than if you are from any other ethnic group. And that's interesting because in the UK, if you're Asian, if you're Asian background, you have no problem going to see your family doctor, you have no problem going to primary care, and the way you get referred is via primary care, usually. But in fact, if you are Asian, even though you're very happy to go see your family doctor, the likelihood of being referred on to psychological therapy is really low. Half that of a white British person. And the problem is that when you do get into therapy, much more likely to drop out, less likely to recover. So essentially, we have a situation whereby people are overrepresented in crisis and secure services, but underrepresented in treatment. So what about, and that's healthcare, and that's obviously a major problem, this clear health inequity. But what about for doctors and, you know, the workforce? What we know is in Britain, it's like with America, you know, to get to be a medical student, you have to have really, really brilliant grades. And in Britain, we have A-levels, and you have to have at least three A-stars, that's like, you know, getting 90% plus in your exams. And, you know, not just that, you also have to, you know, play cello to grade A and be the captain of the football team and, you know, have a blueprint for solving world peace and things like that. But what we know is that people who go into medical school all meet that standard, really high standard. And across the board, no matter what your ethnicity is. However, once you start going through medical school, something unusual happens. And it seems that when you're looking at people who are graduating from medical school, people who are from minoritized ethnic backgrounds are far less likely to graduate, less likely to pass their exams, less likely to meet the competencies of what you need to be able to become a doctor. And then when people become doctors, if you're from a minoritized ethnic background, you are much more likely to be referred to our regulatory authority, the General Medical Council. And, I mean, that's really significant, actually. And then when people are doing their postgraduate exams, you know, membership at the Royal College and things like that, then if you are from a minoritized ethnic background, you are far less likely to pass than your white counterparts, to the extent that the GMC have said the biggest determinant of career progression and outcome for doctors is a person's race. So we looked at this at the college and said, oh, well, how are we doing? How are we doing at the college? And these are statistics from 2018, actually, just before 2018, because we were looking at these stats for mental health at review. And this, on the left of the table, these are the members. So this is people who have got membership of the Royal College of Psychiatrists. And on the right are people who are fellows. And so you get your exam, you become a member. Then 10 years later, if you're of good standing, you're a good egg, you can become a fellow. And you have to, you know, you've done something a bit good and you have to get nominated by a couple of other fellows. And you can see that there's actually, we're actually quite a diverse group of people, actually, psychiatrists. You know, there's a good 30%, 40% of psychiatrists are from minoritized ethnic backgrounds. But look at this. When we look at the senior psychiatrists who become fellows, then suddenly, despite the fact, look at that 30%, essentially 25% to 30% of psychiatrists are South Asian background. But look at the percentage who actually are given fellowships. It's half as many. So it made us think, actually, we need to start doing something because we need to get our own house in order, as well as thinking about what's going on with our patients. So that's actually most of what I've got to tell you, actually, except for this. So on my way here, I was on the plane. And I was sitting in the second row on the plane. And, you know, the hostess was coming along asking people for their food orders and drinks orders. And she looked to the left at the row, you know, the row in front of me and asked, you know, the passenger what they wanted. She asked the passenger to the right of her what they wanted. And then she asked the passenger behind in the second row what they wanted. And then she asked the passenger behind me what the passenger wanted. And she says to the passenger, okay, so you want that drink? And you've got a special meal, right? And the passenger said, no, I don't have a special meal. Actually, I was looking, I wanted the chicken. And she said, no, you've got a special meal, haven't you? No, no, no. And I said, actually, I've got a special meal. And she looked at me, she was absolutely astounded. She just, she was, and she looked behind her to see where I'd come from. I've been there the whole time. She just did not see me. She did not see me. And that's the problem actually, because in Britain, we have now really quite a diverse group of people who live in the country, whose health needs are quite significant. They do not have the same access, experience or outcomes from healthcare. And that is because essentially, in our fair and equal society, what we're doing is we're not seeing people. We're not looking at the data and we're not interrogating it. And that means we don't know what the problems are. So that is my final quote. While it is better to be loved than hated, it is far better to be hated than ignored. So I'm going to finish there and hand over back to Adrian. Thank you. Thanks, Sally. I'm sorry to hear about that experience. And yeah, you can be in the room, but still not be noticed. And you can speak, but not be heard. So let's move on to our next speaker. And it gives me great pleasure to introduce Paul Rees. Paul is the Chief Executive of the Royal College of Psychiatrists, been Chief Executive now for six years. He's a transformational leader. He's changed the whole way in which the college is run. He did a huge amount of work before the COVID-19 pandemic in preparing for something which we didn't know was going to happen. But when it did happen, we were in a very good place. So the whole functions of the college really continued, not as if nothing was happening, but we rose to the challenge in a very effective way. And Paul is going to tell us, we've had the background, the context from LADEE. Paul, you're going to tell us what we did and what happened. So Paul, over to you. And I'd say we're very proud of Paul that he was given an MBE in the last year for his services to mental health and equality and diversity. So Paul, over to you. Right. Hello, everyone. It's great to see you. And thank you very much, Adrian, for that introduction. Hopefully I'll be able to work the slides properly. It's always a bit of a challenge, I find. So as Adrian said, I've been at the college for a number of years. I've been with the college for seven years now as chief executive. My predecessor, Vanessa Cameron, was in post for 33 years. So I think I've still got another 26 years to go. So LADEE's talked about the background in terms of what the UK is like and the idea of Britain being like a fair and just gentleman. Well, we've tried to make sure that our organisation internally is fair and just. So I'll start off with some good news. In 2019, we won an award for charity of the year across Europe in the European Diversity Awards. And you can see there's someone in the middle just to the right of it with a bow tie. His name is Raj Mohan, and he's played a massive role along with Adrian, LADEE and Subodh in terms of helping the college get to a really good place in terms of equality, diversity and inclusion. This is an award we had last year. We won the award across the whole UK membership sector for the best equality, diversity and inclusion work. And you can see LADEE in the middle there holding the award with a man in a very natty suit. That again is Raj Mohan. So we also, earlier this year, we won an award. And when you win awards, often you think, well, that's just good news. It's a mark of excellence. But this award actually caused a bit of a tiff, a bit of an argument, a bit of a row within the Medical Royal College. So we were awarded what is called a Stonewall Gold Award. And what that means is we were named as being in the top 100 employers across the whole of the UK for creating an LGBTQ plus inclusive workplace. Now, we agreed to start working with this charity, Stonewall. It was around about three years ago and when we had a new strategy. And we thought if we did great things in terms of being inclusive, we might get a Stonewall Bronze Award. But that would be it because we'd said to Stonewall, not everything that you think we should do, we can actually work with because they've got so many measures that they want organisations to meet, so many things they want you to do. It's actually 380 different measures they want you to prove you've met. So we went through them all line by line and decided we could meet about 300 of them, but not the other 80. We thought they wouldn't be appropriate for the college. So we weren't expecting to get any higher than a Bronze Award. And then in February this year, we found we were a Stonewall Gold Award employer in the top 100. So why are Stonewall controversial and why were some of our members actually quite concerned? Well, the reason is in the UK, probably similar to America, the issue of trans rights is a very controversial issue. And obviously we live in a polarised era. We live in an age of rage and Stonewall have come down conclusively on the side of trans rights. But obviously that means some people say, well, then that is potentially negative for the rights of women. That's the argument some people make. So the fact that we got this award was controversial, but many members obviously were very happy at the same time. So who is in the Stonewall top 100 apart from us? Well, lots of famous sort of blue chip organisations such as Bank of America, Barclays Bank and the NHS itself, and then Citibank, KPMG, HSBC, etc. So moving on, we also joined the Disability Confident Employer Scheme. And through that, we provide work experience placements for children locally with disabilities and in the UK there's an organisation called the Equality and Human Rights Commission that is government funded and they published a blog about our work last month setting us out as an exemplar organisation for other organisations to follow. Doesn't mean we think we've got everything right, there's always more to do and there's certainly much more for us to do but that was great that we were recognised by them. So I don't know if people recognise this person, this is Wendy Byrne, Adrian's predecessor. She was the president who sort of started the ball rolling in terms of equality, diversity and inclusion and while she was in post we launched our college values which put equality, diversity and inclusion very much to the heart of the organisation and then Adrian was elected three years ago on a platform of promoting equality, diversity and inclusion and that has been one of his top four priorities while he's been in office and that's been a real game changer. So we've got a strategy, the Artsy Cycle Equality Action Plan, we pulled that together over the course of about six months and it's got 29 actions in there that we've pledged to deliver and one of the things that Lade mentioned when we were pulling it together is lots of institutions publish equality plans to a big fanfare and then forget all about them but what we try to do is make sure we track how we're doing on a weekly basis to make sure we deliver all the 29 actions as promised and we've delivered 26 out of the 29. So there's Lade and Raj, they are the two presidential leads for equality, for race and equality in the college and they've done huge work to help us deliver on those actions in the Equality Action Plan. So although we've got 29 actions in our strategy we've actually got in total 433 actions on equality, diversity and inclusion that we try to deliver. We prioritise four areas, in the UK there are nine protected characteristics, we prioritise sexuality, gender, disability and ethnicity because we feel that they are the most key issues when it comes to the issue of mental health and mental health service delivery. So Lade, who you've heard from, she's the next president of the college, she takes up office on the 11th of July, we're very proud to have Lade as our next president and she will be the first black woman president of any college in the UK and this was the cover that we had in our membership magazine in March to celebrate that fact. So all of this work is underpinned by our college values, courage, innovation, respect, collaboration, learning and excellence and this is a poster we've got. Now lots of organisations have got values, they might have them on the website or they have them on a piece of paper in the kitchen area in the office and to be quite frank most organisations don't really take them that seriously but we actually have put them to the heart of the organisation and we genuinely make all of our decisions based on our values and that's across the senior management team working with our senior elected members. The reason for that approach is this person here, John Frost, he's a management guru and when we pull together our values he said you've done the easy bit, the hard bit is to decide what do you want to be, what do you want to do with the values, do you want to be a values based organisation and make sure that everything you do is based on those values and we decided that's what we wanted to do and he said it will be a hard road, you'll have to make lots of tough decisions, there'll be lots of unpopularity but if it's the right thing to do then you should do it and the high performing organisations are those that are values based and values led. This is our current officer team, you're going to hear from all of them apart from Trudy who can't be here unfortunately and John is taking part via video but they are a fantastic team and they live out the values on a day by day basis. This is Dame Fiona Caldicott, one of the most famous psychiatrists in the UK of recent years, she was the first female president of the Royal College of Psychiatrists, she sadly passed away two years ago but pretty much the day that we announced that we were taking this values based approach in 2018 she emailed me and she said this is one of the best things that we've done as a college because if you take a values based approach not only will you create a fair and just culture for everybody, you will also prioritise equality, diversity and inclusion and if you do that, that benefits everyone because if you make sure that the culture is right and everyone has a fair chance that benefits everybody regardless of their background or their characteristics. So until we launched our values back in 2018 as a college we didn't ever celebrate major diversity events within the UK but now they are massive parts of the college calendar so every year we now celebrate International Women's Day, Black History Month, Pride, South Asian History Month and International Day of People with Disability. So what does the mix of our college look like, how diverse are we and are we as diverse as the APA? I don't know the APA's figures but certainly these are our figures so 46% of our members are women, 40% of our members are black, Asian and minority ethnic, 8% of our members have a disability, 7% are LGBTQ+, on the staff side we have about 440 staff, 70% are women and 21% are staff of black, Asian and minority ethnic. So we have staff forums to represent our staff teams on these issues, we have an African and Caribbean forum, sexuality, gender equality and inclusion forum and a disability forum and we have made massive strides on a whole host of issues, one of them is the gender pay gap. So in the UK if you look at this graph on the right hand side, that is what the average difference is between what a man is paid and what a woman is paid in the UK, 15.4%. But because we have run a very dynamic gender equality action plan and we adopt equal opportunities in the way we recruit and retain people, our gender pay gap is 2.85%, that's the figure on the left, that's as close to zero as you will get as an employer body in the UK. And then in terms of ethnicity, in London where most of our staff are based, the gap between how much white staff are paid in a typical organisation and black, Asian and minority ethnic staff is 24%, but for us again because we take this values based approach it's just 5.81%. So we do a lot of media work within the UK with the joint top college in terms of media coverage along with the Royal College of General Practitioners, this is a story we gave to the national media last year, we did the first survey of any medical royal college to look at the experience of doctors who are LGBTQ plus in our specialty and we found that almost half have reported hostility at work in the last three years, we gave this story to the Guardian and other media outlets and now off the back of this work two mental health trusts in the UK have said that they will now work to the measures we say all employers should work to in order to ensure LGBTQ plus inclusivity. This in the middle here is Subodh Darvi who is going to be speaking in a little while, this is a set piece interview he did with his wife Ananta on the left on TV, British TV, Channel 4 News about race discrimination within mental health services. Because of our values we take what we see as being a courageous approach, shortly after the murder of George Floyd we published this cover in our membership magazine which highlights the Black Lives Matter movement. Now no other medical royal college felt able to do that, they felt that was too controversial in the UK and also we were one of only two medical royal colleges to publish a statement condemning all forms of racism in the aftermath of George Floyd's murder. But we don't shy away from from difficult issues again using our value of courage, this was a feature we published in our membership magazine just recently looking at the issue of gender identity, the troubled issue of gender identity and we gave a platform to one member who was trans affirmative, one member who was gender critical because we felt as a broad church organisation with members with a whole host of views it was important to look at this issue in a respectful and a fair way. And the feedback so far has been that most of our members say that and they were on both sides of the argument, they say the feature was respectful and they thought it was a positive contribution. This is our HQ in central London, during the pandemic it was empty for two years because people were working from home, we used that opportunity to refurbish our building, we've got this history wall as you go into the college up to the auditorium that shows the diversity of the specialty and the college. We've got a massive digi wall as you go into the atrium on the right hand side and this screen changes every few seconds and it shows a fair cross-section of our membership because our membership is diverse and that's something that we want to highlight and we're proud of. If you go to a number of other UK medical royal colleges you will not see any diversity in the atrium or the entrance, everyone in the paintings etc looks just the same. So this is what our members used to say about us, we did focus groups in 2016, they said that we were London centric, we were elitist, cliquey, invisible but this is what our members say about us now, they say we're diverse, influential, forward-thinking and inclusive, that's based on a membership survey two years ago and focus groups last year. Our membership keeps on growing and that's whilst we're taking these stances, it's not leading to membership attrition, it's not going down, our membership continues to grow up from 17,900 in 2016 to 20,500 now and this is just a picture here, I'd like to thank Adrian for being a brilliant president, a fantastic friend, he's really led from the front, if you're really pushing hard on equality, diversity, inclusion it's a tough road and often it's easy to sort of start to drop things and start to moderate your position, Adrian's always been really clear that he's not going to do that on his watch and he very kindly put me forward for an MBE, so in the Queen's last news honours I got an MBE for services to mental health and to diversity, equality and inclusion, that's one of the proudest moments of my life, I was at Buckingham Palace in November getting that award, so I was very proud. Lade is a CBE so she's two tiers above me in terms of the pecking order but it was a fantastic moment, so thank you very much for that and I think now it's, well it's actually John's video, is that right? Yes, great, thank you. Great, well thanks Paul, really impressive and Paul leads our amazing staff group, we have fantastic members like Hassan, I've just spotted you, in leadership positions and but we work really very closely, our members, our leaders along with our staff and this is the result, so thank you Paul and again many congratulations on your MBE. So I am now going to, whoops, see, so we're now going to hear from John Crichton who is the treasurer of the college, John unfortunately couldn't be here, he intended to be but he had eye surgery, so he has done a pre-record and so he's going to tell us about equality, diversity and inclusion in the devolved nations. So we as a college, we're a global organisation, we've got 3,800 members outside of the United Kingdom but within the United Kingdom we cover England, Wales, Scotland and Northern Ireland, they all have their separate governments and different stages of independence, so they often have different policy, for example in health, so we have devolved councils for the parts of the college that cover Scotland, Northern Ireland and Wales and John's going to tell us about that and as he will tell you he is based in Scotland, so over to you John. Well hello everyone, I'm very sorry not to be with you in person, I'm recording this presentation from central Scotland not far from the village of California, it was so named to entice people to move there and I'm not sure that it could be described as the sunshine village but I feel very close to you in spirit. My first slide please, the Irish playwright John Bernard Shaw is attributed to having made the remark that England and the United States are two countries divided by a common language and it was therefore with some trepidation that on January the 26th 1942, Private Milburn Henk from Hutchinson, Minnesota was the first American GI to step onto British soil during World War II. The troop ship landed in Belfast, Northern Ireland not far from the shipworks at Highland and Wolfe where the Titanic was constructed. To assist the GIs, a guide to Britain was issued packed with helpful advice, never criticize the king or queen, don't laugh at the funny accents, be warned Brits can't make coffee but bear in mind you can't make tea properly and perhaps most pertinently for our topic today, it is not shameful for a man to take orders from a woman, at least a woman in uniform. Perhaps one of the most confusing aspects of Britain would have been that we are not one country, we were not then one country and we are not now one country. Next slide please. The UK is a partnership of four nations, England, Northern Ireland, Scotland and Wales. We have different cultures, different population demographics, different traditions and different laws and responding to the diversity of the four nations of the UK presents a particular challenge to our seaside. It presents challenge to our inclusion work and how we're tackling that is my topic today. So how much older do you think Great Britain is compared to the United States? You might be surprised, Great Britain is only 69 years older than the United States, that was when the political union of the kingdoms of Scotland and England together with the Principality of Wales came into being. Northern Ireland is a much more recent entity created in 1921 as Ireland partitioned and Southern Ireland became independent. Next slide please. Her Majesty Queen Elizabeth awarded the George Cross, Britain's highest award for gallantry outside combat, to the National Health Service in recognition for our work carried out in response to the Covid pandemic. It was not to one National Health Service, it was to NHS Northern Ireland, NHS Wales, NHS Scotland and NHS England. There were four medals, not just one. Our use of the term national is inherently confusing in the British context. It can either mean the whole of the UK or one of her four component countries. Instead you will hear us use terms like four nations when we're referring to the UK as a whole. Four nations of the UK are not united in a federal system. Next slide please. The Kingdom of England, dating from 927 of the Christian era, has the highest population with 55 million, roughly equivalent to the combined populations of California, Oregon, Washington and Arizona all put together, but with a land size similar to North Carolina. Unsurprisingly, 85% of RC Psych UK members live in England with the greatest concentration in and around London. Next slide please. The Kingdom of Scotland is older, founded in 843 in the Christian era. It has a population about a tenth the size of England at 5.5 million, similar to both the population and land mass of South Carolina. 9% of UK psychiatrists live in Scotland. Next slide please. This is a picture from a hotel room when I was speaking in Wales, and Wales was founded in 1056 in the Christian era. It has a population of 3.2 million, that's similar to Nevada, but with a land mass similar to New Jersey. And next slide please. Northern Ireland, only 100 years old, with a population of 1.9 million, similar to Idaho, but with a land mass slightly larger than Connecticut. 4% of RC Psych UK members live in Wales, and 3% in Northern Ireland. Next slide. The British Parliament of Westminster has been the UK Governing Assembly since 1707 for England, Scotland and Wales, and for Ireland from 1801. Until the creation of the Northern Irish Assembly in 1998, the Welsh Parliament in 1999, and the restoration of the Scottish Parliament in 1999, it was the Westminster Parliament that would pass separate laws for Scotland, Northern Ireland, and the single legislative entity of England and Wales. So it was the Westminster Parliament, with 80% of its MPs representing English constituencies, which enacted the Mental Health Act 1983 for England and Wales, the Mental Health Scotland Act 1984 for Scotland, and the Mental Health Northern Ireland Order 1986. Now following the devolution of powers to the four nations just before the millennium. Next slide please. It was therefore the Scottish Parliament, not the one at Westminster, which passed the Mental Health Care and Treatment Scotland Act 2003. And next slide. And the Northern Irish Assembly that passed the Mental Capacity Act Northern Ireland in 2016. But the devolution of powers to the nations of the UK comes with limitations, with the Westminster Parliament reserving key powers, and the UK Supreme Court the arbiter of disputes. The European Convention of Human Rights, that bit of Europe that we're still a part of, must be followed in the devolved administrations and in any devolved legislation. The registration and regulation of doctors, curricula for medical schools, the content of postgraduate medical training is not devolved and remains under the ambit of the UK's General Medical Council, a four nations approach. But devolved to the nations of mental health policy, mental health services, the delivery of training of psychiatrists, and in Northern Ireland and Scotland, mental health legislation. With devolution has come divergence. Current Northern Irish mental health legislation fuses mental health detention and interventions for those who lack competence to consent to physical treatment. Reform of the law in Scotland is heavily influenced by the United Nations Convention on Rights of People with Disability, whereas parallel proposals for reform in England do not. The structure of the NHS in the four nations is different, as are the inspection of health services, healthcare standards, and treatment guidelines. ICD-11 became the official diagnostic framework for mental illness diagnosis in Scotland in November 2022, whereas the rest of the UK uses ICD-10. Next slide, please. So to respond, RC Psych built on its existing UK regional structures. We put additional resources into the devolved nations and the chairs of the RC Psych in the devolved nations became vice presidents of the college. In 2018, we created devolved councils. But changing titles and names is one thing. Another is changing attitudes. We make special checks now to ensure the policy statements from the college are either correct for the four nations or accurately reflect differences of practice. If funding is secured for a training initiative in one nation, we seek matching funding elsewhere. When potential difficulties arise in the policy position between the four nations, we aim to identify these early, arrive at concord, or explain any differences of approach. For example, Scotland has recently passed legislation regarding gender identification and it's soon to consider Oregon-style death with dignity legislation. There are also specific legal requirements in the four nations, which the College has to be mindful of. In Wales, there are strict rules regarding the Welsh language. In Northern Ireland, there are special safeguards regarding religious diversity. And in Scotland, there are requirements to include on official maps the entirety of the country and not simply put the islands on the edge or leave them off or put them in a box on the side. Next slide, please. There's also a realisation that by the College embracing diversity between the nations, we create opportunities and mutual learning. We have, in effect, a great natural experiment between the UK nations, so we can compare the success or otherwise of various different approaches. The Wesley review of mental health legislation in England and Wales shamelessly borrowed many aspects of Scottish legislation, which has been shown to work. Integration of health and social care was first introduced in Northern Ireland. Next slide, please. And minimum unit alcohol pricing was introduced first in the UK by Scotland, influenced by a Scottish Royal College of Psychiatry campaign. We also have to be mindful of the different demographics in the four nations, where there are substantial differences in ethnicity, both of the population and of psychiatrists. 49% of UK psychiatrists come from an ethnically diverse background compared to the general population, which stands at 18%. In Wales, 48% of psychiatrists come from an ethnically diverse background, but the Welsh population is much less diverse at only 6%. In Scotland, 26% of psychiatrists come from an ethnically diverse background, with a population which stands at 4%. And in Northern Ireland, 12% of psychiatrists come from an ethnically diverse background, with a general population figure, which is 3%. That creates a challenge in each of the devolved nations of how we support members from an ethnically diverse background working in their particular contexts with populations with different demographic characteristics. One initiative of how we support international medical graduates coming to work in the UK, who after all make up 46% of the UK psychiatric workforce, is special training. Next slide, please. I don't know how well you'll be able to see this, but this is a training slide that we use and it illustrates that when we use colloquialisms in our devolved nations and regions and say, for example, that something is not bad, if I say something is not bad, that's actually taken in Scotland as being really quite good. But it might not be what's heard by somebody who has knowledge of English from elsewhere. This table is used for training, not simply of our international medical graduates, but also alongside them, their trainers and tutors, so that they can appreciate how language differences can be overcome. Next slide, please. I don't know if any of you have roots in the northeast of Scotland, but one challenge in certain parts of the country is to understand the local dialect. And before anyone, in fact, practices as a doctor in the northeast of Scotland, they need to have a little bit of dialect coaching. The language up in Aberdeen is known as Doric, and there you'll discover such things as Yorksters, which is the local name for the armpit and other interesting descriptors of anatomy. Up until 2011, RC Psych included, on the same basis as the nations of the UK, the Republic of Ireland. Members of the Republic of Ireland, up until 2011, paid full membership fees, and a proportion of our meetings were located there. There were difficulties in that relationship, however, particularly with the Irish government in their interaction with an organisation which looked very British. And the Irish College of Psychiatry was founded as a result. Yet, even now, 700 psychiatrists from the Republic of Ireland remain international members of RC Psych. However, no longer do we enjoy the same closeness of mutual learning and campaigning that occurred before. Now, there were good reasons for the split between the Republic of Ireland and the UK, but the fact remains that RC Psych is diminished without the diversity that follows full engagement with psychiatrists in the Republic of Ireland. I have been very mindful of the potential of constitutional change within the UK. In Scotland, 55% of the population rejected a vote on independence in 2014. Yet, a majority for independence may only be along in a matter of time. In recent polling, 74% of 16 to 24-year-olds favoured independence compared to 40% of those over 65. When I was chair of RC Psych Scotland, I was always mindful that the membership in Scotland were evenly split on the topic of independence. For me, the real test of our diversity and inclusion work within the nations of the UK will be continued cohesion and full participation of psychiatrists in RC Psych across the four nations, whatever constitutional changes the future holds. Thank you all very much, and I wish you every success in the conference. Well, thanks very much, John, who I think probably is asleep. At least, I hope he is now. It's always good to be reminded of your own history. We now move on to our final speaker, Professor Subodh Dhave. Subodh is the Dean of the College. It's been my privilege to work with three amazing officers, and Subodh is one of those. He's a great innovator, a great strategic thinker, and he's really transformed the way in which we look at training and education. It's the Dean's responsibility within the College. He's also a great runner, and he did the Bay to Breakers run yesterday, so very proud, but he agreed to put his clothes back on for this presentation. So, thank you very much, Subodh. Over to you. Yeah, thanks. So, just to probably explain to members in the audience who are not familiar with the Dean, I think Dean is really the Chief Educational Officer, so I'm responsible for both training and workforce, and I think sometimes the second part of my job profile is forgotten, I think. So, as a College, we set standards for training. We design the curricula, and then how psychiatrists should be trained, and what are the competencies and capabilities that they need to acquire. We conduct exams to quality assure whether the trainees and learners have acquired those capabilities, but we also manage the workforce and their competence, and thinking about is the workforce ready and fit for purpose in terms of actually delivering the kind of quality of care that we want our patients to get. So, that's where, oops, okay, it's going good, just to see, so I'm not going to spend too much time talking about it. If people are interested in following and looking at our work streams, the different kinds of things we're doing, as a College, we're involved in a whole range of activities, and I won't really have time to cover them all, but do have a look. If you Google RTCI Dean update, it should take you to this page, which kind of lists all the work that my team are doing. I think I've got a fantastic team of Associate Deans and Special Advisors who support me in a range of activities, from curriculum design, to exams, to retention and recruitment, and I'll touch on some of the things, but what I really want to focus on today is this whole idea of health and workforce inequalities, and I think I'm very aware that I'm doing this talk in the US of A, which the healthcare system here is very different to what we have in the UK. We have a nationally funded healthcare service, and so talking of equity and equitable access to all, everyone, every single person in the country is probably a very different conversation that happens in the US, but two points to make here. Firstly, that if there was no cost bar, if there were no resources implications, I'm sure all of us would want all of our patients to do very well, and none of us, if we flip the argument around, would we be happy with a system that consistently delivers better outcomes for patients who come from black and Asian ethnic minorities, or would we be happy for poorer outcomes for a range of people who are refugees? I'm sure that that would not be acceptable to us, so I think that's one argument, but the second thing, I think, is recognizing that at a pragmatic level, let alone at a moral level, I think at a pragmatic level, and I think you made the case as well, that that really speaking, polarized societies don't do very well on health outcomes, and I think there's a lot of data that is gathered now, and we know that if you're a billionaire in in London, Kensington, then obviously your health outcomes are going to be quite good, because you have access to the best quality healthcare, but they're still poorer compared to a matched billionaire living in Helsinki or in Tokyo, and I think that is sometimes forgotten, that actually living in a polarized world is bad for all of us, it's not something that only affects the people at the receiving end of the disadvantage, and so reducing inequalities is essential and is imperative, really, to ensure that all of us can do well in terms of health outcomes. So I just wanted to take a brief journey, so the oldest school there, which I think is a black and white photograph, that's the Grant Medical College, which is where I trained and did my MBBS there, it's the second oldest medical school in Asia, and I think while I was working there, I would have thought of myself as a very conscientious doctor, someone who was really keen on providing good quality care to my patients, and indeed we did, you know, I think I had great teachers, and we regularly discussed the latest evidence, latest research, and I thought of how do we apply it to our patients. Now I don't know whether anyone here is familiar with how healthcare works in India, but I think it's very, in the public sector certainly, it's very, very busy, and an average morning in outpatients clinic, I would have something like seven or eight new patients, and anything from 50 to 80 follow-up patients, and people come milling around for seven in the morning, and probably I would only get to see some of them at two in the afternoon. All the years that I was there, not once did the thought enter my mind that we, why don't we set up some kind of register system to, so that people can come in, sign their name, go and have a coffee, or cup of tea, or do some other thing, and then come back at allocated time, and the point I'm trying to make is that it's very easy for us to forget as medics that our health, our science is only as good as it actually delivers care outcomes for our patients, and I think quite often, I think that that is the best that is not really taught, and for me, I think that lesson was driven really, you know, it became an aha moment for me when I started developing the postgraduate training program in Zambia. So when I went there in Zambia, they had three psychiatrists for a population of 15 million, and University Teaching Hospital in Lusaka, where Ravi Paul, my friend and colleague, was leading the program, was tasked with developing the training program, and he invited me to support him and help him, and this was funded by the British government, and what I realized was that the curriculum in Lusaka was exactly the same as in inner city New York, or inner city London. Now on one hand, you could say that, well, that's how it should be, that, you know, that all doctors should be trained to the same curriculum across the world, and in fact, that's what is the norm at the moment, but at another level, you kind of think that, well, how is that making sense, that how is that, that you have the same curriculum for people who are living in a very rich nation, and then another nation like Zambia, where you're spending 40 hours learning details of neuroimaging, when there's only one functioning MRI scanner in the whole country. And so for me, that was a salutary lesson, and in fact, in year three of our trainees, our first crop of psychiatric trainees, we put in their curriculum the requirement to go and attend health select committees, because we knew that the first batch of psychiatrists would be writing the mental health law, would be designing policy, would be engaging with politicians, and then would need those skills. So I think for me, it was a real lesson that, well, you have to tailor the curriculum to the needs of the population. You have to produce doctors and psychiatrists who will actually deliver health care to the best possible way for the local population. So we need globally competent doctors, but we need doctors who can provide their care locally, relevant, locally invested doctors. And that has then led me, in my own work at the University of Nottingham, to work with patients. We have a very large patient educator program. We have 50 patient teachers involved in teaching medical students, and we employ five of them as faculty members. So they are part of the faculty, and that's quite a unique program that's been very, very successful. So this is Flexner. Some of you may recognize Flexner, and I think medical schools, the modern medical schools as we know them, started in 1910, all thanks to Flexner. And surprise, surprise, they haven't really changed much. I think the medical schooling generally across the world is pretty much follows the same model. And I think the model is, you know, you study your basic sciences, you study psychopathology, and then you, well, pathology, and then you kind of learn treatment. And that is also being professionalized, and I think the Good Medical Practice, which is our professional guide in the UK, but there are similar documents across the world, I think then institutionalizes that and enshrines that. So the whole teaching of ours, the way we work, is all about the doctor-patient relationship. So the model is, you know, that if your liver is, there's something wrong with the liver, we'll palpate your liver, we'll scan your liver, we'll figure out what's wrong with the liver, and then we'll treat your liver. And the word community, for example, in Good Medical Practice occurs just once, and that once is in the context of, well, do you know how to manage an emergency in the community setting? So you can see that the whole way in which we treat doctors is very much focused around, well, do you know how to manage an individual pathology? Do you know how to manage, do you have the skills to manage an individual patient? The idea that we should be responsible for the care, not just of individual patient, but for the community that you care for, I don't think is woven into our identity, it's not woven into our training, it's not woven into our being, and that's the thing that we're trying to address as a Royal College of Psychiatrists. So we, this is a paper I was involved in, I think, not sure you can see that, it's in BMJ Innovations, but essentially we were trying to look at how can we start changing this culture, so that how do we get doctors to start thinking of themselves as being responsible for the care of the wider community, and not just their patient. And so we had, we invited a whole bunch of people, medical educators, leaders in health, so medical directors, and then people or administrators. We also had patients, carers, so we had a wide stakeholder representation, and we organized two roundtables. And panel one, the question was, what are, how do we drive this through curriculum and assessment change? What is it that we need to include in our curriculum and assessment that focuses on inequity, inequality, and social determinants of health? The second one was more around how do we actually get people to think about issues which seem very, very complex, and almost, I think people know how to answer the questions, like we've all, for example, in this room, I'm sure we knew, we've known for at least four decades that if you've got schizophrenia, poor housing is a significant risk factor. It's going to make, you know, your chance of relapse, it's going to increase that. But what do you do with that information? How do you use that information to actually improve the quality of care for your patients? It's not something that's always thought about. So what are the themes that we came up with? So you can see the emerging themes. So one of the key themes was that most of our training happens in either inpatient units or it happens in outpatient clinics, but real community engagement, learning in the community is not something that's very well institutionalized. Now I've been sending my medical students actually in the community for quite some time, and when they go and attend a day center where they see patients cooking or playing or just having conversations, the learning that they acquire in that setting is very different to the learning they acquire in outpatient setting or inpatient environments. And I think we, I think as medical educators, forget that there's a whole lot of learning that has to be acquired in those settings. You know, the feedback that we get is absolutely astronomical, and I think that's something that we really need to be thinking about as medical educators. But also thinking about our role as social innovators, I think we are taught to know the dose of risperidone, what's the correct dose of medication that you should be prescribing, and what are the interactions. But whether the patient actually then follows that up, you know, what happens if they don't take the medication, how do you deal with that, that is not always left to us. We don't really think of it as our responsibility, and I think that kind of ball is lobbed somewhere, and we expect that some kind of social care system will take care of that. So my responsibility is to know the right dose, the right diagnostic criteria, and the right prescription. Whether that actually then delivers results is not always thought of as our responsibility, and I think so our panel felt that thinking of doctors as social change agents was quite critical. And then the shifting the focus from the individual patient to the community as I outlined. Also learning, I don't know how many of you were at the opening session of the Congress, of the conference here, Saul Levin introduced himself as an IMG, and I'm an international medical graduate myself. We've heard Gladys and John mention international medical graduates, and I feel that the talk around international medical graduates, both in the USA and the UK, is very much in a deficit model, and I think as to what have they failed to achieve, how they're not succeeding as much as they should be, or you'd expect them to, how they're not occupying senior leadership positions, which is all true, but I think on the flip side, there's hardly ever any conversation around what are the strengths that they bring. And I think certainly I feel that as an IMG myself, having migrated to the UK from India, I belong to a community, and I think, you know, I recognize that the community gives me strength. How do I use that strength to actually inform my work in the UK? I don't think that we've tapped into that kind of understanding and learning, and I think that's something that we really need to be doing, and how do we really learn from the low-income, middle-income countries? And I think, Anusha, you're here in the audience. And I think Anusha's from South Africa. And I think we were discussing this yesterday, that how research also has been very, very influenced by the significant domination is of papers published in the West. And I think that ignores evidence and intrinsic learning that's available elsewhere. And I think that's something that we need to be changing in our medical education. And I think, clearly, unless we specifically talk about things like racism, diversity, advocacy, inclusion in the curriculum, and empower people to use them, things are not going to change. So what have we done? As a college, we've decided to take a step. We've changed our curricula. We've got two big lenses in our curriculum. One is about person-centered care. It's how we personalize the care to an individual, taking into account their unique psychobiosocial context. So we obviously want, and as psychiatrists, we recognize that we are the one branch of the multidisciplinary team that can synthesize those elements, that we have the knowledge from the psychological, biological, and social spheres. And then, so personalizing that, how do you apply guidelines which are population-derived to individuals? And that's one focus. The second focus is very much around public mental health. How do you learn from a case-based discussion and generalize it to the community, to your catchment area, to your wider community? So just some examples of the kind of capabilities we've introduced in our new curricula. So things about health promotion, things about prevention, they figure quite strongly in our curriculum. Understanding the factors that cause and perpetuate health inequalities figure very strongly in our curriculum. It focuses on intersectionality, understanding on how protective characteristics may impact on clinical presentation, how they may impact on the treatments that we offer, et cetera. So I think these are things that were not there in our previous curricula. And I think they don't exist in any other post-graduate training curricula to my knowledge. These are optional things, or they are couched in high-level outcomes, not listed as specifically as we have. Now, obviously, listing this in the curriculum does not mean that it gets translated into action. And so for us, the next step is about actually making sure that we have the resources in terms of training our health workforce in these capabilities. And an important enabler in that will be data and digital literacy. And I think people have been talking about this. I think right now there's a parallel session going on on the use of social media. And I think we all have seen the big explosion in social media over the last decade. All our patients are using them. Our patients are using apps. Last year alone, something like 6 billion pounds, so that's almost $8 billion, was invested in mental health apps, mental health tech. And yet, I don't think our training, our psychiatrist workforce is attuned to that. So I think as a college, we've launched our digital literacy framework. We want to make sure that our workforce is digitally literate, is able to tap into that, take a social media history, is able to actually understand data, understand and use data to actually improve the quality of care that they provide to their patients. And finally, I want to just touch upon health inequalities. As I try and finish my talk, I think, Ladi, you talked about this. 80% of the medical workforce, and this is pretty much true across the world. This is UK data, but I've looked at US data, and it's very similar, is that social classes, the top social classes, in the UK, we divide them in five grades. 80% of doctors come from social class 1. Social class 2, 3, 4, and 5 together make up only 20% of the medical workforce. And I think that's a question that we need to ask, is that representative enough? And does that skewing, does it have an impact on the quality of care that we provide? And I think it's a question that we probably haven't asked very explicitly. We need to be looking at that. The lack of diversity in leadership, Ladi, you've touched upon that. I mean, that's something, as a college, I think we are a very diverse organization, as Paul has outlined, but across the board, when we look at healthcare provider organizations, even medical education organizations, I think that lack of diversity has an impact on the kind of training that you provide. And I know there's been a whole movement on decolonizing the curriculum, and we'll be talking about that, but I think we need to really think about decolonizing in the widest possible way. I think it shouldn't just be about decolonizing from a race or ethnicity point of view, but also decolonizing from a point of view of the domination of academic publications from the West, and the non-inclusion of the lower and middle income countries, and their academic outputs. So I think there's a lot of work to do, and a mountain to climb, in terms of really achieving the benefits of diversity and inclusion. But I think the risk is that we kind of can fall into a very protectionist way, measure as you start thinking about the workforce inequalities, and then we start thinking, well, how do we safeguard our own workforce? The reality is that, as psychiatrists, this is a global issue. There's a global shortage of mental health workforce. I think, well, healthcare workforce, more broadly, but certainly mental health workforce, I think. So we are one million short in mental health. Specifically, in the UK, we have a 10% vacancy rate at consultant level, which is attending psychiatry level, and retention is an issue. We've done quite well with recruitment over the last four or five years. We've been running a campaign called Choose Psychiatry, and from a fill rate of about 60, 65%, we've crossed 100% now, and we are seeing very high competition ratios to enter psychiatry, which is great news. And I know that that's not the case across the world, but it's something that we can learn, that actually investing in those recruitment methodologies and supporting medical students in getting a better understanding of what psychiatry can offer actually does boost recruitment. We are now going to work on a similar program to kind of boost retention, because that's something that we are aware that there's an issue. But the reality is that we have to be prepared for a globally mobile workforce, and I think that certainly is the case in the US here, and it's true of the UK and Australia and Canada that we see people from all over the country, all over the world, working within our workforce. And increasingly, we will see the same issue happening across the world, and I think we have to be, as medical educators, be prepared for that, so how do we address that? Ladi, you touched upon differential attainment. We've got our chief examiner, Ian Hall, here in the room, sitting in the back there, and he's done a lot of work in trying to address differential attainment. I think essentially, we know that we've had worse outcomes for international medical graduates, and things have improved steadily, marginally, but at least we've started looking at it. We've got a whole set of data, and we know that we have a lot of work to do in terms of how we support our international medical graduates in the first time when they enter the UK, and again, as a college, we led a whole program of induction and supporting trainees and mentoring programs for international medical graduates, which have been quite successful, and in fact, have informed national programs. Finally, I think we are doing a lot of work around workforce well-being. We know that workforce morale, I've been talking to colleagues here as well, I think, both from US, Canada, and across the world, and I think, across the world, I would say that healthcare workforce is under stress. I speak to my colleagues in South Asia regularly, and I think demand is rising. We have a workforce shortage, and that does place a lot of pressure on the existing workforce, and I think looking after our workforces is quite critical, too. So I talked about the Choose Society campaign. So just a little thing about numbers. How are we doing? I think we've got our numbers increasing. We've done quite well in terms of recruiting numbers, and each year, we've increased the numbers, and we fill them all, so that's been really good news. We've also launched programs specifically to upskill the existing workforce, so in areas like eating disorders, in autism, we've got a national autism program to kind of train, upskill the workforce in those areas, and as a college, we are specifically driving a whole suite of CPD, Continuing Professional Development programs to upskill the workforce in areas where there's a clinical need. And then finally, I think, just touch upon differential attainment. So we, as a college, led some innovations. We created some masterclasses, and we've shown that the masterclasses were very effective in actually improving pass rates in exams quite significantly. We also had a series of educator masterclasses where we showed that, actually, educators were acquiring a much better understanding of what international medical graduates needed, I think, once they'd been through our masterclass, that they were able to have those conversations and then show the curiosity about international medical graduates, which is much needed once somebody's entered the country quite fresh. And significantly, a year later, those changes were sustained. So I think they were not only just learning new things, but they were actually translating that into behavior in the way they were. I had a couple of examples where one of the educators recognized that their trainee was, their new trainee was very much stressed about the fact that their partner was employed in Scotland, and they were based in the Midlands in the UK, and so helped them in trying to kind of solve that issue, recognizing that that kind of a personal issue was actually having an impact on their educational performance. And I think that's the kind of, I think, compassionate approach that we need more and more in our medical education. So I think I'm going to stop there, and Adrian, I'm going to invite you. Great, well, thanks very much, Subodh. Really fantastic work, so good to see. I'm going to ask our speakers to come to the front, and we've got 15 minutes for Q&A. So please feel free to ask us questions, challenge us, give us more ideas about what we can do. Hassan, do you want to come to the microphone? I think the mics should be on. Thank you very much, and great to see all the officers here today. Question for Ladi. So the General Medical Council acknowledges that the IMG referral rates are disproportionately high. Do you have any explanation or reflection for why that is? Is that the trust of the organizations, or is it? Sure, hi. Thanks for the presentation. My name's Jim Richter. I'm a clinical director at Indianapolis, Indiana. And this probably just represents some of my own ignorance, and just hoping that you could clarify. So it's kind of a two-part question. How is it that the Royal College, in the IDE efforts, reconciles Britain's history of colonization? And what is the Royal College maybe doing in terms of recruitment and representation of those that are British territories? Okay, I don't know who wants to come in. Paul, do you want to have the first go at that? Thanks, Adrian. Yep. So I think the question of the role of the UK in colonization is something that's increasingly being talked about in the UK, I think, as a negative thing. I think the fact that the UK had an empire was seen as being a fantastic thing, generally, in the UK. It's only the last sort of 10 years, five years, people started to see it possibly being negative. So there is a conversation happening. And I think that's something that we, as a college, would want to bring to the fore, because we are open about that. And it leads to some challenging conversations. So, for example, when we, as a college, decided to work with Stonewall, because we wanted to do the right thing by people who are LGBTQ+, we weren't necessarily thinking that could lead to divisions amongst people on membership, those who've got concerns about trans rights versus the rights of women. And so it will lead to difficult conversations. But I think that's healthy in a sort of democratic organization. We're a broad church, we've got members with lots of different views. So I think that's something that we would want to, you know, be debating. But then the fact that Sir Bode has led a change in a curriculum, looking at structural inequalities, that also addresses those points, because psychiatrists need to be aware of that as an issue, the structural discrimination that is left behind. And now I think we're hoping that people going through the process now will be better armed and equipped in order to tackle the impact that has on people, obviously, on the ground. I don't know if any of my colleagues want to add anything to that. Hi. So it's Anusha from Cape Town. But I have two thoughts. This one from my cap, not from the society, but from the university that I belong to, which is Stellenbosch University, and they have a commitment to decolonizing the curriculum as part of one of the sort of top priorities and principles. One of the most difficult things that we've seen in the last five years, when the process started, was just pinpointing medical education itself for undergrads. And so they moved towards revamping the medical curriculum into health and wellness, medical detective and intervention, as opposed to sort of, you know, arbitrarily dividing it into pathology and anatomy, then into clinical, then into whatever. And one of the biggest difficulties was, it's all great in principle to have this idea of how you want to restructure it, but who would do the teaching? And one of the, and it leads to my point about how do people who are receiving the teaching perceive the teachers? Because one of the most difficult things we've had has been recruiting educators, so other doctors to become medical educators, people of color particularly, because there's an impression that if you are, we don't have many IMGs in South Africa, but we do have a disproportionate number of black graduates relative to white. And I would imagine it's similar in the UK, if I think of your bar graph there about the privileged student population. Have you done any focus groups or any sort of research or have any feedback on what the recipients of this change, this kind of prominence of IMGs being the educators, how are they perceived by the medical graduates? Because it's been really difficult on our side. There's this perception that if you don't speak English properly, because we have nine efficient languages, English being only one of them, that the medical students believe that the quality of the information is inferior by some regard. And that is based purely on how you speak English against, again, the language of the colonizer in South Africa and also the color of the skin. So I'm just interested if you'd had that feedback or if there was space for that reflection, because that would also influence, I imagine, how receptive people are to the change. Thanks. Subodh, do you want to come in on that? Yeah, so a very interesting question, Nisha. So I think we've done some work, I think my group has done some work on specifically looking at undergraduate medical students and then what happens as they go through. And I think what we do know, that even if you're a first generation or second generation, you know, British-born from, I think, minority and have the same grades, by the second year of MBBS itself, second year of your medical training, you're already falling behind in grades. And I think a lot of that is to do with social capital, but it's also to do with the way universities perceive them. So that goes on to your question. I think universities don't have an understanding because they treat everybody equally. I think I've had so many, and when we started the work in the college, so my portfolio was specifically addressing the first attainment before I became dean. I think I have trainers tell me all the time that, well, this is something, why should we treat people differently? Why should we do that? So the whole issue of equality versus equity, and I think it really gets submerged in that. But I feel that there is a greater awareness now that actually we need to be thinking about the differential needs of our learners. And to me, I think it really is an educational issue, and I feel that, you know, if you're a good educator, you recognize that each individual learns differently. You have to individualize your learning offer, your training offer to the learner. I think, and in many ways, I think it's that message which has been lost, I think, because people are so focused on providing a consistent offer for everyone that there is no investment in actually thinking about how do we personalize the learning offer. So in fact, our curriculum, we talk about person-centered care for patients. We also talk about personalized training for our learners. I actually think, when you were talking initially, I was thinking about a couple of things. One of them is internalized racism, actually. And what you described is the majority black undergraduates or graduates thinking that the person who either was of color, but more importantly, the person who didn't have the right kind of accent was just not so good. And that really comes from the idea that if you don't sound a particular way, then there's something wrong with you. And that clearly is an internalized problem. And we see it more obviously in parts of Africa, in parts of India, in Caribbean, where when you think about people's skin color and people lighten their skin, the lighter you are, the better you are, and things like that. And there does need to be a conversation about that internalized racism and how that impacts on, for example, your teachers. It's something that we're talking more and more about and teaching people more about so that they understand that because it's a journey that people have to go through for themselves. But I think that there are ways of, as Sloboda's saying, there are ways of structuring your curriculum and structuring your teaching so that it eliminates that kind of unconscious bias and that it doesn't matter who's, people are taught to teach well and the students are taught in a particular way. It helps people to feel confident about what it is that they're learning. It doesn't matter who the teacher is. And just to add, I think, so as Paul said, we're starting quite late with this. I mean, I think even data wasn't available. You know, I think so 10 years ago, the phrase differential agreement didn't exist, to be honest. You know, I think when I looked at schools of psychiatry and schools of medicine across the UK, they didn't really have that data around how, so I think we have to really think of those and actually get the data as well, because that's important. Unless you have the data, you're not going to figure out what is wrong. And then who's doing it? And I think, and sometimes the data kind of astonishes you. And I think, you know, I think we've always wondered whether there was a white, non-white interaction between examiner and examinee. We've looked at the data and that's not the case. And in fact, you know, when we've done our focus groups, sometimes trainees have said, addressing the point that Nadia said, that sometimes it's your non-white examiners who are more discriminatory. So I think, which is why I don't feel that this can be simplified as a, and so I really worry about when people kind of just apply the word decolonization in a very binary fashion. I think we have to really look at the data and then understand what are the nudges that we need to make, drive people in the right direction. Okay, we're going to have to finish there, but before we do, I'm going to ask each of our presenters just to say, what's the main lesson, the work that you've all done in this area, what's the main lesson that you've learned in order to make this work a success? Paul. For me, it's the importance of taking a values-based approach in an institution. The concept of values sounds quite sort of management-speak and a bit dry, but actually if you put values and the values-based approach to the heart of the organization, you genuinely take different decisions pretty much on a day-by-day, week-by-week basis. Okay, thanks. So, go ahead. For me, I think it's that difference between the doctor-patient and the doctor-community, and I think we really need to be driving that through our medical education system to make sure that we produce doctors who are really going to start making a difference at the community level, not just solely for the individual patients. And for me, I'd say it's about interrogating the data. The data's there, actually, but when you look at it and you look at it carefully, then you start to see, actually, there are quite significant disparities here, and if you don't look at the data and you don't interrogate the data properly, then you don't know about it, and if you don't know about it, you can never do anything to sort it out. Okay, well, thanks very much. Thank you to our speakers. Give a round of applause. Thank you to you, the audience, and particularly for the great questions. Feel free to take the rest of the day off. The sun is shining. Now you've been to our session, just go and enjoy yourselves. So, thanks very much indeed for coming and enjoy the rest of your APA. Thank you.

Royal College of Psychiatrists

equality

diversity

inclusion

Adrian James

Lade Smith

mental health

Paul Rees

cultural differences

medical education

organizational performance

patient outcomes