Championing the case for compassionate leadership

Professor Dame Carrie MacEwen's speech at the Royal Free Compassionate Leadership Programme, held in Hampstead on 17 April 2024.

I am delighted to be here today, thank you so much for inviting me.

I have been Chair of the GMC for around three years now, but I continue to practice as a consultant ophthalmologist, and compassionate leadership is something I care about in both of those roles.

It was early in my career when I first realised how much of an impact good leaders have on morale and wellbeing of teams, and it is something I have seen time and time again through the additional roles I have taken on, including my role as the ophthalmology clinical lead for Getting it right first time – otherwise known as GIRFT – and a similar programme in Scotland. When a team has a good culture, and is led well, there is a palpable sense that it is a safer place to work, for the staff, and also for the patients. And of course, these tend to be more productive teams too.

Now, in my role at the GMC, I am in the privileged position of seeing first-hand the wealth of data that supports the value of good leadership, and the damage caused by its absence.

The need for compassionate leadership and its effect on the delivery of safe patient care is now well evidenced.

Doctors don’t always realise that the role of the GMC extends beyond holding the register and taking action on concerns raised with fitness to practise processes. It’s the actions we take against individual doctors that grab the headlines, but actually our role is much, much wider than just stepping in when things go wrong. We set the standards for doctors working in the UK, as well as overseeing all medical education and training, quality assuring its delivery.

Our purpose, across all of these statutory functions is to promote patient safety and public confidence in the profession. In order to fulfil that purpose, we use our insights to highlight where change is needed to the conditions doctors are working in, to ensure they are empowered to deliver the best quality care.

As we hold the UK medical register, we are in a unique position to collect and analyse data on the workforce and the experiences that doctors have in the workplace. That informs our thinking, and we build on that by commissioning further research.

In 2019 we asked Professor Michael West and the late Dame Denise Coia to carry out a UK-wide review of the factors which impact on the mental health and wellbeing of doctors and medical students.

The resulting report, Caring for Doctors, Caring for Patients, set out what was needed to make the NHS a better place to work, and to ensure that patient needs were met. It identified compassionate leadership as the single biggest driver of positive culture in healthcare.

One of the recommendations in the report was that all UK healthcare organisations should have a programme of compassionate leadership across every sector and regularly obtain feedback from doctors and healthcare staff to evaluate its effectiveness.

It recommended that clinical leads and other doctors’ leaders should be recruited, selected, developed, assessed, and supported to model compassionate and inclusive leadership. In other words, a good, effective leadership style should be seen as essential, not a nice to have – and needs to be actively sought out in those wanting to hold positions with formal leadership responsibilities.

The report was also clear that all doctors have an important leadership contribution to make – it was not dependent on upon holding a leadership role or position, more a philosophy of professional standing.

In the Foreword to the report, my predecessor as Chair of the GMC, Dame Clare Marx, said that the signs at the time were good with general recognition of change needed to create healthy and sustainable workforces, and a unique opportunity to drive real and lasting change. Of course, we published this just a few months before the pandemic hit and some of that opportunity dissolved as the whole of the health service had to rapidly reconfigure itself to deal with the crisis at hand.

There were noticeable positive changes during Covid, but we will come back to that.

Of course, we still feel the reverberations from the pandemic, significant backlogs are coinciding with high demand, and there is no sign of let up. We will continue to feel the effects for a long time to come.

We have reported that the pressures doctors are feeling now are having a deep impact on their own wellbeing, and on the workforce as a whole in The state of medical education and practice in the UK: workplace experiences report which we last published in June last year.

The report set out how unmanageable workloads reduce job satisfaction, leading to more doctors than ever being at high risk of burnout. This causes changes in working patterns, with doctors either reducing their working hours, or leaving the profession in the UK altogether. This fuels a vicious cycle, as more doctors leave or reduce their hours, pressure on their colleagues intensifies, they feel the effects and make changes themselves.

The manageability of workloads is something we focus on closely in our annual Barometer survey, where we ask thousands of doctors a series of questions about their working lives.

On various measures we can see that workload has intensified from 2021 to 2022. The number of doctors working beyond their rostered hours on a weekly basis jumped to 70% in 2022 from 59% in 2021. 68% said they had difficulty taking breaks each week versus 49% in 2021. And in 2022 data 42% of doctors felt unable to cope with their workload each week versus 30% in 2021. These were big changes, with doctors’ reported experiences worse than at any time since the Barometer survey began in 2019.

Meanwhile we see this drop off in job satisfaction – which is what can keep doctors going through tough times. Only 50% told us they were satisfied in 2022, and that’s down from 70% in 2021. I find that worrying and actually really saddening, that half of doctors are unable to take satisfaction from their jobs.

All these factors make it unsurprising that overall wellbeing is being negatively affected. We identified that a quarter of all doctors were at high risk of burnout in 2022, up from 17% in 2021.

We know some groups are under particular pressure. Our national training survey provides good data on the wellbeing of trainers and trainees, and this needs attention.

We measure burnout by using The Copenhagen Burnout Inventory, asking seven voluntary questions and grouping responses into four categories of risk, high, moderate, or low.

In last year’s data, 66% of trainees were measured to be at high or moderate risk of burnout, an increase from 62% since 2021. And 52% of trainers were at high or moderate risk of burnout, and while there has been no increase in the last year that is obviously still a worryingly high percentage.

From 2021 to 2022, the proportion of doctors who said they were likely to make a career change in the next year grew significantly—from 58% of doctors to more than three-quarters. We broadly define a career change as a change to working practices, so that might be reducing hours, taking a career break or even leaving the profession.

There was a startling jump in the number of doctors who took what we consider hard steps toward leaving, so for example applying for a job, applied for training for a new role, or being in touch with a recruiter. That number jumped from 7% in 2021 to 15% in 2022.

Of course, intentions to make a change or leave don’t always translate to actually doing so, but these are nonetheless worrying data.

Clearly these effects on our workforce have an impact on patient care. The data show us that doctors are increasingly finding they are unable to provide patients with the care they need.

You can see here that in 2022 44% of doctors told us they found it difficult to provide a patient with the level of care they consider adequate at least once a week, a big jump up from 25% in 2021.

Conversely, you can see that the number of doctors who say they never have a problem with this has dropped down to just 15% from 33% in 2021.

That’s very alarming – and illustrates the effect this is having on patient safety.

Long-term, strategic, workforce plans are needed to make levels of work intensity sustainable, but in the meantime, a focus on evolving and developing what it means to be a leader can help make things better for everyone by ensuring that the working environment is supportive and understands the issues raised by staff.

We highlighted this as one of the key improvements that can lead to the kind of positive interventions and turn vicious cycles into virtuous ones.

In this scenario, doctors feel better supported and more valued, and have a strong sense of belonging within their work or training environment. This can result in higher satisfaction, lower risk of burnout, improved retention of doctors, and ultimately better patient safety and care.

Previous writers on compassionate leadership have talked about the four key behaviours that typify this approach, including Professor Michael West writing for The King’s Fund.

Professor West talks about attending – being present and visible, and listening effectively, and understanding – taking the time to properly explore the situations that colleagues are dealing with, looking at conflicting perspectives, and not imposing your own perspective. He also highlights the importance of empathising – feeling the emotions affecting colleagues, whether that is a positive or negative emotion – but without allowing oneself to become overwhelmed by the emotion to the extent that you cannot help. And finally, helping – taking thoughtful and intelligent actions to support individuals and teams.

This is an effective shorthand guide for how you can think about compassionate leadership, and it fits with the recommendations we made in the State of medical education and practice in the UK: workplace experiences report that were based on data analysis and interviews. Interestingly, in the report we were able to highlight that doctors reported to us that a number of positive actions on leadership were implemented during the pandemic, but had since been lost, often due to extreme service pressures.

If efforts can be made to recapture some of these positive leadership behaviours – it is clear that we will contribute to better wellbeing, and safe care for patients.

Specifically, being available, understanding the needs of colleagues and teams, listening to concerns and providing personalised support – these are important characteristics.

Understanding and empathising have become increasingly important as doctors – especially the most junior ones - are pulled in multiple different directions and expected to work not just in one static role, but across teams, across specialties, and with those in other roles.  Showing understanding is also of course incredibly important when doctors are under so much pressure, and clearly in distress.

Providing constructive support, moving away from a blame culture, building learning opportunities into practice and providing compassionate, constructive feedback are all key factors in the mix. This helps doctors feel able to speak up about concerns so that issues can be tackled. And it gives doctors the confidence to behave honestly, using their professional judgement, without the fear of making a mistake. Mistakes and missteps will happen – we are all human – but being afraid of the consequences encourages over investigation and the likelihood of errors being covered up when they occur. Both will potentially affect patient safety.

Inclusion matters greatly. If I can refer back again to Caring for Doctors, Caring for Patients, that report identified belonging as one of a doctor’s three core needs - alongside autonomy or control and competence or ability - all of which must be met to ensure confidence, wellbeing and motivation, and to minimise workplace stress. I think we can all understand that – to want to belong is a very natural, human experience.

Our workforce is growing ever more diverse. We have very high numbers of international medical graduates coming to work in the UK – many of whom are from a black or minority ethnic background. In fact, only 37% of doctors joining the register in 2022 graduated in the UK. We know from our Barometer data that black, and minority ethnic doctors generally feel less supported than their white colleagues.

There is also cause for concern around doctors with disabilities. Our data show they also feel less supported than non-disabled colleagues, as well as having less workplace satisfaction.

So, leaders must ensure that their leadership style feels compassionate to all, and not just to people who look, act and are considered to respond like them.

In January this year, the updated Good medical practice came into effect. This is the first time we have updated it in almost a decade – and it includes a significantly strengthened focus on workplace culture and on treating colleagues fairly and supportively.

One of the words we put into the professional standards was kindness, which drew quite a lot of comment on social media. The concept of treating our patients with kindness should never been controversial, although this became mixed up with being incompatible with the delivery of upsetting information – which is a time when kindness is most needed. But we also need to be kind to our colleagues. At all times we should treat each other the way we want to be treated ourselves.

The use of the word kindness was actually very well supported in our consultation, which was very extensive. I know Crystal is doing a session on kindness today so I will be interested to hear what she has to say.

Good medical practice has four domains – working with patients, working with colleagues, skills and knowledge and professionalism and trust – each being as important as the other in the make-up of a good doctor.

There are some quite significant changes throughout, but I just wanted to show you some from the Domain on Colleagues, culture and safety. As you can see, we are asking all doctors to contribute to positive working and training environments, to be aware of how their behaviour may influence others both within and outside the team, to be aware of bias, and to show respect and sensitivity.

The updated Good medical practice also sets out a clear expectation that all doctors will demonstrate leadership skills relevant to their role. While there are additional expectations for doctors with formal leadership or management responsibilities for instance when dealing with harassment, bullying or discrimination, it is clear that all doctors can and should lead.

We have a number of clinical fellows, all doctors in training – and those who work at the GMC are called Marx Fellows - they carry out important work for us. One of our senior Marx Fellows, Aneka Popat, who works as an FT3 trainee in occupational medicine, has developed A doctor’s guide to everyday leadership, a set of leadership principles that are focused on supporting doctors as they develop in their careers and transition into new or more senior roles.

She sets out principles as they apply to doctors themselves, to employers, and to responsible officers. Here, you can see that of the four key principles she has identified for doctors, creating compassionate workplace cultures is one of them.

Aneka researched the project by speaking to organisations in the leadership landscape, the Statutory Educational Bodies across the four countries, and employers. She also listened to the experiences of a diverse group of doctors.

You can read a blog she has written about this on our website, to understand a little about her motivation and the perspective she brings. Her view is that much of the responsibility for identifying and accessing formal and experiential opportunities lies with doctors themselves and she highlights that formal training and teaching opportunities can be difficult to access for doctors facing significant pressures at work.

She suggests we should move away from leadership being something that is ‘taught’ and suggests that the best leadership skills development actually comes from hands-on experience. I hope the principles she sets out will be widely adopted, they are clear and easy to follow, and set out expectations for different parties. They are an excellent resource for a workable approach within today’s challenging environment, and one that should inspire all doctors to think the development of leadership skills is achievable, and something they can take ownership of themselves, while they can also reasonably expect the support of their employers.

These principles call on employers to do a number of things to support leaders in development, but amongst them, they highlight that employers must recognise and celebrate compassionate leaders so that others can see what ‘good’ leadership looks like. Aneka makes the point that not only does this encourage better cultures, but it can also improve the retention of doctors who recognise that their workplace aligns with their values, wants to support them and wants to help them deliver the best patient care.

I’d urge you to have a look at the principles on our website and Aneka’s blog.

I enjoy the opportunity to be able to talk to people as I am doing today as it gives me the opportunity to signpost resources like the leadership principles, not only hopefully adding value to you but also demonstrating how much we do as a regulator.

We have also just published new research which again, we hope will be insightful. This was commissioned from Hull York Medical School and is titled Teamworking: Understanding barriers and enablers to supportive teams in UK health systems. A key factor that all participants discussed was the role of leadership. A leader was described as an individual who is understanding, supportive and approachable. Other characteristics were discussed, such as being outstanding professionally, strong, consistent, charismatic, self-aware, kind, calm, welcoming and compassionate. Leaders of the team must be able to turn dysfunction around and not react or treat other team members badly within high pressured situations. And they need to promote professionalism through role modelling and training the generation below them in leadership too.

We commissioned the research because we are keen to look at how to support doctors within increasingly diverse teams to achieve the common goal of delivering best care to patients. As the make-up of our workforce changes, with the greater number of international medical graduates, we are also seeing a shift to more locally employed doctors and SAS doctors. The growth of these non-traditional roles changes team dynamics and we know that these groups have different experiences – not universally better or worse – but certainly different – to doctors on the more traditional, linear training and career path. There is also a need to understand more about other healthcare professionals such as physician associates and anaesthesia associates, as well as advanced healthcare practitioners who are becoming more of a feature of the healthcare workforce in order to increase capacity to provide care.

There are all kinds of interesting nuggets of information in this research that are of value to leaders and leaders in development. It highlights for instance that technological shifts, particularly post-Covid, and evolving healthcare organisational structures continue to shape how teams’ function and indeed what constitutes ‘a team’. This all gives food for thought when developing local approaches.

We are pleased to be able to support research like this that provides deep insights. Please do take a look at it on our website if you would like to read more.

We provide excellent support in developing compassionate workplace cultures through our Outreach teams – GMC teams working locally with hospitals, ICBs, GPs to understand and deliver support close to home.

They assist doctors, responsible officers, and employers…..helping them look at how to embed positive cultures, overcome barriers and promote excellence in working and training cultures.

Increasing investment in our Outreach function also signals our desire to move more towards a model of upstream regulation, not just stepping in to investigate and impose sanctions when things go wrong, but helping to encourage a local-first approach to resolution of problems that becomes more achievable as more and more doctors begin to lead with compassion.

We also continue to use our influence at country level, to highlight the poor experiences of doctors and be clear that long term workforce solutions are urgently needed, to allow compassionate cultures to really flourish.

This year’s The state of medical education and practice in the UK: workplace experiences report will be published soon, as will the national training survey, allowing us to share the latest data. While we are hoping to be able to report improved experiences for our doctors, we should be realistic that pressures continue.

I know that we will be repeating our message that improvements to workplace culture, championed by compassionate leaders, are required.

We recognise of course that it can feel like we are adding more pressure calling for doctors - all doctors - to step up in this way, but it is of course when systems are under pressure that this is needed more than ever to help doctors provide better patient care.

Compassionate leaders, at all levels, cannot solve the deep-rooted problems we have in the health services, but they can offer an antidote, and their actions can support the development of virtuous cycles where the overall positive effect is greater than the sum of the parts.

That is why we have written this into the updated standards. We need doctors, at all stages of their careers, to take this on. By being here today, you are clearly signalling your wish to champion this approach.

However, there is absolutely a balance to be sought between the personal responsibility of doctors and the need for employers and policymakers, to enable that to happen. We will continue to play our part with that side of the equation too, investing in deeper dive research and using our insights and influence to shape the environment by informing those who make policy decisions so that your efforts can have a greater reward.

Thank you very much for listening to me today.

I hope it’s been helpful to see some of this data. I’d be very happy to take your questions now.