This is the speech as drafted and may differ from the delivered version.
Charlie Massey at Westminster Health Forum
‘Proactive, flexible and fair: why today’s NHS needs responsive regulation’
It’s nearly 40 years since the Medical Act, the main piece of legislation that governs how the GMC regulates, was passed.
Since 1983, the world as we know it has changed dramatically – from the invention of the World Wide Web and the launch of the iPhone, to the introduction of technologies that have expanded the horizons of medical possibility.
The backdrop to these advances has been one of profound social change.
For a start, we’re living longer. That’s good news. But it also means a greater number of older people requiring care for complex diseases like dementia, while chronic illnesses like obesity and diabetes are also on the rise.
Meanwhile, the medical profession, like the population it serves, is undergoing a significant shift.
Today, greater proportions of doctors are stepping out of UK clinical practice – choosing to work abroad, retire early or simply seek a better work/life balance by reducing their hours1.
If we’re to keep up with this changing picture, the manner in which we regulate must also change.
But while the health landscape has been transformed over the last 40 years, the laws governing its regulation have remained unchanged.
The consequence is more than mere bureaucratic frustration. It goes to the heart of the care patients receive.
If the health service is to deliver what the public requires from it today, its regulation must be more responsive. For that, we need urgent legislative reform.
There are three areas in particular I’d like to cover today:
- First, breaking down barriers to international recruitment
- Second, supporting and retaining doctors already in the workforce
- And third, widening the pipeline of future medical talent
Breaking down barriers to international recruitment
The first thing even a casual observer of the current legislation would note is that it is highly prescriptive.
For example, the way the legislation works means that a doctor from outside the EEA would have to provide around 2,000 pages of information and spend over 9 months gathering evidence to work as a GP or consultant in the UK.
It’s no surprise, then, that the number of senior doctors from outside the EEA joining the GP or specialist register each year is far below the numbers needed to address shortages in the NHS workforce.
The UK continues to be a popular destination for international medical graduates. In fact, last year, for the first time, we saw more graduates joining the workforce from overseas than coming out of UK medical schools2.
But while we expect around 10,000 overseas doctors to join the register this year, last year only 10 GPs or consultants from outside the EEA joined via the relevant specialist registration route and were able to practise at a senior level immediately.
In order to improve this picture, we need more flexibility.
That doesn’t mean a reduction in standards, simply a change to legislation to give us more discretion for determining how senior international doctors can demonstrate their knowledge and skills.
And that could increase the rate at which senior doctors join the workforce – meaning more practitioners to support patients in need.
"We need more flexibility. That doesn't mean a reduction in standards, simply a change to legislation to give us more discretion for determining how senior international doctors can demonstrate their knowledge and skills."
Chief Executive, GMC
Supporting and retaining doctors already in the workforce
Getting doctors on the register is one thing, retaining them is another.
I mentioned earlier that we’re seeing significant numbers of doctors step out of UK practice, impacting the ability of the NHS to plan for growing demand.
Workplace pressures play a big part in this. Half of GPs tell us that they feel unable to cope and that they work beyond their rostered hours3. Meanwhile, a quarter of doctors in training tell us that they are burnt out to a high or very high degree4.
There is a direct correlation between the conditions in which doctors work and the care that patients receive. It is no exaggeration to say that patient safety depends on doctors’ wellbeing.
So reports that doctors feel increasingly unable to cope should worry all of us. The question is what we do about it.
For us at the GMC, it increasingly means seeking to influence doctors’ working environments from the outset, rather than simply stepping in when harm has already been caused.
This isn’t straightforward, and there are lots of factors to unpick – from subtle things like ward culture and the confidence to raise concerns, to more practical considerations, like having basic facilities for doctors and other healthcare professionals.
We’re looking at the role we can play in delivering this.
We’ll shortly be taking on the regulation of Physicians Associates (PAs) and Anaesthesia Associates (AAs). We hope this will allow PAs and AAs to maximise their contribution to the workforce, improving patient care and alleviating pressure on doctors.
We’re also looking at what we can change to ensure we’re the most proactive, responsive regulator we can be.
Given the current stresses on the health system, doctors’ actions must be understood in the context in which they occur. Last year we rolled out Human Factors training to all our Fitness to Practise decision-makers and case examiners, so the role systems and workplaces play in events is hardwired into investigations.
We want to give doctors the assurance that their actions will be seen clearly against the backdrop of any system failings. This matters because doctors who are scared that honest mistakes will be used against them are not open when things go wrong – and that lack of openness can breed a culture where lessons are not learned when things go wrong.
The Paterson Inquiry, whose findings were published earlier this month, shows the damage that’s done when doctors notice something’s not right but do not feel willing or able to raise their concerns.
The Inquiry also demonstrated the need for most robust local governance. Responsible Officers (ROs) are a core part of this. But they do not always have all the information they need about a doctor’s practice. Existing regulation could be strengthened to improve information-sharing, better equipping ROs to identify and address failings much more quickly.
In cases of serious or persistent failure to deliver good medical care, our Fitness to Practise (FtP) process is there to protect patients and ensure public confidence.
But it can be a blunt instrument. Under current legislation, we’re obligated to look into every allegation that meets our threshold. Even if it concerns a one-off mistake. And once an investigation is open we’re required to complete all prescribed steps, even if we know it’s likely that no further action will be required. The result is that around 80% of clinical cases are closed with no action taken5.
Since the Medical Act was passed, the volume of complaints we receive has increased dramatically – from around 350 in 1983 to well over 7,000 last year6.
The result is that we spend the bulk of our time processing complaints – the majority of which come to nothing – rather than focusing our resources on stopping doctors getting into difficulty in the first place.
Whilst there are some steps that we can and are taking to address this, legislative reform would allow us to be much more proportionate and precise, so we could prioritise the areas of greatest concern.
This would not only reduce costs, and reduce the number of doctors taken out of the workforce while under investigation. It would also mean we could spend more time dealing with the small minority of doctors whose fitness to practise is a serious concern, and do so faster.
Ultimately we want to see fewer doctors going through FtP. That means intervening early, before problems crystallise, rather than simply picking up the pieces when things go wrong.
Widening the pipeline of future medical talent
As well as helping support those already practising, regulatory reform could help develop the pipeline of future doctors.
Medical education today is informed by the European Directive, which stipulates at least 5,500 training hours and five years of study before students become doctors.
The UK’s exit from the EU could offer the opportunity to reform these requirements and bring education more in line with today’s needs – by aligning it with the outcomes we’re looking for, not the time spent doing it. It could also help to broaden routes into medicine – helping address doctor shortages in our towns and regions in the process.
It’s important to emphasise that there aren’t any quick fixes here, but we’re keen to explore what might be possible – provided everyone is clear that we won’t compromise on patient safety or undermine the quality of UK medical education, which is admired across the world.
The Medical Licensing Assessment (MLA) could play an important role here. Due to come into force from 2024, the MLA will provide a common and consistent approach to ensuring doctors have the knowledge and skills to practise safely.
As such, developing the MLA has the potential to be a powerful enabler of innovation and change.
The bottom line is that to build the workforce we need today, the focus must be on outcomes, not inputs.
The world around us is changing.
Demographic shifts are reshaping the profile of today’s patients, while doctors’ career choices are challenging the ability of the NHS to meet demand.
In this new reality, we must not only recruit and retain more doctors, but also widen access for the practitioners of the future.
We’re doing what we can to respond to the changing context. Central to this is a focus on positively influencing the environment in which doctors and other healthcare professionals work, rather than simply stepping in when things go wrong.
But the reality is that the limits of regulation are now being stretched.
Instead of red tape, we need responsive regulation.
With sensible changes to that legislative underpin to what we do, we are confident that we can do much more to support doctors – so they can focus on delivering first-class patient care.