The role of the regulator in ending inequality in medicine

Charlie Massey's speech for British Association of Physicians of Indian Origin, October 2021

Introduction

Thank you for giving me the chance to speak this afternoon about unfairness in medicine and the regulator’s role in tackling it.

It’s a measure of how enduring these inequalities are that this is my fourth speech at BAPIO’s annual conference.

Over this time, much has been said about the disadvantage and discrimination that continue to blight BME doctors’ working lives.

There is a very clear moral case for tackling these issues – it is unambiguously the right thing to do. BME doctors do not start with a level playing field. The status quo is quite simply unjust.

And unless things change, more and more doctors will be harmed by it. Last year, 61% of those joining our register identified as BME, compared with 44% in 2017. Meanwhile, more international medical graduates (IMGs) joined the workforce than UK and EEA graduates combined.

But as well as the ethical imperative, there is a very important practical one.

Doctors who work in supportive, inclusive environments deliver better care than those who work in closed, exclusionary ones. Inequality and prejudice breed poor clinical outcomes. That’s why, as a patient safety body, we see tackling these issues as mission critical.

There’s now a growing clamour for change across the health system. Dealing with the disadvantage that pervades medicine is one of the most pressing priorities across the NHS. And it’s increasingly recognised as a priority by political stakeholders too.

But sadly, as all of us here know, these issues are not new. They have marred medicine for many years. And while there has been much goodwill, the pace of improvement has not been proportionate to the scale of the challenge.

We’re past the point where warm words will suffice. What is required now is tangible, appreciable action.

I want to talk to you today about the GMC’s role in delivering that.

Accelerating the pace of our ED&I programme

All of us in the health system have a part to play in making meaningful progress on these issues.

As BAPIO’s Bridging the Gap report makes clear, inequality is evident across the full life cycle of BME doctors’ careers. Piecemeal change won’t cut it – we need real reform across the whole system.

I recognise that we as the regulator have a particular role to play within that.

We’ve already taken steps in the right direction. Nearly 4,000 doctors attended our virtual induction training for IMGs last year, with 96% saying they’d change their practice as a result. Our Outreach teams are working closely with responsible officers on things like appraisal, so it fulfils its purpose as a wellbeing and professional development tool. And we’re supporting the Medical Schools Council with new guidance on inclusivity in undergraduate medicine.

But to turn the tide, and end the cycle of inequality that’s holding BME doctors back, we need to do more.

That’s why we’re stepping up the intensity and ambition of our ED&I work.

Our strategy is driven by one central ambition – to level the playing field, so every doctor has the chance to thrive.

It is centred around four priorities.

Employer referrals

The first is employer referrals.

Our Fair to refer research shows that BME doctors are referred to us by their employers at twice the rate of their white counterparts. Employer referrals are much more likely to lead to investigations, so this imbalance has a very significant impact on who we see coming through our caseload.

What is driving that disproportionality? The research points to an absence of protective factors like timely feedback, proper induction and informal advice.

Particularly pernicious is the presence of insider/outsider dynamics, which feed blame cultures and leave BME doctors without the support they need to prosper.

Indeed, research we published last year found BME doctors were less likely than their white colleagues to report improvements in teamwork and knowledge sharing during the pandemic.

This confluence of factors conspires to put BME doctors on the back foot long before they reach our front door. That’s why earlier this year we committed to eliminating disproportionate fitness to practise referrals from employers, in relation to ethnicity and primary medical qualifications, by 2026.

We don’t have all the levers of control over these issues, many of which relate to doctors’ workplaces. Setting these targets means holding ourselves accountable for the ask we are making of others. This puts us in new, and not entirely comfortable, territory. But it’s clear we all need to be pushed out of our comfort zones to deliver the progress that’s long overdue.

For us as a regulator, this means building on the significant investment in our outreach activities over recent years, using that to build stronger relationships not just with ROs, but provider boards too. It also means working more intensively with ROs to improve the fairness and consistency of referrals, including redesigning the referral process to make ROs confirm the steps they have taken to ensure referrals are appropriate. And it means working harder with national and regional bodies to align our efforts and use our data to show where further improvement is needed.

To succeed will require a concerted effort across all parts of the system. Regulation is only one piece of the puzzle – we all have to come together to dismantle the structures that deprive BME doctors of a fair chance.

Fairness in education and training

And that leads me to the second part of our strategy, focusing on education and training.

As both BAPIO and our own research makes clear, BME doctors suffer a significant attainment gap in undergraduate education and postgraduate training.

Exam pass rates reflect a 12%-point difference between white and BME UK graduated trainees, rising to over 30% for overseas graduates. We see similar differences across specialty exams.

Disadvantages faced in medical school compound inequalities throughout a doctor’s career. BME doctors report receiving less support and feedback during training and experience more barriers, hindering progression. It’s no surprise, then, that FY1 BME doctors are less likely to report feeling prepared for their first post than their white colleagues.

In response, we’ve committed to eliminating discrimination, disadvantage and unfairness in undergraduate and postgraduate medical education and training by 2031.

To get there, we will continue to publish our data on differentials. We will also continue to commission and publish research on practical steps and good practice, trialling interventions with others that we think will close the gap. And we will be working more closely with education and training bodies to ensure that they devise and implement annual action plans, and hold themselves to account in making progress.

As with the target around disproportionate referrals, setting ourselves this challenge means making ourselves accountable for an issue over which we don’t have all the levers of control. But goodwill will only take us so far, which is why we have set ourselves a very challenging ambition, focusing our and other people’s actions on how to eliminate that unfairness.

Looking inward

The third plank of our strategy concerns the inclusivity of our own organisation.

As we are holding a mirror up to the profession, we need to hold a mirror up to ourselves. In the last couple of years, I’ve had conversations with colleagues that have shocked me. Not because I thought the discrimination and disadvantage they describe didn’t exist, but because I didn’t think it was prevalent in our own organisation. But it’s clear that some colleagues have felt much less well supported than others and have lacked opportunities to progress.

We’ll only be credible in our ambitions for the health service if we match them with progress in our organisation. So we have to make sure our own house is in order.

That’s why as well as setting targets as a regulator, we’ve set them for ourselves as an employer. This includes improving representation, especially in senior roles, and improving BME staff retention.

We’ve already increased the level of BME representation at all levels since last year. And we’ve more than doubled the number of offers we’ve made to BME candidates at manager level and above.

But there’s much more to do. As CEO it is my responsibility to look these issues in the eye and set about to resolve them.

Fast and fair regulation

The last plank of our ED&I strategy concerns regulatory fairness.

Our priority as a regulator is to support doctors so they can deliver first-class care. But I know that some doctors still view the GMC and its processes with fear.

To do our job well we need to provide assurance to doctors – and to ourselves – that our decision making is consistent and robust.

We regularly commission independent research to test for transparency and fairness in our processes. And the most recent independent audit of our fitness to practise decisions found no evidence of bias in the way they were reached.

But I understand that not everyone will take comfort from this. So it’s clear we need to reassess our approach. Last month we laid out some of the ways we’re doing this. They include:

• Firstly commissioning an external review of past research and audits on fairness in our processes.
• Secondly reviewing high-stakes decision points in our processes to improve how they promote and maintain fairness
• And, third, undertaking an external legal review of open fitness to practise cases over two years old.

These are changes we can and are making ourselves. And we aim to go much further in being much more transparent in publishing data that evidences whether our processes are as fair as I would want them to be. So as well as looking to others to play their part in tackling unfairness and disadvantage, we are also committed to looking inwards and allowing others to hold us to account.

But we also hope there are more fundamental improvements coming down the track as a result of the government’s consultation on regulatory reform.

The GMC exists to protect the public, not to punish the profession. We want to spend more of our time and resources supporting doctors to stop issues occurring, rather than simply stepping in when something has already gone wrong.

But as it stands, we’re required to fully assess every complaint we receive, even if it doesn’t raise fitness to practise concerns and won’t meet our legal thresholds. This means we end up investigating complaints that don’t need investigating, creating unnecessary distress for doctors.

The reforms offer a unique chance to fundamentally redesign our processes and embed fairness across everything we do. For example in helping us reform the CESR process and break the glass ceiling that stops so many SAS doctors from progressing.

So these reforms will give us more time to focus on the things that matter in today’s health service – by making the complaints process more proportionate and less adversarial; by allowing us to manage more cases locally, and resolve them more quickly; and by giving us more freedom in deciding how doctors can demonstrate their ability to step into more senior clinical roles.

Conclusion

There are no shortage of warm words when it comes to tackling inequality and unfairness in medicine. But the time has come to take those well-meaning words and turn them into action.

I hope I have been able to explain today how we at the GMC are holding ourselves accountable and upping the pace of our activity – both as a regulator and as an employer.

But this is everyone’s problem. Solutions are needed. They're needed now and they're needed at all levels of the system. Now is the time to come together, creating a momentum that cannot be undone.

Thank you.