Compassionate leadership in regulation

Professor Dame Carrie MacEwen's keynote speech from the International Association of Medical Regulatory Authorities (IAMRA) conference, Dublin, on 6 September 2025.

It’s a pleasure to be here this morning amongst such insightful speakers. The focus of this conference is ‘people-focused regulation for a safer global community’. And that’s a really apposite reminder of what we’re all here to do.

The role of trust

Regulation is often perceived as being dry and technical, or somehow removed from the daily experiences of real people.

But it is one of the strongest safeguards we have against harm. And in medicine, it can literally mean the difference between life and death.

As regulators, we have to constantly re-make the case for what we do – especially in world, fuelled by social media, that is increasingly sceptical and distrustful of institutions like ours.

At the heart of that case is trust – trust in every aspect of our work and our very being.

As doctors, the great privilege of our profession lies in a patient placing their health in our hands. In them sharing with us very private and personal information. And in them counting on us to use our skills to make a difference, even when the course of action may be uncomfortable or invasive – and in itself carry risk.

Affording us that privilege is inherently an act of trust. And in a fragmented world, where mis – and dis – information is rife, trust is a precious commodity.

As regulators, trust in our processes and our overall philosophy – from the public and the professions we regulate – is essential. Without it, we cannot be effective.

The consistency and robustness of our actions are crucial in giving patients confidence in the healthcare system as a whole – from upholding high standards, to rooting out bad actors.

And for the profession, the pride in being a doctor is partly driven by the preservation of those high standards, and the knowledge we’re working a field where skill and professionalism matter.

An upstream approach

In a modern health system – especially one under severe pressure – it is not only doctors’ skill and professionalism that dictate outcomes, but the wider context in which they’re working. That makes our task as professional regulators more complicated.

It is well established that the environment in which a doctor works materially affects the care they’re able to provide.

That doesn’t just mean access to adequate equipment, drugs or staff – though these are vital to the maintenance of standards – but also the presence of extreme pressure.

This pressure undermines the quality of care, and affects working culture and support mechanisms. For example:

• being new to a country will mean a doctor struggles to adapt to practice there without the right induction and support
• being unable to speak up when things go wrong inhibits corrective action and future learning
• experiencing discrimination or lack of fairness causes conflict and inhibits vital professional communications
• and being shut out of opportunities to progress professionally – especially where they are afforded to peers – leads to dissatisfaction and a feeling of being undervalued.

That’s why we do not believe it is a binary choice between supporting doctors or protecting patients – the two are inextricably linked. 

In order to deliver the standard of patient care we are all striving for, all doctors – no matter their background – need to feel supported, included and valued. 

That begins far before any complaint about a doctor’s conduct or practice reaches our door. It must be embedded in all standards, education and revalidation processes, and in how we work with others.

How the GMC is perceived

So, instead of simply dealing with issues as they arise, our objective is to try and prevent them materialising in the first place.

We believe using our influence in this way is a core part of our duty to protect patients. And in recent years, we have re-orientated our efforts to this end, focusing on improving doctors’ experiences and working environments.

But the reality is that this shift is not as well understood as we would like.

There remains an entrenched view that we don’t understand, or care about, the pressures doctors face. Worse, in some quarters there’s a perception that we’re prejudiced and punitive, even that we’re ‘out to get’ those we regulate.

Much of this is driven by fear:

• fear of being treated unfairly if a complaint is made
• fear of an investigation dragging on for years
• fear of an innocent mistake being construed as something malign
• fear that is often heightened by misinformation, complex legal processes and power imbalance.

In truth, most doctors will never come into contact with our fitness to practise processes. And if they do it is highly unlikely to be due to clinical concerns – of the 250 cases concluded at the Medical Practitioners Tribunal Service (MPTS) in 2023, only five were related purely to issues of performance. The vast majority of cases (nearly 78%) were related to misconduct, including things like lying about qualifications and sexually motivated or violent behaviour. I think most would agree that these are issues that require regulatory action.

But emotion proves to be more powerful than data in determining people’s reactions. And, when it comes to the GMC, the prevailing emotion of some doctors is fear.

There is obviously a balance to be struck here. 

It is important that both the public and those we regulate believe that we will take action if standards aren’t up to scratch, or if genuine misconduct has occurred. Respect for the regulator’s role in delivering this duty is an important element of this.

But that’s different from fear. 

Fear is corrosive. It makes doctors act defensively and skews decision making. It breeds cover-up. And it hinders learning.

So, for their sake, and the sake of their patients, we do not want doctors to fear us. 

Regulatory reform

But this cannot be passive – we need to ensure that respect is both earned and maintained.

Over recent years, we’ve changed the way we regulate to try to minimise fear and increase trust.

Our aim is not that registrants think we won’t take action, but that, when we do, they can be confident that we will act fairly, swiftly, and without prejudice.

In the UK, until now, we’ve been hindered by the legislation that underpins our work – the 1983 Medical Act.

Over 40 years old, the Medical Act was developed at a time when personal computers were in their infancy, there was no such thing as social media and doctors were more autonomous in their medical practice.

Under the precepts of the Act, we are required to fully assess every complaint we receive. That includes those that don’t raise serious fitness to practise concerns, or won’t meet our legal thresholds.

And as the number of doctors on the register has grown, so too has the number of complaints we receive.

The result is that, while in 1983 we were receiving one complaint a day, we are now dealing with nearly 11,000 a year. And the rigidity of the current legislation means we don’t have the discretion we need to take a more proportionate approach to managing them.

Fortunately, the government has committed to reforming this legislation and will shortly be consulting on the changes. We hope the reforms will take effect as soon as possible after that, lessening the burden on all involved and providing more rapid outcomes. We hope this will reduce stress on both patients and the professions we regulate.

The importance of culture in driving outcomes

Until then, we are not letting the grass grow under our feet and instead are pushing on with the changes we can within the current constraints. 

A key part of this is the shift towards influencing the culture and working environments I mentioned earlier.

What doctors see, hear and experience every day is material to the quality and safety of care they’re able to provide – from how they are treated by their employers, to the interactions they have with their patients.Particularly formative in this are the relationships between doctors themselves.

It is well documented that the medical profession is tribal – something I've seen throughout my own career as an ophthalmologist. Cross-specialty working is not always smooth, not to mention the tensions that can arise between different healthcare professionals.

But ensuring respect, courtesy and understanding in every interaction is vital to the safe delivery of care. As I have already mentioned, the consequences of feeling unable to ask a question, raise a concern, or clarify a course of action can be catastrophic for patients. And for those practising in such inhibitory environments, just coming into work every day can feel traumatic.

That’s why we believe that more must be done to improve doctors’ leadership and communication skills.

These qualities are not necessarily innate. And the pressures of the job can cause some to go too far the other way – and lose their empathy entirely as they contend with a system under strain.

But even if you’re not naturally a good communicator, you can become one. Like any surgical skill or diagnostic expertise, the ability to express yourself, clearly and compassionately can be developed and honed. And, as with other core medical skills, it is crucial to patient outcomes that we take the time to get it right.

It is this thinking that was behind the updates we made to Good medical practice, our core guidance for doctors, which came into effect last year.

The refreshed Good medical practice highlights doctors’ duty to 'listen to colleagues' and 'communicate clearly, politely and considerately'.

It also includes a strengthened focus on workplace cultures and inclusion, as well as more detailed guidance around discrimination, bullying and harassment.

What our data tell us about doctor wellbeing

Tackling such behaviours is not merely a nice-to-have, but absolutely key to the environments in which doctors work, and therefore the care they provide. 

The Covid-19 pandemic was hugely taxing for the healthcare professionals thrown into the eye of the storm. And we saw significant impacts on wellbeing throughout that period as a result.

But, while we've seen some recovery in the years since, our data tell us there is still much to be concerned about when it comes to doctors’ workplace experiences. 

Research we published last month shows that in 2024:

• nearly 30% of doctors were classed as ‘struggling’
• nearly a fifth of doctors are categorised as being at high risk of burnout
• and almost a quarter of doctors took a leave of absence due to stress.

Against this backdrop, it is perhaps unsurprising that UK doctors’ perceptions of care are notably poorer today than pre-pandemic. 40% of doctors witnessed patient safety being compromised in 2024, compared to 32% in 2019.

That's why shining a light on these experiences through our data is a key part of our duty to protect patients. And we share these insights with employers, policymakers, system regulators and others so they can target action where it is most needed.

The regulator we want to be

Ultimately, we want to reach a point where we’re only dealing with concerns that impact either a doctor's fitness to practise or public confidence.

The regulatory reform I mentioned earlier is a key part of this, but it won’t happen immediately.

So while we wait, we’re doing all we can under the current framework.

For example, we’ve reviewed our guidance to allow for more discretion and flexibility when considering allegations of minor violence and dishonesty. Examples of this might include a doctor pushing a colleague out the way following an argument, or a one-off penalty fare for failing to buy a train ticket.

As well as being more proportionate in our approach, we’re also taking a more compassionate approach to our interactions.

In 2015, we asked Professor Louis Appleby, a leading mental health expert, to review our investigation process.

He made a number of recommendations, which we’ve since adopted, around things like communication. For example, the volume of legal material in our correspondence with doctors was creating an impression of us being cold and distant. So we removed the legal content from the body of the letters to allow us to adopt a more human tone.

We also established a specialist team to handle cases involving vulnerable doctors. And commissioned the BMA, UK doctors’ professional body, to create the independent Doctor Support Service for those going through an investigation.

Crucially, we’ve also been focusing on fairness in our processes.

In 2019, we published Fair to refer, which showed that international medical graduates were two and a half times more likely to be referred to the GMC by their employer than their UK-trained colleagues. Black and ethnic minority doctors were more than twice as likely to be referred than their white counterparts.

Employer referrals are much more likely to lead to investigations, so this has a big impact on our caseload. But it is notable is that these referrals frequently do not lead to regulatory action, suggesting that many should never reach our door in the first place.

As Fair to refer found, the disproportionality we see is not an issue of competence but rather isolation, inadequate induction and an absence of timely feedback.

The research identified the influence of the ‘insider/outsider’ dynamic in medicine. And how being part of the ‘in’ crowd acts as a protective factor, with those doctors benefiting from a level of support that is absent for those on the ‘outside’.

This is acutely unfair for the affected doctors. So for the past few years we’ve been undertaking a programme of work to redress the balance.

In 2021, we set a target to eliminate disproportionate employer referral by 2026. This is a stretching goal, but we’ve been pleased to see progress made year-on-year.

A key component in tackling this issue is the local, employer-facilitated resolution of concerns. Our Outreach team has been working with doctors and employers on the ground to promote this more proportionate approach where appropriate – and avoid escalating concerns into regulatory investigations at all.

Another focus has been our own cultural competence.

We've rolled out training to our decision makers on the impact of a doctor's background on their communication, attitudes and behaviour. This is considered when investigating concerns.

But we're not there yet. Indeed, a feature of this work is that we’ll never stop learning, and will always be striving to improve. But we’ve come a long way, and the trajectory is now firmly set.

Conclusion

As I reflected at the start of these remarks, regulation performs an immense public service in safeguarding safety and quality. But doing that well requires trust – across all involved – regulator, public and profession.

It’s in all our interests that this relationship is underpinned, not by fear, but by mutual respect and understanding.

Because ultimately, we, the public and our registrants share the same ambition – for doctors to be empowered to deliver the best possible care for their patients.

We – I – believe compassionate regulation plays a fundamental role in enabling this – and we’re fully committed to embedding it in everything we do.

Thank you.