Culture and care in a system under pressure

Professor Dame Carrie MacEwen at GMC Conference, 4 May 2022.

Introduction

Good morning, everyone. It’s a real pleasure to welcome you to this year’s GMC conference, and it’s lovely to see so many of you joining us here in person, as well as the even larger number online.

Being able to stand here and look at an audience instead of faces on a screen still feels like quite a novelty.

The last time we held a conference in person was in 2019 – which seems like a very long time ago – and how blissfully unaware we all were of what the next couple of years would bring.

Marx fellows

At that conference, our Chair was my colleague and friend, Dame Clare Marx. I took on the role of interim Chair of the GMC in July last year, when Clare, very sadly, had to step down due to ill health. I would, of course, rather have taken up this position of Acting Chair under almost any other circumstances.

But Clare had made such a strong start to her tenure, and had such sound priorities, that I’ve been honoured to be able to take the reins for a time, to continue some of the important conversations and relationships that Clare started, and to build on those foundations.

And that’s why I’m delighted to announce that from next year onwards, doctors who join the GMC on a clinical fellowship placement will be known as Marx fellows.

Our clinical fellowship programme is a valuable way for the GMC to forge links with the profession. Clinical fellows bring a wealth of experience and knowledge to their roles and both parties benefit from a productive exchange of insights and perspectives.

Those kinds of supportive links between regulator and profession are things I know Clare has always been passionate about.

So, we’re grateful to Clare for agreeing to lend her name to our clinical fellowship programme, and I’m sure our Marx fellows of the future will be a fitting tribute to everything she has achieved.

Workplace culture

When I first joined the GMC as a member of Council, I often heard staff saying that patient safety is the heart of what they do.

That is undoubtedly true for the GMC as a regulator – and reflects the purpose and sentiment of every doctor.

Indeed, those of you here today who are not doctors would say the same: that the overall goal of anyone working in healthcare is to make sure treatment and care are of the highest standards. That is what patients both deserve and expect.

We’re all working towards to that same end. I want to be very clear that our primary role as a regulator is to protect patients – and it is through supporting doctors, and the wider healthcare system, that we are able to do that.

That healthcare system is under pressure and the pandemic has certainly intensified that pressure. However, it existed before Covid-19 and it has simply been exacerbated by it – and perhaps brought more into the public consciousness too.

It’s inevitable in any walk of life that sustained pressure increases the risk of error and making mistakes – so it won’t come as a surprise to learn that alleviating those pressures, in whatever ways we can, is key to patient safety.

We also need to recognise that a one-size-fits-all solution does not exist for every problem. The GMC covers all four countries of the UK, and each has its own particular challenges in healthcare, as well as operating against its own political backdrop. Those differences have rarely been clearer than they were during the pandemic, when the health services in each country were very publicly working amid different rules and restrictions.

Having said that, there’s still much common ground, and some practical solutions are widely applicable. I suspect there isn’t a person in this room from England, Wales, Northern Ireland or my home nation of Scotland who wouldn’t welcome more equipment, more space and better IT, for example.

And these practicalities are key – the profession is only as good as its people, but its people can only be at their best in environments that enable them to provide the best care they can and to thrive – so that they can be the best they can.

And it’s those environments that are, all too often, lacking. They are preventing doctors from reaching their full potential – by undermining their confidence… or not allowing them to speak up… or not treating them fairly.

We’ve seen some disturbing reports of late of large-scale failures in healthcare systems, with some devastating consequences for patients. The Ockenden report into maternity care is the most recent one that springs to mind and tells the same story as many previous reports.

There are many factors at play in failures on that scale, but there is one common link – one that’s not actually connected with clinical expertise. And that’s workplace culture.

We can break that down into different elements – there might be bullying, poor communication, a lack of respect for colleagues, lack of transparency or just plain bad leadership. But ultimately, those things all add up to one common overall sum – that of a toxic culture.

And when we listen to what doctors tell us about their work, we can see that workplace culture has a huge impact not only on their job satisfaction, but more importantly on their ability to care for patients – a double whammy, as failure to provide optimal care results in more psychological trauma to the doctors involved.

We also know that doctors from ethnic minority backgrounds and doctors with disabilities have a significantly poorer experience of working in the UK health services – and that means we run the risk of losing talented clinicians, at a time when they’re needed more than ever.

You’ll no doubt be aware of some distressing accounts in the media of sexual harassment and even assault suffered by doctors. When women in medicine report this sort of behaviour as something widespread, rather than a shocking one-off, this suggests that a more general lack of respect for colleagues is at the root of it. And that’s before we even start to look at gender pay gaps.

All these things have a direct impact on patient safety, on doctors’ wellbeing, and on their desire to remain in the profession.

That’s not to say that fatigue, burnout and overwork aren’t also a factor – of course they are.

But even in a highly pressurised environment, doctors are best able to cope with those challenges if the accepted culture is compassionate, open and inclusive.

I see it, very much, as the GMC’s role to support doctors but also to work with employers and all other stakeholders in building those cultures. At a time when the profession is facing high levels of burnout, and workforce retention is an urgent priority, we simply cannot afford not to act.

This is quite a challenge – culture change doesn’t happen overnight – but it is people who create cultures, and we need to do all we can to empower doctors to be a key part of that change.

Good medical practice

In fact, we think this is so important to the profession that we’re making positive behaviours and supportive cultures part of the most fundamental guidance that sets out the standards we expect from doctors. That guidance is, of course, Good medical practice.

Put simply, Good medical practice describes what it means to be a good doctor. It is nearly 10 years since it was last updated and, although the fundamental principles remain the same, it needs to be brought up to date to mirror changes in society.

There is a lot more to being a good doctor than just clinical expertise, there are relationships – the doctor-patient relationship, our relationship with communities and our relationships and responsibilities to our colleagues.

Our proposed updates to Good medical practice are now out for consultation – and I hope you will comment and feed back to us. The draft is the result of months of working with doctors, employers, stakeholders and patient representatives, and this is your chance to tell us if we’ve got it right – and if not, how to improve it.

The proposed updates to Good medical practice make it explicitly clear that doctors have a duty not to harass, bully or discriminate against anyone.

And just as importantly, doctors must act if they become aware of such behaviours from colleagues – or support others to act.

These points are aimed at tackling the most serious and harmful behaviours, of course. But we go further than that – not just in preventing destructive behaviours, but in developing strong positive ways of working together.

We know from our broad engagement that simply working effectively in multi-disciplinary teams, sharing knowledge and learning and respecting each other’s skills and expertise, all make a huge difference to workplace cultures and job satisfaction – so we’re proposing that this will be part of Good medical practice too.

Finally, supportive cultures need supportive leaders – and when I say leaders, I don’t just mean the most senior staff. All doctors need the leadership skills that are right for their role, and Good medical practice is clear on that. All doctors are leaders.

To be clear – leadership isn’t just about management, delegation and advice. Far from it – it’s about being a role model and playing our part in collectively shaping cultures that are positive and welcoming: creating places in which doctors want to work, and where they want to stay.

Good medical practice isn’t a prescriptive rulebook. It’s a supportive framework: a guide for doctors that they can, and want, to apply to their practice.

From the moment a student enrols in medical school, Good medical practice sums up everything they are working towards. Those principles form the backbone of their practice, right up until the day they retire.

Conclusion

The fact that we’re updating something so fundamental to include those wider workplace behaviours is a measure of how important we think positive cultures are – for doctors’ wellbeing, of course, but also for the benefit of our health services and for the standard of care we provide.

And it is not just for clinicians – employers, education bodies and other regulators all have a role in this too. No one can do this alone – culture change is far-reaching, and it needs everyone’s buy-in.

If we don’t look after our doctors, they can’t look after their patients. Strong, compassionate leadership means compassionate cultures, and compassionate cultures mean compassionate care.

I look forward discussing all these issues and more with you today. Thank you.