Cultures of compassion: modern regulation for modern medicine

Professor Dame Carrie MacEwen's speech at the Annual John Addenbrooke Lecture, held in Cambridge on 27 March 2024.

It is a great pleasure to be here with you today.I was thrilled to be asked to deliver this lecture today, I am honoured to follow in the footsteps of your other marvellous guests – Sir Magdi Yacoub, Sir John Savill, Dame Carol Black to name just a few.

There is a very special atmosphere here at St Catharine’s College and it is wonderful to be part of an event that celebrates the life and work of John Addenbrooke and his contribution both here within the College and to the city of Cambridge – importantly, leaving funds to set up Addenbrookes hospital, stipulating that it was to treat the poor of any parish or county.

I wonder how many people who come in and out of Addenbrookes on a daily basis are aware of him and his desire to provide care to people regardless of their background or status. The philosophy that he lent to the hospital seems, even after all this distance of time, to still chime with the ethos of the NHS. His legacy is certainly worthy of celebration.

Although I do note that at the time he received his medical education here in Catharine Hall - as this college was then - he would not be “required to attend any lectures but was left to acquire his knowledge from such sources as his discretion may point out.” As Chair of the General Medical Council which has responsibility to oversee all medical education and training this concept rather makes my hair stand on end!

We have a broad audience today, but I understand that we are joined by a number of medical students in the latter years of their studies. As you get closer to your graduation it is no doubt an exciting, if somewhat daunting prospect.

It is now forty years since I graduated, and as you head out into the world of medicine, I am somewhat envious that you have exciting and interesting careers ahead of you. I still enjoy working as a doctor alongside my role at the GMC. I hope you will all go on to have a similarly enduring and enjoyable career, although you will be joining a very different health service to the one I stepped into in the early 1980s, and over the course of a four decade career you will, no doubt, see dramatic changes in the way medicine is practised – just as I have done.

I will be talking to you today about how the way we work at the GMC is changing.
However, our purpose is unchanging – we work to maintain patient safety and public confidence in the profession. We do this through our statutory functions, overseeing all medical education and training, setting professional standards, carrying out fitness to practice investigations and, of course holding a register of those with the appropriate medical qualifications and behaviours.

Our work as the regulator of doctors in this country is governed by the Medical Act which came into law in 1983, 40 years ago.

Coincidentally, that’s around the same time I was finishing my own studies and I can as attest to just how much we, as doctors, have needed to change over that period of time as society has changed and medicine developed.

We are fortunately now about to enter a period of regulatory update and reform which will see the legislation in that 1983 Act being brought up to date. This will affect each of our statutory functions.

We need reform to the legislation to be able to make all the changes we want to make us into a truly modern and responsive regulator. But in the meantime, we are changing where we can within the current legislation in order to better support doctors. We want to be an effective, upstream regulator, and by updating our internal policies and interactions, our objective is to be a compassionate regulator.

Some doctors sadly see the world of regulation and medicine as one of ‘them and us’. But, remember, regulation was first introduced by doctors themselves as long ago as 1858, educated, trained doctors, for good professional reasons - in order to protect patients from ‘quacks’ and poor practices, and also so that they could be recognised in society as being qualified doctors – to be given appropriate status and trust.

These motivations still apply – particularly that shared goal of protecting patients that still drives all we do. But today, we need to view this in a wider context – that of the environment in which a doctor works and delivers care. No longer are doctors the totally autonomous beings they once were – they are highly affected by the environment in which they work. It has a bearing on their work and what they are able to achieve. The way regulation is carried out is of course dramatically different now, almost 170 years on.

But, it needs to keep pace. When we look forward, we know there are changes in population demographics ahead, there will be changes in patient expectations, and of course scientific and technological changes that we don’t even know about yet. Our role overseeing medical education and training is important – we need to look for ways to innovate, to be flexible and move with the times.

We also need to have a robust medical workforce that is ready to face the future. Although we carry no statutory responsibility for this, we play our part. We are in a unique position as holders of the medical register – we can use the data we have to inform and influence policymakers and workforce planners as they look to find solutions to the significant workforce challenges currently facing the health services.

While workforce problems cannot be solved overnight, there are things that can be done to improve workplace experiences and consequently improve patient care. I will share data and insights with you today that highlight some steps we can take. I am going to underline how compassion, something which there is no shortage of amongst those choosing a medical career, should be central to efforts to make work better for doctors, and safer for patients.

Firstly – let’s just take a moment to think about the current medical workforce position and possible challenge.

The makeup of the medical workforce is changing. We have the largest medical workforce we have ever had. In 2018, just over 250,000 doctors held a licence to practise - in 2022, this had increased to just short of 300,000, a growth of 18% in four years. Since 2019, the number of doctors joining the workforce each year has been increasing at a rate of more than double the number who leave. Sounds good so far - but that’s not the whole story. The number of those leaving is also growing, and the figures aren’t simply reflective of retirement numbers….it is also those leaving the profession to take up another career or to leave the country – often early in their careers.

What’s more, because we are only measuring headcount, the increases we see in numbers are still not enough and are not translating to capacity on the frontline – for example although there is a 5% increase in GP numbers, we have seen a 7% drop in overall FTE due to reduction in the overall hours worked.

More and more doctors are reducing their hours because excessive workloads are leading to burnout, or because they are seeking greater work life balance, in some cases as a preventative step for their own wellbeing.

That’s why, despite record numbers of doctors in this country, governments across the UK are planning major efforts to increase the numbers of medical students. This was written into NHS England’s Long Term Workforce Plan which was published last year.

There is a note of caution. The plans to increase numbers of medical students have been defined based on NHSE workforce modelling and projection of future needs. But have they got the numbers right?

Last week The National Audit Office published a report that highlighted significant weaknesses in NHSE’s modelling. It said that some of the assumptions may be optimistic, and the conclusions cannot be totally relied on. They made several recommendations to NHSE on how the modelling can be improved in order to offer a greater degree of certainty for workforce planning. They specifically cited numbers of medical student places and lack of educator capacity as examples where adjustments may be needed.

So, we shall have to wait to see how NHS England responds. In the meantime, we plan for the increase in medical student numbers as promised.

Obviously, the increase is welcome, but we must remember that it takes a long time to train a doctor. We will have to wait at least a decade before we see the benefit of those efforts.

Thankfully, the Long Term Workforce Plan also rightly identified that retention is a major problem. We need to find ways to stem the flow of doctors leaving or changing their working patterns if we are going to have a sustainable workforce. In the short term to navigate current challenges, in the medium term as we wait for new generations of doctors to join the frontline, and in the long term as we undergo societal shifts.

There is no point in training more doctors if we can’t keep them.

So, with all that in mind, let’s start by looking at the workplace itself, and let me share with you why I believe we need a greater focus on a compassionate culture to look after members of our profession.

In June last year we published The state of medical education and practice in the UK: workplace experiences.

This report shares data from our annual Barometer survey and national training survey and provides insights on how doctors are faring with workloads, with their wellbeing, and with the environments they work in.

Our findings supported the concept of a vicious cycle of unmanageable workloads leading to low job satisfaction and ultimately the burnout that is resulting in many doctors choosing to change the way they work by reducing their hours, or walking away from UK health services. This, in turn, puts more workload on the reduced numbers remaining – and the cycle continues.

Let’s take a closer look at the figures that support this.

In 2022, more doctors reported working beyond their rostered hours on a weekly basis (70%, up from 59% in 2021), having difficulty taking breaks each week (68%, up from 49% in 2021), and feeling unable to cope with their workload each week (42%, up from 30% in 2021).

Only half of doctors reported that they were satisfied at their work in 2022, a significant drop down from 70% in 2021.

These are clearly statistics that are worrying and this combination of high work pressure and low satisfaction is known to lead to burnout risk.

Burnout is a state of emotional, mental, and often physical exhaustion that is often characterised by depression and lack of motivation. Our survey includes seven questions from the Copenhagen Burnout Inventory, an internationally recognised and validated tool for assessing the physical and psychological fatigue associated with burnout. Differing risk levels for burnout were calculated based on the number of indicators to which participants gave a ‘negative’ score.

In the 2022 survey, a quarter of doctors were categorised as being at high risk of burnout, giving negative answers to six or seven of the seven questions. 17% were considered to be high risk in 2021 so it is quite a jump up.

The number of doctors leaving has increased from 9,825 in 2021 to 11,319 in 2022, and more doctors say they are taking hard steps to leave – going from 4% - 15% over the past two years. Of course, as doctors make changes to their working patterns or worse, walk away, the vicious cycle intensifies.

Caught in the middle of this are patients - retention issues undermine the sustainability of the workforce which, in turn, jeopardises future patient care. However, we are hearing that patient care is already affected.

In 2022, more than two-fifths of doctors (44%) said they found it difficult to provide sufficient patient care at least once a week. That’s a significant increase from 2021, when it was a quarter (25%).

There is a significant crossover with burnout here - high proportions of doctors who found it difficult to provide patients with sufficient care were also at high risk of burnout (70%) and felt unable to cope with their workload at least once a week (also 70%).

We know that patient safety is compromised in workplaces that are not supportive – where doctors don’t feel able to speak up. In unsupported workplaces, mistakes are more likely, and there is more of a tendency towards blame than constructive opportunities for learning. These factors all add up to put patients at risk.

We know that this is a complex problem and there are deep-rooted, multiple systemic issues within our health services that are fuelling unmanageable workloads, and these require long-term workforce planning solutions and adequate funding.

However, while these are being developed, it is also possible to disrupt the vicious cycle with positive workplace interventions. Interventions that improve workplace satisfaction can serve to kickstart virtuous cycles, where the overall effect will be greater than the sum of the individual parts.

Higher workplace satisfaction can act as a buffer against burnout, and can lead to better retention, which ultimately feeds into more manageable workloads for all.

So, while efforts are made to tackle the core, underlying issues, there are steps that can be taken now to try and make things better for everyone. In The state of medical education and practice in the UK: workplace experiences report we recommended initial steps focus on improving workplace conditions, evolving and developing what it means to be a leader, building strong teams, and improving induction and onboarding.

These are all steps that can be rooted in an awareness and understanding of the experiences and needs of those with whom we work - showing compassion and consideration.

Improving workplace conditions is crucial… Inflexible and non-consulted rotas, and a lack of or outdated and worse-for-wear facilities and physical environments, can leave doctors feeling undervalued and fatigued.

Solid inductions and onboarding, for both new joiners to teams and returners, are essential. We run Welcome to UK practice workshops for new IMGs which we know are considered extremely valuable – practical advice regarding the nature and philosophy of working in the British NHS, information about local communities and introduction to buddies and friendly faces. Our Outreach teams are working locally to support the introduction of the updated Good medical practice, and also continuing to highlight the findings of our report Caring for Doctors, Caring for Patients. Not everyone needs the same, and some degree of tailoring to the individual is important.

That the concept of leadership continues to evolve is critical. There needs to be a focus on senior leaders being visible, quick to respond and available to offer advice and support. Palpably moving away from any blame culture is particularly important to build learning opportunities into practice, ensuring feedback is constructive. There is good evidence that this will help doctors to feel supported and will give them 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 potential to cover them up, when they occur. Both will potentially affect patient safety.

Building strong teams is also incredibly important. Something that has been lost over time is a sense of closeness and belonging to allies who are experiencing the same things as you and who you can trust and confide in. When I reflect on my first years practising, we drew hugely on support from our ‘firms’. But things have grown more complex, doctors are drawn in different directions, working with more people in different roles – and peer group support is not so well established or readily available.

In our surveys, teamworking metrics were worse across the board in 2022 than previously, and yet we know good teamwork can help to prevent mistakes, by feeling confident to ask if uncertain… before, during or after an intervention. Good teamwork also drives productivity and effectiveness.

I was the ophthalmology clinical lead for GIRFT in England and a similar programme of the national eyecare workstream in Scotland, working with hospitals across the country, sharing good practice, and identifying what was required to overcome barriers to implementing that practice. In particular, we were looking at how you can increase throughput in cataract surgery, working to increase volumes of patients so that the theatre teams were completing one procedure every 30 minutes. The emphasis was on teamwork, one dissenting voice (medical, nursing, management) inevitably meant that this became an impossible ask. Everyone was key to success. The sense of purpose and satisfaction when surgical flow improved and waiting lists began to drop was energising and acted as further propulsion for more change – and that feeling that ‘we did it together!’.

The most impressive change I witnessed was in my own department – which is a very inclusive and cohesive unit - where my colleagues and I, many years ago, introduced day case surgery. There was no funding, but we recognised that we couldn’t increase our surgical flow without this development, and our joint determination ensured that we succeeded. The benefits for patients acted as a catalyst for even better teamworking across all areas of our department – as changes to all were required to make this work.

The GMC’s recommendation in The state of medical education and practice in the UK: workplace experiences report is that more support is essential. Providers should identify and focus on groups who currently report poorer workplace experiences.

Inclusion is a vital part of this picture - the working experiences of all doctors needs to improve, across the board, if we have any hope of retaining the doctors from the many different backgrounds within the UK workforce.

Inclusion is a term that would have been alien to my supervisors back in the early 1980s, but it is something we have come to understand as important… a result of changes we have seen in the composition of the medical workforce – as well as the patients we serve.

The medical workforce has diversified significantly in forty years. The most obvious example is the increase in female medical school graduates. The Sex Discrimination Act was only introduced in 1975, and prior to that the number of female medical students was capped in most universities at about 30%. When I started university there were 3,000 medical graduates per year, but only 1,000 females. That has rocketed – there were nearly 5,000 last year.

In the intervening years the so called ‘feminisation’ of the medical workforce was seen as a ‘problem’, one that needed to be sorted. There was overt sexism and discrimination – and, on a practical level, training was very difficult because of the long hours- especially for those who had childcare, or other caring responsibilities. I became one of the first LTFT associate deans in the UK because it is clearly unreasonable to expect women to either give up training when they had children or wait until they complete their training (as I had done) before starting their families. ‘Work/life balance’ and ‘family friendly policies’, at that time, were unknown terms and I spent much time persuading consultant colleagues in many specialties of the benefits and need for flexibility, helping to deliver balanced rotas and providing pastoral care for trainees who were not being supported by their clinical departments. LTFT training has now become a normalised method of training, partly with the passage of time but also with more female medical leaders who trained this way and who understand and are able to better empathise.

We have called out sexism in our latest version of Good medical practice and although this is definitely still a work in progress things are getting better for women.

International doctors have always made a valuable contribution to our health services but that contribution is now greater than ever before.

In fact, of the doctors who joined the medical register in 2022, only 37% were UK graduates – a figure that most people find surprising.

We are extremely fortunate that the UK is still seen as an attractive place to work. Overseas doctors are playing a crucial role in all areas of the medical workforce, bringing a welcome diversity of experience and perspective, as well as better matching the needs of an increasingly diverse patient population.

International medical graduates, many of whom are from an ethnic minority reported that that they were less well supported by their immediate colleagues than UK graduates.

And the data on disabled doctors gives cause for concern. As they were less likely than their non-disabled doctor colleagues to be satisfied and more likely to be struggling with their workload. They were also less likely to feel part of a supportive team than non-disabled doctors.

Inclusion must be seen as an important part of a compassionate workplace – and, unlike women, there are very few ethnic minority or disabled leaders within the health service.

Losing doctors from our workforce because they feel excluded and lack a sense of belonging is not something we can afford to do.

In Caring for doctors, caring for patients, highlighted the need for doctors to feel that sense of belonging. The report authors found that it is one of doctors’ key needs, alongside autonomy or control, and competence. The report detailed that without a sense of belonging, doctors will not be able to perform to their best, and will not be in the best position to promote the wellbeing of the patients and communities they serve. Feeling part of a team – or a ‘tribe’ – is a basic human need.

We need to think about inclusion through this lens. t can be easy for leaders to fall into the trap of feeling as though they have created a supportive and caring workplace, and fail to recognise that not everybody feels included. When we focus on belonging being an essential need, we can start to recognise the impact on those that feel like outsiders.

We presented this diagram in The state of medical education and practice in the UK: workplace experiences report. It shows the connections and strong inter-relationships between belonging and support - which of course comes from compassionate, inclusive culture and leadership – improved workplace experiences, and better patient care and safety.

And you will note the arrows that point both ways, not only does the compassionate environment lead to better patient care, for example, but the provision of better patient care also points to a stronger sense of team support and belonging – as we felt so strongly when we introduced day case surgery and surgical numbers grew.

The smaller triangle shows how this picture then plays into reducing the burnout problem, which in turn feeds and improves retention issues.

So, compassion, with inclusion, is critical.

Creating caring cultures should become easier over time. As more evidence mounts that this is needed to make the workforce sustainable and deliver safe patient care, resistance to compassionate models of leadership should be gradually broken down.

Systems need to adapt. Our health systems have always prioritised patient care, but it is only recently that those with decision making responsibility began to realise that the quality of patient care depends on staff wellbeing, and staff wellbeing, in turn, depends on leadership.

One of the recommendations in Caring for Doctors, Caring for Patients 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. The recommendation was that clinical leads and other doctors’ leaders should be recruited, selected, developed, assessed and supported to model compassionate and collective leadership. In other words, a good leadership style should be seen as essential, not a nice to have – and needs to be actively sought.

When it works, it should work for everybody. A successful leader can blur the boundaries between individual team members, to promote a sense of belonging and trust. This builds an environment where everybody is included and appreciated and receives support. All team members can then contribute fully to team performance.

Of course, poor working conditions, excessive workload, time pressure can all get in the way of a focus on leadership style. But it is arguably when services are under the most pressure that this is most needed, to ensure the wellbeing of the team and the best conditions for provision of good, safe patient care.

Just a short note on self-compassion. One of the authors of Caring for Doctors, Caring for Patients, Professor Michael West, who is very eloquent on this subject, suggests that this is important.

Doctors have very high standards – particularly for their own work – and we can find it difficult when these standards cannot be met. Being kind to ourselves not only helps us develop a kindness habit, it can help sustain us through a lengthy medical career with its natural ups and downs.

Self-compassion is particularly needed while services are stretched, and we have worries and preoccupations about the provision of patient care. In the workplace experiences report we specifically called out that doctors under significant pressures are at risk of moral injury.

Moral injury is distress caused by people acting, or seeing others act, in a way that goes against their values and moral beliefs. We do not specifically measure moral injury at the moment in the Barometer survey, but it’s clear there is a risk. Causes include not being able to provide patients with the level of care they would have wished - I have already stated that nearly half of the doctors surveyed found it difficult to provide sufficient care - having to prioritise some patients over others due to a lack of time or resources – and long waiting lists are contributing to this, or being unable to support colleagues as much as they would like.

It is clear that there is a need to improve workplace experiences – and thus safe patient care - by focusing more on understanding, valuing and respecting all those with whom we work and treat - and I’ve talked about some of the practical steps that can be taken to do that.

Now I would like to talk about why we, as the medical regulator, are also increasingly focused on compassion – supporting and demonstrating understanding to those who we come into contact with us through our regulatory processes.

Our fitness to practise duties tend to dominate our reputation and we are undoubtedly viewed as a negative organisation by some doctors – which has also permeated down to medical students. In some instances this manifests itself as fear of the regulator. Fear of referral for investigation of a complaint, even though it may be misplaced, can have a negative effect on doctors’ wellbeing and performance.

That fear is often heightened by misinformation, complex legal processes and a power imbalance - we understand this.

As a doctor, the odds are that you won’t ever been investigated by the GMC. The number of complaints we receive each year versus the number of doctors we regulate is small – of those complaints, the number that are taken forward is much smaller still.

There are just over 350,000 doctors on the register, and in 2022 we received nearly 9,000 referrals. There were only 101 suspensions issued and 68 erasures in the whole year.

And it’s important to understand that the small number suspensions and erasures are for things like criminal activities, sexual misconduct, serious dishonesty – not related directly to clinical care, and when they are, they are usually associated with covering mistakes up or demonstrating wilful disregard for those affected.

We know that if we want to achieve the cultures that will deliver the best in patient care – learning, listening and responding - we need to do what we can to dispel fear of the GMC, amongst all doctors, perhaps particularly those in the earliest days of their careers.

Fear of clinical mistakes can push the profession back to a more traditional and familiar command and control model of leadership, and fear of professional mistakes can get in the way of honest communication that allows for speaking up, rectifying mistakes.

Compassionate regulation covers all our statutory roles – not just our fitness to practice processes - and, in essence, affects the way we work and carry out all our functions. Part of this is our much bigger ambition to become a modern upstream regulator, as I mentioned previously. Upstream regulation is about improving the overall performance of doctors through excellent education and training, preventing errors by helping to work through system weaknesses that might leave doctors vulnerable and reducing the number of referrals we get by addressing appropriate complaints locally. We have fantastic Outreach teams that work across the country to embed these ‘local first’ policies and further guidance to prevent unnecessary referrals reaching us.

We are very limited in what we can do because of the laws that proscribe our statutory functions – but we are hoping to soon enter a period of regulatory reform where we will have the opportunity to finally make the changes that we have been trying to push through for many years. We have long recognised the disadvantages of the rigid laws under which we operate.

This is taking time – the law moves slowly – so we have been doing what we can within current legislation to reduce the harm caused by any interactions with us. By closely examining our policies, and looking anew at training for our people, we’ve been able to make some significant changes to all of our processes.

Specifically, regarding fitness to practice referrals - whatever the outcome, the doctor or complainant should be confident that they will be treated fairly, kindly and proportionately, with their personal circumstances and vulnerabilities taken into account. We’ve made various changes, less legalistic language; a phone call – rather than a letter – being used to make first contact; better updates regarding timelines and delays, and more one to one staff involvement.

This means the patient who has taken the difficult decision to raise a complaint trusts the process too. Overall, communicating more clearly and actively listening, acting more quickly on feedback, responding to queries in a timely fashion and making sure we do so in an empathetic way.

This is not about dropping standards - it is about doing things better. Robust, effective regulation will always be needed because we are there to support the safety of the patient. But we believe that robustness and compassion can go hand in hand.

With reform of The Medical Act, we are also looking forward to more flexible and consistent ways to quality assure medical education. In the meantime, we are progressing with a programme to reform medical education and training.

We are working with others to plan for the years ahead, to ensure we can build a bigger, more diverse, and better supported multidisciplinary educator workforce; to deliver increased flexibility and innovation in training, and to ultimately better support all doctors throughout their careers.

We need to be sure that undergraduate and post-graduate medical curricula reflect the current and future needs of all patients and the expectations of employers. We need to make sure that doctors are trained to adapt and reduce the risk of perpetuating health inequalities – something that John Addenbrooke would have wanted – although he would have been amazed at the change in what medicine has to offer today!

There are several factors in education and training that are out of step with modern times. Failure to adequately value skills obtained outside recognised training pathways is one aspect that jars with our modern workforce. A system that still rewards doctors in training for sticking to a traditional, unbroken path through training, without breaks, is another that needs to be brought up to date now that we have better understanding of wellbeing and work life balance. We are looking for competence and outcomes – rather than time spent or numbers done.

Training to be a doctor is a long, and arduous path, and unfortunately there is evidence - much of it gathered through our own national training survey - that shows that many doctors in training are already suffering from burnout, and we know from insight work we do with medical students that stresses and strains can become an issue even before graduation. No doubt this is heightened by worries about pressures on the workforce.

Compassion, for doctors, needs to be baked into undergraduate training, postgraduate training, and lifelong learning, again, without any loss in standards.

In January this year, the updated Good medical practice came into effect. This was developed with full input from the profession, the public and those with whom we work as doctors.

This updated version included a much stronger focus on treating our colleagues fairly and supportively.

We are clear that all doctors have a responsibility to contribute to a positive, fair workplace, not just those doctors with formal leadership responsibilities. We ask doctors to help create the right kind of culture by role modelling good behaviours, and we ask them to be aware of how their own behaviour may influence others within and outside their teams.

In addition, our standards emphasise that we must be aware of the risk of bias and to consider how our own life experience, culture and beliefs may influence our interactions with others…. and may influence our decisions and actions, as well as showing respect for, and sensitivity towards others’ views, culture and beliefs.

This is all quite a step forward, and I am pleased that we have these explicit references to kindness in the professional standards now, as I believe we need to recognise and be honest about how important this is.

The things I spoke about earlier in terms of the need for practical steps to establish these cultures is reflected here. The emphasis on all doctors demonstrating leadership behaviours, and the focus on positive teamwork, listening, communicating effectively, working collaboratively, being accessible.

The standards are clear. Patient safety must always be the priority and we must be open and honest with our patients but, no matter how difficult the conversation, we should always be kind to them.

A key priority for us is to continue to inform and influence policy and decision makers, part of our role that has undoubtedly grown over the last few years. With the wealth of data we have at our fingertips, we can offer significant insights, and advice, to those whose responsibility it is to tackle workforce problems. We do not shy away from making comment. The state of medical education and practice in the UK: workplace experiences report made it clear that educators were not supported and were at risk of dropping that commitment – with the ambitions to increase medical student numbers we need many more educators who are happy in their roles. We have shared these data with decision and policymakers and this has become a recognised area of priority.

Our role has certainly evolved and our interactions and work with many stakeholders have made us all more influential – the whole being greater than the sum of the parts where real change is being proposed.

We are aware that we will not be able to stand still. As societal shifts take place there will also be questions about the future scope of regulation, will there be a role for regulation of preventative healthcare, for the regulation of new technologies, for instance, who will regulate artificial intelligence? It will be interesting to see what is required of regulation forty years from now. While the world of healthcare is likely to be quite different, doctors will still be doctors, and will still benefit, I do not doubt, from a compassionate regulator.

To retain our current workforce, and to enable those entering medicine to have long, satisfactory careers, much needs to be done. It is going to take collective effort, from policymakers and influencers - and I include the GMC in the latter group - to help create a backdrop where all who work in the NHS are considered as assets that need to be understood, valued and cared for.

Only by focusing on caring, inclusive workplaces can we hope to deliver the best patient care, tackle the current retention issue, and create sustainability, although, of course, this is not the whole answer. The tangled, interconnecting systemic issues we face now cannot be solved solely by an infusion of compassion. But equally, they cannot be solved without it – and it is our only hope of keeping things going until the bigger issues are solved.

There is scope to make every interaction in our health services, between colleagues, between patients and between different parts of the health ecosystem - including between the regulator and regulated more supportive. Our current times require it – and we all deserve it.