Dame Clare Marx GMC Conference keynote speech 30 November 2020
It’s a real pleasure to welcome you to this year’s GMC Conference.
The last 12 months have seen phenomenal change. None of us has been left untouched, and the impact on medicine has been particularly profound.
In the face of severe pressure, healthcare workers have overcome huge hurdles. At an unprecedented moment in NHS history, they have risen to the occasion.
The challenge of delivering care in a system under strain is not new. It’s one we grapple with year in, year out. But this has been an extraordinary situation.
Many had questioned if change in the health system was “an impossible dream”. How could one change this vast and unwieldy tanker, on a course which only generations would alter?
But the pandemic has upended conventional wisdom. The unchangeable has been changed.
Let’s look at training, where innovation and flexibility have come to the fore. At a time when coronavirus has caused huge disruption, it has also been a catalyst for positive changes. From the creation of the interim Foundation Year 1 post for newly qualified doctors, to the challenges and opportunities of redeployment.
The task now is to build on that foundation. Doing so is vital, not only for the next generation of doctors, but also for the patients in their care.
The doctor of the future
Over the 43 years I have been qualified, I’ve seen medicine, training and the delivery of care shift dramatically.
When I was a student, computers were so big and clunky they took up whole rooms. Today, a video consultation can be held over a mobile phone. This speaks not only to changes in technology, but also in expectations. Many patients today are comfortable with delivery modes we couldn’t have dreamed of in the 70s.
We’ve also seen wider socio-economic shifts. Life expectancy has steadily increased until recently, meaning a larger group of the population is ageing with many complex health issues. Social inequalities which underlie health have recently increased and rates of obesity and diabetes are at historic highs. Increasing numbers of patients suffer from multiple illnesses, born of poor diet, poor housing and lack of secure employment.
As demand is growing, there is a very real strain on supply. Healthcare environments are grappling with financial pressures and the challenges of recruitment and retention.
We know the composition of the workforce is changing. This year, 61% of those joining the medical workforce are from BME backgrounds compared to 44% in 2017. And figures from this year’s The state of medical education and practice in the UK report show how ethnic diversity amongst medical students has been growing.
In short, the world new doctors enter has changed radically.
It is clear that if tomorrow’s doctors are to have the skills they need, medical education and training must also change.
So what does this mean in practice? We don’t have all the answers, but we know where efforts need to be focused.
Firstly, combining generalist and specialist skills.
I mentioned that many patients today suffer from multiple conditions. The presence of clusters of disease around things like smoking, diabetes and obesity have major implications for care. Rather than treating each disease in a patient as if it exists in isolation, doctors are taking a more holistic view.
But training pathways are not always constructed to support this. Many doctors become more specialist as they progress through their careers.
Whilst this increased specialisation has been crucial in treating single diseases, it has not always supported patient care. To meet today’s needs, there must be a more systematic approach, looking at the patient as a whole. It must be embedded throughout a doctor’s career, from medical training to the end of their careers by continuous professional development.
The GMC will work alongside medical schools, royal colleges and the governments of the UK to consider how this is delivered.
The prize will be doctors with both the specialist skills they require and the foundation to adapt and learn. This will allow them to respond to changing patient needs throughout their careers.
This pandemic has given us an example on which to build. Providing complex care to the most vulnerable patients, many doctors worked across teams and specialties. So we know there’s an opportunity for greater flexibility. The challenge is how we embed it for the future.
"To meet today’s needs, there must be a more systematic approach, looking at the patient as a whole. It must be embedded throughout a doctor’s career, from medical training to the end of their careers by continuous professional development."
Dame Clare Marx
Secondly, how should medical students be prepared for life as a doctor.
Early in the pandemic, we worked with partners to get the role of interim Foundation Year 1, or FiY1, doctor up and running. This new post allowed graduating medical students to start practising early, to support the wider effort.
While undoubtedly a dauting experience in the middle of a pandemic, FiY1 doctors have reported positive experiences, finding the post a useful stepping stone. The transition from education to practice is a steep one. I can still recall the mixed feelings of pride, confusion, exhaustion, fear and achievement of my first few days as a preregistration doctor. So the chance to gain experience while still receiving extra support is valuable. And for many it gave an opportunity to start their first job confidently as doctors.
To learn more, we’re developing a full research project to track these experiences, but even at this early stage there are encouraging signs. Our National training survey showed that those who undertook FiY1 felt more prepared than those who didn’t.
Speaking to stakeholders across the system, it’s clear there is real appetite to replicate the best lessons from the FiY1 experience. So we’ll be looking together at the elements we want to keep for graduating doctors, to lock in these benefits for the future.
Thirdly, curricula and assessments can’t stay the same.
We’ve seen through the pandemic that curricula, college exams and other assessments can be simplified and streamlined.
Although coronavirus created an immediate need for expediency, there are obvious lessons to carry through. Chief amongst them being the development and delivery of changes to curricula, assessments and the process of progression.
Embedded in any change must be a recognition of how current approaches disadvantage some groups.
The same system of medical education in the UK which is said to be the envy of the world can also be inflexible. International medical graduates, BME groups, less than full-time employees and those with disabilities and other protected characteristics all confront barriers.
It’s long been known that BME doctors face an attainment gap, both in undergraduate and postgraduate contexts, exam pass rates and recruitment.
Inequalities that occur at an early stage can be compounded as a doctor progresses. FY1 BME doctors are less likely to report feeling prepared for their first post than their white colleagues. This in turn impacts on their subsequent experiences.
In this year’s National training survey we asked doctors whether they felt their working environments are supportive regardless of background, beliefs or identity. Strikingly, responses show some small but significant differences based on ethnicity. So the widespread disruption to training caused by the pandemic creates the risk that existing inequalities will be exacerbated.
The iniquities and disparities illuminated by the pandemic show why it’s crucial we make headway in tackling systemic unfairness.
Now is the time to make education and training more inclusive.
This has been recognised by our partners across the system. But real consensus must be built on to show progress in concerted action. We have a central role in this. Not only in reflecting on our experience of making the curricula change process more flexible during the pandemic, but also in pushing for changes to assessment where it makes sense to do so.
Doctors as leaders
There are practical changes we can make here, such as reviewing policies or processes that create barriers to progression. But a significant part is attitudinal and comes down to our behaviour as doctors and colleagues.
As leaders, we must create supportive working environments that allow all doctors to perform at their best.
This is not a nice-to-have. It is essential to the care patients receive. Doctors that work in open, compassionate environments deliver better patient outcomes. Where those environments are absent, patient care is compromised.
Listening to and communicating with colleagues and patients, acting with decency – these skills are as essential to good care as diagnosis or surgical ability.
They are the building blocks of a doctor’s craft from the earliest moments of their career.
Here, again, the pandemic has given us examples of how this can be done. In this year’s National training survey, most doctors reported positive experiences around teamwork and feeling valued and supported – despite the pressures of coronavirus. So we know how to do it. Now it’s a matter of carrying through beyond the pandemic, so that inclusive and compassionate cultures are the lived reality for all doctors. We’ll be convening with others across the system to identify how we can support doctors to do this.
As doctors we are leaders who have we have a profound responsibility – to our patients, to our colleagues but also to the public at large.
Our profession is held in high esteem. This gives us the opportunity to promote practical, preventative public health, such as health literacy and wellbeing in the communities in which we work.
Leadership skills have to be learnt, and then perfected. None of us emerge from the womb as fully fledged leaders. We never stop learning and part of leadership is leading the change. We must do this to respond to the evolving needs of patient, communities and those with whom we work.
2020 has certainly tested the mettle of the health service.
But even in the face of acute need, doctors have responded with flexibility and collaboration.
We have a chance now to build on this, to embed the lessons of the last few months, so we can create a health system that meets today’s needs.
At the heart of this is the ability to respond to the changing context in which doctors work.
As the pattern of health and disease in the population evolves, so too must doctors’ skills.
That requires education and training that prepares doctors for the realities of practice today. It also requires a genuinely inclusive approach, that gives all doctors the best possible experience of medicine throughout their careers. And it requires us all to be flexible, adapting as the situation demands.
We at the GMC are committed to playing our part in delivering this. But we can’t do it alone. Genuine change will only come as part of a system-wide effort. So let’s seize the opportunity we have now, so we can continue to deliver for the patients we serve.
I look forward to working with you.