Flexibility, recognition, induction and inclusion – all key to better support for locally employed doctors

Charlie Massey, Chief Executive, was speaking at the Locally employed doctors: good practices, a regional event hosted by University Hospitals Birmingham NHS Foundation Trust on 2 February 2024.

Good morning, everybody.

I really want to take you through some of our data and some of the key insights that come from it. But first of all let me say that I really do think the Long Term Workforce Plan is an enormously exciting opportunity for us to take stock and think, yes there are lots of challenges within the profession, but there is also a real opportunity to seize.

So let me share the insights from the work we’ve been doing at the GMC to develop a fuller picture of the experiences of locally employed doctors. These insights are drawn from our Barometer survey data, and I think we are now really beginning to shed better light on the issues that are faced by locally employed doctors.

What I want to do is to share how I think these insights can lead us to a future where locally employed doctors are better supported and better empowered to provide their best to our health services and patients. That depends in my view upon each part of the health services ecosystem taking responsibility for the key changes we can each make, and I include the GMC in that ecosystem.

Of course, we do have a starting point where our health services are under exceptional strain at the moment, and that can create quite a pressure cooker situation where all of us are focused on survival rather than best practice. However, I believe that those strains are only going to be exacerbated if we don’t step up to the plate and address key issues, particularly those that impact retention.

I am really pleased to see so many people here today who clearly recognise the need to support locally employed doctors, and who understand the link between this, the future sustainability of the workforce and the delivery of good, safe patient care.

And I’m going to set out the four key challenges that I believe we must collectively address.

Firstly, I think we must take steps to fully and more meaningfully embrace the trend towards workforce flexibility that is typified by locally employed doctors.

Secondly, I think we must acknowledge a historic and persisting failure to sufficiently value locally employed doctors, and take steps to remedy it.

Thirdly, I believe we need a step change in our approach to prioritising induction. We must equip our locally employed doctors to succeed right from the start. Currently approaches to induction are variable, often quite patchy, and too often severely wanting. Particular care and attention is needed for those locally employed doctors who have joined the register having gained their primary medical qualification overseas.

And finally, I believe there is a need to intensify efforts to build inclusive cultures and leadership in health service workplaces. It’s critical in my view that all locally employed doctors feel valued and appreciated. For international medical graduates in particular, and those who are from a Black or Minority Ethnic background, there is a lot of work to do to ensure they do not feel like outsiders throughout their careers.

So I have four key words for you today – flexibility, recognition, induction and inclusion. And I believe organisation and team leaders, policy makers, workforce planners, regulators, and stakeholder organisations, all have a part to play here.

But I’m going to start by just talking a little bit more about what our data tell us about this sizeable and growing part of the medical workforce.

We’ve traditionally monitored numbers of locally employed doctors alongside SAS doctors. Taken together, they make up almost a quarter of the total number of doctors in the workforce, and they represent the fastest growing component. Over the last five years, their numbers have increased at over four times the rate of those on the specialist register, and almost six times as those on the GP register.

In fact, the growth of these ‘non-traditional’ roles represents one of the most rapid shifts in the composition of the medical workforce that we’ve seen since we started digital analysis of our data in 2001.

But it has been a frustration of ours for some time that limitations of register data sets have constrained us to reporting on SAS and LE doctors together as one cohort. We do know these are two very distinct groups of doctors, with discrete characteristics and experiences. And grouping them on the basis of what they are not – neither GPs, nor consultants, nor doctors on the formal training pathway, risks missing who they are, what they are, and what they bring. And it’s also, I would argue, quite reductive and demeaning.

We’ve invested considerable time and effort into our data approaches and were delighted that last year we were able to provide more detailed differentiated data for the first time. We shared this data in two of our key reports, The state of medical education and practice: workplace experiences, and workforce 2023 reports. These were published in and June and November respectively, and in October we also published a more detailed Spotlight report which focused in detail on these two data sets, and it’s well worth your time to read.

But these detailed data do give us a much more informed starting position for conversations about locally employed doctors.

In England and Wales, where data is available to us, we can immediately see that the number of locally employed doctors has been growing much faster than the number of SAS doctors, and it’s now a bigger group by some margin.

We also now have a clearer view of the challenges LE doctors face. We can see that 39% of all the locally employed doctors we surveyed think it likely they will move abroad to work. That such a large proportion of this group feels this way should give us all pause to reflect, as well as significant motivation to act.

We develop these insights not just to influence and inform policy makers and workforce planners at a national level, but also to help at a regional and local level, to help you develop best practice. We believe it’s important that all stakeholders and employers have an accurate and detailed understanding of what the workforce looks like, and what it needs to look like in the future.

Now that we do have more detailed information on this cohort, I do think that we’ve got a great opportunity to build insights into the foundations of best practice.

We need to start from a point of understanding that not only are locally employed doctors different to their SAS counterparts, but as the improved Barometer survey has shown us, that the locally employed cohort itself is full of diversity.

71% of locally employed doctors who completed our 2022 survey gained their primary medical qualification outside the UK. 88% of these overseas graduates are from a Black or Minority Ethnic background. And broadly speaking this group is an older cohort than the smaller group of locally employed doctors who qualified in the UK, 59% of whom are under 30.

While both UK and international graduates in locally employed roles face challenges that require our attention, these groups unsurprisingly report different concerns. And interestingly, within both groups, experiences then vary further depending on their length of service.

So for example, we can see that regular, stress-related leave is more prevalent amongst overseas graduates with less than five years’ experience in the UK.

Likewise, when we look at doctors who graduated in the UK, it is the less experienced cohort who are more likely to report experiencing compromised patient care.

Being able to break the data down to this granular level is I think really useful, and should help all of us develop approaches that genuinely speak to the experiences of the doctors concerned.

Our Barometer survey revealed that locally employed doctors who qualified within the UK but have been practising for less than five years have a range of negative experiences. Many of these are broadly in line with those reported by doctors in training but some are striking in their difference.

So for example, just 13% of this group said they felt supported by colleagues in non-clinical management roles, versus 29% of those on the formal training pathway – and let’s just note that 29% is not a great number in the first place. That’s quite a gap and I think we need to ask ourselves what lies behind that difference.

This group includes those who have completed their Foundation training but stepped away from the training pathway while continuing to work. This break in training as we all know is now so common that people now colloquially coin it the ‘F3’ year. And whilst there are many reasons for it, the ubiquity of the Post Foundation Training Break makes it really all the more important for us to understand any frustrations amongst this group of doctors, especially given the plans in the Long Term Workforce Plan to increase numbers of doctors over the next decade.

And some of those frustrations should give us real cause for concern. Alarmingly for example, the data show that a quarter of these doctors have already taken hard steps to leave UK practice. And by hard steps we mean things like writing applications, talking to headhunters, so taking active steps, not just idly looking.

So I would argue that there is a need for a collective change of mindset to maximise our chances of retaining these doctors, and embrace the desire of many doctors for more flexible ways to build and use their skills. In turn that will mean more action to ensure that these doctors get access to quality assured training away from the formal training path.

And instead of seeing such changes as a threat to workforce stability, we need to reframe them as a positive. Our data show that options for greater flexibility can help reduce burnout and dissatisfaction, so this should ultimately keep doctors in UK practice for longer. Indeed, research we commissioned showed that many educators already see the step away from formal training positively, and we need to disseminate this positivity more widely.

Workforce thinking needs to keep pace with changes in the way in which people want to work across the span of their career. The ability to provide good patient care, now and for the foreseeable future, depends on the ability to respond quickly to changing demographics and approaches, and to think clearly about making the most of the resources available. So, embracing flexibility is absolutely key.

This mindset shift is inextricably linked with the need to appropriately value LE doctors, my second theme for action. And this applies both to those who graduated in the UK, and those who graduated elsewhere.

For IMGs, while some may make a positive choice to work in locally employed positions, for many that’s not the case. Too many face an uphill battle to have their skills and talents recognised in the UK, often when they have years, perhaps even decades, of experience behind them.

There’s no shortage of anecdotal testimony to doctors’ frustration about this. And I have no doubt that it has driven many talented doctors out of our health services altogether.

We have however had a recent win here. After a number of years calling for change, we finally succeeded in persuading government to change the legislation around pathways to the specialist or GP registers for doctors not in formal training. The wording of the legislation prior to the changes was very rigid and very prescriptive, meaning that applicants faced incredibly burdensome evidential requirements, a process which was very slow, and they also faced high failure rates.

That legislation changed in November, and I am really grateful to Royal Colleges for working with us to ensure that we have a new approach which is considerably less arduous. We can now assess a doctor’s knowledge, skills, and experience in a more flexible way, making the whole process more proportionate, and removing needless barriers to the progress of many doctors.

Of course, there’s much more to recognising value than acknowledgement of past experience. So an important part of our focus must be on supporting doctors to develop further, allowing them the opportunity to flourish and fulfil their potential.

And again data can help us focus our efforts. For example, amongst overseas graduates, it is those who have practised in the UK for five years or more who are more likely to say that they lack access to learning and development opportunities. And for UK graduates it is those with less time under their belts who feel this lack of opportunity more.

Whichever cohort you choose to look at, this should be ringing retention alarm bells, and I would urge all employers and policy makers to think really hard about what more they can do to demonstrate that locally employed doctors, in all their glorious diversity, are really and properly valued.

The importance of induction is my third area of focus today.

It matters for all locally employed doctors, and it can make a huge difference to how settled and valued doctors feel. But there is an additional induction challenge for international medical graduates who are joining UK practice for the first time. This is fundamentally a responsibility for employers, but I also recognise that the GMC has a really important role.

We have been running our Welcome to UK practice workshops for about a decade now. These serve an important function, helping newly registered doctors by offering practical guidance about ethical scenarios they may encounter, and the chance to connect with other internationally-qualified doctors.

While the fundamental values of medicine are the same across much of the world, the way in which they are expressed can vary according to the social and cultural landscape of each country, something which affects doctors moving from all parts of the world to pursue their career.

Highly technically skilled doctors can often find that they struggle to adapt to professional practice in the UK, and their hard work, dedication and best endeavours can be impacted by difficulties they experience acclimatising to UK practice. To be clear, this isn’t about a problem with those doctors, it’s about the system. It’s about how all of us make the changes we need to be more culturally competent, in order to enable those doctors to fulfil their potential. It’s a system responsibility to address these issues.

We commissioned independent research last year to evaluate our workshops and were pleased to find that participants rated it extremely highly. They told us it helped with their awareness and understanding of key ethical issues, and helped them understand how they can apply our guidance to deliver safe care. They also said it helped with their communication skills and that they came away with a clearer idea of their own learning needs. 

But we did also uncover some challenges.

Attendees told us how hard they found it to fit in to their diaries once they had started work. We’re aiming to tackle that as a priority as we want as many doctors as possible to attend. We’re now offering workshops on Sundays, and we’ve added in more Saturday and evening options as well. We’re also looking at ways we can work better with Trusts, health boards and Royal Colleges to make use of their venues and networks, and combine with other events where we can. We want to make it as easy as possible for doctors to attend those sessions.

A recent survey of supervisors found that the majority were unaware of the Welcome to UK practice workshops we offer. Clearly, we are some way off where we want to be. Ideally, we want supervisors and providers to be actively encouraging their international medical graduates to attend, and to facilitate their attendance. We need to work harder at our end to ensure that all parties know our workshops exist and how we can make sure it’s feasible for them to allow their doctors to take part.

But whilst I hope that the induction we offer is useful, high quality, comprehensive, local induction is also critical. Indeed, I think it’s hard to overstate the importance of the induction process for international medical graduates.

That issue was laid bare a few years ago when we commissioned independent research into why employer referrals to the GMC are higher for some groups of doctors, particularly those from a Black or Minority Ethnic background. The resulting Fair to Refer? report cited evidence of doctors receiving inadequate induction and inadequate support in transitioning to their new environment. It showed how this was connected to insider and outsider dynamics, and how important it is that when doctors do come to the UK to work, we don’t set them up to fail.

Now I recognise that giving time to induction can be challenging when services are under the sort of pressure they are, but it is those pressures that make this more important than ever.

At the GMC we’ve long called for more consistency and quality in approaches to induction for doctors new to UK practice. We collaborated with NHSE, Health Education England as it was then, the BMA and the Medical Protection Society, to co-produce Welcoming and Valuing IMGs, which is a set of induction standards that set out the comprehensive, supportive induction we would like to see every employer provide. We remain keen to work with all partners to help achieve high standards, and our outreach teams stand ready to support providers in that endeavour.

Important though induction is, it must be followed through with good, inclusive workplace culture. This is the fourth area where I think attention is needed.

Inclusion is a critical piece of the jigsaw, in particular, but not exclusively for international medical graduates.

It’s not however a totally bleak picture. In fact, against a number of measures, LE doctors with a non-UK primary medical qualification actually seem to be faring quite well.

However, specific data are telling. Regular stress-related leave for all is higher than UK graduates, and when asked how supported they feel by immediate colleagues there is a clear gap between the responses from the UK graduating and overseas graduating groups. And the Welcome to UK practice evaluation also revealed a general lack of support for overseas doctors when they’re in practice.

Now we’ve long known that there’s a clear link and connection between inclusive environments and the provision of good patient care. So we need to address this urgently.

The Fair to Refer? report confirmed that ‘in’ groups and ‘out’ groups exist in medicine, and that allocation to the ‘out’ group can occur as a result of where qualifications are gained, and ethnicity. Further, it identified that members of ‘in’ groups can receive favourable treatment and those in ‘out’ groups are at risk of bias and stereotyping.

The research showed that these problems can get compounded when organisational cultures respond to things going wrong by trying to identify who to blame rather than focusing on where the learning lies. This creates particular risks for doctors who are ‘outsiders’.

It also identified that doctors in diverse groups do not always receive effective, honest, or timely feedback because some managers avoid difficult conversations, particularly where the manager is from a different ethnic group to the doctor. And that means that concerns may not be addressed early and can therefore develop and result in a referral to us at the GMC.

This combination of factors creates an inherently unfair, and no doubt deeply uncomfortable workplace, and of course puts patient safety at risk as well. It also means that we are not getting the most from the entirety of the medical workforce – so it’s an issue of productivity as well as one of patient safety and fairness.

In 2021 we set fairer employer referral targets to try and tackle the root causes of the imbalance in doctors referred to the GMC. I’ve been really pleased to see a great deal of work take place since we set the targets, and I’m encouraged that we have seen consistent improvement across those measures over the last couple of years, and that we forecast that to continue.

Of course, we can only seek to influence, not control, that referral process, but it is a really important priority for us.

But while we focus on eliminating disproportionate referral, there is more to the inclusion task. We know that to create the best environment for the delivery of good patient care all doctors need to feel a sense of belonging at work.

Earlier this week the updated version of Good medical practice came into effect and that has a much-strengthened focus on good workplace cultures and inclusivity.

In Good medical practice we ask doctors to pay attention to how their behaviours may influence others in and around them at work, and show respect for and sensitivity towards others’ life experiences. This is as well as much strengthened, much more explicit guidance around discrimination, bullying and harassment.

We must ensure that doctors who come here to work do not feel like they have additional work that they must do to support their own inclusion. That is not a burden they should carry. Inclusion must be central to team and organisational culture, and those with leadership responsibilities wherever they sit in the system must step up to that plate.

The four areas where I am calling for changes – adaptation to flexibility, recognition of value, improved induction, and inclusive cultures – can, I believe, make a difference to locally employed doctors, as well as our wider healthcare workforce.

I believe progress in each of these areas is urgently needed if doctors working in a locally employed capacity, either temporarily or for the longer-term, are not to be unnecessarily hindered or held back.

And there’s work for us all to do.

Healthcare policy makers and workforce planners need to play their part in embracing increasing flexibility within the workforce to make sure that the opportunities created are maximised.

Employers need to ensure that locally employed doctors are not disparaged or disadvantaged because of their role, and that they feel the support not just of their immediate teams but also of non-clinical staff. It’s a basic responsibility of employers to get induction right, and to safeguard induction processes even in times of great pressure.

And employers need to do more to create inclusive, respectful environments where all doctors, regardless of their background, can flourish. The Long Term Workforce Plan calls for providers to undertake a regular ‘cultural review’, which I think is a really excellent proposition.  

I hope employers will remember that diversity is a huge gift to our health services. It presents opportunities that we really must not squander. I would urge everybody to ensure that they don’t walk away from a focus on equality, diversity and inclusion. We have a moral duty to prioritise this, and patients and the public need us to pay this serious regard and have difficult conversations where they are needed.

Individual doctors, and certainly those with leadership responsibilities, also have responsibilities when it comes to equality and inclusion. We mustn’t forget the power of the individual to advocate for change, and champion change, and to tackle non-inclusive behaviour when they see it. And I hope that our updated version of Good medical practice will empower more doctors to feel that they are able to be change-makers in that regard.

As the regulator, we have responsibilities too. We need to work hard to raise awareness and improve access to our induction training. And we must maintain our drive towards eliminating disproportionality in employer referrals. Collaborative efforts are required as we work to address the long-standing inequalities across the system. I’ve been impressed by the energy of partners here, and progress so far has shown that we can change things for the better.

But it’s also obvious that system pressures are affecting organisations’ ability to make some of the changes we are calling for. Our outreach team is always on standby to work with you and lend support.

And of course, we will continue to build and use our data on the locally employed workforce to best effect, to inform and influence policy makers and planners and to help you develop your practice from an informed position.

To conclude, locally employed doctors are now - and will continue to be - an incredibly important part of our workforce. I’m pleased that we now have better insight into their experiences. And we need to build on that and act on that with purpose to celebrate and value this crucial and rapidly growing part of the medical workforce.

Thank you