‘What is the role of the regulator in wellbeing?’
Carrie MacEwen's speech for Royal College of Physicians and Surgeons of Glasgow conference, October 2021
Thank you for inviting me to speak here this morning. It’s great to be in my hometown and to have the chance to see you face-to-face after months of Microsoft Teams.
I’d like to start by paying tribute to Dame Clare Marx, who was due to speak here today. Clare has very sadly been diagnosed with pancreatic cancer and stepped down from her role as Chair of the GMC.
It gives me no pleasure to take up the role of acting Chair in these circumstances. But I am glad to be here to talk about something that both Clare and I feel is profoundly important – the role of each and every doctor’s wellbeing in determining the welfare of the profession and how this contributes to the delivery first patient class-care.
I know this is also something the RCPSG cares about deeply. Together with ourselves and the BMA, the college is a key member of the Medical Wellbeing Stakeholder group. Through this forum, we’ve worked together on demystifying revalidation and appraisals, including their role in supporting wellbeing. So great work is already being done, with much more to come.
For those of you who I do not already know, a few words about myself. I’m the immediate past Chair of the Academy of Medical Royal Colleges and a practising ophthalmologist in Dundee.
My daughter is also a junior doctor and many of my friends are medics, particularly in primary care – all of whom have become particularly vociferous since I took up my new post. So I know, both from what I see myself and what I hear, that this conversation about wellbeing is needed now more than ever.
So, what is the role of the regulator in wellbeing? The two are not always considered natural bedfellows! However, we believe that they are intrinsically intertwined, and a better understanding of this relationship is vital.
Burnout, bullying and bad culture
The past 18 months have showcased the extraordinary dedication and professionalism of healthcare workers in the UK.
But now uncertainty, care backlogs and continuous high demand are creating a perfect storm for an already exhausted workforce.
These pressures are generating enormous difficulties for patients, and all those involved in their care.
For patients, waiting for operations, or even initial examinations, the uncertainty can be crippling. For us doctors, who pride ourselves on our ability to make things better, it’s deeply distressing.
Not being able to give patients what they need has a cumulative effect, one that undermines patient trust and wears doctors down.
In our this year, a third of trainees said they felt burnt out to a high or very degree because of their work. That’s compared to around a quarter in previous years. 44% felt their work was ‘emotionally exhausting’.
Training time for our next generation of doctors has also been disrupted by the pandemic. This impacts not only on the morale of junior doctors, but also on the pipeline of future talent.
We know that doctors experiencing severe workload pressures are more likely to consider stepping back from practice. Our Barometer survey last year showed that amongst doctors in Scotland intending to make a career change, almost a third were considering reducing their hours.
However, this is not new – shows that doctors who left UK practice between 2004 and 2019 gave dissatisfaction and burnout as two of the main reasons for doing so. And this was before the start of the pandemic in early 2020.
As this research makes plain, wellbeing issues are driving doctors out of the service.
Worse still, bullying was included as a reason by nearly 6% of respondents.
Sadly we know that doctors can be on the receiving end of poor treatment – both from colleagues and patients. Courtesy is a pre-requisite for a pleasant working environment whatever your profession. But in the charged atmosphere of a consulting room or operating theatre, it is essential.
When we drill down into the different protected characteristics of respondents, the picture is more worrying still.
Disabled doctors more often reported bullying as a factor in why they left medicine. Some religious groups reported higher levels of bullying and harassment. And LGBTQ+ doctors more commonly reported mental health issues. Meanwhile, female doctors reported greater burnout.
This matters. Not just because bullying, burnout and bad culture are a moral stain on our health services. But because they have a material impact on the number of doctors available to staff them and look after our patients.
There’s no doubt that Covid-19 struck a hammer blow to doctors’ wellbeing. But while these issues have been exacerbated by the pandemic, they were not created by it.
The role of the GMC as regulator
It’s clear that this situation isn’t sustainable. Solutions are needed now, and they are needed at all levels of the system.
We all have our individual roles to play, including the GMC, and we’re committed to playing ours.
We know burnout and stress are damaging to our physical and mental health. And for doctors, that means they can compromise the care they provide.
Simply put, poor working environments lead to poor outcomes for patients. That’s the main reason this work is a strategic imperative for us.
To quote Professor Michael West and Dame Denise Coia: “Patient safety depends on doctors’ wellbeing”.
As they note, doctors with high levels of burnout have between 45% and 63% higher odds of making a major medical error, compared with those with low levels.
Not only do burnout and stress undermine patient safety. As I outlined earlier, they also undermine retention of doctors working within the profession.
There’s a vicious cycle at play here. Staff shortages exacerbate existing pressures, leading to more stress and doctors voting with their feet.
That’s why we see supporting doctors to deliver first-class care as central to our role.
This represents something of a shift for us.
It’s not lost on me that the GMC is viewed with scepticism – and even fear – in some quarters.
But over the past few years, we’ve been on a journey. We want to shift from stepping in when things go wrong, to fostering supportive environments that stop harm from happening in the first place.
We’re doing this in a few different ways.
Research and data
The first is through research and the collection of data.
What gets measured gets done. Issues like culture can seem nebulous until you quantify them. Through things like the National training survey, which nearly all trainees in the country complete, we’re able to put meat on the bones. Granular data like this give us sight of what’s happening on the ground, right down to provider level.
It also allows us to pick out trends, so we can stop problems before they occur.
Induction is a good example. Our data shows us that too many international medical graduates (IMGs) end up in our fitness to practise processes early in their careers. Not because they’re bad doctors, but because they haven’t had the right support. So we developed free induction training to give them the skills and knowledge they need to navigate UK practice.
We’re organising these Welcome to UK Practice workshops in partnership with NHS Education for Scotland (NES) in two regions. It’s been heartening to see local Directors of Medical Education (DMEs) support these as part of induction for IMGs, and we plan to approach DMEs in the other regions to do likewise.
As well as hard data, we sit on a lot of on-the-ground insight thanks to our Outreach teams and National Offices here in Scotland, as well as in Wales and Northern Ireland.
All of this gives us a detailed picture of doctors’ working lives, meaning interventions can be targeted and action can be anticipatory.
At the same time, we’ve been looking critically at our own processes.
Back in 2015, we began work with Professor Louis Appleby to review our fitness to practise process. We know that this is an area of huge concern to doctors, so the aim was to make it less stressful for those going through it.
This included softening the tone of our communications, training our staff to recognise when a doctor may be vulnerable and introducing provisional enquiries. We are also working more closely with Responsible Officers so local clinical governance systems are geared towards properly supporting doctors throughout their careers.
As a regulator, we don’t expect to be popular with registrants. But we do want to be recognised as fair and respected for keeping patients safe through appropriate processes for our registrants. So we hope these changes will help us show a more ‘human’ face.
Equality, diversity and inclusion
The second plank of this work is our ED&I programme.
A sense of belonging is fundamental to a doctor’s wellbeing. But, shamefully, too many doctors do not feel included in their workplaces. That disadvantage and discrimination has only become more keenly felt over the last 18 months or so. And the pace of improvement has not matched the urgency of the challenge.
This plays out in doctors’ education, training and beyond into their wider careers.
Disadvantage identified in medical school is demonstrated by persistent gaps in exam performance. BME doctors report receiving less support and feedback during training and experience more barriers. No wonder, then, that FY1 BME doctors are less likely to report feeling prepared for their first post than their white colleagues.
Postgraduate exam success and progression through the ARCP process similarly demonstrate differentials between white and minority ethnic groups.
Meanwhile, research by Dr Doyin Atewologun and Roger Kline in our Fair to refer report found that BME doctors are referred to us by employers at twice the rate of white doctors.
What explains this?
The Fair to refer report points to an absence of ‘coffee cup’ conversations and the presence of insider/outsider dynamics. In other words, BME doctors aren’t receiving the timely feedback that prevents problems from crystalising. And they aren’t getting the support that helps them develop their skills and thrive.
These are issues that affect the whole system, and they need a whole system response. But we at the GMC consider that we have a specific role to play as we interact as part of that wider system.
That’s why we’ve set targets around eliminating two persistent areas of disproportionality – fitness to practise referrals by employers and differential attainment in undergraduate and postgraduate education and training. We are also looking at our own internal processes to ensure no areas of discrimination.
The targets we have set are stretching. And we don’t control all the levers to deliver them. That puts us in a position we haven’t been in before. But it’s painfully obvious that we all need to be pushed outside of our comfort zone to meet the scale of the challenge.
All too often, issues around wellbeing come back to one simple fact – not having enough staff to meet demand, leading to the downward spiral I referred to earlier.
Recruitment is, of course, a big part of that. You may be aware of the government’s consultation on regulatory reform, which offers cause for optimism. For one, it will bring Medical Associate Professions (MAPs) into regulation under the GMC, allowing everyone to get the most out of these important roles. But it will also cut down on red tape and improve flexibility, for example around the process that allows doctors from outside the EU to work as a consultant or GP here.
But more than recruiting doctors we need to retain them. Bringing more doctors in will leave us standing still if we can’t keep hold of the ones we already have. That’s why we’ve put leadership, culture and support at the heart of our corporate strategy.
We know fantastic work is already being done on this front.
Here in Scotland, the Workforce Specialist Service has been offering mental health support for health and care staff since January this year, with doctors the largest group. Understanding the specific experiences of practitioners with mental illness has been key to its success so far.
All of this points to a sea change in how these issues are viewed. Across our health services, there’s now a shared understanding that wellbeing has a material impact on outcomes.
And while the working situation for doctors today is undoubtedly intense, support is more available than it’s ever been. That is to be welcomed.
Conclusion – the GMC takes the wellbeing of doctors very seriously.
We’ve come a long way from the buttoned up medical world I entered in the 1980s. And we have different challenges that require different solutions.
But we know cultural change in the service can be slow to emerge. That’s why it requires an active effort – on the part of system leaders, regulators and, yes, us clinicians, to turn intention into action.
While wellbeing issues have been made more urgent by Covid-19, they far predate its arrival.
What the pandemic has done is give us the platform to push for progress, providing us with a unique chance to make real, lasting change.
Working together with employers, education bodies, governments and others, we, as the regulator, have an important role – to improve the wellbeing of doctors and our profession.
As we look to the huge challenges and uncertainties ahead, we must not let the opportunity pass us by.