Being fair: challenges and opportunities
Conference report
Contents
Introduction / 3Conference summary / 5
Session 1: Defining the issues
- Fairness and the professional regulator
- Ethnicity and BME doctors / 8
11
Session 2:
- The interplay between fairness and public confidence
- Workshops
- Dealing with concerns and complaints
- Progression in medical education and training
- Raising standards through revalidation / 12
15
20
25
The way forward: next steps / 29
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Published December 2012.
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Introduction
The challenge of being fair in the context of professional regulation came under the spotlight at a conference organised by the General Medical Council (GMC) on 12 September 2012 at the British Museum.
‘Being fair: challenges and opportunities’ brought together senior players from across the UK healthcare sector to explore a concept that is fundamental to being a modern professional regulator.
Dame Julie Mellor, Parliamentary and Health Service Ombudsman, chaired the discussion. Participants explored the challenges for the GMC and other bodies in being fair in delivering their core functions. They also looked at some of the related issues for doctors, patients and the wider public. These developments include progression for different groups of doctors, the impact of revalidation, maintaining the medical register and dealing with concerns and complaints.
Participants included representatives from government departments and agencies, medical directors and responsible officers, the medical Royal colleges, medical schools and deaneries, other regulators, doctors and patient organisations.
Like many of its counterparts in the regulatory sphere, the GMC has an extensive programme of work underway to ensure that it is being fair in its work. This includes producing guidance for medical schools on making reasonable adjustments for people with disabilities, auditing each stage and publishing statistics on its fitness to practise procedures, and working with other organisations to ensure that all doctors have a route to revalidation.
The GMC is committed to taking forward some of the key findings and recommendations from the Being Fair conference into its work. This report provides an overview of the main themes of the discussion, and the contributions made by the people attending to shaping an important agenda for the regulatory landscape.
About the GMC
The General Medical Council is the independent regulator of the UK's 250,000 doctors.
Our job is to protect, promote and maintain the health and safety of the public by ensuring proper standards in the practice of medicine.
We do this by managing entry to the medical register and setting the educational standards for all UK doctors through medical schools and postgraduate education and training. We also determine the principles and values that underpin good medical practice and we take firm but fair action where those standards have not been met. This role and the powers to do it are given to us by Parliament through the 1983 Medical Act.
We are not here to protect the medical profession - their interests are protected by others. Our job is to protect patients. We are independent of government and the profession and accountable to Parliament.
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Conference summary
The challenge of being fair
Like many other organisations the GMC is wrestling with a number of fairness dilemmas that cut across all of its activities. For example, setting standards involves making daily judgements about someone’s competences and skills, their honesty and trustworthiness, and ultimately, whether or not they pose any risk to patient safety. The professional regulator’s assessments can fundamentally affect someone’s livelihood, whether they feel listened to or understood, or whether they have faith in the system that is there to protect them.
The day unfolded as a discussion in two parts: firstly defining some of the issues where fairness plays a role in how people perceive the GMC. Secondly, exploring potential solutions and the way forward. Speakers talked about how the challenge of being fair manifests itself in their own work:
Dame Julie Mellor, Parliamentary and Health Service Ombudsman, chaired the event and talked about the challenges for her own organisation in being fair and transparent when dealing with complaints from the public.
Professor Sir Peter Rubin, GMC Chair, gave an overview of the work of the GMC and its statutory functions. He shared insights into the work to specify practical procedures for undergraduate medical education and training as an example of the challenges on fairness that arise in the GMC’s work.
Paul Philip, GMC Deputy Chief Executive and senior sponsor for its work on equality and diversity, used the opportunity to acknowledge some of the constraints the organisation faces in trying to be fair. The law requires different groups of doctors to be treated differently when they apply to go on to the register. Some groups of doctors are overrepresented in fitness to practise procedures. The GMC must always choose protecting the safety of patients over anything else, even when it creates a conflict with balancing the rights of patients and doctors.
Professor Rajan Madhok, spoke wearing two hats: GMC Council member and Chair of the British Association of Physicians of Indian Origin (BAPIO). He focused on the specific fairness issues across the healthcare system for black and minority ethnic (BME) doctors.
Elisabeth Davies, Chair of the Legal Services Consumer Panel, talked about the growing public expectations of being treated fairly, and the consequences for the work of regulators and other public-facing organisations. Her remarks were echoed by Dean Royles, Director of NHS Employers, who spoke about the need for better data and intelligence about doctors and service users, and for greater engagement with NHS staff, public and patients to foster greater openness and transparency.
Delegates participated in one of 3 workshops:
· Dealing with concerns and complaints: Exploring what the GMC and others can do to reduce the risk for particular groups of doctors who are more likely to be involved in its fitness to practise procedures. The value of taking early preventative action to reduce the growing number of referrals to the GMC.
· Raising standards through revalidation: The GMC knows from its engagement with interest groups across the UK that there are concerns that some doctors will be disadvantaged by the process and requirements of revalidation. The revalidation workshop looked at the particular needs of doctors taking breaks from practice, trainees, specialty doctors, and the role of employers and employees in appraisals.
· Progression in medical education and training: In June 2011, a GMC seminar on student selection showed that processes for student selection vary between medical schools. What’s not clear is why. The workshop also looked at what more can be done to promote fairness in exams and assessments while maintaining high standards of education. 92% of participants in the workshop said that that the GMC should produce standards for examiner training and assessments.
Niall Dickson, GMC Chief Executive, summarized the next steps for the GMC and others:
· More analysis and sharing of data to understand what’s happening, and to prevent problems occurring in the first place.
· Doing more work to understand the rising tide of complaints and the patient perspective: who complains, why they complain (and why they don’t).
· Joint working to provide more help for those who want to raise concerns to navigate the system.
· A programme of work with the Medical Skills Council looking at career progression and fair selection into medical schools.
Session 1: Defining the issues
‘What we do is impartial’
Dame Julie Mellor, Parliamentary and Health Service Ombudsman, opened the discussion by sharing some observations about her organisation’s approach to being fair. She summarized its mission as three-fold: to resolve complaints, to use the evidence to drive service improvements, and to act as the ‘guardian’ of the integrity of the complaints system.
The Ombudsman resolves 6,000 of the 25,000 contacts it receives each year. Of these 400 involve formal statutory investigations. The organisation takes a number of steps to ensure that it deals with complaints in a fair and transparent way, including ensuring that its services are accessible through use of Typetalk, communicating in different languages, writing down complaints on someone’s behalf, through to ensuring that an appropriate representative is on hand to support a complainant where there may be capacity issues.
As part of a strategic review the Ombudsman is looking at translating its broad ambition to be fair into clear measures of what success would look like. These indicators will be used to drive and focus action.
Fairness and the professional regulator
‘It’s a difficult balancing act’
Paul Philip, Deputy Chief Executive, GMC, talked about the role played by subjectivity in shaping perceptions of fairness. “We’re challenged every day of the week and rightly so,’ he said, ‘what people think matters.’
The senior sponsor for the GMC’s work on equality and diversity noted that whilst the regulator lived up to its legal obligations and could defend its actions in a court of law, it was losing the battle for hearts and minds. He shared some examples of the fairness issues that arise for the GMC in delivering its statutory purpose:
· Revalidation
The difficulty of having a meaningful dialogue with doctors around revalidation against a backdrop of mistrust. Concerns that revalidation will be overly burdensome, and that some cohorts of doctors (for example locum doctors, specialty doctors and doctors who work overseas) will be somehow disadvantaged by the introduction of revalidation.
· Medical education and training
Setting the standards for entry to the profession which may exclude people with disabilities. Social mobility and access to the profession for people from certain backgrounds. The differences in outcomes and attainment rates for some groups of trainees and doctors (men compared with women, BME compared with their counterparts) in examinations.
· Registration
Over 10,000 doctors come on to the register every year. The law does not allow the GMC to treat all doctors the same. For example, international medical graduates (IMGs) are tested for their clinical and language skills. Given the importance of communication to treating patients safely, the GMC is lobbying hard to get the law changed to allow the regulator to assess the language proficiency of all doctors, including those qualifying in the European Economic Area (EEA).
· Fitness to Practise
Paul described this as the most contentious and high profile area of work for the GMC to date. There is a corresponding range of concerns about different aspects of fitness to practise procedures including the following:
· Doctors vs patients: who receives harsher or more lenient treatment?
· How quickly the GMC acts, and the challenge of doing things more quickly whilst being fair to doctors, patients and witnesses.
· The speed with which bad or incompetent doctors are identified. Paul said that the GMC receives roughly 10,000 complaints every year and refers about 250 of these to a hearing. 80% of doctors referred to a panel get a finding of impairment.
· The impact of invasive processes on sick doctors, and the need for sensitivity in dealing with doctors who are vulnerable.
· The profile of doctors involved in the GMC’s fitness to practise procedures: male doctors, psychiatrists, surgeons and GPs, doctors practising in their 40s and 50s, overseas qualified doctors at all stages.
· The overrepresentation of some groups of doctors in referrals from the police and the NHS. Paul noted that UK qualified BME doctors are not overrepresented, whilst overseas qualified doctors are overrepresented at every stage, regardless of their ethnicity.
Referring to the GMC’s workforce of 800 staff and 1000 associates, Paul said that ‘We need to be vigilant in our working life to ensure that unconscious bias doesn’t creep in. Each of us has our own value sets; we carry them around with us every day.’ Safeguards include regular audits of decisions, objectivity, maximising transparency, and ensuring that the appropriate checks and balances are in place.
Ethnicity and BME doctors
Professor Rajan Madhok spoke from the dual perspective of being a member of the GMC’s Council, and Chair of the British Association of Physicians of Indian Origin (BAPIO). He called for action to turn good intentions into real outcomes:
‘Of course the GMC is not the total solution – it is part of the whole system. But as a regulator it is an important, or indeed the most important player- it needs to lead by example and hold others accountable. There is a lot that can be done within the GMC and its process to help BME doctors, and as the flag bearer for standards in medicine it has the leadership role and needs to work with and influence the rest of the system.’
Rajan said that the various networks of BME doctors accept that there is a shared responsibility for driving positive changes, given that no one wants to see poorly performing doctors compromising patient safety in the NHS. He acknowledged the work being done by the GMC to tackle the challenges faced by BME doctors who are affected by its activities. The BAPIO Chair said that concerns about the fairness of the GMC’s approach cannot be solved in isolation, because there are wider systems issues involved.
Session 2: Defining the solutions