Speaker1: [00:00:00] None of those things will happen. It's not just about pay. This is fundamental. You know, that ship has sailed. That's been determined by Parliament. It is now law. There's been a lot of social media noise. 1 in 5 doctors reducing their hours just to be able to cope. We see more doctors on our register from ethnic minority background than white doctors. 

Speaker2: [00:00:22] Voices of Care, the healthcare podcast.

Speaker3: [00:00:25] Charlie, welcome back to Voices of Care. It's really good to see you again. 

Speaker1: [00:00:28] Thanks, Suhail. It's great to be here.

Speaker3: [00:00:30] Now, it's been a year, just over a year I think, since we last met. And it's been extraordinary. What a change, a new government. I want to start, if I may, with the Darzi report. Not the details necessarily, but very good recognition of the clinical excellence in the UK workforce from Lord Darzi.

Speaker1: [00:00:47] Yes. And I think that's very welcome. I mean, Ara is a surgeon himself. But also I think has been very honest about some of the challenges that face the NHS and yes, we did see him applaud the clinical excellence, but we also have seen from the new government a strong narrative about the degree of challenge in the NHS. The NHS is broken narrative. And certainly we can see in our own data at the GMC and we may come on to talk about this. The degree of challenge that exists. And so I think what he says is very resonant to the data that we see. And I think also, I know it's been controversial at times. This kind of NHS is broken narrative, but I think what it does do is it demonstrates that sticking plasters aren't enough, that we actually have to have a bigger conversation about reform as well as funding for the NHS. And so I very much welcome the direction that the new government is taking.

Speaker3: [00:01:50] And of course, we've got the ten-year plan. All of these changes are afoot now in your own sphere of interest. The long-term workforce plan that we talked about last time has within its plan, a big increase in the number of doctors, but also physician associates. Now, I wanted to tackle that head-on. There seems to be quite a very important time of year in December 2024. You're becoming a multi-professional regulator. But there's been quite a lot of heat, if I can put it mildly, around the consultation scope of practice and just generally around the new roles of physician associate and anaesthesia associates. What say you around that? 

Speaker1: [00:02:30] Okay. So well, the first thing to say is these aren't new roles. Physician associates have been around in the NHS for 20 years. And if you step back from a lot of the noise that we see, essentially the GMC has been asked to bring into regulation professions that have formerly not been regulated. And I think that can only be a good thing and a positive thing in relation to improving patient safety. But as you say, there has been a lot of concern, a lot of controversy about it. I think part of that has been driven by some of the challenges we've seen within the medical workforce. So we know that doctors have felt incredibly pressurised. We see workloads going up. We see in our most recent data, we saw, you know, 1 in 5 doctors reducing their hours just to be able to cope. And we have particularly seen early career doctors not feeling as valued as they might. We see that both in terms of industrial action around pay and terms and conditions, which we don't get involved in, but we also see that in terms of the way in which people feel used within the wider healthcare team. And of course, at the same time we've had, just in 2023, a long-term workforce plan, which I expect, to a very significant extent, the new government will back which has committed to increase the number of physician associates in the workforce. And that's given rise to some concerns from some that there is a plan to replace doctors with physicians.

Speaker3: [00:04:06] A lot of fear around that. 

Speaker1: [00:04:08] It has.

Speaker3: [00:04:09] Some of the social media noise has been there.

Speaker1: [00:04:11] There's been a lot of social media noise. And I don't think that's always been healthy. And I don't think some of the behaviours have always been what they perhaps could have been on social media. But I would just put some of those numbers into context because what the workforce plan envisaged was increasing the number of physician associates and anaesthesia associates by 8000 by 2036.

Speaker3: [00:04:34] 12, 13 years.

Speaker1: [00:04:35] So over the next 12 years, another 8000. We have 380,000 doctors on our register. And over my time as chief executive of the GMC. So over the last eight years, we've seen the number of doctors on our register go up by on average about 10,000 a year. So the degree to which there is a credible enumerated argument to say that there is a plan to replace doctors with physician associates just is not backed up by those numbers. But as I say that, I do know that there are very genuine and very strongly held views and anxieties about physician associates. And what we've also seen is that with the level of service pressure out there employers haven't always been as good as they could be in deploying these individuals into appropriate roles. And that will fuel some of those anxieties that we just discussed. So I think, you know, the advent of regulation, which is only weeks away now will, I hope, just begin to settle things down a little bit. We are very clear that physician associates are a supervised profession, and we're going to be very clear to employers about our expectations of them. And we are also obviously going to set the floor in terms of the standards that those individuals need to meet to come onto our register. So there is a lot of concern. But, but I think it will settle down. And I do believe that some of the concerns people have got can be relatively easily addressed. They're not all for the GMC to address, I should add. But we will play our role in doing what we can both to bring those new rules into regulation safely, but also to reassure doctors that we do care very deeply about doctors being properly valued within the workplace and indeed that those doctors are in training. Resident doctors, as we now call them all, to have that training protected and safeguarded. That's a very important part of our response.

Speaker3: [00:06:36] Yeah. And you've set it into context. I mean, physician associates. I mean, I think the long history going back to the States were the first graduates in that role back in the 1960s from Duke University. And this regulation that the consultation, which has been subject to this heat that we've talked about. There's been many years in which this has been trailed, I think, for everyone to get used to this idea. 

Speaker1: [00:06:56] Yes. So they've been around for 20 years. The government first consulted on the idea of bringing these roles into regulation, and asking the question about who should regulate them back in 2017. There've then been further government consultations on the detail of that which led to the legislation that now requires us by legal duty. Yeah. So although I know some people would prefer it not to be the GMC regulating these roles, you know, that ship has sailed. That's been determined by Parliament. It is now law. We will be regulating them, from the 13th of December.

Speaker3: [00:07:31] Then there'll be a requirement for associates and anaesthesia associates to register over the next couple of years. I think that's the process.

Speaker1: [00:07:38] So the law sets a two-year transition period, in effect, my guess is that the vast majority will want to come onto our register as soon as they possibly can, because that is part of the requirement that employers will have that they know that these are healthcare professionals who are on a professional register. And that, of course, speaks to the benefits and the values of regulation. Because what regulation means is that it provides, if you like, a stamp in the box that says, these are people who meet the requirements that we set in terms of being able to practice with that title, but it also means that there's accountability if things go wrong, that we can actually look at that through our fitness to practice processes. And that's actually in the interests of patients, employers, and the healthcare professionals that we regulate.

Speaker3: [00:08:28] And ultimately, going back to the medical act, your legislation, it's the idea of promoting, I guess, public trust in these in these roles. I keep calling them new roles, but these roles that are newly to be regulated, if I can put it that way.

Speaker1: [00:08:40] Yes, indeed. And I think generally the public do trust regulators in terms of how they safeguard their interests. I mean, our job as a regulator is fundamentally about promoting the health of the nation through the way in which we regulate at the moment doctors and soon to be physician associates and anaesthesia associates. So that is absolutely our job and we take it incredibly seriously. And that's why we ran a very detailed consultation process earlier in the year. We'll will publish our conclusions and the analysis of all of the responses from that just before we start regulation. And, I think what people will see when we publish that is that we have listened, we have listened and we've reflected and we've made changes to how we're regulating those roles. When that takes effect.

Speaker3: [00:09:32] I'd just like to go on a tangent slightly. You talked about the role of regulation and the GMC. Very, very important. It's been a bit of a tough year for regulators. 2024, CQC, Penny Dash's report, NMC. Just wanted to touch upon your comments around how important regulation is and in light of some of these less than positive reports.

Speaker1: [00:09:57] Yes, I think the Penny Dash report at the CQC makes sobering reading. And I do think that Julian Hartley's appointment as chief executive is an excellent appointment. And I think we'll rebuild some of the trust and confidence that the CQC has lost with providers. And I know Julian pretty well, and my belief is that he will share the view that I have, that regulation should be a positive driver of improvement in healthcare. there are many narratives of regulation that are about burdens. But actually, I believe regulation could and should be a force for improvement. You mentioned the NMC as well. And obviously, they're in a very challenged situation at the moment. And, you know, they're a sister regulator of ours if you like. And we've reached out directly. So two of my most senior colleagues are currently on secondment to the NMC to try and help them address their challenges, both in relation to culture and to fitness, to practice. And of course, it won't surprise you that at the GMC we've reflected on those challenges amongst those other regulators. 

Speaker1: [00:11:08] I think the first thing to say is we're not in the least bit complacent about our own room for learning, growth, and improvement in everything we do. But equally, I think, I think we're not in the same position as those regulators. The Professional Standards Authority is if you like, our regulator and that kind of essentially assesses all of our performance against the standards of good regulation. We've always met all of those standards. And we look very carefully as an organisation at things like our people survey and are very clear about the need for us to be very attentive to our leadership. And if you like to practice what we preach, we talk a lot about leadership and culture in healthcare. And, you know, we don't really have the right to talk about that unless we are equally humble in thinking about our own leadership and culture at the GMC. And I'd like to think we do that reasonably well.

Speaker3: [00:12:05] And just very briefly, also been an important year. Lots of work you've been doing across. I just wanted to touch upon the publication at the beginning of the year, the Good medical practice, because I think you're on record as saying that's your most important document, one of the most important documents you produce. I just want to touch upon that, because I think that's been quite a seminal document, because it covers a lot of things which we can't go into all the detail. But I think it's the first update you've done for a decade. 

Speaker1: [00:12:29] Yes. And it's the most extensive consultation process we've ever run. And we had thousands of responses. We ran workshops, we ran fora with different patient-facing groups. And so it was a massive endeavour. But it's a really important piece because when people think about professional regulation, they often think about the nasty things we do, you know, striking doctors off and suspending them. And actually, what good medical practice does is it does the reverse of that. It sets out what we believe are the standards of good practice that we set in terms of expectations for doctors. And it's from that, that we determine our standards that we set in relation to medical schools in terms of undergraduate education and essentially the outcomes that graduates need to be able to demonstrate they reach in order to come onto our register. It also underpins everything we're doing in postgraduate training. And the latest version of good medical practice does contain within it a greater emphasis on some of the generic skills that we expect from doctors. So things around leadership, good communication, working with patients with many more, multiple comorbidities, a lot of echoes, actually in advance of some of the conversations that we're hearing from the government in terms of moving from cure to prevention, from hospital to community, a lot of those are actually embedded in good medical practice, but also some really clear commentary in there about what is unacceptable. So we've pushed a lot harder in terms of the standards we expect in terms of sexual misconduct. And we've created a new bystander duty so that if people observe sexual misconduct, bullying, discrimination, harassment, they have an obligation to report that. And I think I think that's really important in terms of us setting the standard that we expect from doctors in terms of both their own behaviours, but also their colleagues behaviours as well.

Speaker3: [00:14:21] No, absolutely. I'll pick up on that theme of unacceptable behaviour, because one of the key things we've talked about, the long-term workforce plan, expansion of medical roles and physician associates, etc. but of course, retention is going to be critical over the next few years and always has been. And I wanted to ask you the question. I mean, how concerned are you in light of your recent report about inequality being embedded in medical careers?

Speaker1: [00:14:51] So we have real concerns around that. When we spoke last time, I talked about some of the ambitions we set for ourselves in terms of equality and in a way they were rather un GMC-like in that we set ambitions that we can't control. We set an ambition of eradicating the overrepresentation of ethnic minority doctors in our referrals from employers. We set an ambition to eradicate the difference in terms of progression in undergraduate education and postgraduate training. And what we do now is we publish a report annually that holds the mirror up to the system and to ourselves, because we also set ourselves some important targets in relation to equality and diversity. And the latest data is encouraging. It shows that over the three years that we've been publishing these data, that we have seen a significant reduction in the overrepresentation of ethnic minority doctors and referrals.

Speaker3: [00:15:48] Fitness to practice.

Speaker1: [00:15:51] Fitness to practice referrals. Yes, a narrowing of the gap in terms of attainment. And it shows that if you kind of extrapolate that data going forward, we could still meet that ambition to eradicate that disproportionality by 2026 in fitness to practice. 

Speaker3: [00:16:04] And 2031.

Speaker1: [00:16:07] Very well done. 2031 for education. But what we also say is we must not be complacent. There is still a huge journey to travel and the honest truth is that inequality exists in medicine. It is persistent, it is pernicious, and it affects every stage of a doctor's career. So whilst I'm pleased to see some of that progress, I think we should still be very sobered by some of the data we see about the inequality that still exists. So my glass on this one is probably more half empty, and I do see a real need for both us and the wider system to really grip that in a much more fundamental way than I think has yet happened.

Speaker3: [00:16:54] Well, I think the phrase you used when your report came out was that it was a clarion call for, if my memory serves, cultural upheaval. And can we just expand upon, what does that mean in reality? Because you actually made a very broad and if I may say, very powerful, call for all stakeholders to be held to account, because if you harness diversity, it can be transformative.

Speaker1: [00:17:18] Yes. So what we mean by that is really very visible and meaningful efforts at a ground level to address some of the things we talked about. So what does that mean in practice? It means programmes for international medical graduates. Well that's a huge one because we've seen such an increase in terms of overseas-trained doctors in the UK. But it's but it's not just about doctors. This is about all healthcare professionals and indeed patients as a whole. So we think more boards should be making sure that they have the data that enable them to have meaningful conversations about equality and diversity, that they are developing anti-racism resources. Educators need to be better trained in relation to equality and diversity. We need more support for learners. We've seen some really encouraging pilots that so, for example, with the Royal College of Psychiatrists in the North East, we did some pilots which demonstrated that actually some support for learners can have some very significant impacts in terms of narrowing that gap in assessment. So we need to be better then at applying the learning from those pilots as well. 

Speaker1: [00:18:28] And I know this is difficult because employers will sometimes say to me, that's all very well, Charlie, but, you know, we have enormous service pressures. And what you're asking is for us to carve out time that doesn't exist to do these other things. My argument back, actually, is this is fundamental to your bottom line.

Speaker3: [00:18:48] It's not a nice to have.

Speaker1: [00:18:49] This is not a nice to have. You know, actually, at the heart of effective and efficient health services is equality. If you do this well and there are some places that do do this well, you will have a better motivated, more highly valued workforce, a workforce that is more likely to stay and a workforce that will feel able to, better enable to provide good patient care. You're going to see better patient outcomes. So what we've described in some of our publications is how do we move from a vicious cycle to a virtuous cycle. And whilst we've talked about that in relation to kind of workloads and working environments, I think it applies equally well to the whole question about addressing inequalities that we see in the medical workforce.

Speaker3: [00:19:32] No, absolutely. And holding the mirror up to yourself, to use your phrase earlier, some of the steps that you've taken, I think, in terms of the regulatory training for internal staff and representation of ethnic minorities within your own organisation.

Speaker1: [00:19:45] Yes, so we do hold that mirror up to ourselves. We set ourselves targets to improve the ethnic minority numbers within our staff at large. And we're on track for that. We are not on track in terms of that representation of ethnicity at a more senior level. And that's something that we are striving to address, particularly as we have just recently seen a little bit more turnover. That gives us more opportunities to address that. We've also put a lot of work into how we ensure that we're being as fair as we can be in all of our decision points. So we've mapped out all of our high-impact regulatory decisions, and we've embedded approaches like one that we describe as professional curiosity. That essentially gives us a pause button or a rewind button as cases make their way through our fitness-to-practice processes. And we've also embarked on a huge programme of training across the organisation. In fairness, so we're doing a lot. We're not there yet, but I'm really pleased with the degree to which my colleagues within the GMC are as committed as I am to making progress against all of that. 

Speaker3: [00:21:01] Great, thank you for that update and sticking with this retention issue, we're going to come on to the State of Medical Education report, which has just been published. But going back to the state of education, the State of Medical Education report work experiences, which you published in the summer. How concerned are you about there being an exodus of doctors from the UK? Not just people reducing hours, but I think the research showed there's a significant number, material number considering leaving the UK altogether.

Speaker1: [00:21:31] Yes. So, we published that that workplace experience report in the summer. We also published some other research just before that actually about doctors who are considering leaving the UK and I think it does send a warning signal to us. So, as I mentioned earlier, 1 in 5 doctors saying that they're reducing their hours simply to be able to cope. 2 in 5 doctors refusing to take on extra work. But what we also saw in the migration research were that there were nearly a third of doctors who said they were likely or fairly likely to leave the UK in the next 12 months. Now that's intention. It doesn't necessarily translate to action. So we need to be careful with that. But what it does tend to do is to reinforce this sense that we collectively need to do more to make doctors feel valued. And it's not just about pay. Pay is an element, but it's not just about pay. We did some work some time ago with Michael West, and Michael has helped us think through what does it mean in order to be able to really embrace doctor wellbeing better? How do we make doctors feel better valued in terms of their competence, their autonomy, their sense of belonging? And so and all of that links back to many of the same interventions we were talking about earlier in terms of the cultural upheaval in relation to equality. So, many roads lead to exactly the same destination. 

Speaker3: [00:22:54] And I think it's important that, it's really important that you bring that out in terms of an exodus. There are some who would argue that we have an overreliance on non-UK graduate doctors, and that the long-term workforce plan will probably balance that. But I guess the state of medical education report that's just come out will give us some hard numbers around the diversity of the workforce.

Speaker1: [00:23:16] So, yes. So I think there are several really interesting things in those data. One is that for the very first time, we see more doctors on our register from an ethnic minority background than white doctors. And you could say that's it's just a data point, but I think it's a really significant milestone. The medical workforce is probably one of the most diverse workforces of any sector in the UK, and I think that's something we should embrace and celebrate. I think that diversity is something that should enable that workforce to provide the best possible patient care to a very diverse set of populations that it serves. And that's why some of the things we talked about earlier around equality and diversity are so important. And of course, within that, we have also seen a continuing increase in doctors who've qualified overseas coming to work in the UK. Now that's part of what's driven that data point around ethnicity. But when I started in this role, eight years ago, we had around half the number of doctors coming onto a register from overseas, as were graduating from UK medical schools each year. And the year that we just had, we've had nearly three times as many doctors from overseas coming onto our register as coming out of UK medical schools. So that number has gone up from about 3000 a year to about 20,000 a year. And what that's done is it's driven a complete shift in the makeup of the medical workforce.

Speaker1: [00:24:52] So locally employed doctors, doctors who aren't either consultants or doctors who are in formal training programs make up an increasingly important segment within the medical workforce. And I think that raises some really quite fundamental questions for us and for government about how do we enable all of those doctors to thrive, how do we enable those doctors to develop their clinical skills, and how do we make sure that when those doctors do develop those clinical skills, we can recognize that in enabling them to step into more senior clinical roles? And as the government gets to grips with the workforce agenda and thinks about how that reform narrative will play out in relation to education and training, I'm really up for some quite serious conversations with government and with other stakeholders about how we can relate that to how we embrace and support those doctors who are new to UK practice as well, of course, as those in formal training programs and elsewhere. 

Speaker3: [00:25:53] And this is going to be a very important piece of work, and I think it's important just to make the distinction when you say that for the first time, minority doctors from minority backgrounds are outnumbered. That, of course, encompasses people who have been born and trained and graduated here. It's not just international doctors.

Speaker1: [00:26:10] Yes. No, indeed. And indeed within medical schools, in the UK, we've seen an increasing proportion of students from ethnic minority backgrounds, which is also something that we should celebrate. So all of those trends come together in that data point that I described.

Speaker3: [00:26:26] And what would you say to that? There are corners of the market commentators worried that we are over reliant on international medical expertise, and that we should be self-sufficient in this country. What would you say to that concern? Because people do raise it.

Speaker1: [00:26:43] People do. And I think it's important to recognise that our job at the GMC isn't to make those decisions around workforce. Our job at the GMC is to make the process as seamless as possible, and make sure that any doctors who are practicing medicine in the UK meet the standards that we set. And that's what we do through our lab tests, both our knowledge and our skills test that we carry out in the UK. I think it's really incumbent on government and employers to really reflect on the ethics of global recruitment. But I would also say that for all of the likely commitments that will follow in terms of the exact proportionate increase in medical school places in the UK, we will continue to rely enormously on overseas trained doctors in the NHS that that kind of, you know, that Rubicon has already been passed. And so nobody should believe that this is not an important agenda to grasp. We have 80,000 locally employed doctors in the UK, not all of them from an overseas trained background, but we have many, many thousands of doctors who've trained overseas who are working in the UK, and they deserve our support to be the best possible doctors they can be. 

Speaker3: [00:27:57] And I think that comes to the final point, if I may. You've touched upon it, of course, Professor West's work, etc. bringing all of this together, looking ahead, working with government, you're up for that challenge, etc.. Just how important will compassionate leadership... I think it's something that's touched upon in your publication in January. A) What does that comprise? And B) how important will that be as we move forward to make all of the workforce valuable and stop this threat of an exodus and reduction of hours? 

Speaker1: [00:28:29] So I think compassionate leadership is the glue that holds this entire conversation together. So whether we're looking at the world through the lens of equality. Whether we're looking at the world through the lens of retention, whether we're looking at the world through the lens of productivity and service efficiency and effectiveness. None of those things will happen without compassionate leadership. And where we have compassionate leadership, we see these virtuous cycles where we see colleagues feel very well supported, feel valued. They want to stay. They provide better patient care. They feel able to speak up. They feel part of a team. Medicine is, after all, a team sport. So I think compassionate leadership is fundamental to everything that we've been talking about. The challenge is making sure that we are helping people do that at the front line, recognising that this isn't just a nice to have, that this is fundamental to everything we do. And, it is worth remembering there are many places that do do this well. It's very easy in these conversations to almost kind of create a sense that there is a challenge universally across our health services. But there are there are places that do this well, and we need to be better at learning from them. And back to your earlier question about the role of regulators. If regulators are really going to be forces for positive change, one of the things we need to be better at collectively is identifying and sharing that best practice and helping people really implement that in reality.

Speaker3: [00:30:06] Well, I think on that note of a call for regulators to really work together with all stakeholders. Thank you very much for your time once again, Charlie Massey. It's been a pleasure to talk to you. 

Speaker1: [00:30:15] My pleasure. Thank you for having me.

Speaker3: [00:30:17] My pleasure. If you've enjoyed this episode of Voices of Care, please like, follow, or subscribe wherever you receive your podcasts. And if you want to learn more about how we're turning the dial on the debate on health and social care, please visit newcrosshealthcare.com/voicesofcare. In the meantime, I'm Suhail Mirza. Thank you very much for joining us and I look forward to seeing you on the next episode.

Speaker2: [00:30:37] Voices of Care, the healthcare podcast.