Disproportionate referrals of black, Asian and minority ethnic (BAME) doctors to fitness to practise processes could be driven by poor induction and support, working patterns which leave them isolated, and poor feedback by managers, a new report has found.
Employers and healthcare providers refer BAME doctors to the General Medical Council (GMC) at more than double the rate of their white counterparts. Official figures show that between 2012 and 2017 1.1% of BAME doctors were complained about by their employers to the GMC, compared to 0.5% of white doctors. And compared to UK graduates, non-UK graduates are referred at two-and-a-half times the rate (1.2% of non-UK graduate doctors compared to 0.5% of UK graduate doctors). This means they have more chance of being investigated and, in turn, receiving a warning or sanction.
Previous audits of GMC processes have found no evidence of bias so, to help address the disparity in referral rates, the GMC asked Dr Doyin Atewologun and Roger Kline to conduct UK-wide research and deliver recommendations that the GMC and others can act on.
Their report Fair to Refer makes recommendations that focus on four key areas: support, working environments, inclusive leadership and delivery. They include practical recommendations including:
- Improving support for doctors new to the UK or the NHS or whose role is likely to isolate them (such as SAS doctors and locums).
- Addressing the systemic issues that prevent a focus on learning, rather than blame, when something goes wrong.
- Ensuring engaged, positive and inclusive leadership is more consistent across the NHS.
- Developing UK-wide mechanisms to ensure delivery of the recommendations.
Atewologun and Kline spoke to more than 260 clinician and managers from across the NHS. Their report found a combination of factors that could explain disproportionate referrals of BAME doctors to the GMC:
- Some doctors don’t have adequate induction or enough support in transitioning to new social, cultural and professional environments.
- Doctors from diverse groups do not always receive effective, honest or timely feedback which could prevent problems later. This is because some clinical and non-clinical managers avoid difficult conversations, particularly where they are from a different ethnic group to the doctor.
- Working patterns mean that some doctors working in isolated roles lack exposure to learning experiences, mentors and resources.
- Some groups of doctors are treated as “outsiders”, creating barriers to opportunities and making them less favoured than “insiders” who experience greater workplace privileges and support.
They also found that some organisational leadership cultures have a knock-on effect. Where leadership teams are remote and inaccessible, doctors struggle to approach them for advice and support, and may not be listened to and divisive cultures can develop. In addition, a focus on who to blame when things go wrong, rather than what needs to be learnt from an incident, compounds the disconnect between doctors and leaders.
They conclude that the same workplace factors that created greater risk for BAME doctors at the same time, provided a level of protection for their UK-qualified and non-BAME colleagues.
Dr Doyin Atewologun, director of the Gender, Leadership and Inclusion Centre at Cranfield University, said: "The factors behind disproportionate representation of certain groups of doctors in fitness to practise referrals are multiple and intricately linked, with ‘risk factors’ for certain groups of doctors and ‘protective factors’ for others layering upon one another to create a cumulative positive impact for some and a cumulative negative impact for others. We hope this study will help ensure these protective factors are present for everyone, and not just accessible to those doctors who happen to be ‘insiders’.”
Roger Kline, research fellow at Middlesex University Business School said: "We hope our research will prompt serious, sustained work to ensure that all doctors, irrespective of their background or characteristics or mode of employment, are treated fairly within NHS employment, disciplinary processes or GMC referrals."
GMC chief executive Charlie Massey said the GMC welcomed the recommendations: "We’ve already started discussions with employers about how we can make sure safeguards are in place locally so that clinical governance arrangements for doctors are fair and free from bias and discrimination. Our commitment is to play a convening role to help us and other bodies make these recommendations a reality," he said.
Dr Chaand Nagpaul, British Medical Association (BMA) council chair, said: “The BMA has long raised concerns about the way that BAME doctors are treated in the workplace. This valuable group of doctors, who make up more than a third of the medical workforce, are more likely to be bullied, less likely to raise concerns, more likely to feel blamed and less likely to feel included.
“Worryingly, they are also more likely to face referral to fitness to practise processes to the GMC, than their white counterparts, are more likely to have their cases investigated and are more likely to face more serious sanctions following an investigation.
“Therefore, we very much welcome this research into the factors behind not only this, but why being an overseas qualified doctor, a locum, or an SAS doctor, increases the risk of being unfairly treated."