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Unwelcome attention

Back of doctor in hospital, 16x9, BMA news cover image

Overseas and BAME doctors are referred to the GMC in disproportionately high numbers. How do you make the system fairer, and keep those doctors who shouldn’t be there out of an intensely stressful process? Keith Cooper reports

The pressure on doctors accused of making mistakes can be huge, especially when managers, regulators, inspectors, and NHS England all investigate.

That some get more attention than others – those trained overseas or from BAME (black, Asian and minority ethnic) backgrounds – has been a trend itself investigated, again and again, down the years.

The latest scholarly exposé of this apparent injustice, by respected academics Doyin Atewologun (pictured below) and Roger Kline, aims to be different.

Published last month, Fair to Refer (pictured right) hopes to stop doctors getting caught up in unnecessary probes in the first place. Its focus is on employers, not regulators or inspectors. Hundreds of doctors and managers have been quizzed. And in line with a general move in the NHS, it calls for investigations, if necessary, to look for lessons to be learned not people to be pilloried.

‘The priority should be to keep people out of the disciplinary process – not just to improve it,’ Dr Kline told The Doctor. ‘This is not the only thing to be done – but it can make the biggest difference. Are there ways we can stop people entering the process who shouldn’t be there?’

This focus on employers, of course, means the GMC, which wrote the research remit, has itself escaped scrutiny. Its previous ‘audits’, a spokesperson says, found ‘no evidence of bias’. The last one, in 2014, was two years after Hadiza Bawa-Garba, the doctor whose case prompted the study, was referred to it by her employer, the University Hospitals of Leicester.

‘We cannot allow doctors working hard in incredibly tough conditions to continue practising in fear’

Some doctors remain unconvinced by the limited scope of the research.

‘We welcome the recommendations but it is a little disappointing that it appears to absolve the GMC of all responsibility,’ says BAPIO (British Association of Physicians of Indian Origin) chair JS Bamrah.

‘If the GMC is to change its own process, it needs help to do that too.’


GMC ‘not complacent’

GMC chief executive Charlie Massey tells The Doctor a new audit is imminent following advice from its BAME forum. BAPIO and the BMA are members. ‘I am not in the least being complacent about our own processes,’ Mr Massey adds.

The researchers themselves are confident their findings will make a difference to doctors, as long as employers and NHS officials agree to their suggestions.

‘In order for things to shift in a sustainable way all of the key stakeholders need to be involved and mindfully so,’ say Dr Atewologun.

So, what did it find and what does it recommend?

First, they examined the high-level numbers. BAME doctors are referred to the GMC by their employers at double the rate of white doctors. Those trained overseas are 2.5 times more likely to be referred than UK graduates.

On digging deeper, they found reasons to explain these disproportionate referral rates.

For instance, locums and staff, associate specialist and specialty doctors, which have high BAME representation, are described as a ‘potentially exploited workforce’ in the report.

SAS doctors felt treated as ‘nameless and faceless’ and ‘workhorses’, locums seen as a ‘commodity… almost traded between trusts’. While full-time employees were helped with errors, locums would be referred to the GMC. ‘What else can you do?’ one doctor asked the researchers.

Another reason for disproportionate rates among overseas-trained GPs and those from BAME backgrounds is their prevalence in small or single-handed practices in down-at-heel areas, such as the inner cities, ex-mining communities and seaside towns. One spoke of their struggle to join ‘larger, white practices’.

GPs in such tough environments are also subject to NHS England’s inspection regime, which includes a network of PAGs (performance advisory groups) at local level. There is ‘significant variation’ in the approach of PAGs in England, the researchers found. The Doctor has focused on the conduct of some of these PAGs in previous issues.

One ‘perfectly healthy and capable’ 70-year-old GP, who was trained overseas, was subject to an ‘interrogation which was bullying in tone’ in one PAG meeting, they heard. His records were reviewed, the Care Quality Commission arrived. He was locked out of his premises. The pressure forced him to resign yet no fitness-to-practise allegations were levelled. ‘The NHS lost a good GP,’ the researchers heard.

In light of these concerns, the report calls for a ‘review and report’ on all ‘processes for responding to concerns about doctors’, including PAGs, across all UK administrations. NHS England has refused to release data to the BMA on its performance investigations, despite numerous requests since late last year.

The circumstances and situations which led to disproportionate referrals left some doctors isolated, distanced from colleagues, and ‘othered’, Dr Atewologun says.

‘The demographics for these groups can be different; the fault lines might be different, too. But while the specifics of what makes someone an insider or outsider are different, the implications can be similar.’


Racial hierarchy

The fault lines in medicine, the research found, divide the profession along multiple lines: where you went to medical school, which country, region, and which type of university. There are hierarchies of race: Asian above black.

‘Many of the groups that are disproportionately affected in referrals to the GMC are commonly perceived as lower-status outsiders.

‘An Indian medical qualification is viewed as inferior to a European medical qualification, which is viewed as inferior to a UK qualification,’ one clinical director said.

Using their analysis, the researchers arrive at a series of recommendations and examples of good practice (see ‘good practice’ boxes on all pages), drawn from the dozen or so trusts they examined. Bespoke inductions and personal support for overseas-trained doctors, an early-warning system for GPs under pressure, and a commitment to the BMA’s SAS charter are among them.

‘We deliberately looked at trusts that we thought might be better than average and we found stuff that looks like it works,’ Dr Kline says.

The GMC’s Mr Massey admits that the problem of disproportionate referrals has long been the ‘elephant in the room’ of medical regulation.

‘Groups that are disproportionately affected in referrals to the GMC are commonly perceived as lower-status’

The senior NHS officials he speaks to agree they must ‘up their game’, he says.

He hopes to establish a ‘project board’ of ‘NHS leaders’ to oversee this and other recommendations from the reports and recommendations sparked by doctors’ anger about how Dr Bawa-Garba was treated. The final one, into workplace stresses on medical students and doctors, is due in late September.

BMA council chair Chaand Nagpaul welcomes the report and backs its calls for a fairer approach to regulation, a point he and the association has long called for.

Last month, he launched Equality Matters, a broad programme to ‘embed a culture in which every member can flourish and achieve their best’, he told the BMA annual representative meeting in Belfast.

‘We cannot allow doctors working hard in incredibly tough conditions to continue practising in fear,’ he says of the report.

‘We need better inductions, more inclusive leadership, a recognition of systemic pressures in investigations, a review of NHS England’s performance management processes, and wholescale improvement to the entire culture of the health service – leaving behind the toxic environment of blame and instead focusing on support and learning.’


Good practice – identified by researchers

Professional induction

Newly arrived, overseas-trained doctors in one organisation are given a short supernumerary period with intensive mentoring and support. Each new arrival is assigned a ‘buddy’ from their specialty. The supernumerary period helps it assess their clinical skills and acquaint them with local practices and procedures.

‘It is unreasonable to expect someone to travel halfway across the world, land in a different social and clinical environment, social mores and language and not expect there to be challenges,’ the organisation’s clinical director says.

Social support

Another organisation reliant on overseas doctors appointed a member of staff part-time to improve support. They meet them on arrival, help with accommodation, bank accounts, and connections with communities from their home country.

‘Doctors were bringing to work a whole range of worries which could distract them from a focus on induction and their new job,’ its responsible officer said.

The SAS charter

This organisation depended on SAS doctors but without appropriate support or opportunities. The medical director supported adoption of the BMA’s SAS charter to improve their opportunities for training. SAS staff here were found to be significantly more ‘upbeat’ than in other organisations.

Early intervention for struggling GPs

One clinical commissioning group has an early warning system which flags GP practices likely to suffer above-average pressure. It regularly compares sizes of patient lists and demand related to their demographics to pinpoint where extra support is necessary.

‘It is better to fix the car when the brakes need checking than after it’s crashed,’ is its mantra.

‘Groups that are disproportionately affected in referrals to the GMC are commonly perceived as lower-status’

‘We cannot allow doctors working hard in incredibly tough conditions to continue practising in fear’

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