What lies beneath: getting under the skin of GMC referralsBMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m338 (Published 12 February 2020) Cite this as: BMJ 2020;368:m338
If you’re an ethnic minority doctor working in the NHS you’re twice as likely as a white doctor to be referred by your employer to the General Medical Council (GMC). If you trained outside the UK that figure rises to two and a half times as likely.
These facts are not new. But less is known about the reasons why, says Roger Kline, research fellow at Middlesex University Business School and coauthor of Fair to Refer?,a 2019 report1 commissioned by the GMC that sought to understand why certain groups of doctors more often fell foul of complaints about their fitness to practise.
“People have known there’s been an issue around disproportionality without understanding what lies behind it,” says Kline. He says that the case of Hadiza Bawa-Garba, who was struck off the medical register after the death of a 6 year old child and then reinstated, was the tipping point for action.
Although it’s not only employers who can refer doctors to the GMC, only referrals by employers show a disproportionate representation of ethnic minorities (see box). Complaints from employers make up only 4.3% of all referrals—but 77% of these result in a GMC investigation, compared with only 9% of complaints from patients.
Dynamics of belonging
The Fair to Refer? report highlighted a pervasive insider-outsider dynamic in the NHS. Doctors perceived as lower status outsiders—such as doctors trained outside the UK—are not given the support they need by bosses and colleagues and are more likely to end up being blamed and facing disciplinary action when things go wrong.
Ethnic minority doctors, whether trained in the UK or overseas, may also feel less confident about raising concerns or challenging an accusation for fear of a backlash. They are also over-represented in roles that can isolate them, such as in locum posts or in small or demanding general practices, leaving them more vulnerable to complaints.
About 40% of doctors working in the NHS in England in 2019 were from ethnic minorities,2 and 38% of the 300 030 doctors working in the UK had trained overseas. A BMA survey carried out the same year found that only 55% of ethnic minority doctors felt included in the workplace, compared with 75% of white doctors.3
Doyin Atewologun, director of the gender, leadership, and inclusion centre at Cranfield School of Management and coauthor of Fair to Refer?, says that racism is not the only reason why some doctors are treated like outsiders. “When you get these insider-outsider dynamics, they infiltrate systems of socialisation, learning, and leadership and lead to these differentials that we sometimes take for granted,” she says. “It’s associated with factors linked to racism but also with how we don’t question who ‘naturally’ belongs.”
Lack of preparedness
One reason why overseas doctors in particular may find themselves the subject of a disciplinary process is that poor inductions can leave them inadequately prepared to work in the UK. An ineffective induction could include anything from a lack of advice on how to find accommodation to not being made aware of what’s expected of doctors practising in the NHS.
Subodh Dave, a consultant psychiatrist at Royal Derby Hospital who has worked on enhancing the Royal College of Psychiatrists’ support for overseas doctors, says that expecting international medical graduates simply to absorb the culture, values, and nuances of working in the NHS leads to problems later down the line.
“Overseas doctors are completely set up to fail,” he says. “The NHS saves £250 000 [€300 000; $320 000] by not having to train an overseas doctor, but we don’t even spend £200 on giving them a proper induction. We just throw them in at the deep end and give them a link to Good Medical Practice.
“For example, most international graduates are not aware of issues around confidentiality and safeguarding. Asking doctors about their learning needs is key.”
One key factor highlighted in Fair to Refer? is the unwillingness of some colleagues and managers to engage in difficult conversations with doctors across ethnic or social divides, even though timely feedback can help avoid unnecessary referrals.
Chaand Nagpaul, BMA council chair, highlights the role of a widespread blame culture in the NHS. “We have a system in the NHS that’s driven by looking at personal blame when things go wrong, but we know that the vast majority of medical errors are contributed to by systemic factors,” he says. “If doctors don’t raise concerns they’re less able to fend for themselves and more vulnerable to being blamed for medical errors, which can lead to more disciplinary action against them.”
Jenny Vaughan is law and policy lead at the Doctors’ Association UK and led the successful campaign to overturn the conviction of David Sellu, a surgeon who was wrongfully accused of gross negligence manslaughter.4 She says that the reluctance of some ethnic minority doctors to raise concerns is what makes them particularly vulnerable.
“Minority ethnic doctors feel less confident about reporting concerns, because they feel they are more likely to be blamed because there’s a lot of subconscious bias,” says Vaughan. “Fair to Refer? revealed how toxic working conditions are more likely to lead to a disproportionate referral rate of ethnic minority doctors to fitness to practise processes. The figures [in the report] illustrate how it appears easier to blame ‘outsiders.’”
Sellu concurs. He says, “The view among ethnic workers is this: the health service in the UK is among the best in the world in many respects—though we lag behind on some measures. Everyone gets praise for the things that are right, but ethnic minority workers get the blame for its failures. This is unfair.”
Focusing on “learning, not blaming” is one of the key recommendations of Fair to Refer?, which also calls for better inductions and improved leadership that is more representative of the workforce, Atewologun and Kline told The BMJ. Kline is “moderately optimistic” that the report will make a difference.
They add that the regulator is currently working on turning these recommendations into practical steps. This includes how to support employers to be more accountable and to ensure that they assess whether a formal complaint is really necessary before launching one, as well as looking into systemic issues that may have contributed to a mistake.
Charlie Massey, GMC chief executive, says that his organisation is also looking at making changes to how it handles employer referrals and is talking to employers about local safeguards to ensure that clinical governance arrangements for doctors avoid bias and discrimination.
In a separate move, Dido Harding, chair of NHS Improvement, sent a letter to NHS trust leaders last May spelling out the best practice for managing and overseeing local investigation and disciplinary procedures.5 The guidance followed scrutiny of the events that had led to a nurse, who was dismissed from London’s Charing Cross Hospital in 2015, taking his life in 2016 after dousing himself in petrol. An investigation into how Amin Abdullah had been treated by Imperial College NHS Trust found that the trust’s disciplinary processes were “weak and unfair” and that the evidence gathered about the incident that had led to Abdullah’s dismissal did not form “an honest and complete picture.”6
Abdullah’s case led to more widespread scrutiny of disciplinary cases in other trusts that had been criticised, to see whether further lessons could be learnt. This analysis found a raft of poor practices in the NHS, resulting in new advice for trusts, most of which could be applied immediately, said Harding. Like the measures the GMC is looking into the advice was to examine closely whether formal action was justified and whether it took account of wider systemic circumstances.
Some way to go
The BMA’s Nagpaul welcomes the GMC’s action, but he says that there’s still some way to go before the factors affecting ethnic minority doctors are understood and internalised in a way that will bring about the cultural and systemic changes necessary to tackle the bias they experience. “There needs to be an explicit awareness of the factors that affect ethnic minority doctors,” he says. “We haven’t got that at the moment.”
Some doctors and campaigners believe that the GMC itself needs to be more closely scrutinised. Sellu says that it hasn’t shown beyond doubt that it doesn’t disproportionately punish doctors from ethnic minority backgrounds. He says, “It was disappointing that Fair to Refer? only dealt with referrals, but what happens when these doctors are referred? There is an accusation, not convincingly refuted in the view of many, that ethnic minority doctors get treated more harshly and are given stiffer sanctions by the regulator for equivalent misdemeanours.”
Ramesh Mehta, president of the British Association of Physicians of Indian Origin, agrees. “Why is the outcome so bad for ethnic minority doctors if there’s no discrimination within the GMC?” he asks.
Kline, however, says that the focus on referrals is the right one. “Insofar as we might make a difference, we are more likely to make a difference on why referrals are coming in than looking again at the GMC’s own processes,” he says. “We are clear that it’s the decision to start a formal investigation that’s key to whether someone is disciplined or referred.”
Disproportionality in numbers
In 2020, doctors from ethnic minority backgrounds made up 40% of doctors working in the NHS in England. And 38% of doctors received their primary medical qualification outside the UK.
Of 473 sanctions delivered by the Medical Practitioners Tribunal Service in 2018, 44% (209) were to doctors from ethnic minority backgrounds and 36% (168) were to white doctors.
Of 80 doctors who were struck off in 2018, 38 (47.5%) were from ethnic minority backgrounds and 21 (26%) were white.
From 2008 to 2018, 874 doctors were struck off the UK medical register. Of these, 37% (324) were from ethnic minority backgrounds and 28% (241) were white.
In 2018 the General Medical Council (GMC) received 122 complaints from employers about ethnic minority doctors (representing 0.12% of the total population of ethnic minority doctors), compared with 95 employer complaints about white doctors (0.06% of all white doctors).
In contrast, referral rates of ethnic minority and white doctors by the public were roughly the same. In 2018 the GMC received 1243 complaints from the public about ethnic minority doctors (1.21% of the ethnic minority doctor population) and 2047 public complaints about white doctors (1.3% of the white doctor population).
Most complaints (39%) received by the GMC in 2018 both for white and for ethnic minority doctors related to the doctor’s knowledge and experience.
Note: Where numbers do not add up to 100% the ethnicity of doctors was unknown.
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Commissioning and peer review: Commissioned; not peer reviewed.
For more articles in The BMJ’s Racism in Medicine special issue see https://www.bmj.com/racism-in-medicine