General Medical Council (GMC) – Written evidence (FFF0009)

Building a public services workforce fit for the future – GMC evidence submission

Our role

1. The General Medical Council’s (GMC) role is to protect patients and improve medical education and practice across the UK. As part of this, we oversee UK medical education and training, and we set the standards that doctors need to follow throughout their careers. We also take action where necessary to prevent a doctor from putting the safety of patients or the public’s confidence in the profession at risk.

Summary

2. We welcome the focus of this inquiry. Ensuring that medical professionals are equipped with the right skills and capabilities for future needs is central to our role. In addition to this, we can make important contributions to wider planning for workforce needs and policies – through the data that we hold on workforce trends and changes, our extensive research and insight work on doctors’ experiences in the workplace, including their wellbeing, motivation, ability to provide the best care to patients, and their career choices.

3. Key findings from this data, research and insight work are relevant to the Committee’s inquiry, namely:

• The medical workforce, more than perhaps any other public service staff group, needs long term workforce planning to ensure needs are met. Shortfalls in capacity over recent years – alleviated in part by significant increases in doctors trained outside the UK – suggest that a more comprehensive approach to workforce planning is needed.
• Retention of staff, and enabling them to deliver the best care, is critical, especially to respond to pressures in the short term. This requires a leadership and culture that makes health services, and public services more broadly, to be inclusive and supportive environments where all staff can thrive and provide quality care.
• Central to that is action to promote equality, diversity and inclusion – for all staff, but especially for the medical workforce where nearly 40% of all doctors (and more than 60% of new joiners) are from a Black and Minority Ethnic background. More needs to be done to ensure that all doctors have the same opportunities to provide their maximum contribution to the health service.
• In collaboration with partners across the system, we must continue to develop approaches to education and training for doctors – widening access, supporting more flexible training pathways, and focusing more on outcomes rather than time spent in training. Innovations during the pandemic offer a helpful platform for change. Maintaining standards, however, remains paramount to ensure patients’ interests are protected.
• As the GMC prepares to bring within regulation new professional groups (Physician Associates and Anaesthesia Associates), the NHS needs to maximise their potential, expanding training and supporting employers to develop new models for clinical teams.

Evidence

Question 1

4. To help sustain the medical workforce we need, we need both short- and long-term actions. In the short-term, actions to support retention of existing staff could have the biggest single impact on overall workforce numbers. In research for ‘the State of medical education and practice 2021’, 23% of doctors said they were planning to leave the profession, up from 19% in 2020. We know from research among doctors who have left the NHS[*] that workplace environments and cultures are critical drivers for those who leave, with factors such as bullying, dissatisfaction, and burnout cited as reasons for leaving. The GMC has consistently called for greater priority to be given to improving working environments and workplace cultures to protect staff wellbeing and support retention, and with the current workforce pressures as we move from the pandemic to recovery this is truer than ever.

5. Looking further ahead, we share the concerns voiced by many in the health and care system about the need for a more comprehensive and transparent approach to workforce planning – recent years have seen continuing shortfalls in capacity, as well as a significant increase in doctors trained outside the UK, who currently make up more than half of those joining the UK medical workforce (see Annex A).

6. Given the time it takes to train a medical student to consultant or GP level,[†] planning must consider demand and supply further into the future. Planning needs to assess the overall patterns of health and care needs, the development and changing mix of professional roles (including Physician Associates and Anaesthesia Associates, covered below), changing trends in career patterns (for instance, growing numbers of doctors wishing to work part-time), and the balance of UK and international recruitment. The GMC would not be responsible for the overall workforce planning system – that lies with the four governments across the UK – but we want to contribute to it, with our extensive data and insight, and be closely involved in any planned changes to UK education and training numbers, so that we can assure quality and standards of training provision.

Question 2

7. As we consider the future of education and training in the UK, we expect to see more flexible approaches, based on the premise that education and training progression should be based on the skills and competencies that are needed of doctors, rather than proving that a certain process has been followed. The outcomes we expect of both under- and post-graduates have been updated to reflect this.

8. More flexible approaches were put into practice during the pandemic when disruption to service delivery made it difficult for trainees to follow the usual processes. For example, in the Physician speciality curriculum the number of outpatient clinics that a trainee would be expected to have attended was removed, with greater emphasis placed instead on the skills that trainees needed to gain. Similar changes were made in other specialties.

9. All the changes made during the pandemic, and considerations of educational reforms into the future, are based on the following principles:

• patient safety is paramount;
• we need to maintain standards – the level of competency/ Certificate of Completion of Training (CCT) standard should remain consistent;
• assessment should be of whether outcomes are achieved not periods of time spent training in an area;
• assessment should be of competency rather than based on the number of times trainees have completed specific tasks;
• curricula should be proportionate and support diversity

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10.                     It is in line with this final principle that we are working to ensure that training cultures are fair for all doctors, and all are enabled to reach their full potential (covered further below). 
11.                     In the future we aim to build on the flexibility which was proven to work during the pandemic and create more flexible training structures that are better able to respond to changes to demand and meet the needs of a diverse range of doctors. We need to work with the healthcare system to manage the pipeline of trainees and ensure that they can build knowledge and skills to meet the standards we require. That means thinking differently about how training is organised, the content of training, how doctors are assessed, and how we manage the balance between service delivery and training.

12.                     We believe that there are four areas that the experience of the pandemic suggests will be crucial to this: preparedness for practice, finding the right balance of specialist and generalist skills, developing an appropriately flexible approach to progression and assessment, and considering the role of leadership. We are working with partners across the system deliver on them.

13.                     Alongside developing flexibility in training, we are also looking at how to better enable doctors to progress throughout their career. We are working with government to reform the processes by which doctors can gain specialist or GP registration, in particular to simplify the requirements for International Medical Graduates to demonstrate that they have the necessary knowledge, skills, and experience to meet our standards. This will provide improved opportunities for doctors, many of them working in Specialist and Associate Specialist (SAS) roles, to gain specialist registration and work as a consultant or GP in the NHS. This change is one of the elements of the wider government proposals for professional regulatory reform, which we strongly support and want to see enacted as quickly as possible.

Question 4

14.                     In terms of attraction, there is no shortage of interest in becoming a doctor and following a medical career; places in UK medical schools continue to be heavily oversubscribed. However, as noted above, greater efforts to retain staff are needed. The NHSE/I Medical Retention Programme is taking steps to retain doctors in the NHS in England through elements such as pensions, induction, and flexibility.

15.                     Alongside these practical actions, there are also cultural improvements that must be made to keep doctors in the health system. Our research on doctors’ who have left the profession[‡] emphasises the importance of workplace cultures, with negative pressures including bullying, dissatisfaction, or burnout, cited as reasons for leaving. These factors, and their associated impacts, could all be mitigated by a greater focus by leadership on inclusion and supporting wellbeing.

16.                     In healthcare, staff wellbeing is linked to improved service user experience, increased productivity, and increased willingness of staff to continue working in challenging and complex environments. It is therefore imperative that action is taken to support doctors’ wellbeing and keep them in the profession, providing safe, high-quality care.

Question 5

17.                     It is important to have a diverse workforce that is representative of the populations it cares for. There are many elements the government and employers need to consider when improving diversity across the public services workforce, but the first step must be to ensure that all those already working in the system have the same support and opportunities, irrespective of their protected characteristics. Action to address equality, diversity, and inclusion in the medical workforce goes beyond the fact that it is the morally right thing to do – given the make-up of the medical workforce, it is an essential part of meeting the workforce challenges ahead.

18.                     38% of all licensed doctors in the UK are from Black and Minority Ethnic backgrounds and this is growing – doctors from Black and Minority Ethnic backgrounds accounted for 61% of new doctors joining the register in 2020, up from 42% in 2017. Yet we know that these doctors are more likely to face barriers around induction, career progression, and to end up in disciplinary or regulatory processes.

19.                     Our ‘Fair to refer?’ research found that not all doctors benefit from the same supportive cultures within medicine. Some doctors receive the personal and professional protection of being in ‘insider’ groups, while others are in isolated ‘outsider’ groups. Being in an ‘outsider’ group is more common among doctors who gained their primary medical qualification outside the UK and doctors from Black and Minority Ethnic backgrounds. Doctors in ‘outsider’ groups are more likely to face disciplinary action, and to be referred to the GMC for regulatory action. This disparity is also seen in the progression of medical students and trainees.

20.                     The GMC has set targets to eliminate the disparities seen in employer referral rates to us, and in education and training attainment, and is working with partners across health and care to support the steps needed to tackle the underlying causes.

21.                     We have given specific focus to Black and Minority Ethnic doctors because of the starkness of the evidence showing disparities in their experience, but our research highlights other challenges. Research for ‘the State of medical education and practice 2021’ found that doctors with a disability were less likely to feel supported by colleagues and senior staff and were nearly twice as likely as non-disabled doctors to have taken ‘hard steps’[§] towards leaving the medical profession.

22.                     These negative experiences shared by doctors with particular protected characteristics are not just personally challenging but bake in inefficiency and a lack of productivity across the system and, ultimately, will push people to leave. It is tackling these kinds of inequalities that will be vital in recruiting and retaining doctors from underrepresented groups into the workforce and ensuring that the health system is able to benefit from the full potential that every individual brings.

Question 10

23.                     The COVID-19 pandemic has had, and continues to have, a huge impact on the working lives of the medical workforce. In 2020, 81% of doctors reported a significant change to their working life and 42% had been redeployed[**]. Doctors also reported new challenges around the delivery of remote care, and the fear and confusion of working during a rapidly evolving global pandemic.  While there have been many challenges, there have also been changes to ways of working, such as better multidisciplinary team working and increased availability of senior leaders, that many doctors would like to see sustained in the long term. As these changes are embedded, it is important that the advantages are spread more evenly across the workforce.

24.                     There is now an opportunity to build upon these changes. Many of the positives achieved during the first year of the pandemic (2020) have already been retained and even improved upon - in 2021 60% of doctors saw an improvement in knowledge sharing across the profession, compared with 54% in 2020. Similarly, there is an opportunity to build on the better teamworking across professions seen in the early stages of the pandemic. This opportunity must be taken by health services to create effective multidisciplinary teams that maximise the skill mix across all professions.

25.                     As discussed in our response to question 2, the pandemic necessitated several changes being made to medical education and training. These demonstrated the importance of having flexibility in education and training to be able to quickly respond to current and future changes to demand on health services.

26.                     Finally, a key aspect of workforce reform and effectiveness is the change to professional roles, with professions taking on skills and clinical responsibilities that had previously been undertaken by other professionals such as doctors, and working in multi-professional teams. The GMC will be taking on responsibility for regulating Physician Associates and Anaesthesia Associates in the near future, following legislation to be brought forward by government. Bringing these professionals into regulation is a major step forward, but regulation is only one part of the picture. In order to gain the benefit of this change, NHS national bodies will need to plan for expansion in training, steps will need to be taken to extend prescribing responsibilities to them, and employers will need to be clear about their roles and responsibilities and how they can be deployed most effectively in clinical teams.

February 2022