Further written evidence from Professor Sue Carr, Deputy Medical Director, General Medical Council (GMC) [WRH0061]

Thank you for the recent opportunity to give evidence to the Women and Equalities Committee’s Inquiry into Women’s Reproductive Health.

I offered to provide you with some more information about what we know about the complaints we receive. I also thought it would be helpful provide you with some more detailed supplementary evidence on our regulatory functions, and our oversight of medical education and training.

We recognise there is a clear need for a system-wide approach to improve the safety and quality of care for women, and we’re working with other regulators to achieve this through challenging problematic workplace cultures, encouraging transparency, and working collaboratively to protect patients.

We are committed to working with partners across the UK health services to improve working environments and cultures, making them supportive, inclusive and fair for medical professionals. This leads to higher satisfaction and better patient safety.

We recognise that women's health touches on all areas of medicine. Gender related issues are prevalent in General Practice and Obstetrics and Gynaecology, although they are also present in many other specialities. Greater awareness of women's health issues is essential in making an accurate and timely diagnosis (or to give advice to women who are pregnant or planning a pregnancy).

Our guidance for doctors is clear that they must put the care of patients first, and provide care

appropriate to each individual patient’s needs.

The education and training outcomes we set for doctors are designed to be broad and high-level. They prioritise themes of patient safety, person-centred care, and safeguarding vulnerable groups.

However, we believe that education and training could be more explicit in preparing doctors to meet women’s health needs, and we will continue to work with partners to make sure that the standards we set on these areas are fully embedded in education and training.

Given the complexity of the healthcare landscape, and in particular the different roles of organisations within medical education and training, I have set out in Annex A the detail of our expectations of how women’s health issues are covered during a doctor’s education and training during their career. This includes reference to our upcoming Medical Licensing Assessment, which I

mentioned during my evidence, and has specific women’s health issues identified within the content

map and is described in the government’s Women’s Health Strategy. I hope this is helpful.

Our data and insights

I offered to provide the Committee with some of our data and insights regarding the complaints that we receive. In addition to this, I have also set out some more information about our role and function, as well as how we support patients in raising concerns, as we know it can be worrying when care goes wrong.

We know that there are differences in concerns raised with the GMC about a doctor's fitness to practise when gender is taken into account. However, we only collect complainant’s gender when a concern is submitted to us via our online complaint form and they may choose not to share this.

         In 2017, we received 8527 complaints. Our data shows that rates of complaint to us between genders is relatively consistent – for example in 2017 2,735 of complaints came from men and 2,571 came from women. Where we could identify the gender, in 2017 838 women complained about female doctors, and 1309 women complained about male doctors. 477 complaints were men complaining about female doctors; and 1718 men complained about male doctors. Men consistently complained to us more than women from 2017 until 2021.

         In 2022 complaints from women surpassed that of men (2,312 vs 2,267). This trend appears to continue into 2023 where (as of 16 November 2023) we have had 2,136 complaints from men, compared to 2,296 for woman.

Looking at our most recent data, from 2022 until mid-November 2023, I can confirm we received 17,787 complaints. The same caveats around data collection for complainants above applies. This means we only have this information for 50.1% of complaints (9,011)*.

* Caution should therefore be taken in interpreting these figures as different populations may be more or less likely to use this method to submit a complaint. It is also important to be aware that the data shows both the number of concerns and the number of doctors raised with us. One doctor may have received more than one concern raised about them.             

         Of those complaints, where we could identify the gender, we know that 2,148 of those were women complaining about male doctors, and 1,375 women complained about female doctors. 823 complaints were men complaining about female doctors; and 2,687 men complained about male doctors.

         Women were just under twice as likely to complain about male doctors not listening to them compared to men complaining about female doctors (10.2% of female complaints about male doctors - 220 out of 2148 complaints vs 6.7% of male complaints about female doctors - 55 out of 823 complaints).

         Women are also more likely to complain that male doctors have failed to provide appropriate information than the other way round. (6.7% vs 4.7% - 142 out of 2148 vs 39 out of 823).

Raising concerns

I can assure you that we take every concern raised about a doctor seriously and we investigate when we believe a doctor poses a serious risk to patients or has significantly or repeatedly failed to meet our standards.

Our functions and the way they are carried out are set out in law. We are currently working with the government on regulatory reform will fundamentally change the way we regulate, giving us more flexibility to set our own processes and change them when evidence suggests there are improvements that can be made.

New fitness to practise processes will allow us to focus our resources where they are most needed, giving us greater powers to resolve cases more quickly and therefore making sure patient safety issues are addressed sooner.

Reform will also provide us with a less adversarial process that supports complainants to raise concerns and supports registrants to learn from mistakes and remediate concerns.

We usually only investigate concerns when these raise issues about a doctor’s ability to practise safely or threaten public confidence in the profession; including serious or repeated mistakes in patient care; abuse of professional position, for example, an improper sexual relationship with a patient; violence, indecency or sexual assault; a serious criminal offence; discrimination against patients, colleagues or others; fraud or dishonesty; if a doctor’s health affects their practice or conduct; or serious concerns about a doctor’s ability to communicate in English.

Some of the things that we don’t investigate include minor clinical errors, disagreements over a diagnosis and medical reports, waiting lists and access to appointments. This means that we are unable to help patients with providing an explanation of their treatment, finding a doctor, or making a doctor provide a different treatment.

However, while there are some concerns we cannot help patients with, we do our best to ensure that those who get in touch with us are able to find the right organisation who may be able to support them or investigate their concerns.

We recognise how important this is and as one of a number of organisations responsible for keeping patients safe in the UK, we provide clear information to patients to help them find the right place to raise their concern. More information on this is on our website Concerns about doctors - GMC (gmc- uk.org).

Revalidation

During the session, you asked about revalidation, and how feedback from women is included.

Every licensed doctor who practises medicine must revalidate. Revalidation supports doctors to develop their practice, drives improvements in clinical governance and gives patients confidence that doctors are up to date.

Our revalidation requirements are sufficiently flexible to take account of the wide range of medical practice carried out by licensed doctors in the UK.

It is the doctor’s responsibility to have an annual appraisal that has Good medical practice as its focus and covers and reflects whole practice. We use the cycle of appraisals to enable Responsible Officers (ROs) to make revalidation recommendations. There are six types of supporting information doctors must collect, reflect on and discuss at their appraisal. They are:

         Continuing professional development

         Quality improvement activity

         Significant events

         Feedback from patients or those to whom you provide medical services

         Feedback from colleagues

         Compliments and complaints

We expect supporting information must be generated from a doctor’s whole UK practice. We say that all doctors must reflect on their supporting information and what it says about their practice. They should focus on what they have learned and what changes they need to make.

We have streamlined our Supporting information guidance for appraisal and revalidation which explains the professional values doctors need to demonstrate as part of their appraisal.

The guidance states that doctors should think about the activities or work in which they have been involved that has focused on quality improvement. Examples of this include the Audit of outcomes             

from clinical guidelines, devices and innovations recently introduced, including training received and any changes to practise.

         The guidance has a section on Continuing Professional Development (CPD) to encourage doctors to consider the diversity of their patient population and its needs, as well as encouraging them to have appropriate knowledge of equality, diversity and inclusion, when considering the CPD they will undertake.

         This reflects changes to Good Medical Practice 2024 to include consideration of a doctor’s own life experience, culture and beliefs, to help address the impacts of biases and the impact that these have on patients.

         We also refreshed our patient feedback guidance in 2020 which is explicit around the requirement to use a representative sample of patients.

Revalidation is not a way to raise or address concerns about a doctor’s practice. Concerns should be

raised when they arise, through relevant local governance processes and not through appraisal. Where concerns are serious, they should be referred to us through our existing fitness to practise processes.

Sexual harassment.

Towards the end of the evidence session, you asked about what steps the GMC is taking to tackle sexual harassment. While this is not part of your Inquiry into Women’s Reproductive Health, I thought it would be helpful to provide more information about this, given your interest in the topic.

We have been clear that sexual harassment, bullying and discrimination are entirely unacceptable. Where workplace cultures of this kind of behaviour go unchecked, they are detrimental to wellbeing, performance and patient safety. Doctors are increasingly, and bravely, speaking out about it, and as a regulator, it is important we leave no doubt that such behaviour has no place in our health services.

Our existing guidance already makes clear that doctors must not act in a sexual way towards patients or use their professional position to ‘pursue a sexual or improper emotional relationship’. Those who experience harassment or discrimination must feel supported to speak out, by employers, peers, managers and leaders.

As I mentioned in my response, our revised guidance for doctors Good Medical Practice was published on 22 August of this year and will come into effect on 30 January 2024.

It has been shaped by feedback from thousands of medical professionals, patients and others

supporting the UK’s health services during our consultation on the draft guidance in 2022. We

listened to those who contributed to the consultation process and the updated version reflects the feedback we have received. In total, over 4600 individuals took part in either our main survey or our short surveys for healthcare professionals and patients, and we spoke to over 3800 people at the virtual and in-person events we ran.

We have used the first update of Good Medical Practice in ten years, to ensure that sexual

harassment of colleagues is covered explicitly for the first time. The guidance says doctors ‘must not

act in a sexual way towards colleagues with the effect or purpose of causing offence,

embarrassment, humiliation or distress’.

The standards make clear this includes verbal or written comments and displaying or sharing images, as well as physical contact. The guidance also sets out what doctors should do if they witness bullying or harassment. Depending on circumstances, this could include:

         offering support to the victim, including letting them know the behaviour witnessed is unacceptable

         challenging the behaviour by speaking to the person responsible, either at the time, if safe to do so, or at an appropriate time and place

         reporting the behaviour in line with workplace policies, making sure the person targeted is aware of and supports that intention.

It also makes clear the supportive role those in positions of formal leadership and management must play in making sure behaviours are addressed, dealt with promptly and escalated if necessary.

We hope that by addressing this issue so clearly in the standards, this will spark discussion on making meaningful cultural change throughout medicine.

Finally, since my appearance before your Committee, we have published our latest report on the medical workforce, State of medical education and practice: workforce report 2023. Annex B provides an overview of the changing workforce by gender.

I appreciate this is a lengthy response, but hope it is helpful to you, and shows just some of the steps we are taking to play our part in the safety and quality of care for women as you consider issues around diagnosis, treatment and awareness of women’s reproductive health.

Annex A: Women’s Health in Medical Education and Training

The GMC works to make sure that education and training outcomes prepare doctors to deliver good, safe patient care across the UK.

We approve their undergraduate and postgraduate training and the assessments they must pass.

We do this by assessing all courses and programmes and by carrying out reviews and regular monitoring. We also talk to students, trainees and educators to hear about their experiences.

Women’s health in undergraduate education

We decide which organisations can award UK primary medical qualifications. We also carry out quality assurance of institutions that want approval to issue a medical degree, or to start a new programme.

The Government’s Women’s Health Strategy (WHS) for England has a helpful explanatory paragraph on our role in undergraduate medical education which states:

Undergraduate medical curricula for people training to be doctors are set by individual medical schools, with the GMC’s Outcomes for graduates ensuring that all doctors have the requisite set of skills required to progress into specialty training. The GMC will be introducing the Medical Licensing Assessment for the majority of incoming doctors, including all medical students graduating from academic year 2024 to 2025 and onwards. Within this assessment, there are a number of topics relating to women’s health. This will encourage a better understanding of women’s health among doctors as they start their careers in the UK.

Outcomes for Graduates

       We published our new Outcomes for graduates in 2018 after extensive consultation with stakeholders in medical education and training. The outcomes set out what newly qualified doctors, from all medical schools who award UK primary medical qualifications, must know and be able to do.

       Whilst our powers do not extend to directing specific content in undergraduate curricula, schools must demonstrate to us that they meet both the outcomes and our standards.

       Medical students must apply their knowledge and skills in a competent and ethical manner. They must use their ability to provide leadership and to analyse complex and uncertain situations. Although Outcomes for graduates does not refer comprehensively to issues related to women,

the general approach to learning to manage patients and apply knowledge will include women’s

health. For example, under diagnosis and medical management we say:

• 14 Newly qualified doctors must be able to work collaboratively with patients, their relatives, carers or other advocates to make clinical judgements and decisions based on a holistic assessment of the patient and their needs, priorities and concerns, and appreciating the importance of the links between pathophysiological, psychological, spiritual, religious, social and cultural factors for each individual.

       Under applying biomedical scientific principles we also say:

• 22 Newly qualified doctors must be able to apply biomedical scientific principles, methods and knowledge to medical practice and integrate these into patient care. This must include principles and knowledge relating to anatomy, biochemistry, cell biology, genetics, genomics and personalised medicine, immunology, microbiology, molecular biology, nutrition, pathology, pharmacology and clinical pharmacology, and physiology.

       We also say that newly qualified doctors must be able to recognise and identify factors that suggest patient vulnerability and take action in response. They must be able to:

• (a) explain how normal human structure and function and physiological processes applies, including at the extremes of age, in children and young people and during pregnancy and childbirth.
• (f) adhere to the professional responsibilities in relation to procedures performed for non- medical reasons, such as female genital mutilation and cosmetic interventions.

Medical Licensing Assessment (MLA)

         We will be introducing the Medical Licensing Assessment (MLA) in 2024. This will mean that all students graduating from UK medical schools in academic year 2024/25 will need to pass the MLA.

         The MLA will also replace our current exam – PLAB – as a way for overseas doctors to demonstrate they have the knowledge and skills to practise safely in the UK.

         Everything that could be tested in the MLA, and which candidates will be required to know, is set out in a comprehensive content map, available on our website. It includes wide-ranging

clinical presentations and conditions that relate to women’s health, including an ‘Obstetrics and gynaecology’ section on p33-4 and includes key topics relating to women’s health, for example, menopause, pregnancy, breast and vaginal conditions.

Women’s health in postgraduate education

The UK's medical royal colleges and faculties design the curricula and programmes of assessment for postgraduate specialty and GP training. We then approve these curricula and assessments, making sure they meet our standards.

They are responsible for the delivery of the post-graduate curricula. We actively check on, postgraduate training organisations to ensure they are meeting our standards. Our model aims to be a flexible and collaborative approach to the quality assurance of the organisations we work with.

Generic Professional Capabilities

Our Generic professional capabilities (GPC) describes the essential capabilities which underpin professional medical practice and are a fundamental part of all postgraduate training programmes. The framework was published in 2017, alongside Excellence by design which sets out the standards all postgraduate curricula in the UK must meet.

         The framework sets out the core professional values, knowledge, skills and behaviours that all doctors should be aware of.

         By the end of specialty training, students are expected to be capable of applying and adapting to a range of clinical and non-clinical contexts.

         Under domain 3 (professional knowledge) of GPC’s we say, Doctors in training must be aware of their legal responsibilities and be able to apply in practice any legislative requirements relevant to their jurisdiction of practice, for example:

• female genital mutilation
• equality and diversity, including legally protected characteristics.

Postgraduate Curricula

         Women are included as part of the broader population in outcomes, curricula and Generic Professional Capabilities, however we recognise their lack of direct visibility in these standards can lead to a default male bias in how health is viewed. As they are not always articulated separately in curricula, often doctors in training are only exposed to women's health opportunistically on placements. Where a patient first presents, i.e. the care setting, will generally impact on how they are treated.

         However, through Generic professional CPCs and generalism, we look to influence competence in managing healthcare of different groups. Some examples of topics covered in curricula include:

General Practice

         Reproductive health and maternity

         Gynaecology and breast

Obstetrics & Gynaecology

         Recognising, assessing and managing emergencies in gynaecology and early pregnancy and obstetrics

         Recognising, assessing and managing non-emergency gynaecology and early pregnancy care, and obstetrics care.

         Championing healthcare needs of people from all groups within society.

         Playing an active role in implementing public health priorities for women and works within local, national and international structures to promote health and prevent disease.

Community Sexual & Reproductive Health

         Pregnancy planning, abortion care and general gynaecology

         Ultrasound scanning

         Menopause and PMS

Annex B: State of medical education and practice: Workforce report 2023

The Committee may also find our data on gender balance of the workforce of interest. Chapter One provides an overview, and some highlights are set out below.

         The increase in the proportion of licensed female doctors has continued at a slightly faster pace in the last two years than between 2017 and 2020. But parity has not yet been achieved.

         In the 2018 to 2022 period, there was a 22% increase in the number of female doctors holding a licence.

         Meanwhile the number of male doctors has increased by 15%. This meant the proportion of female licensed doctors grew by 1.3 percentage points, leading to a mix of 49% female and 51% male doctors

         Currently, females make up a slightly larger proportion (52%) of doctors who join the workforce. This is due to the high proportion of female UK graduates (58%) joining the workforce in 2022. However, over half (52%) of IMGs who joined in the same year were male. The slightly higher proportion of female UK graduate joiners is set to continue. The 2022/23 medical student intake was 62% female.

                       The composition of those leaving the profession also affects the gender balance of the workforce. In 2022, 56% of doctors who left the workforce were male. This was especially true among leavers aged 50 or over, of whom 63% were male. The overall gender composition varies between specialties.

                       Obstetrics and gynaecology had the highest proportion of female doctors (61%). This was followed by paediatrics (59%), general practice (58%), and public health (56%). The lowest proportion of female doctors was seen in surgery, which was 16% female in 2022, although this did increase from 9% in 2012.

         The overall gender composition varies between specialties.

         The proportion of female doctors in all specialties increased between 2012 and 2022.

         Obstetrics and gynaecology had the highest proportion of female doctors (61%). This was followed by paediatrics (59%), general practice (58%), and public health (56%).

         The lowest proportion of female doctors was seen in surgery, which was 16% female in 2022, although this did increase from 9% in 2012.

November 2023