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Safer care for all

Solutions from professional regulation and beyond

In our report - Safer care for all - (published in September 2022) we examine the current state of professional health and care regulation in the UK. However we go beyond this in identifying and proposing solutions to some of the huge challenges facing health and social care today.

Our report considers four main themes:

  1. Tackling inequalities
  2. Regulating for new risks
  3. Facing up to the workforce crisis
  4. Accountability, fear and public safety

Next steps for Safer care for all and how it ties in with our strategic direction

We published Safer care for all in September 2022. Since then we have been carrying out extensive engagement with stakeholders (including by consulting on our draft Strategic Plan) to develop our focus for the next three years and plan for 2023-24.

During 2023/24 we intend to focus on the interlinked issues of workforce, inequalities and accountability. A recurring theme in our discussions with stakeholders was that of culture in health and care. We realise that the PSA, alone, cannot tackle poor workplace culture or the problems associated with it, but we hope that with the ambitious aims we've set out in our strategic plan, we can make a start and work with others to to highlight improvements needed to assure better and safer care for all.

  1. Workforce – we know that workforce shortages impact patient safety as well as professionals’ workplace wellbeing. We want to focus on building the evidence base around the regulatory barriers. Working with regulators and wider stakeholders, we want to identify solutions to help create a more agile workforce as well as encourage innovation. We think this work will help us shape a practitioner regulatory strategy. We believe this is needed to support health and care workforce strategies across the four countries of the UK.  
  2. Inequalities – in addition to the work we are doing to revise our expectations of how regulators will meet Standard 3 as part of our performance review process (Standard 3 of our Standards of Good Regulation is focused on regulators understanding the diversity of their registrants, patients and service users and not creating barriers through any of their processes/disadvantage people with protected characteristics), We are also introducing a new EDI standard for the Accredited Registers. Our work in this area will focus on engaging and convening stakeholders on key issues where we can add value and support action. This will include disseminating our consumer research on perceptions of discriminatory behaviour in health and care and looking at barriers to complaints and the role of healthcare professionals in tackling health inequalities.
  3. Accountability – our main focus in this area will be to work with regulators to encourage clear messaging on the role of professional regulators when there have been serious failures of care. We also want to facilitate and encourage stakeholders to look at how to learn from serious patient safety incidents. This will include consideration of the wider issues we are aware of that may impact on professionals’ fear of regulation and wider accountability mechanisms, such as blame culture, barriers to candour and experience of ‘moral injury’ by healthcare professional involved in major failures of care.      
  4. Safety system – work in this area will be primarily focused on building our evidence base on how the functions proposed for the Health and Social Care Safety Commissioner might be delivered in different ways across the four UK countries and engaging with existing bodies fulfilling some or all of these functions across the UK. We want to explore how improvements in the safety system might be achieved. We also intend to engage with stakeholders on the case for a more coordinated approach to public inquiries and reviews (through a Commissioner role or otherwise).     

We will continue having conversations with stakeholders as we take forward this work through the year so watch this space.


Take a closer look at the four issues

Tackling inequalities

There are still unequal and unfair outcomes for protected groups in aspects of professional regulation. There is also a lot we still do not know about how inequalities affect all-important complaints mechanisms when care has gone wrong – or indeed what this could tell us about biases in care itself. Professional regulation must work to address its own issues, and support professionals to help tackle inequalities in the design and delivery of care. But as a sector, we also need to be better at hearing diverse voices, and collecting, analysing and sharing data.

>>Find out more

Facing up to the workforce crisis

Workforce shortages are putting patients and service users at risk across the UK. Engrained attitudes to professional regulation and qualifications aren’t helping. Is it time to rethink the contribution of professional regulation to workforce planning?

>>Find out more

Regulating for new risks

Changes in the way that care is funded and delivered are sometimes made with limited focus on the risks and impacts on patients and service users, and how to manage them. Reforming the regulators gives us an opportunity to address known problems, and may even build in some agility for the future – if we take the opportunity presented to us. But we also need better, more reliable ways to anticipate these changes.

>>Find out more

Accountability, fear and public safety

Just cultures and individual accountability are both essential to better, safer care, and must coexist. Professional regulation should be clearer about its role, to reduce unnecessary anxiety and inappropriate complaints. We need to find ways for these new approaches to safety such as ‘safe spaces’, to incorporate openness with patients, service users and families, and action against individuals where it is needed for public safety.

>>Find out more

Read all recommendations

You can find a table of all our recommendations here. This is not also a case of the 'we say, you do' - we have also committed the Authority to play an active role in tackling these challenges. These commitments are also listed in the table.

What would you like to read?

We have several versions available.  Not got time to read the report in full? You can read through the executive summary here. This encapsulates the four main themes set out in the report as well as the recommendations we have put forward. Even more pressed for time? Then read The essentials - this (very) short section tells you what the report is all about.

You can also download:

There is also a Welsh translation available of front part of the report, including The essentials and the executive summary. You can download it here

We also have a Word version of the full report available. Please get in touch - using the email address below - if you would like a copy.

Please get in touch with us if you would like a Word version of the full report.

Starting the discussion

Safer care for all conference 

When we published Safer care for all in autumn 2022, one of our main aims was to start a debate on the issues highlighted and the recommendations we put forward in the report. To take the next steps we organised a conference. On 9 November 2022, over 250 attendees came together (virtually) to discuss issues highlighted in the report, including:

  • 'Does regulation need to change to deliver the workforce of the future?'
  • 'Do health/care professionals have a duty to tackle inequalities?'
  • 'Is regulation keeping patients safe?'
  • 'Are learning cultures compatible with individual accountability and openness when mistakes are made?'

The conference provided an opportunity to hear experts’ views as well as consider and contest the themes raised in the report. Speakers and delegates came from both professional and system regulators as well as patient organisations, the ombudsman, the NHS, health and care sector organisations and Chairs from major healthcare inquiries. You can find a summary of the main themes that came out of the discussions here.

Safer care for all guest blogs

We are also publishing a series of guest blogs written by stakeholders from across the sector. You can find all our guest blogs published to date below:

Read our blogs

A vision for an anti-racist NHS

Jan 17, 2023, 10:57 by Indranil Chakravorty, Chair of the Bapio Institute for Health Research
As part of our series of guest blogs to look in more detail at the themes highlighted in our report Safer care for, Indranil Chakravorty, Chair of the Bapio Institute for Health Research writes about their vision for an anti-racist NHS

Our report Safer care for all  launched at a Parliamentary reception on 6 September. It highlights some of the biggest challenges affecting the quality and safety of health and social care across the UK today.

We want Safer care for allto start a debate on the issues we highlight and the recommendations we have put forward in the report. As part of this debate, we are publishing a series of guest blogs written by stakeholders from across the sector. This blog is from Indranil Chakravorty, Chair of the Bapio Institute for Health Research, an arms-length body of the British Association of Physicians of Indian Origin.


Just over a century after the Spanish flu of 1918, which killed circa 50 million people, the world has not faced worse devastation than the COVID-19 pandemic, which has caused nearly 7 million deaths directly and immeasurable catastrophe to the socioeconomic fabric of society. While there were many positives, such as rapid digital connectivity, collaboration in science and technology across borders and a revolution in the speed and effectiveness of vaccine development and therapeutic advances, there were many unhappy revelations. Citizens worldwide quickly realised the contribution of healthcare professionals (HCPs) who faced the pandemic at a high cost to themselves and their families, many paying the ultimate price for their dedication to their profession.


The COVID-19 pandemic has exposed deep, ingrained societal inequalities and variable outcomes for patients and healthcare staff. It also exposed the chronic underfunding of healthcare in most countries, the often hostile and uncivil environment that HCPs work and train in and the challenges of recruiting, training and retaining staff. There is a global migration of HCPs from high-population, resource-poor countries to those with higher GDPs, better remuneration and higher per capita investment in population health. Yet, this traditional pathway of HCP migration lets the high cost to the public purse of healthcare education be borne ironically by resource-poor countries. The World Health Organisation has encouraged such net receivers of trained HCPs to sign up for ‘ethical migration’ policies to prevent the adverse impact of such emigration to the populations of resource-poor countries. In addition, the HCPs usually are minorities in their adopted countries or healthcare systems. The UK and its National Health Service have benefited from the contribution of international healthcare professionals from before its inception. Over the last seven decades of its existence, almost a third of the trained HCPs have been trained overseas. More international medical graduates have registered with the regulator in recent years than UK-trained ones. The UK healthcare system and most net-positive HCP migration countries depend on international HCPs for safe and effective care delivery to their citizens. Yet, the international HCPs and minorities are exposed to significant bias and exclusion at work, socio-economic discrimination, oppression and racism. Many are unfairly treated in career progression, excluded from non-mandatory career development and leadership opportunities. HCPs from minority backgrounds are much more likely to be reported to the regulator, investigated for professional misdemeanours and handed out disproportionately harsher punitive decisions. This leads to physical and mental health consequences, burnout, and dropout from the workforce. There are adverse consequences for patients under the care of teams where HCPs are themselves experiencing incivility, bias and discrimination. 


The British Association of Physicians of Indian Origin (BAPIO) was founded in 1996 to address inequalities, support international HCPs and work towards excellence in healthcare delivery in the UK. In its quarter-century of existence, BAPIO has had many achievements in addressing inequalities, the principal among them being the legal challenge to the Royal College of General Practitioners (2014) on differential success rates for candidates from minority ethnic backgrounds in the clinical examination, the change of visa rules and access to training for international medical graduates (2008) and more recently, the work undertaken in tackling differential attainment by its arms-length research institute in 2021 - the Bridging the Gap project (BTG21).

In the BTG21 project, Bapio Institute for Health Research (BIHR) undertook a systematic synthesis of evidence for differential attainment across the entire life cycle of the medical profession. The series of workshops built consensus with experts, stakeholders, grassroots organisations and individuals on the interventions that would lead to effective change in the status quo of differential attainment (DA) for HCPs from minority ethnic backgrounds and with protected characteristics.

In tackling DA in recruitment and career progression, the BTG21 consensus recommended several actions for stakeholder organisations, including:

  • Recognising the demonstrable economic benefits of diversity in the workforce,
  • Celebrating the contribution of international HCPs, the skills and experience they bring from their home countries and different healthcare systems
  • Implement and resource a comprehensive induction and support package for all IMGs (and for other professionals)
  • Removing structural bias by

○  Decolonising the medical curriculum and assessments (i.e. SJTs)

○    Widening participation in healthcare careers through initiatives in every higher education institution, reaching into schools and communities which are traditionally under-represented

○      Affirmative actions such as removing subject prerequisites which perpetuate the DA at entry, but also subsequent applications such as research funding/career choice; providing access to foundation courses for those without previous attainment in traditional STEM subjects; providing a proportionate balance of access to applicants from state or public schools and IMGs

○      Breaking geographical disparities in access by targeting areas with multiple deprivations or low participation in higher education or research funding

○      Balancing economic disadvantage by providing bursaries in school and through higher education, access to apprenticeship medical courses, removing the advantage for intercalated diplomas/ degrees as essential criteria, and providing resources to pursue early career academic/research opportunities for talented individuals

○      Removing the structural disadvantage for IMGs in summative assessments by – decolonising curricula, rationalising the requirement for high levels of English proficiency, supporting with preparatory courses in clinical communication, consultation skills and guided understanding of prevailing legal, cultural and ethical norms.

  • Work to remove differences between career doctors (with a national training number) and non-career doctors (Trust doctors or locally employed doctors), a 2-tier training and employment system and thus unify nomenclature as a postgraduate doctor in the national or local training scheme.

○      Agree on a national job description, recruitment process and support for all doctors, including national employment and supervision for Locally employed doctors (LED) and SAS doctors.

  • Remove barriers and widen participation at various entry points – specific required traditional criteria and interview questions used to rank an applicant may have little bearing on being a good doctor or researcher. They may reflect a need for more opportunities and access to resources rather than ability or talent. Identify people with talent and foster/nurture them into aspiring roles.
  • Review, measure and report all assessment processes' equality and diversity impact.

○      Undertake root and branch reform of established content, curricula and assessment processes to take into account EDI with a diverse, representative panel

○      Rethink processes which consistently fail to achieve equality and diversity – multiple, multi-dimensional, low-stakes summative assessments undertaken in real-life workplaces, supported by adequate training, resources and time to train assessors

○      Use formative assessment and structured, meaningful feedback; make holistic progression decisions based on a 360-degree assessment of knowledge, behaviour, and skills collated and triangulated from multiple sources at ARCPs.

○      Share responsibility and accountability with supervisors, training program directors and learners to ensure that appropriately defined standards for success/ progression are met.

For many years, the focus of organisations and well-meaning members of healthcare leaders has been focused on a ‘deficit model’, therefore developing supportive interventions to bring the disadvantaged HCPs to meet the expected standards and promoting acculturation. These policies and processes have inadvertently created dissonance among the affected HCPs and an imperceptible change in the DA that exists in every HCPs journey. The BTG21 approach has been radically different and recognised that the societal bias reflected in institutional discrimination could not be solved by adopting small interventions to support the oppressed/disadvantaged. Therefore, the BTG21 review has recommended systemic change and measures that address the issue’s root cause. Our recommendations are aimed at changing policy at the organisational and national levels. Ultimately, organisations and their leaders must recognise, acknowledge and lead the change. They must be held accountable and comprehensive datasets must be collected, analysed and presented annually. We are working with project evaluation teams to develop self-assessment analytical tools for organisations and a national benchmark, which will enhance the results from Staff surveys and Workforce Race Equality Standards.

There are the early winds of change appearing. The regulator for doctors (General Medical Council), nurses (Nursing & Midwifery Council) and General Pharmaceutical Council recognise the lack of equality and diversity in their processes (e.g. refreshing of the Good Medical Practice guidance by GMC UK) and are collecting and presenting data to be transparent, offering external reviews of its decisions and pledging to achieve fairness for all. Academic institutions are opening their books to external scrutiny (i.e. Royal College of Surgeons of England commissioned Dame Helena Kennedy to review discrimination in its processes) and reviewing curricula, the equality and diversity impact of its assessment/ outcomes. At a national level, the UK NHS has pledged through its people plan to provide a level playing field, recognise the diversity of its staff and publish the equality of access to career progression to senior roles, pay parity, tackling incivility in the workplace and considering a review of its complaints, whistleblowing and investigation processes.

Ultimately, unless NHS England, UK Health boards, the UK Department of Health and Social Care and the UK PMO undertake an anti-racist, anti-discrimination policy, the Equality Act of 2010's provisions will not be realised. BAPIO and its allies in the Alliance for Equality for Healthcare Professions will need to continue to work collaboratively with the government and stakeholders in developing standards, building consensus and evaluating the effectiveness of interventions undertaken.   

Find out more


Read our full report Safer care for all - solutions from professional regulation and beyond  or through chapter 1 -  No more excuses - tackling inequalities. There are also shorter versions available, including the executive summary, you can download these versions here.

Find out more about BAPIO here and the Bapio Institute for Health Research here

Get in touch

Contact us if you would like to join the discussion about how we can work together to make health and social care safer for all. You can get in touch by emailing