As regulator councils set the strategic direction for the organisation, it is important that the membership of those councils should reflect the wider public, their patients and their registrants. But this has not always been the case, so we and the regulators have been working together to drive more diversity among council members.

A lesser-known role we play at the PSA is advising the Privy Council about the appointment of candidates recommended as council members for the health regulators. Our role is to check the recruitment process used and assess whether it is fair, open and inclusive.

In the past, the potential of many capable individuals to become council members may have been missed; either because they assumed council membership was not for them; or limited advertising for the role meant it was not seen by a wider, more diverse range of possible recruits. Equally, regulators may have held fixed ideas about the seniority and experience required to fulfil a council member role that may have resulted in recruiting from a narrow field of candidates.

While we cannot influence the regulators’ decisions about who to recommend for appointment, we do encourage them to adopt strategies we believe will deliver the widest and fairest competition.

The approach regulators are taking to ensure that they increase the diversity of their councils and recommend candidates from the widest possible field has become increasingly sophisticated, challenging any lingering assumptions about potential candidates and panellists.

Requirements

Good planning is essential to attracting the most competitive field of candidates. 

Regulators’ selection criteria should be broad and avoid unnecessary requirements that may deter a wider field of candidates (such as younger candidates or those with busy careers or businesses).

The approach to EDI

• As part of planning, an Equality Impact Assessment (EIA) should be undertaken. We want to see an EIA that has:
  • Considered the outcomes of previous processes.
  • Learned from external research and best practice.
  • Assessed barriers to participation and produced an action plan to mitigate those barriers with tangible actions.
• The methods used to deliver a diverse shortlist, such as the advertising and search for candidates, should be informed by the EIA and action plan. For example, we expect regulators to use a mix of specialist and generic jobsites when advertising roles and to use their stakeholder networks, including representative groups.
• If the regulator uses search consultants, these should have a track record in delivering diverse longlists and operate with the same commitment to EDI as the regulator.
• Regulators must be open to reasonable adjustments, asking for these proactively and individually of both long and shortlisted candidates.

The selection process

• Selections should be made by a diverse and well-prepared panel of three to five individuals.
• Panel members should receive guidance on the selection process and EDI training. This usually includes training on understanding unconscious bias.
• We recommend anonymisation of candidate identities at least until the end of the longlisting stage to ensure early decisions are made on merit alone.
• An effective complaints process for candidates is also important to ensure that any concerns of unfavourable treatment are promptly addressed.
• An Independent Panel Member (IPM) with a high level of experience in appointments provides the PSA with assurance about the process, specifically:
  • How well EDI matters were managed.
  • How well the process was chaired.
  • If they can recommend the process as demonstrably fair.

Is the regulator approach to EDI in council appointments working?

Recent evidence shows that it is. Regulator councils and the candidates who are applying to become members are more diverse across protected characteristics. However, some regulators are having more success than others and we urge regulators to learn from the successful approaches adopted by their peers.

We are also seeing more regulator initiatives, like council apprentice or associate schemes, to develop candidates and get (usually) younger input into council business. The PSA runs such a scheme and recently welcomed our new Associate Board Member Ruth Ajayi.

One of the Councils whose method has impressed us is the General Pharmaceutical Council (GPhC). We asked its Chief of Staff, Laura McClintock to tell us a little about their approach.

---

General Pharmaceutical Council case study

As the independent regulator for pharmacy in Great Britain, we want our workforce to reflect the diversity of the public we serve and the professions we regulate. It’s vital that our council members are drawn from the widest possible talent pools, bringing with them a diversity of life experiences, ideas and perspectives, to enhance our decision-making. This is a core part of our EDI strategy and one that frames our work in relation to appointments to our governing council. This is also something that’s promoted through the PSA's Good Practice in Making Council Appointments.

Greater board diversity is about diversity of thought and experience, as well as the legally protected characteristics. While we’ve seen significant progress on gender and ethnicity at the GPhC, we know we have more to do on other characteristics and different types of registrant roles. For example, we know that pharmacy technicians are still under-represented in senior leadership roles in the sector compared to pharmacists and we receive fewer applications from pharmacy technicians for council member roles. We’ve been engaging with stakeholders to identify collaborative ways to break down some of those barriers and promote more participation in future recruitment rounds.

What’s working for us?

Moving the dial on board diversity takes a dedicated and co-ordinated approach, with a genuine commitment from everyone involved in the process. This includes the staff involved in running the appointment processes, any external recruiters, members of selection panels and everyone involved in the oversight and scrutiny process. 

Here are some of the practical steps which have helped us progress in this area:

Ruth Ajayi joined our Board as an Associate Board Member in May 2024. The role is designed to provide experience of non-executive leadership roles. It came about as part of our first Equality, Diversity and Inclusion action plan to enhance the diversity of the PSA’s Board.

In this blog, in the form of a Q&A, we find out more about Ruth, why she applied, what she aims to bring to the role, and what she hopes to gain from the experience.

Q. You have held a number of roles and have a lot of experience working in the health and care sector. What drew you to the role of Associate Board member for the PSA?

I have always been passionate about patient-centred care and public protection, and this role provides an opportunity to continue my work in this vital area at a strategic level. As a patient advocate, the mission of the PSA – "to protect patients, service users, and the public by improving the regulation and registration of health and social care professionals” – deeply resonates with me.

Having worked in various roles within the health and care sector mostly as a Programme Manager, I was looking to transition to a career as a Non-Executive Director. The Associate Board Member role provides me with the training and experiences necessary for this progression and allows me to influence healthcare on a broader scale.

Q. And did you know much about professional regulation before you applied?

My understanding of professional regulation was quite basic before I applied for this role. However, the interview preparation process gave me a good insight into the complexities and importance of professional regulation.

Q. What are you hoping to gain from the experience as an Associate Board Member?

I aspire to gain many things from my experience as an Associate Board Member. This includes becoming a competent and experienced Non-Executive Director by utilising the structured induction, mentorship, and tailored training opportunities provided by the PSA.

I also hope to contribute to the strategic direction and governance of the PSA by utilising my experience and adding to the diversity of perspectives around the Board table.

Lastly, I aim to strengthen my professional network and build confidence in board-level responsibilities. This experience will prepare me for future Non-Executive opportunities within the healthcare sector and beyond.

Q. And what would you like the PSA to gain from your appointment and the skills, experience and expertise you bring to the role?

I hope the PSA can benefit from my experience in patient advocacy and public and patient involvement (PPI) to raise its profile among the public. The PSA can utilise my network to embed PPI in the implementation of its Strategic Plan 2023-2026, ensuring that patient voices are central to our initiatives.

I have a strong interest in Artificial Intelligence (AI), and I would like the organisation to explore how its adoption can enhance our efficiency. I am skilled and experienced in stakeholder engagement and PSA can utilise this with its counterparts in Europe and the rest of the world in fostering international collaboration and knowledge-sharing.

Additionally, I bring a unique perspective to the Board due to my career path, which differs significantly from the traditional paths of most directors and board members. This diversity of thought will enrich board discussions and contribute to innovative, out-of-the-box solutions for the challenges we face.

Q. How do you think the lived experience can contribute to improving regulation and making care safer for all?

I strongly believe that lived experiences are crucial in improving regulation and making care safer for all. By learning from both success stories and adverse events, we can gain essential insights that drive meaningful change. If our organisation's ethos is to protect the public, we must continue to actively seek and incorporate the lived experiences of both the public and healthcare professionals.

Understanding their experiences and the challenges each party faces is essential. We need to learn what public protection means to them and gather their ideas on how the PSA can effectively collaborate with and support regulators and other key stakeholders. By doing so, we can support the regulators to facilitate an environment, systems, and processes that encourage and support healthcare providers in delivering safe care for members of the public.

Additionally, we can benefit greatly from learning from regulatory organisations similar to the PSA in other parts of the world. By understanding their approaches and the outcomes they have achieved, we can incorporate best practices and innovative solutions into our own regulatory frameworks.

This collaborative approach ensures that our regulatory frameworks are informed by real-world experiences, leading to more effective and practical solutions that ultimately enhance public safety.

Q. You are an advocate of patient-centred care – can you explain more about what this means and how it can improve healthcare? How could the regulators facilitate this approach?

Patient-centred care focuses on respecting and responding to the preferences, needs, and values of patients. It places the patient at the heart of all decisions, ensuring that they are active participants in their own care.

This approach can significantly improve healthcare by fostering better communication between patients and healthcare providers, which leads to more accurate diagnoses, increased adherence to treatment plans, and overall better health outcomes. When patients feel heard and respected, their trust in the healthcare system strengthens, leading to higher satisfaction and engagement.

Regulators have an important role in facilitating this approach. They can set standards and guidelines that prioritise patient-centred care, ensuring that healthcare providers adopt practices that truly involve patients in their own care. Additionally, regulators can support healthcare professionals in addressing the power dynamics that often exist between practitioners and patients. By promoting equal partnerships, healthcare professionals can ensure that patients feel empowered and respected.

Providing patients with all the information they need to make informed decisions is also essential. Regulators can mandate that healthcare providers offer comprehensive, understandable, and accessible information about diagnoses, treatment options, and potential outcomes. This transparency enables patients to make informed choices about their care, further enhancing their involvement and satisfaction.

Moreover, regulators can support training and development programs that equip healthcare professionals with the skills needed to implement patient-centred care effectively. By promoting continuous education and fostering a culture of empathy and respect, regulators can help healthcare providers better engage with their patients.

Regulators can also facilitate the collection and analysis of patient feedback to continuously improve care delivery. By promoting transparency and accountability, they can ensure that patient experiences and outcomes are consistently monitored and used to drive improvements in the healthcare system.

Regulators are already making strides in these areas, but it is crucial they continue to ensure healthcare providers and practitioners consistently adopt and embed the principles of patient-centred care into their practice – it should be the golden thread that runs through their practice. Continuous monitoring and reinforcement of these principles are necessary to sustain improvements in patient care and safety.

Q. What difference or contribution would you like to make during your term?

During my term, I aim to make a meaningful contribution by finding innovative ways for healthcare practitioners and the public to participate in our decision-making processes. I would love to see a regulator, healthcare practitioner, or member of the public share their experiences during our public board meetings. Additionally, I am keen to see the PSA collaborate with patient organisations and other patient- and public-focused organisations in the UK. Establishing a patient panel or network and including that in the governance of our board would be a significant achievement.

I would like to contribute to the strengthening of international collaboration by building relationships with similar organisations worldwide. This exchange of knowledge and best practices can lead to innovative solutions and improvements in healthcare regulation on a global scale.

I also hope that my contribution as an Associate Board Member will serve as evidence and a case study of how diversity and inclusion benefit boards in the UK. By proactively seeking diversity, the PSA is demonstrating the tangible benefits of varied perspectives and experiences in enhancing board effectiveness and decision-making.

Defining restorative justice and professional regulation

What do I mean by restorative justice (RJ)? The Crown Prosecution Service describes RJ as a process through which parties with a stake in an instance of wrongdoing “collectively resolve how to deal with the aftermath of the offence and its implications for the future.” Major proponents of restorative justice, Strang and Braithwaite (2002), use a similar definition: "Stakeholders affected by an injustice have an opportunity to communicate about the consequences of the injustice and what is to be done to right the wrong."

Imagine a playground dispute where Chris snatches away Robin’s ball. An RJ approach would be to see whether they might sit down together. Robin then explains to Chris how that incident made them feel. Chris might be asked to reflect on what motivated them to do it. Together they may resolve what would right the wrong and how to deal with the same situation in the future. The message sent out is one of reconciliation and resolution, but it probably does not set a precedent for future resolutions and there is no general regulatory conclusion to be drawn. Authority is not invoked in a visible way.

Now let’s look at professional regulation. In a recent consultation, the Government stated the purpose of the regulation of health and social care professions was “to protect the public from the risk of harm from the provision of health and social care services.” The aim is to do so using the “most effective and proportionate means.” For professions not regulated by statute, “Accreditation by the PSA provides assurance that a register meets standards in a number of areas, including protecting the public, complaints handling, governance, setting standards for registrants, education and training, and managing the register.”

In the same playground dispute, Robin becomes a complainant, then witness to Robin’s rule breaking. The rule against snatching is rehearsed and the circumstances examined to determine whether the rule has been broken. Consideration is given as to the likelihood of Chris doing it again, the general message that will be sent out by making any consequence public and the appropriate steps to prevent Chris or anyone else snatching balls from others in the future. Robin may or may not get their ball back. Ball games could be banned because they are the cause of frequent disputes. Chris might get suspended from playing ball or just be given a warning. The rules are reinforced and perhaps refined and authority is reinforced.

Contrasting the models

Restorative justice focuses on righting wrongs, resolution and a sense of collective healing and rebalancing. Professional regulation focuses on preventing harm, defining boundaries of acceptable conduct and maintaining public confidence and professional standards.

Restorative justice operates with someone (or a particular community) in mind, while professional regulation has everyone (or the general public) in mind. When looked at this way, for the complainant/victim, restorative justice processes feel, well, more just. That’s because the whole purpose of RJ is to make the complainant/victim feel that way. Invariably, that’s also the experience of people who are the subject of the complaint, because coming to acceptance is part of the process’ objective.

Regulation feels altogether a colder process. It’s not aimed at addressing the feelings of the participants, but at a principled approach which satisfies an unspecified public ethical attitude. When rules meet people, there is often an untidy fit and explaining to a complainant/victim that the regulator is there to perform a public duty, rather than address a private wrong, can feel unjust and unsatisfactory.

Restorative justice looks at how the past and people’s narratives can be used to understand how people think and feel now and how those thoughts and feelings and will influence future behaviours and attitudes. With regulatory decision-making, the past is taken, so far as it can be, to be a predictor of future conduct and risk. There is a subjective element in relation to the alleged wrongdoer and the likelihood that their attitude and behaviour will predict compliance in the future, but the complainant’s experience is only really relevant to the extent that it is a measure of harm and potential harm to be prevented.

When is RJ a solution for resolving professional complaints?

In my view, the situations where an RJ approach might be appropriate include four categories of situation – drawn from an analysis of using RJ approaches across the Commonwealth.

1. Restorative justice is a useful mechanism where complaints processes are being widely used as a dispute resolution mechanism, rather than for the purposes of addressing issues of public harm. This might be the situation where the organisation deals with complaints between professionals or complaints about the standard of service outside the boundaries of public safety. Using RJ in these circumstances is a question of pragmatism and cost-benefit analysis. It might be seen as a supplementary benefit and could improve the public perception of the profession. Care should be taken to ensure RJ processes do not impinge on the processes in place to ensure fair, consistent and systematic investigation of issues relating to public safety.

    

2. Restorative justice may be appropriate also in “hard cases.” With the best will in the world, authors of professional standards procedures can’t envisage every circumstance. When the question of whether an issue is covered within those standards, proportionality will tend to favour a conservative view of the rules. This invariably means that ambiguities or loopholes should be resolved in favour of the accused professional. However, it may be apparent that there is manifest unfairness to the complainant which may also be harmful to the profession.

    

   In those circumstances, with the consent of both parties, the organisation may elect to use an RJ approach to support dispute resolution and professional reflection and development. Care should always be taken not to infer that this is an alternative to formal processes or that if not engaged with, it may lead to formal action.
   

   A significant benefit of this approach is the potential for organisational learning to inform any required tweak of processes or practice guidance.
   

    

3. Restorative justice can be very useful when dealing with a closely related cluster of complaints or a community who are collectively, but differentially, affected. RJ can be effective when there is a systemic issue, such as where there is a breakdown in confidence in the profession or professional organisation.

   It may be appropriate where both the organisation and the complainants lack the means or time to pursue independent complaints with hope of timely redress. In such circumstances, the process is one whereby the organisation assumes a collective responsibility for the profession, rather than forming the basis of action against specific members.
   

   This is a mature approach to regulation of a profession and not without risk. It adopts a community resolution approach and often requires the enlistment of expertise and facilitation outside the organisation. As a methodology, it contrasts with the “independent inquiry” approach, which may be appropriate where there is an identification of formal failures.
   

    

4. Organisations with considerable experience with patterns of professional conduct that lead to complaints may decide that an RJ approach can provide an educational and rehabilitative approach to assist a professional to be less prone to be a threat to public safety.

   It would be quite a fine-tuned judgment to state that using an RJ approach, rather than formal mechanisms, can meet both the dispute resolution outcomes desired by stakeholders and the public safety duty, without compromise to either.

   This approach, which is often informed by the view that a standard sanction is less likely to be effective in protecting the public than an RJ approach, is seldom cheaper, less bureaucratic or quicker than following standard procedures.

   That being said, this approach is much more in line with the general ethos of reinforcing professional integrity and a sense of confidence in a profession, rather than standards of service.

Conclusion

Restorative justice is not an appropriate approach for the resolution of complaints that go to the heart of protecting public safety. Situations where formal sanctions would reasonably be considered are not ones which should normally invite RJ processes. They lack objectivity, predictability and consistency. Since they focus on achieving outcomes that satisfy the complainant, they tend to involve the consideration of issues and outcomes that may not be relevant to a laser-focus on protecting the public.

However, RJ schemes to divert service complaints and other disputes can be useful to promote public confidence in bodies and professions. These disputes require resource, and, in my experience, few stand the test of time. Legal challenges modify organisational risk appetites and maintaining the expertise and resources to manage the processes can be difficult.

The same can be said of RJ diversions where it may provide an alternative means to achieve the public safety regulatory ends. The ethos of this approach is actually highly desirable in a professional regulatory context but is also a resource-intensive and risky approach.

As a means to address the confidence of a community, RJ can provide an effective and sometimes neglected supplement to organisational dispute resolution.

So, how do we deliver RJ in professional regulation? Well, that’s a whole other question.

1. Listen to patients and service users

2. Education, education, education

3. Balance the carrot with the stick

4. Regulation should set a good example

5. Speak with one voice

In March 2024, the PSA convened a roundtable discussion entitled ‘Accountability, fear and public safety’ to explore some of the recent NHS safety culture initiatives in England and their relationship with professional health regulation. Representatives from patient advocacy groups, NHS organisations and regulators took part. We began to explore how to bring the best of safety culture initiatives and the best of regulatory processes together to do more for patient safety. It was a wide-ranging discussion, with some predictable recurring themes.

Not all safety culture initiatives are the same. But all, whether it’s the Health Service Safety Investigations Body (HSSIB), NHSE’s Patient Safety Incident Response Framework (PSIRF), or Mersey Care’s just culture have a number of things in common. The first is a focus on learning from errors and understanding and acting with a focus on system failures rather than individual failures in order to make improvements. The second are myths and misunderstandings about what safety culture initiatives do. For example, much of the focus on HSSIB has been on the misperception that the intention is to exclude patients and families from all its investigations. Other misperceptions are that HSSIB can investigate serious misconduct, and that it prevents other investigations from occurring at the same time. Similarly, PSIRF, with its intent to focus on learning and compassionate engagement with all parties, has been misunderstood as a ‘less robust’ process than its predecessor, the Serious Incident Reporting Framework. We also heard from Mersey Care that just culture is often misunderstood as ‘zero blame’ culture, rather than an approach which seeks to balance safety, accountability, learning and fairness into one, building ‘safety from below’ rather than imposed from above. In short, ‘just culture’ does not equate with ‘zero blame’. There will often be individuals who must be held to account. But if staff feel safe, they will be inclined to be ‘candourous’ too.

Evidence from the Parliamentary Health Service Ombudsman (PHSO) and NHS Resolution suggested that, in many places, professionals do not feel safe or free to speak up or raise concerns. There was consensus that the most risky workplaces are often ‘anxiety spaces’ – characterised by high accountability and low levels of psychological safety. These workplaces tend to have low staff retention rates and poorer outcomes for patients.

All participants agreed with Action against Medical Accidents (AvMA) on what patients want – acknowledgement, apology (meaningful), accountability, action (learning so it doesn’t happen again), and access to justice (to put right the harm that has happened). Equally, AvMA said, accountability is not just about the individual, it is about systems, processes, leaders, management and governance. Sands (a charity saving babies’ lives and supporting bereaved families) pointed to the high levels of frustration when families see no change, and the same issues recur time and again. Patients and families want to be involved in the learning and to know their voice is valued and listened to.

Regulators at the roundtable welcomed the emphasis on patient involvement, alongside the focus on learning. They too pointed to misconceptions and misunderstanding of what regulators do. Fitness to practise should be one part of the safety system, but only a small part for a small number of individuals.

Common myths and misunderstandings: healthcare, safety cultures & regulation

1. Just culture means zero blame and no accountability
2. Regulation is ‘out to get’ health care practitioners
3. Accountability always leads to sanction
4. Accountability is only about people, not about systems, places and processes
5. Health practitioners will lose their registration if investigated
6. Healthcare comes without risk

If nothing else, this roundtable highlighted the complexities involved in delivering a safe, accountable system of health care. The pull of a just culture, towards learning and openness, against the push of regulation, which appears to want to hold individuals to account for mistakes and errors, seems irreconcilable. So where does this take us?

In essence all these new, and not so new (Dekker, 2012) safety culture initiatives are about creating a learning environment in which all parties are involved, respected, seen as equals, with a view to restoring and re-building what is broken. They tie in with the principles of speaking up, increasing cultural competence and striving for equality and diversity. These are all hugely important building blocks of better healthcare.

And here lies the contrast. Alongside this we have built a system of individual redress in UK health professional regulation that is adversarial for all parties. Regulating ‘in the public interest’ can engender the very thing that is toxic to learning and health care safety and improvement – fear, some would say terror, even (Berwick, 2013). Adversarial approaches by definition precipitate defensiveness, and defensiveness supresses learning. To add to the complexity, regulatory decisions that result in practitioner suspensions where there is no obvious risk to patients (GMC versus Arora) invite criticism and dismay in a regulatory process that seems out of step not only with the ambitions of safety cultures, workforce pressures and the enormous stresses of our post pandemic health care environments.

What is not talked about to any great extent with the public or health practitioners is that professionals in health care don’t turn up to work to do a bad job. Bad things happen. Some elements of health care are risky. There will be system failures and human error. Risk is inherent in healthcare, and this acceptance is essential to tackling patient safety issues – to allow both the organisation, and the staff involved to learn from mistakes.

The fear of regulatory action, even when it is not likely to occur, can have negative consequences for individuals, their colleagues. It can also run counter to maintaining a healthy organisational culture. The majority of failures are system failures that involve humans, not human failures that involve systems. The sharp end of regulation therefore should be reserved for the latter, and just culture approaches, which use a restorative response to harm and involve patients and families, for the former.

This roundtable discussion suggests that health professional regulation needs to be refined, re-purposed and refocused to go with the grain of improvement, compassion, restoration and learning. Regulators need to open the door to just cultures becoming the norm in health care whilst keeping the safety of patients and families paramount. Health professional regulators could do more through their communication and engagement to address regulatory myths, for example that referral to the regulator will inevitably lead to a sanction, or that regulators will, by default, blame individuals for system failures. Sharing data and insights, being clearer about expectations and outcomes of complaints, referencing safety cultures in standards and education and training, in short, using the evidence in more proactive ways to help with this. Perhaps most urgent is thinking about how to address the fear factor in fitness to practise processes, which contributes to distress, damage and in rare and tragic instances, the untimely death of practitioners.

Doing the best for patients, in a just culture environment, means early resolution and engagement with patients and families as soon as possible after an event, learning from errors. It does not equate to zero blame, however. Successful safety culture initiatives are mindful of the need to maintain accountability, and the cloak of anonymity should not be necessary in a strong just culture in which people feel able to speak candidly about mistakes.

In the very rare cases of deliberate harm, intent to deceive, boundary violations and exploitation of power, individual accountability and swift regulatory action will always be required.

What do we hear time and again from patients? They want to be listened to, they want transparency, involvement, shared learning and no-one experiencing the harm again. In rare instances, they seek punishment. Health care, like every other human service, needs strong safety nets to protect patients from poor care, deliberate harm. These are the finely crafted and co-designed standards on education, ongoing learning, competence and conduct. But these are not enough. For health care to thrive, we need a seedbed of trust. And for trust to thrive we need a workforce to feel safe at work, free to be honest when things go wrong, not to be blamed for system failures. Just culture environments have been shown to deliver positives – not only trust and learning, but also, crucially, better professional wellbeing, better patient outcomes and safer environments. If regulation is to stay relevant and respected it must go with this grain, and not against it.

There is more work to be done to bring the best of safety culture initiatives and the best of regulatory processes together to do more for patient safety.

Anna van der Gaag

Visiting Professor, Ethics and Regulation, University of Surrey

---

Acknowledgements

I would like to thank all those who attended the roundtable from AvMa, Sands, NHSE, NHS Resolution, HSSIB, Mersey Care, PHSO, GPhC, GOsC, HCPC, NMC, GMC and Dinah Godfree, Alan Clamp and colleagues from PSA in attendance.

Professor Louise Wallace, one of the researchers behind the Witness to Harm study into the experience of witnesses in the fitness to practise process, shares principles of a trauma informed approach which regulators could adopt in their fitness to practise processes. 

“….No one was taking responsibility for what happened…it was just kind of like everyone was just ticking a box, that they’d gone through the process of, and this is just my interpretation, ….it was just everyone was going through a motion of doing something about it, because they had to, but ultimately no one was taking responsibility or was held to account.”

This quote, from one of the participants in the Witness to Harm study, illustrates the experience of being a witness in the fitness to practise process of a healthcare regulator. It also reminds us that although the regulator works through these processes every day and gets used to them, many of these concerns involve someone who has experienced harm. 

We hear a good deal these days about how witnesses in criminal trials can feel that they are the ones on trial. They can feel disbelieved and undermined as they try to give their evidence. Often, they've told their story numerous times before being cross examined. Each time for them can be not only distressing but bring back feelings, emotions and images that feel as real and in the moment as the original trauma. We know that this undermines the way in which they give their evidence. We also know this is an example of re-traumatisation by the criminal justice system.

In professional regulation, those who make a complaint and go on to be a witness in a hearing against the healthcare professional who harmed them, may feel there are marked similarities in their experience. Research conducted by five universities into the experience of the public in the fitness to practise process (FtP), is globally the first study conducted independently to evidence their expectations and experiences.

Professional regulators are aware that they need to encourage and support the public to make complaints and to give their evidence, precisely because that evidence may be crucial to a case and therefore to keeping the public safe and upholding the standards of the professions. They also know that the FtP process is distressing and arduous for healthcare professionals, confirmed by independent research, for example on suicides in doctors related to the FtP process. The Witness to Harm research involved engagement with regulators, professional bodies, the lawyers and unions that defend the healthcare professionals and who cross-examine witnesses in FtP. Most importantly, people who have experienced the process as witnesses have contributed as advisers immensely and selflessly, throughout. And while the regulators seek to support the public through the process, we found that the witnesses’ experiences shared with us did not reflect a compassionate, respectful or dignified approach.  

We found that regulators describe on their websites the processes and reasons for the stages of the FtP process. But they seldom describe how long this is expected to take. So, it’s not made clear what will be involved for a member of the public if they have the courage and tenacity to stick with the process over what is often many years since they raised a concern. Nor do they set out that through this time witnesses may be passed along a conveyor belt of contacts within a regulator, and have to repeatedly re-tell their story to different people. Professional regulators describe their approach to the public in various ways, including phrases such as “customer care” and “person centred care”, although how these are demonstrated in practice is often unclear to the public. 

“No, there was no human contact. It's all emails. It's not actually talking to somebody. So, I don't think it's reasonable to respond that way. I think it needs more human contact beforehand, maybe. And more, better advice. They didn't want to talk to you. I don't know why. {..} If I mentioned anything to them, they would say 'we're not allowed to discuss that. No. No. No. No'.”

“... Nobody had explained that to me and I had nobody really to speak to about it. I researched it and worked out why it was happening, but nobody came to me and explained this is why it’s happening.”

The examples above were from the public. Notably, employer witnesses in FtP also reported finding the process unexpectedly harrowing:

“It was awful. And I have a number of colleagues who have been through the same. So much so that now if we have someone going to the [regulator] we send someone with them. We make sure that they’ve got a senior member of staff going with them because it’s, the way they were made to feel was appalling. And the way I was made to feel was really really awful, really awful.”

Trauma Informed Approach

In our research we came across an approach imported from the criminal justice systems in Scotland that had been adopted by the Scottish Social Services Council and part of a Scottish government-wide commitment to delivering trauma informed public services (Initially called the National Trauma Training Programme, established in 2018). The trauma informed justice framework is based on heavy-weight research in the experience of sexual trauma victims and victims of other traumatic crimes going through the criminal justice process. 

According to  NHS Education for Scotland being ‘Trauma Informed’ means being able to recognise when someone may be affected by trauma, collaboratively adjusting how public service providers (such as regulators) take this into account and responding in a way that supports recovery, does no harm and recognises and supports people’s resilience.

Further, it can be argued that doing so enables people to give their best evidence, which is in everyone’s interests. Witnesses should be protected as far as possible from further harm that might be induced by the FtP process, and particularly from adversarial cross examination. This can include misinterpretation or misrepresenting the impact of the original trauma on the witness or how they give their evidence in the case.

Our research has evidenced the multiple touch points in the FtP journey that can be not only distressing for most people, but potentially re-traumatising for some people who have experienced harm and who may be experiencing lifelong impact from post-traumatic stress.

The trauma informed approach also recognises the importance of supporting the wellbeing of those who provide public services at the front line. In regulators, these are often administrative rather than legally qualified staff who interact with those who have experienced harm previously. This repeated experience is potentially distressing. If repeated and unsupported, it could lead to burnout and to compassion fatigue. Their wellbeing and how they cope with what may be challenging conversations, is an important part of the trauma informed approach. It necessarily depends on trauma informed (and compassionate) leadership and the culture of the regulator.

Principles

From our findings, and the trauma informed approach, there are some principles that we recommend regulators should consider putting into place not just for those people who have been harmed by the original events but as a compassionate approach for all members of the public who engage with the FtP process:

1. Do what you said you would do when you said you would do it.
2. How can I make the FtP process safe and predictable as possible for this person?
3. How can I help them understand, in plain English and avoiding jargon, what is happening and why, and who in the process will be making what decisions?
4. How can people be prepared for what to expect in cross examination, and enabled to have a sense of agency in this process?

As a lay adjudicator member myself for two regulators under the PSA, I can also see the potential for more focused training and guidance to panel members in preparation for hearings involving the public as witnesses.

We are refining our recommendations from this unique research.  We are building resources for all stakeholders – professionals, and their employers, the regulators and the public. They will be publicised in the next few months on our website and beyond.

https://wels.open.ac.uk/research/witness-harm-holding-account

Louise Wallace, Professor of Psychology & Health, The Open University.

This project is funded by the NIHR HS&DR programme, NIHR131322. The views expressed are those of the author and not necessarily those of the NIHR or the Department of Health and Social Care.

Discrimination is a pervasive and entrenched issue that affects individuals and communities around the world. Every individual deserves to be treated with dignity, respect and fairness, regardless of their gender, sexual orientation, race, disability, or any other (protected) characteristic. In recognition of the importance of tackling discrimination in all its forms, Zero Discrimination Day is observed annually on 1 March. This day is a reminder for us all to celebrate diversity and to take action to promote equality, diversity and inclusion.

Zero Discrimination Day was first observed by the United Nations 10 years ago in 2014, following a campaign by the UNAIDS programme to promote equality in access to healthcare services for people living with HIV and AIDS. Inequality in access to care is a familiar issue to us in the UK, as recognised in our Safer care for all report in 2022. Over the last 10 years, Zero Discrimination Day has developed to include a broader set of themes of inclusion and acceptance for all people, regardless of their background or identity.

Zero Discrimination Day is an opportunity to celebrate the diversity of our collective experience. Diversity enriches our workplaces, our communities and our societies. It brings together unique perspectives, experiences and talents. It fosters innovation, creativity and growth – more diverse organisations are more successful. We should take the chance on Zero Discrimination Day to reflect on all the benefits of diversity and to appreciate the value it adds to our lives.

Post-reflection, we need to recognise that Zero Discrimination Day is a call to action. This means taking concrete steps towards creating more equitable and inclusive environments in our workplaces and communities – and striving to do better, day after day. Tackling discrimination was once described to me as like walking the wrong way on a moving walkway – you have to work really hard to make progress, and, if you stop or even slow down, your efforts then you end up going backwards. Zero Discrimination Day is not just a day – it is a reminder to redouble our efforts and to do so 365 days a year (or 366 days in 2024).

What action can we take? We undertook research last year to find out what the public see as discriminatory behaviour in health and care and how this can have an impact on confidence in healthcare professionals and on patient safety. With this report, we have started conversations to help the regulators and Accredited Registers we oversee take a more consistent approach in dealing with this type of behaviour.

Clearly there are actions for governments, local communities and organisations to take; but the focus of this blog is at the level of the individual. We each have a role to play in creating a fairer and more inclusive world. We can educate ourselves and others about different forms of discrimination and their impact. At the PSA over the last two years we have had memorable professional development seminars, designed and delivered by people with a diverse range of lived experiences – all of which have illustrated the impact of ignorance and discrimination. We need to use this education to challenge prejudice and to advocate for inclusive policies and practices in the workplace. We need to speak out against discrimination – individually and as an organisation; and we need to be an ally to those who experience discrimination.

On 1 March each year, Zero Discrimination Day should be a line in the sand, marking our best endeavours of the previous year and reminding us to double our efforts in the forthcoming year. Progress is staccato and can sometimes feel like ‘two steps forward and one step back’, which is clearly inadequate on a moving walkway. We have to believe that our individual commitment, corporate commitment and collaborative approach can together turn zero discrimination from an aspiration into a reality. 

With talk of New Year’s resolutions still in the air, I thought it timely to reflect on a busy year and predict some key areas that the PSA will need to focus on as we settle into 2024.

Though I don’t have a crystal ball to hand, I may not need one as in the world of professional regulation, change happens at a measured pace. This means that as one year ends and another starts, what we focus on will not be dramatically different in 2024 from the work we were doing in 2023. We will still be very much focused on our role of protecting the public and making sure that this is a key consideration for both government and regulators during the upcoming reforms to regulators.

Reforming regulation

The end of 2023 saw a real milestone in efforts to reform professional regulation with the laying of the draft legislation to enable the General Medical Council (GMC) to regulate the Anaesthesia Associate and Physician Associate roles in the UK. This happened on 13 December and was almost a year in the making with the Government’s initial consultation on this launching in February 2023.  

The intention is for this order to become the blueprint for full scale reform of other healthcare professional regulators (impacting more than 1.5 million professionals working in healthcare).

Reform is essential to make regulation of these professionals more flexible, efficient, consistent and proportionate. We support reform and all the things we hope it will achieve, but we don’t want it to come at the cost of public protection. Protecting the public throughout the reform process remains a key consideration for us. We encapsulated these views in our consultation response and the briefing we prepared for stakeholders. We have also worked intensely with the Department for Health and Social Care (DHSC) on the detail of the draft Order, highlighting areas where we felt that public protection could be better served.  

In 2024, we expect we’ll need to increase our activities to support regulators as they get ready to exercise their new powers and ensure they continue to be as effective as possible in protecting the public. We are developing guidance for reformed regulators and will be consulting on this shortly. We expect to be continuing the conversation with the DHSC throughout the year on legislation to reform the other regulators. 

Collaboration

A clear point emerging from our Safer care for all report published in 2022, was the need to collaborate across the health and social care sector if we are to have any chance of tackling the complex challenges identified in the report. The five themes of health inequalities, new risks, workforce crisis, accountability and fear and a flawed safety framework are too big for any one part of the system to address on its own. That’s why in June we held a symposium to bring together professional regulators, registers, professional bodies, system regulators, patient organisations, academics and others around the topic of how we can collaborate towards safer care for all. This timely event was well-received, promises to give birth to new working partnerships and in 2024 we will continue to convene a range of stakeholders to work towards solutions to the knotty issues identified and emerging ones. Collaborating is key but just as important is cooperation and communication.

Non-surgical cosmetics

2023 saw many stories of botched cosmetic treatments highlighting the popularity of procedures such as Botox and fillers and the lack of regulation around them.

The prevalence of these stories caused us to speak out about our concerns in July. We highlighted the great risk of harm to people and urged the Government to speed up their plans to put a new licensing scheme in place. We encouraged people to use a practitioner on an accredited register when getting such services, to help steer them towards safer practices. We were pleased to see the Government consultation on a new licensing scheme launched in September and we provided our views on the proposals. We expressed our support for setting a minimum age of 18 for access to all non-surgical cosmetic procedures, placing high-risk procedures under additional regulatory oversight, establishing a simple and transparent licensing system and taking a consistent approach across the four UK countries to avoid ‘cosmetic tourism’. We look forward in 2024, to the next steps the Government will take on this work and are ready to do all we can to support the speedy implementation of the new scheme so that people are better protected.

Regulation of NHS Managers

In August, the sad and shocking case of Lucy Letby and the baby deaths at the Countess of Chester Hospital brought the issue of regulation of non-clinical NHS Managers to the fore. It is an issue that had been raised previously and is now being reconsidered. We contacted NHS England to offer our expertise in exploring options for the way forward. With our oversight of statutory regulators and management of the Accredited Registers programme for voluntary registers, our understanding of the broad spectrum of regulatory options means we can bring valuable insights to the debate. Initial discussions have been positive and we remain keen to support collaborative efforts to address risks to patient safety in 2024 by helping to work towards appropriate solutions.

Scotland Patient Safety Commissioner Bill

A focus of Safer care for all was the gaps in the safety system. Our report highlighted the need for a coordinating function which could take an overarching view of where adjustments are needed to improve safety across the system. The establishment of a Patient Safety Commissioner in Scotland provided an opportunity to shape a role which could help to address some of the gaps we’ve identified, by making it a role with broad responsibility for identifying, monitoring, reporting, and advising on ways of addressing patient and service-user risks. We felt it was important to encourage a role that would be broader than the current English equivalent, which we would like to see expanded.

We expressed our views on this and submitted evidence to the Health, Social Care and Sport Committee in Scotland to inform the legislative process related to the Patient Safety Commissioner Bill. The Bill received Royal Assent in November and we are pleased that Scotland is going to have a commissioner that looks at the whole system to spot problems and recommend solutions. This is a vital step forward in ensuring that the system is capable of learning from its failings, as well as identifying and acting on risks before they lead to harm. In 2024, we look forward to the role and office being set up and building effective links with the Commissioner around areas where our work aligns.

Artificial Intelligence

Only the most determined of people will have been able to avoid talk of artificial intelligence (AI) over the past year. It seemed that ChatGPT entered our general lexicon and AI found its way into all sorts of areas from academia to courtrooms; and healthcare was no exception. 

In the Safer care for all chapter on regulating for new risks, we mentioned the increasing use of technology in the delivery of health and care which can bring efficiencies and other advantages but also has the potential to blur lines of accountability and put professionals in uncertain positions. Last year we recognised the need for greater understanding of how AI will impact professional regulation. We made links with experts, joined relevant groups and networks and have been working to build up our knowledge in this area. And we are sharing this knowledge with others. As part of our role supporting regulators and registers on emerging issues, we are hosting a session between government officials from the Department of Science, Innovation and Technology and regulators/registers this month to map out areas where further knowledge-building and action may be needed in 2024 and beyond. We anticipate that this is an area we will need to keep exploring for some time to come.

And all that is in addition to our core work of reviewing the performance of regulators, accrediting registers and reviewing fitness to practise panel decisions. 2023 was a busy year for the PSA. With the need to keep supporting the areas we worked on last year and taking on the new issues which will emerge this year, 2024 promises to be just as busy as we continue to strive to better protect the public.

With legislative reform underway, what are the next steps for professional healthcare regulation? 

This was the theme of the recent Westminster Health Forum Policy Conference, chaired by Lord Hunt of Kings Health (representing the All-Party Parliamentary Health Group), at which I spoke about the need to put public protection at the heart of regulatory reform.

In my presentation I focused on:

• the necessity of reform;
• the need to get the legislation right; and
• our commitment to support implementation of the reforms.

I also discussed how we can promote safer care for all by using reform and by refocusing regulation.

Why do we need reform?

So, why do we need reform? Some might say to improve the efficiency of regulation; to provide up-to-date and more flexible legislation; to have simpler, more coherent and more consistent regulation; or to introduce more proportionate, less adversarial fitness to practise processes. All laudable aims, but secondary to the importance of improving public protection. We need reform to keep us safer – the efficiency, flexibility and proportionality of the processes are important, but not if any of them come at the expense of protecting the public.

For this reason, it is vital we get the legislation right. Along with the obvious desire for the legislation to be fit for purpose, we know that it is the intention of the government to use the forthcoming legislation – which will regulate a few thousand physician and anaesthesia associates – as the blueprint for reform of most of the other regulators. These regulators oversee more than 1.5 million professionals working in health and social care. If it turns out that the legislation isn’t as good as it needs to be to improve public protection, then we must improve it before it is rolled out across the sector.

Reform will replace prescriptive legislation with enabling legislation. We are essentially saying to the regulators, “Here are the powers; it is up to you how to use them”. This additional flexibility brings with it a need for greater accountability and implies that guidance on using the powers will be beneficial.

What is the PSA's position on reform?

The PSA’s position on reform is simple and has not changed: we welcome reform; we will work with others to design legislation that enhances public protection; and we will do everything within our remit, powers and capacity to ensure that reformed regulation is as effective as possible in protecting the public. On this point, we will soon be consulting on our initial guidance documents that will support the implementation of reform.

Driving reform, getting the legislation right, and supporting the implementation of reform will all lead to better regulation. Better regulation can make an even greater contribution to safer care for all. It can help to support effective workforce strategies, respond to new risks, and tackle inequalities – all in the interests of public protection.

This is all good stuff. It is ambitious and forward-looking. The future is bright. But here is the elephant in the room: we don’t yet have large scale reform. The process is slow and clunky, there has been little contribution from the patient voice, the legislation may well need more work before a widescale rollout, and there is a risk that it could all grind to a halt. We can’t let that happen.

If we can keep the momentum going, get the legislation right and support the reforms, then we may just get there one day. But what about the problems we face today, or next week, or next year? Reform is not going to provide the answers to these challenges.

Refocusing regulation

Regulation needs refocusing now to keep us safer. This does not require reform. We need to focus on violations and recklessness, and much less on errors and mistakes. We need to focus on positive and preventative regulation – for example, initial training, continuing fitness to practise, and information, advice and guidance to support professionals to meet high standards of competence and conduct. And we need to focus on a kinder, more compassionate model of regulation.

This does not mean compromising standards, just ensuring that regulation is not excessively draconian in its methods or sanctions. This will reduce fear, promote a just culture, support retention of professionals, and, to quote the Patient Safety Commissioner for England, encourage more “speaking up, listening up and following up”.

Refocused regulation matters – it is better, fairer, more cost-effective and keeps us safer. Refocused regulation is about doing a good job today and an even better job tomorrow. Then, when we get reform, we can use it as an opportunity for a step change in public protection and safer care for all.

Find out more

• Read through our statement in response to the draft legislation laid before the UK and Scottish Parliaments on Wednesday, 13 December 2023 which will give the General Medical Council the statutory powers it needs to regulate the Anaesthesia Associate and Physician Associate professions in the UK.
• Or find out more about reforming regulation here.

PSA Board Member Moi Ali reflects on our recent roundtable in Scotland where the topic discussed was "why are there so many barriers to complaining?"

It’s commonly accepted that complaints are a great source of information, highlighting what an organisation is doing wrong, and what needs to be tackled to improve organisational performance. But if organisations generally, and healthcare regulators in particular, really value complaints, why are there so many barriers to complaining? And why is so little focus placed on removing obstacles? That was a topic that the PSA raised in its 2022 report Safer care for all and the focus for the PSA’s stakeholder event in September 2023 in Edinburgh.

I thought I knew a lot about complaints, having held many senior complaints roles over the years – including, currently, being the first Home Office Independent Complaints Examiner, and also undertaking a similar role for the Crown Prosecution Service. Nonetheless, I went away with plenty of food for thought. I’d been of the view that the so-called ‘chattering classes’ (I hate that term!) – namely, the affluent and well-educated middle classes – were well represented amongst complainants, and did not face the same barriers to complaining. I shall have to question my own prejudices following one participant’s insight: some women in that category are what she termed “people pleasers”, who are reluctant to complain because of the social expectations placed on them.

That got me thinking about another awful expression: “Karens”. My own kids introduced me to this undoubtedly pejorative term: “Oh mum, stop being such a Karen,” they exclaimed when I complained about poor service in a restaurant after a family meal. There certainly is pressure on middle class women not to complain, or to be stigmatised for doing so.

It is worth considering the correlation between a willingness to complain/ability to be heard by women and the apparently high volume of patient safety scandals and incidents affecting this group. In Safer care for all the PSA highlighted that, as well as the frequent occurrence of maternity scandals, both the Cumberlege Review and the Paterson Report highlighted harm caused to predominantly female patients and the difficulties faced by those trying to raise the alarm. The Cumberlege Review described a ‘denial’ of women’s concerns.

Another insight at the roundtable in Edinburgh came from Rosemary Agnew, the Scottish Public Services Ombudsman (SPSO), on the need for child-friendly complaints procedures. Research carried out by YouGov on behalf of the Parliamentary and Health Service Ombudsman (PHSO) found that children (and younger people generally), but those from minority ethnic backgrounds, or with disabilities, are most likely to be affected by public service failures, yet least likely to complain.

Talking of the PHSO, a significant barrier to escalating complaints about Government Departments and other public bodies to this final tier of the complaints system is the requirement to have the matter referred by a Member of Parliament (MP). It would be unsurprising if the most disadvantaged (and least likely to complain) found this a deterrent. Although this doesn’t apply to complaints about the NHS which can be made directly to the PHSO (once the matter has been exhausted through other more local routes) or through an MP it still raises an interesting question about the persistence of such obstacles: Are barriers a deliberate part of rationing healthcare complaints? Discuss.

There are many possible reasons why people don’t complain. They may not realise that they can, or be unsure of how to access and navigate the complaints system. The complexity of their issue/concern may be a barrier – both understanding what went wrong and being able to articulate it. This can be magnified if there are literacy difficulties, English is not a first language, or they have special needs. People may be at a very low ebb, without the emotional energy to complain. They might be ill, or made ill by the stress. Then there’s digital exclusion, which may affect some older people, lower socio-economic groups, migrants and homeless groups.

One of the main reasons people don’t complain, even if they can, is that they feel that nothing will change as a result – or worse, they fear that access to the very services upon which they rely, the ones that have failed them, may be adversely affected if they complain. This was a theme which arose from research the PSA recently commissioned into perceptions of discriminatory behaviours in health and care where some participants feared the consequences if they raised concerns about their experiences of discrimination. This too is unsurprising, but the real challenge is how regulators can reach out to under-served communities to encourage legitimate complaints by building trust in the complaints system amongst those groups least likely to complain. It’s a big ask, but a necessary one if the profile of complainants is to change.

And what exactly is the profile of complainants? Monitoring change requires an analysis of who currently complains and, crucially, which groups don’t – and why. As the PSA highlighted in Safer care for all, the data on who does and doesn’t complain is extremely patchy, particularly demographic information, making it difficult to get an accurate picture of who is and isn’t complaining.  Next, an action plan needs to be drawn up and implemented. Performance needs to be measured along the way, and plans amended as necessary. All of this takes time and money – and it takes staff. This, at a time when some of the regulators are struggling to fill fitness to practice vacancies so that complaints can be investigated and, where necessary, put before panels. Perhaps more cross-working across regulators may be part of the solution.

In Safer care for all we recommended that:

• Regulators work with other health and care bodies to gain a better understanding of the demographic profile of complainants and reduce barriers to raising complaints for particular groups.
• Demographic data on complaints made to the health and care services across the UK is recorded and made available for all bodies to use.

There is a role for us at the PSA in pushing for more accessible complaints systems across health and care, and for sharing best practice. As a first step, building on the discussion in Scotland, we will be holding an event with the Parliamentary and Health Service Ombudsman in January 2024. This event will bring together health and care sector stakeholders to look at what we know about the barriers that currently exist and promote practical action and solutions to address these. However, we will need to think about further steps we as an organisation can take to bring about change in this area.    

I for one stand ready to support this worthwhile piece of work, so that we can start to see the demographic widen, as complaints processes recognise and remove barriers and thereby widen the diversity of those complaining.

In September, the PSA attended and presented at the Council on Licensure, Enforcement and Regulation (CLEAR) 2023 Annual Educational Conference in Salt Lake City, USA. CLEAR’s mission is to ‘promote regulatory excellence through conferences, educational programs, webinars, seminars and symposia.’

A predominant theme at this year’s conference was Equality, Diversity and Inclusion (EDI). EDI has become an area of increasing focus for a range of organisations in recent years and we noticed that many presentations – like ours – considered it.

Steve Wright, a colleague from our Performance Review team, and I presented on the PSA’s approach to EDI for statutory regulators and Accredited Registers. We started with a discussion on the changes we are making to the statutory regulators’ EDI Standard (Standard Three), which has been in place since 2019. In our most recent assessments, all the regulators met Standard Three. We decided to review this Standard last year and engaged with stakeholders for feedback on our proposed changes, which focused on driving improvement. We also presented on the development of the new EDI Standard (Standard Nine) for the Standards for Accredited Registers. We discussed our approach, the results of the public consultation and the challenges faced in developing a new Standard.

Our presentation was well received and from the discussions with other organisations, it was clear that there is a lot of innovative work in train; however, it was also clear that for many, this journey is just beginning. Similar issues were raised across a range of sectors; one being the collection of data. How do you encourage people to complete EDI data surveys to ensure that any results are meaningful? How do you assure people that this data is going to be used for positive change? What about the safe storage of data and potential legislative barriers to collecting it?

Another theme that emerged was the equity vs equality debate, which examines the difference between everyone having appropriate access based on their needs and circumstances to achieve fair outcomes, and everyone having the same access regardless of differences. This is not something we have particularly focused on in our Standards and it isn’t always part of the conversation when we are discussing EDI. The debate certainly gave us some food for thought; a greater focus on equity is something we should consider in the future. 

I also attended presentations on complaints handling, which highlighted the importance of kindness and compassion when handling complaints – not only towards complainants but towards registrants. Terms such as ‘caring regulation’ and ‘compassionate regulation’ were used. Presenters discussed the importance of prevention and having clear and accessible standards so that registrants know what is expected. They also talked about creating ‘compassionate communications’ throughout the process to increase the likelihood of registrants engaging and complying with any sanctions and/or changes to their practice, with the result that they would be less likely to leave the occupation.

There is a lot of innovative work being done to protect the public by regulators from across different countries and sectors. Many are grappling with the same issues, whether that be how to assess EDI or how to implement good practice in complaints handling. The conference was an effective forum for sharing knowledge and good practice; and prompting us to keep thinking about how this applies to our work and the assessments we do. 

To support National Inclusion Week 2023, we are asking ‘What does inclusion mean in the workplace?’. Nefo Yuki-Igbinosa who joined the PSA for three weeks in September as part of our Work Experience Scheme shares her thoughts on what an inclusive workplace looks like. Nefo spent time shadowing colleagues across the PSA before heading off to study English at University. Having previously worked as a tutor, Nefo was keen to get a flavour of a corporate environment and the different roles within it.

---

"The mistake that many employers and organisations make when it comes to Equality, Diversity and Inclusion (EDI) is that their approach lacks humanity. This is the difference between equality and equity.

Of course, organisations will not operate in the same way that a single individual would, and so naturally attempts at inclusion will differ. But the issue is that inclusion is not about equality but rather equity. It is about a combination of being proactive in celebrating differences, but also reactive in responding to the needs of those in your organisation.

Ultimately this can be reduced to acknowledging those that you work with and respecting their differences.

For example, I am a black woman with 4c hair, and I was tasked with playing back a recording of a meeting and taking the minutes. The headset proved quite a challenge to get over my head and my hair as a result of my hair’s volume. Naturally, I think we all tend to shrink away from speaking up if we need a adjustment, which is something that the workplace needs to normalise in order for all staff to feel included, but I digress.

Despite my silence, my co-worker noticed my difficulty in getting the headset over my head, as well as my resulting discomfort when I finally managed to. Her observation did not end when I succeeded in putting the headset on, but she thought deeply about whether I was truly comfortable, and what she could do to help. She then suggested that I could have a go at connecting my personal headphones, as they would obviously be more comfortable for me. This is where inclusion begins. My co-worker saw me as an equal who was entitled to just as much comfort as she was.

Equality is giving me the same headphones as my co-worker, but equity is taking my physical differences into account. Equity is giving me headphones of the same quality, but perhaps in a different model that would fit over my hair a bit better. It is equity that truly makes members of staff feel included.

In this year’s National Inclusion Week, perhaps keep an extra eye out on your colleagues. Do they seem isolated or left out? There are lots of small actions we can take to make our workplaces as welcoming and inclusive as possible. This year’s theme is all about taking action and making impact – this could be by going the extra mile to correctly pronounce a fellow staff member’s name, or respecting dietary requirements regardless of your personal views, or even enlarging the font size before your colleague with a visual impairment has to ask. It can be awkward to have to ask for adjustments that everyone can see you really need – inclusion is about not making anyone feel othered by their differences.

This is the difference between Equity, Diversity and Inclusion, and Equality, Diversity and Inclusion."

Reflections from our CEO Alan Clamp as he travels to give the keynote speech at the Council on Licensure, Enforcement and Regulation (CLEAR) 2023 Annual Education Conference on Thursday 28 September 2023.

Everything that is regulated – people, places and products – is changing. We see changes in technology, the environment, techniques, ways of working, societal norms and expectations, politics and knowledge. Therefore, regulation has to change. 

Regulation is an imperfect model. It reduces risk, but things still go wrong and the consequent harms can be significant. So we always strive to improve, particularly in terms of investing regulatory effort in the riskiest places. When things do go wrong it rarely means that we need more regulation – just better regulation (and we also need to look at non-regulatory actions that can reduce the risk of harm).

I have worked in regulation for over 25 years (in fact it is creeping towards 30 years). It has been endlessly interesting, enjoyable and (I hope) useful. Public – or at least political and media – perceptions of regulation are, however, often a little less positive. It goes something like this …… Regulation is about rules that people have to follow. It is all about compliance with these rules and enforcement in cases of non-compliance. It is officious, bureaucratic, dull and frequently petty. It is all about ‘ticking boxes’ and ‘endless red tape’ – getting in the way and adding no value. Regulators are tin-pot tyrants, imposing excessive burdens and draconian restrictions and sanctions on people and businesses. Deregulation would make the world a better place.

I don’t buy into most of these arguments – at least not for all regulation and not all the time. This is the negative view of regulation and unfortunately sometimes regulators themselves  also accentuate the negative. Negative regulation focuses on regulators in ivory towers, dispensing rules, requiring excessive compliance checks and imposing punitive sanctions. It is based on a regulatory model targeted at the lowest common denominator; a model built on distrust that regards all regulated entities as requiring constant vigilance and the ‘stick’ of regulation to keep them in line. Very little regulation is actually like this, but that can be the perception, and even the most enlightened regulators sometimes focus too much on the negative model.

We need to accentuate the positive model of regulation. If regulation is really about public protection, then it should be more preventative.

First and foremost, don’t use it if you don’t have to.

Second, in professional regulation there is definitely more that could be done in both initial education and training, and continuing professional development, particularly on conduct.

Third, invest more time and resources in information, advice and guidance to help professionals meet the required standards (of competence and conduct).

Fourth, engage with all stakeholders with a role in public protection to improve the effectiveness of safeguards and bring about system improvements where needed.

Fifth, and finally, practice compassionate regulation to: support professional wellbeing; reduce fear and defensive practice; and promote positive workplace cultures. This is the positive model of regulation and it brings better outcomes for all.

It is time to refocus regulation; to shift the balance; to focus more on carrots and less on sticks; to accentuate the positive.

Around this time last year, we published our first report using our new approach to how we carry out performance reviews. The first report was for the General Osteopathic Council and we explained more about our new approach in this blog.

We published Social Work England's report at the end of March (the last of the 2021/22 round of reports) and have now published the GOsC's latest monitoring report. This marks the start of the second year using our new approach. So we thought it would be timely to reflect on how the first year using our new process has gone.

The first year in outline

We developed a new approach to our annual performance reviews so that we review each regulator in detail every three years and monitor their performance in-between. In the first year we published two detailed periodic review reports (for the General Dental Council and the General Optical Council) and eight monitoring reports.

One of the main things we wanted to achieve with the new process was to publish our reports sooner. We set ourselves a target of publishing each report within three months of the end of the review period. We met that target for every review this year. This means our reports can give people a more up-to-date picture of how each regulator is performing. We’ve also been working to make our reports clearer and more accessible.

Involving more people in our reviews

Hearing from people and organisations with first-hand experience of the regulators’ work is another area we want to focus on. We have been working to build the right relationships with different organisations who can tell us about the regulators. This might be through regular meetings, written updates, or just letting them know how to get in touch with us if they have something to say.

Though we cannot get involved in individual cases or concerns, the information people share with us is valuable for our reviews. For example:

• It can highlight things the regulators are doing particularly well
• It can point us towards emerging issues which we might want to follow up – this is an important part of our three-year cycle, because we need to be agile enough to identify and respond to risks effectively
• It can help us understand what impact a regulator’s activities are having on the public and its registrants – particularly where we can compare what people tell us with other evidence.

We give regulators a chance to respond to the feedback we receive. We have also made our reports clearer about how feedback has contributed to our reviews.

Plans for the 2022/23 cycle

After each review we’ve asked regulators for their feedback on the new process. We’ll include their feedback as part of our evaluation of the first year. This should be able to identify what has worked well and where we may want to prioritise further development work. We’re committed to continuing our work to develop how we obtain feedback to inform our reviews.

Over this coming year, we’re expecting to publish four periodic reviews and six monitoring reviews. We’d like to hear what you think of our new reports: do they tell you what you need to know about how the regulators are performing? Is it easy to understand how we decided whether or not regulators had met our Standards? Is there anything else you would want to see in our reports? You can get in touch with us by share@professionalstandards.org.uk.

Find out more

• Find out more about how we carry out our performance reviews
• Read all our most recent reports
• Find out more about our work with regulators

In late March, in partnership with the Welsh Government, we held our sixth annual seminar exploring recent healthcare regulatory policy developments in Wales and across the UK. Delegates from across the sector joined us and together we discussed the current issues and challenges which are influencing Welsh Government policy.

As noted in the opening remarks by the Welsh Government’s Chief Nursing Officer Gillian Knight, there is a clear commitment from the Welsh Government and those in the sector to work towards shared goals of maintaining staff and patient safety despite some differing approaches across the UK. There is also a firm commitment to provide the NHS and care sector with the skilled workforce it needs.

There needs to be close collaboration underpinning a UK-wide commitment to considering issues of regulation. Differences in professional regulation do exist for a variety of reasons; nonetheless, equitable and balanced regulation is crucial, particularly as we move towards a multidisciplinary way of working which creates new challenges for workforce planning.

Ensuring our workforce can deliver safe and quality care

In our first session, we asked the question: ‘What skills do the health and care workforce need and what do services need from regulators to provide safe and quality care?’

We heard from a range of speakers from the General Medical Council Wales, Health Education & Improvement Wales, Social Care Wales and Cardiff & Vale University Health Board. All agreed that legislative reform is now essential to ensure regulation can be effective and support multi-disciplinary team working. As the health and social care system continues to evolve in Wales, regulators must continue to learn, adapt and collaborate with others – and regulation must be seen as a fundamental element of the strategy, not something separate.

Initially, discussions focused on the critical need for reform for the medical profession, amplified by the growing dependence on international medical graduates (IMG). While work is ongoing to improve Equality, Diversity and Inclusion outcomes for doctors, there is still a disproportionate number of IMG and ethnically-diverse doctors being referred for fitness to practise investigations.

More broadly across the healthcare system, stress and burnout issues are a significant challenge. It was observed that workforce data could be better used to support the system, including identifying areas with high burnout rates and addressing staffing shortages which lead to poorer quality of patient care. Lack of education and training opportunities can also exacerbate workforce pressures.

So what can be done to support the workforce? All agreed that prioritising staff wellbeing was essential, so that they can provide the best possible care to patients. Promoting an inclusive and fair working environment and addressing systemic issues through a learning culture will lead to improved outcomes.

And it’s crucial for professionals to have access to ongoing CPD and leadership support so that they can adapt to new ways of working and new models of care, such as providing more care closer to home. Graduates must be supported via agile curricula to ensure they have the right skills for a modern working environment. Regulators also play an important role in supporting professionals: in taking risks, developing new skills and working across boundaries.

When discussing how to embed compassionate leadership in healthcare, the speakers all agreed that regulators should not only talk about it, but also ‘live it’ and set examples for others to follow to ensure a more cohesive and effective system.

At the same time, it is important that regulators do not diverge too much under their new legislation following reform as this may well cause more fragmentation and confusion.

Ensuring public needs are met and their voices are heard

In the second session, we asked the question: ‘What do the public need from the workforce and how can their voices be heard effectively?’

We heard from the representative from LLAIS, a new independent statutory body set up by the Welsh Government, which will replace the Board of Community Health Councils. Their vision is to give the people of Wales more say in the planning and delivery of their health and social care services – locally, regionally and nationally. LLAIS will do this by engaging with community representatives and groups via evidence-based approaches, sharing with the NHS, local authorities, and other decision-makers to ensure that people's views and experiences directly contribute to, and improve, health and social care services.

LLAIS will work in partnership with NHS bodies and local authorities to promote their activities and make arrangements to co-operate in the exercise of functions, including sharing information when asked. It wants to foster clear communication and ensure the empowerment of patients, and its success will be measured by how well it works with the NHS and local authorities. The hope for the future is that, through LLAIS, patients’ voices will be better heard, and mutual communication between the health and social care sector, and the public, improved.

Providing support for a post-pandemic recovery

In the final session, we heard from speakers from Aneurin Bevan Health Board, Royal College of Nursing Wales as well as Unite the union, who discussed what support the workforce needs to help them deliver a post-pandemic recovery.

A series of surveys totalling over 16,000 individual respondents by Aneurin Bevan Health Board found that nearly 60% of their staff reported suffering from fatigue; 61% reported to be struggling to cope with the pressure of increased service demands; and 55% felt pressurised due to staff shortages. On average staff absences due to anxiety and depression account for at least 31% of total absences, an increase of just over 2% from 2022, and 11% since before the pandemic. Data also indicated that nearly a quarter of staff were unsure if current working levels in response to increased demand were sustainable. Most staff who leave do so in their first five years of employment; many of them report feeling undervalued, and unable to settle in environments with high numbers of temporary or agency staff.

Despite these obvious challenges, the Board was focused on staff retention and has increased staff engagement activities, the established Employee Well-being Service has been invested in, and is placing a strong focus on leadership development and healthy working culture. Post-Covid, there has been a change of approach to staff entry points and ensuring training for internal development and progression is in place.

In the discussion, it was recognised that career progression for healthcare professionals is important; there is a need for more career pathway planning, career progression rewards and dealing with middle management bureaucracy that can push staff towards agency roles. If we worked towards a goal of having at least 80% of staff in substantive positions, the current over-reliance on agencies would reduce. Contingency plans in the short, medium, and long term are needed, so that the profession can be improved, and practitioners can receive the support and recognition they deserve.

Closing thoughts and common threads

All our speakers called for a more compassionate and meaningful collaboration within the healthcare system and agreed that effective communication and partnership-building are essential to address the challenges we face and to deliver better outcomes for patients and healthcare professionals alike. Collaboration with system regulators is needed, and regulators should work with each other, and with employers, to break down the perceived professional barriers which can get in the way of creating the roles that are needed.

As always with these seminars, it was great to hear a wide variety of different views from various parts of the health and social care system. It is still quite rare for service providers and patient and staff representatives to talk directly with regulators about shared issues. It was really useful, too, to think about the specific circumstances and ambitions of Wales in this context. 

There could be no doubt at all about the scale of the challenges facing health and social care.  Equally, the energy, enthusiasm and creativity around a shared purpose was really powerful. The Professional Standards Authority is committed to support action it can on the back on the recommendations we made on workforce in our Safer care for all report. Let’s hope it bears fruit soon. 

We held our Accredited Registers seminar last month, which included, for the first time, our Accredited Registers Good Practice Awards. We introduced the awards to encourage good practice among the registers and a shared understanding of our values – the ‘Four Pillars’ of Confidence, Choice, Quality and Protection.

Registers could nominate themselves or others. The winners on the day were:

1. Confidence - UK Council for Psychotherapy (UKCP) for their ‘Learning from Complaints’ event held in June 2022 and good practice in being open about complaints and sharing their learning from complaints made to them with others.
2. Choice - Play Therapy UK (PTUK) for its work on the Children’s Mental Health Charter and raising awareness of the need for children to have access to a registered therapist to support their mental health and wellbeing.
3. Quality - Save Face for their rigorous work to raise standards, promote awareness of the register and working with the media to uncover dangerous practice for non-surgical cosmetic procedures and protect the public.
4. Protection - British Psychoanalytic Council for its work on promoting equality, diversity, and inclusion on areas such as sexual orientation.

 In this blog, the Award winners discuss the work they have been doing to help reinforce the four pillars of the programme and how sharing good practice is an important aspect of the Accredited Registers programme.

UKCP: Confidence category

Play Therapy UK: Choice category

Save Face: Quality category

British Psychoanalytic Council: Protection category

Our report Safer care for all  launched at a Parliamentary reception on 6 September 2022. It highlights some of the biggest challenges affecting the quality and safety of health and social care across the UK today.

With the publication of Safer care for all, we started a debate on the issues highlighted in the report and the recommendations we put forward. As part of this debate, we are publishing a series of guest blogs written by stakeholders from across the sector. This blog is from Sam Rodger, Assistant Director, Policy and Strategy at the NHS Race and Health Observatory.

Everybody’s job

The answer we often hear is that it’s everyone’s job. We’re told that considerations about racial and ethnic equality should be a ‘golden thread’ embedded in all discussions about healthcare. We are told that every policy decision should be underwritten by an Equality Impact Assessment. We are told that every member of staff in the NHS, from the CEO to each and every clinician, should be mindful of potential health inequalities, and should work to eliminate them where they find them.

This means each GP and practice manager should be thinking about ethnic health inequalities in their local population, and that individual nurses, receptionists, allied health professionals, and other members of staff should be culturally competent. It means that commissioners should be allocating funds according to the needs of our most marginalised communities, ensuring that nobody is left out of the great promise of an NHS for all.

More recently, we are told that the newly established Integrated Care Boards will have responsibility for taking a place-based population health approach to delivering services in an equitable way. The hope is that, by joining up the NHS with Local Authorities and other providers of essential services, we will make it impossible for the needs of marginalised communities to fall through the cracks, as has so often been the case in the past.

Nobody’s job

But what is happening on the ground? Is it realistic to expect NHS leaders to give their limited time and resources to race equity when they are under significantly more pressure to cut costs and reduce waiting times? Is it reasonable to expect members of staff – usually from ethnic minority communities themselves – to give their free time to the cause of achieving race equity?

As the old saying goes, when it’s everybody’s job, it’s nobody’s job. Across the system, we see a phenomenon whereby everyone thinks someone else should be responsible for making a difference. There’s not enough money, our leaders might say, to fund the extra community engagement required to properly cater services to our most vulnerable marginalised communities. I recently met a GP who claimed they would love to spend more time out in their local community fostering trust, but that they were already struggling to keep on top of the rising demand for consultations. And perhaps there wouldn’t be such a need to build this trust at a local level if cultural competence were considered at the outset of public health campaigns.

Part of the issue is accountability. Is anyone really held to account for delivering on race equity in the NHS? It is currently possible for a trust with among the lowest scores on the NHS Workforce Race Equality Standard (WRES) to still be rated ‘Outstanding’ by the Care Quality Commission (CQC). What message does this send to Black, Asian and ethnic minority members of NHS staff? What message does it send to members of the public when leaders are not held to account for the continued poorer outcomes experienced by these communities?

In a similar fashion, the NHS announced in 2020 that each provider organisation in the NHS (including both trusts and ICSs) was required to appoint a board-level accountable lead for health inequalities. In our research on these appointments, we found a huge variation in the levels of support available to these leads, and in the amount of power they felt they had to effect change. Moreover, at a national level, it remains unclear who is responsible for ensuring that these appointments have been made, or who is responsible for holding them to account. This is particularly concerning given the lack of representation among ICS Chairs and Chief Executives.

Most concerningly of all, we have recently seen that the NHS has dropped targets in its planning guidance aimed at ensuring an organisation’s leadership reflected the racial diversity of its workforce.

Moving towards an equity culture

As we have seen repeatedly in the past, we are reaching a point where the NHS is under such significant strain that considerations about equity are becoming an afterthought. When targets around equity are forgotten, so too is the dream of an NHS that serves everyone equally and with dignity.  Exacerbating this is an increasing tendency for efforts to promote equity to be dismissed as ‘wokery’ by some media outlets and politicians.

In truth, equity should be everyone’s responsibility. It should be a fundamental tenet of every job description, policy document and target that the health sector produces. But if equity is ever to be more than a tick-box exercise, it must be embedded in a holistic framework of accountability.

For regulators, this likely means considering their internal processes first – ensuring that their fitness to practise procedures and their role in clinical education are free of bias. Then, it means considering how members of the health and care workforce are encouraged and supported to champion equity in their work, but also how they are held accountable for doing so. What, for example, is the role of revalidation and appraisal in making a difference?

Most importantly of all, we must all look beyond our individual roles and consider how each of us can contribute to a culture of equity. A culture is not just carefully chosen words, or a list of generic ‘values’ on a corporate website. A culture is formed of human interactions and behaviours. A culture is formed when people ask questions, when they listen to the views of others, when they speak out in a meeting, when they recognise their lived experience – privileged or not – may be at polar opposites from others in the room.

Accountability is the start of a journey towards health equity. But an equity culture must be the shared ambition of everyone in our health and care sector if we are to move forward.

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 the NHS Race and Health Observatory here. 

A blog from our new Board member Juliet Oliver.

It is an absolute privilege for me to be joining the Board of the Professional Standards Authority.

I recall when the Authority was set up, around the same time as I joined the General Medical Council (GMC) as one of the first members of its then newly established in-house legal team.

A key focus for the GMC at that time was the Shipman Inquiry, and the questions it raised regarding the role of regulation in protecting patients and confidence in health professionals. I was closely involved in responding to the issues, designing and drafting its fitness to practise procedures to, amongst other things, strengthen the independence of regulatory decision-making from the medical profession, and improve transparency for complainants and respondents in the process. My role at the GMC over the years also involved developing the rules for medical revalidation; introducing ongoing checks of clinical competence and processes for bringing together and addressing concerns at a local level.

Working alongside the Authority as it brought its first section 29 appeals and developed its processes to review the performance of regulators and check the quality of regulatory decision-making, I was keenly aware of its work safeguarding the protection of the public - and its influential role in introducing and embedding concepts, such as right-touch regulation, now familiar to regulators across healthcare and other sectors.

The Authority now oversees a wider range of services and professionals than ever, with 60 different occupations covered by its accredited registers programme, alongside its work with the 10 statutory regulators. And perhaps it has never had more important a role to play. We are part way through an exceptionally difficult winter for health and social care with heavy demands on services, and the cost of living and workforce crises, taking their toll on dedicated individuals delivering essential care. The Authority’s recent report, Safer care for all, sets out many of the current pressing challenges. These include tackling inequalities within the workforce and for professionals, patients and users of services alike; and the fast pace of change in the way care is funded and delivered, which brings new innovations and opportunities but also potential risks and impacts for patients.  

I am keen to work with the board in helping to meet these challenges. I bring with me cross-sector experience of regulation in fields such as law, accountancy and chartered surveying – as well as from my work with a number of regulators across health and social care. I also have an appreciation of the frontline delivery of care and experience working with providers and member organisations, from my early years as a healthcare lawyer to the present day.

In my current role as General Counsel and Executive Director at the Solicitors Regulation Authority, I have been working to understand the link between workplace culture and the safe, competent and ethical delivery of legal services, to address rising levels of stress and mental health issues in the legal workforce as well as counter-inclusive behaviours such as discrimination and sexual harassment. This has included thematic work to review current practices within firms and designing new standards targeting workplace behaviours and the treatment of colleagues, alongside resources to promote a healthy work environment and speak up culture.

I am also leading  significant initiatives supporting the adoption of legal technology and innovation. I see this as key to ensuring a diverse and effective legal sector, able to deal with complexity and change not least through exploring new ways of working which increase access to affordable legal services and tackle the problem of unmet legal need. We have had real success in delivering projects funded by the Government’s Regulators Pioneer Fund,  for example a chatbot that helps people to understand and exercise their social care rights, focused on people with learning disabilities.

However, as a regulator, in doing so we need to get the balance right; to ensure that the risks for users of services are fully understood and addressed and key ethical safeguards are maintained.

One way to do this is through sandboxes and pilots. As part of the LawTech UK regulatory response unit, and through its own Innovate platform, the SRA has helped start-ups and innovators to navigate regulatory issues around handling client information, and to ensure that systems build in appropriate accountability for regulatory compliance. A recent collaborative pilot on unbundled services looked at the way tasks can be broken down between law firms and their clients and how technology can help to navigate respective responsibilities and ensure tasks are completed correctly.

Regulatory guidance and resources can also help to raise awareness of opportunities and risks. We have published compliance tips and FAQs for the responsible adoption, use and monitoring of new technologies, including AI - as well as highlighting red flags, for example surrounding traceability of funds when handling cryptocurrencies.

I strongly believe that regulation can play a key part in addressing the challenges of the future – supporting professionals through times of uncertainty and change whilst maintaining a sharp focus on patient safety and strong ethical values and principles. I look forward to joining the Authority as it continues on this journey.

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.

Background

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.

Inequalities

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. 

BAPIO

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.   

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. 

For some years I had an annual speaking engagement to final year students at a college which was training some of the regulated health and care professionals of the future.

As students filed into the lecture theatre, I could see from their facial expressions that expectations of what was to come – a lecture on regulation – were not that high. And maybe my starting point could have been more compelling. I would work through and describe the core regulatory functions of registration, standards, quality-assurance of higher education, and fitness to practise. Many of the students, if not most, looked quite bored and I’m not sure I blamed them. Even so, I did glare at anyone checking their phone.

But where I went from there did get the students more interested, and maybe thinking that there might be more to this than they’d initially realised. I would talk in more depth about fitness to practise. I’d provide some statistics about the kinds of cases that the regulators looked at (including their own regulator to be), providing the list of categories of different kinds of misconduct, and would share some details of particular cases. Who were the people involved; what went wrong; what harm was caused?

This would lead to a conversation about why it is that some people go off track in their professional work, while others continue to be compliant with the regulator’s standards. Where’s the difference?  What sort of circumstances and combinations of internal and external factors might lead to someone causing harm, intentionally or otherwise? Could the students sympathise – almost always, yes – but how then might they then remain vigilant about themselves and others when there were early signs of trouble? Who could they talk to? Where could they turn for support to ensure that patients were kept safe?

By now this would be an animated discussion of the role played by regulation, of professionalism, of standards, of patient safety and of the importance of acting early when hazards arose. It was always extremely rewarding and enjoyable for me as the speaker, and I hope I contributed to the students having a more constructive and positive attitude to the regulator and the part played by regulation within the landscape of care.

I thought of these lectures recently in our conversations with stakeholders about our report Safer care for all, and in particular, at our conference earlier in the month. Within organisations delivering care, who people believe, who they trust and who they fear is instrumental in many decisions and actions relating to patient safety. We need to be sure that as far as regulation is concerned, professionals understand the regulator’s role and purpose and have a constructive approach to what the regulator’s requirements mean in the workplace – how they are interpreted and understood, and what it means to comply.

If we want to support professionals to have a positive attitude to being regulated, a clear sense of the purpose of regulation, and a constructive approach to tackling small problems before they become large ones, the best thing we can do is start early.