DAUK in the BMJ: what lies beneath, getting under the skin of GMC referrals

DAUK talk to the BMJ about Fair to Refer, research commissioned by the GMC which found a disproportionate number of particularly male ethnic overseas doctors being referred for ftp by their employer.

“Aisha Majid asks why ethnic minority doctors are more likely to be investigated by the UK’s medical regulator and what is being done about it

If you’re an ethnic minority doctor working in the NHS you’re twice as likely as a white doctor to be referred by your employer to the General Medical Council (GMC). If you trained outside the UK that figure rises to two and a half times as likely.

These facts are not new. But less is known about the reasons why, says Roger Kline, research fellow at Middlesex University Business School and coauthor of Fair to Refer?, a 2019 report commissioned by the GMC that sought to understand why certain groups of doctors more often fell foul of complaints about their fitness to practise.

“People have known there’s been an issue around disproportionality without understanding what lies behind it,” says Kline. He says that the case of Hadiza Bawa-Garba, who was struck off the medical register after the death of a 6 year old child and then reinstated, was the tipping point for action.

Although it’s not only employers who can refer doctors to the GMC, only referrals by employers show a disproportionate representation of ethnic minorities (see box). Complaints from employers make up only 4.3% of all referrals—but 77% of these result in a GMC investigation, compared with only 9% of complaints from patients.

Dynamics of belonging

The Fair to Refer? report highlighted a pervasive insider-outsider dynamic in the NHS. Doctors perceived as lower status outsiders—such as doctors trained outside the UK—are not given the support they need by bosses and colleagues and are more likely to end up being blamed and facing disciplinary action when things go wrong.

Ethnic minority doctors, whether trained in the UK or overseas, may also feel less confident about raising concerns or challenging an accusation for fear of a backlash. They are also over-represented in roles that can isolate them, such as in locum posts or in small or demanding general practices, leaving them more vulnerable to complaints.

About 40% of doctors working in the NHS in England in 2019 were from ethnic minorities,2 and 38% of the 300 030 doctors working in the UK had trained overseas. A BMA survey carried out the same year found that only 55% of ethnic minority doctors felt included in the workplace, compared with 75% of white doctors.3…

Dr Jenny Vaughan is law and policy lead at the Doctors’ Association UK and led the successful campaign to overturn the conviction of David Sellu, a surgeon who was wrongfully accused of gross negligence manslaughter. She says that the reluctance of some ethnic minority doctors to raise concerns is what makes them particularly vulnerable.

“Minority ethnic doctors feel less confident about reporting concerns, because they feel they are more likely to be blamed because there’s a lot of subconscious bias,” says Vaughan. “Fair to Refer? revealed how toxic working conditions are more likely to lead to a disproportionate referral rate of ethnic minority doctors to fitness to practise processes. The figures [in the report] illustrate how it appears easier to blame ‘outsiders.’”