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Recommendations It is always best practice, in cases where there is no immediate risk to patient safety for concerns to be raised either with one of the GMC’s Employer Liaison Advisers (ELA), where available, or a responsible officer (RO). This allows for attention to be focussed on live concerns and presents an opportunity for matters to be resolved locally. On receipt of an employer referral, the GMC should ask whether efforts have been made to liaise with the RO and, if not, encourage the referrer to consult with them before taking any further action (excluding immediate patient safety concerns). They should also consider further amending their referral form to include a requirement for the referrer to discuss with the relevant RO first. To aid with this recommendation, the GMC should consider updating their triage guidance, to guide a referrer to a local first approach via an RO, if that hasn’t already happened; and before a decision is made on whether to promote a referral to investigation. The UK’s health services, and the GMC, should collaborate to promote a local resolution first culture; and explore whether additional training on complaints handling and investigations at a local level would be beneficial. The GMC should also encourage the Care Quality Commission to include the assessment of complaints handling as a part of their ‘well led’ inspection framework. Trusts and boards across the UK should consider using a digital system to share good practice in the local resolution and handling of complaints, as a means of learning and continuous improvement. The GMC should review their investigation plan guidance to consider whether it should be expanded to say more about the aims, priorities and scope of an investigation; and what considerations should be recorded if a concern has already been the subject of a local investigation, before being referred to the GMC. The GMC should do more to embed a culture of professional curiosity, where individuals in all relevant teams actively seek to add value by raising queries about the evidence provided, and where potential concerns are flagged at the earliest opportunity. To aid with this, the GMC should consider developing an escalation policy and process, to ensure that concerns about cases are raised at the right level(s) until appropriately resolved. The GMC should ensure that all decisions are set out in full and include reference to the seriousness of the allegation(s) and the realistic prospect test. They should include a robust analysis of all of the available evidence, rather than a summary. The GMC should consider whether their low level violence and dishonesty guidance gives those making decisions enough flexibility; and/ or whether supporting information should be provided to decision makers to ensure they fully understand the discretion they have in each case in order to make the right decision. The GMC should consider expanding their existing internal review process across all relevant teams; this should include identification of issues and good practice in case handling; and through post-case discussions, looking at successful and unsuccessful outcomes, to drive continuous improvement. The GMC should consider reviewing their guidance on the process for drafting sanction submissions, to ensure that submissions include the necessary evidence for informed decision making; to reflect that approval for some submissions may be withdrawn in the event only some of the allegations are proven; and to ensure that those who approve submissions are consulted in advance of a sanction hearing, in the event that only some of the allegations are proven. Where a referrer is also a key witness in tribunal proceedings, the GMC should provide them with full details of the allegations they are taking forward. When the GMC provides a witness with a redacted statement, they should draw attention to any changes that have been made, to allow an opportunity for questions or issues to be addressed in advance of the hearing. When the GMC instructs external counsel, they should always ask them to consider the overall merits of the case, and to raise any concerns as soon as they become aware of them. They should also ensure they have an understanding of, and commitment to, the GMC’s aim of compassionate professional healthcare regulation. The GMC should ensure advice from internal or external experts and/ or training is available to relevant teams on issues linked to a doctor’s communication, attitude and/ or behaviours; cultural awareness, competence and sensitivity; diversity intelligence; and eliminating bias in fitness to practise decision making. The GMC and MPTS should consider whether their sanctions guidance should take greater account of the changing demographics of the medical workforce. This includes whether it should demonstrate sensitivity to the interpretation of values, cross cultures, and communication, through the lens of culture competence and diversity intelligence. The GMC should consider how it assures itself that its decision making is fair and unbiased, and whether the systems and processes already in place are appropriate. This includes proactive monitoring for ethnicity related variations in teams and developing frameworks to review practice. Given the small numbers involved, case mix considerations, and risk of confounding, analyses should be used as a tool for internal continuous improvement and interpreted with care. All partners involved in developing the ‘Welcoming and Valuing International Medical Graduates: A guide to induction for IMGS recruited to the NHS’, including the GMC, should encourage induction programmes to be made available to all IMGs, including those working outside the NHS. Induction should cover patient safety, professionalism, legal and ethical aspects and inform and make IMGs new to UK aware that NHS basic indemnity does not cover legal advice and support for other processes including GMC or Coroner investigations. The GMC should consider whether the level of support they offer to doctors in a fitness to practice process is sufficient. They should also encourage medical defence organisations to improve the support they provide to doctors going through a fitness to practice process and extending to a period beyond the tribunal hearing; and responsible officers to ensure local pastoral support. The UK government should bring forward legislative reform for the regulation of healthcare professionals at the earliest opportunity. This would enable our recommendations of compassionate, supportive, fair and proportionate regulation, by allowing the GMC to dispose of appropriate fitness to practise cases consensually.

Key points Research conducted by public bodies has shown that COVID-19 has had a greater impact, both directly and indirectly, on people who share certain protected characteristics (such as belonging to particular ethnicities or age categories, having a disability, or being women or from the LGBTQ+ community). Health and care services have a major role to play in both identifying the extent of these impacts as well as working together to reduce them. This report showcases examples of health and care systems across the country devising innovative approaches to mitigate the direct effects of COVID-19, through targeted vaccination campaigns, and support for people to recover from indirect impacts, through wellbeing and support programmes. These examples evidence that barriers came down during the pandemic to protect staff, patients and resources both within the NHS, and between NHS organisations and external partners in local government and the voluntary sector. They also show that tackling health inequality in an inclusive way is possible. The NHS and its partners must continue to gather data both on the direct and indirect impacts of the pandemic on people with different protected characteristics, and on the effectiveness of different programmes in addressing these impacts. Building on the achievements of the past two years, we must fund voluntary and community sector partners and put processes in place to consolidate partnership working (both within the NHS and between NHS organisations and other stakeholders) to drive continued progress in reducing inequalities affecting people with protected characteristics.

Key points Racism and inclusion have become key areas of focus for the NHS in the wake of the Black Lives Matter movement and the disproportionate impact of COVID-19 on black and minority ethnic staff and patients. With diverse leadership a key plank of the NHS’s strategy to achieve equality, improving the working life for senior black and minority ethnic staff should be a critical priority for the health service. The Messenger Review into health and social care leadership advanced this cause, placing the need for more diverse senior leadership at the top of the NHS agenda. But a greater commitment to act is needed. In spring 2022, the BME Leadership Network conducted an online survey and hosted a series of roundtables to understand the experiences of BME leaders, and to explore the challenges they faced in relation to racism and discrimination as they moved through their careers. This report captures what was found and puts forward recommendations to improve the working conditions of BME leaders. More than half of surveyed BME NHS leaders considered leaving the health service in the last three years because of their experience of racist treatment while performing their role as an NHS leader. A majority said they had experienced verbal abuse or abusive behaviour targeting racial, national or cultural heritage at least once in the past three years, with more than 20% saying this had happened five times or more. Colleagues, leaders and managers seemed to be a particular source of racist treatment, more so than members of the public. This is concerning, given that the NHS has been prioritising equality, diversity and inclusion activities in recent years. This suggests that more focused efforts are required at every level to reduce the incidence of racist behaviour and to improve awareness among all staff of the impact of this type of discrimination. Only 10% were confident that the NHS is delivering its commitment to combat institutional racism and reduce health inequalities and fewer than one in four were confident that their organisation has a robust talent management process that is enabling the development of a pipeline of diverse talent. Senior BME staff reported low levels of confidence in their own organisations’ abilities to manage and support a pipeline of diverse talent and in the ability of the system to achieve this at a national level. Moreover, only a minority were confident they could rely on the support of colleagues to challenge racial discrimination, and a smaller minority believed they would be supported by NHS England and NHS Improvement if challenging prejudice or discrimination locally. Leaders described how structural and cultural issues within the NHS led to a situation where BME leaders were not present in sufficient numbers to generate a climate of inclusivity and were sometimes siloed in particular types of role. This helped to create a situation where career progression was felt to be unduly challenging and where neither succession planning nor talent development were occurring at sufficient scale to support the next generation of diverse leaders. Being able to be authentic in the workplace was an issue that emerged powerfully. Some leaders reported policing their own behaviour in the workplace and compromising their values in order to fit in. Being able to represent their own cultures and be themselves at work was a critically important goal for many. For BME leaders, feeling secure that they will be treated equally, regardless of background, was seen to be the ultimate success measure of equality. It is essential that BME leaders are able to see effective development programmes to support diverse talent, and that they are provided with sufficient support, both locally and nationally, to feel secure in calling out unacceptable behaviour when this occurs. At such a critical juncture for the NHS, action must be taken to end cultures of discriminatory behaviour, to provide personal support to current and aspiring leaders, and to develop succession planning and talent development schemes.

The 'Leadership for a collaborative and inclusive future' review, led Sir Gordon Messenger and supported by Dame Linda Pollard, focused on the best ways to strengthen leadership and management across health and with its key interfaces with adult social care in England. Findings Cultures and behaviours The review found that the current cultural environment does not lend itself to the collaborative leadership needed to deliver health and social care in a changing and diverse environment. Leadership is seen as a job role rather than a characteristic that runs through the workforce. Staff respond reactively rather than constructively and respond to high levels of pressure from above. There is also a lack of accountability and authority in some areas. Although not universal, acceptance of discrimination, bullying, blame cultures and responsibility avoidance has almost become normalised in certain parts of the system. Equality, diversity and inclusion (EDI), which is about respectful relationships and underpins a wider culture of respect, is partial, inconsistent and elective. In some places it is tokenistic. There is a lack of psychological safety to speak up and listen, despite progress being made. The Freedom to Speak Up initiative can be perceived as just relating to whistleblowing rather than also organisational improvement. Standards and structures The review found that management tend not to be perceived as a professional activity and there is a lack of universal standards for management competence and behaviour. There are inequities in how managers are perceived, valued and trained and inconsistencies in appraisals. Regulation and oversight There is a positive view that the Care Quality Commission (CQC) can influence collaboration across the whole of health and social care through its inspections, and welcome its increasing focus on teams and systems. However, there is sometimes an over-emphasis on metrics which can be counter-productive. The review welcomes the shift in emphasis from a punitive model to a remedial one. Clinical leadership The review found incidences of the flawed assumption that simply acquiring seniority in a particular profession translates into leadership skills and knowledge. Doctors are often not properly trained or equipped for leadership roles. Allied health professionals often highlighted that they felt their career opportunities in management were limited. Management and leadership training should be an integral part of all clinical training pathways. Leadership delivery in the future The move towards health and care integration and the work currently underway to merge the arms-length bodies and create a new NHSE offers the opportunity for a fresh approach to preparing leaders and managers in the future. Recommendations 1. Targeted interventions on collaborative leadership and organisational values A new, national entry-level induction for all who join health and social care. A new, national mid-career programme for managers across health and social care. 2. Positive equality, diversity and inclusion (EDI) action Embed inclusive leadership practice as the responsibility of all leaders. Commit to promoting equal opportunity and fairness standards. More stringently enforce existing measures to improve equal opportunities and fairness. Enhance CQC role in ensuring improvement in EDI outcomes. 3. Consistent management standards delivered through accredited training A single set of unified, core leadership and management standards for managers. Training and development bundles to meet these standards. 4. A simplified, standard appraisal system for the NHS A more effective, consistent and behaviour-based appraisal system, of value to both the individual and the system. 5. A new career and talent management function for managers Creation of a new career and talent management function at regional level, which oversees and provides structure to NHS management careers. 6. Effective recruitment and development of non-executive directors (NEDs) Establishment of an expanded, specialist non-executive talent and appointments team. 7. Encouraging top talent into challenged parts of the system Improve the package of support and incentives in place to enable the best leaders and managers to take on some of the most difficult roles. All 7 recommendations have been accepted by the government and publication of the report will be followed by a plan committing to implementing the recommendations.

Key findings Antenatal care Engagement with antenatal care was high with 96% engaging with maternity services in the first trimester of pregnancy and 95% of women engaging fully with midwifery, doctor and sonography appointments. However, for women who experienced miscarriage or pregnancy loss, 61% report that they were not offered any additional support to deal with the outcome of the pregnancy. Labour and birth Just over a third (36%) of respondents reported feeling dissatisfied with how concerns were addressed during labour. 43% percent reported their pain relief options were not explained to them and 52% of women who did not receive their choice of pain relief said there was no explanation as to why it was not given to them. Postnatal care A third of respondents (31%) were concerned about the healthcare they received from their midwife during the birth recovery period. However, 69% of respondents said they were somewhat or very satisfied with the postnatal health check-up performed by the health visitor. While 78% with health concerns after birth those with concerns said they raised their concerns with a Health Care Professional, 36% of respondents said that they were not confident to ask for help on the postnatal ward. Recommendations The report makes the following recommendations to NHS England and NHS Improvement, the Healthcare Safety Investigation Branch, The Department for Health and Social Care and Integrated Care System leaders: An annual maternity survey targeted specifically at Black women Increased knowledge on identifying and diagnosing conditions that are specific to and Improve the quality of Ethnic coding in health records More community-based approaches must be used to improve maternal outcomes An improved system for women to submit their feedback and/or complaints specifically for maternity Ensure that individuals involved in training health care professionals are aware and have an appreciation of the disparities in maternity outcomes