The recent case of Dr Arora has once again shone a spotlight on the fairness of fitness to practise investigations, and has again highlighted concerns about the discrimination which appears to exist in the referral and investigation of ethnic minority doctors.
The case of Dr Arora
The Medical Practitioners Tribunal Service (MPTS) considered two allegations against Dr Manjula Arora (an Indian qualified female doctor) at a General Medical Council (GMC) fitness to practise hearing.
The first allegation that she had asked North West Ambulance Service (NWAS) to switch off their clinical assessment service without approval was found not proved.
The second allegation arose out of her understanding about whether a laptop for work purposes had been “promised” to her. At the hearing, she explained that English was not her first language and might account for some misinterpretation, but it appears that under cross-examination a debate ensued about the meaning of specific words, and whether or not she had exaggerated the situation. Dr Arora appears to have become (understandably) frustrated in the hearing. The MPTS determined she had behaved dishonestly, that her fitness to practise was impaired by reason of misconduct, and that she lacked full insight. Her licence to practise was suspended for one month.
This decision caused uproar and outraged many doctors. Within days of the suspension order being made, the GMC appointed Professor Iqbal Singh CBE and Martin Forde QC to review Dr Arora’s case to consider whether there were any lessons to be learned. Days after that announcement, it was widely reported that the GMC would not be challenging Dr Arora’s appeal of the MPTS’s decision.
The GMC’s “Fair to Refer” Report
The general topic of fairness in the reporting or investigation of doctors from ethnic minority backgrounds has already been considered in detail by the GMC.
In 2019 the GMC commissioned the ‘Fair to Refer’ Report, to understand why doctors from ethnic minority backgrounds were more likely to be referred to the GMC for Fitness to Practise (FTP) investigations. Research was conducted Dr Doyin Atewologun, Roger Kline OBE and Margaret Ochieng, Psychologist.
Selected statistics from the “Fair to Refer” Report
Ethnic minority doctors have more than double the chance of being referred by their employer than a white doctor; non-UK medical graduates are 2.5 times more likely to be referred by their employer than UK medical graduates; non-UK medical graduates are more likely to be sanctioned in the FTP process than UK medical graduates; ethnic minority GP partners are more likely to receive ‘inadequate’ Care Quality Commission (CQC) ratings; seven of the nine doctors convicted of gross negligence manslaughter between 2014 and 2019 were from ethnic minority backgrounds; staff from different ethnic minorities are more likely to enter local disciplinary processes; and across all the healthcare professional regulators, there is a higher rate of referral of ethnic minority registrants to the Fitness to Practise process.
The report did not find any evidence of bias in the GMC investigations themselves. However, just two years later, in 2021 an Employment Tribunal found Mr Omer Karim, who was cleared of misconduct at an MPTS fitness to practise hearing, had suffered unfavourable treatment by the GMC in the way in which they had investigated his case, due to his race.
We recognise that recommendations inevitably take time to implement, but the case of Mr Omer Karim, and arguably now the case of Dr Arora, indicate that there may still be a lot of work for the GMC to do to embed the recommendations of the “Fair to Refer” Report.
Selected findings from the “Fair to Refer” Report
Although many doctors gave examples of experiencing unconscious and conscious bias, ethnic minority doctors are reluctant to speak out for fear of repercussions. They didn’t feel they received adequate training on how to deal with racism from their patients or colleagues. They spoke of keeping their heads down and not raising concerns they had, which eventually led to difficulties occurring anyway.
Cultural and communication styles influenced misunderstandings and bias amongst colleagues, leading to concerns being raised about a doctor’s practice. For example, the report highlighted how “a German doctor perceived as being overly abrupt, a Greek doctor had a very tactile style and a Spanish doctor whose manner was deemed overly expressive”. When things start to go wrong, doctors who qualified outside the UK (as in the case of Dr Arora) might not have the necessary “soft skills” to demonstrate insight in the way expected in the UK.
Ethnic minority doctors were prone to isolation or segregated working. Ethnic minority GPs were disproportionately located in less favourable locations and in smaller practices with heavier workloads.
Locums and Staff, Associate specialist and Speciality (SAS) doctors (who are more likely to move from ward to ward, or from hospital to hospital) found they did not receive the same level of emotional or educational support as their colleagues in permanent posts. They felt they were easy targets for criticism. Employers would often say they were not their responsibility.
Recommendations from the “Fair to Refer” Report
In summary, the writers of the report recommended that the GMC (alongside other bodies) should develop consistent frameworks and standards for supporting all doctors, including minimum enhanced induction programmes for overseas doctors or those at risk of isolation, including locums. The report’s writers found that organisations which offered intensive induction programmes, including training around best working practices and soft skills, and which created buddy systems before any clinical work was undertaken, were better integrated and therefore performed better.
More importantly, the report’s writers recommended systems for monitoring the implementation and effectiveness of all their recommendations and gathering national statistics on whether this reduced the number of referrals, and whether they were “Fair to Refer”. We have not seen any published data around this.
Further matters to address
It remains to be seen what Professor Singh and Martin Forde QC will conclude. It seems logical to expect that they will look at how it came to be that the GMC only identified the flaws in the Arora case once the entire GMC/MPTS process had concluded, and seemingly as a result of the uproar and an appeal.
Whether or not these issues are encompassed in their review, we consider there are wider issues which could be addressed in more detail as a result of the “Fair to Refer” Report, and some of the cases which have followed since. Those issues include:
Induction of foreign qualified doctors; education around cultural and communication styles, to alleviate misunderstandings and unconscious bias, especially where English is not the doctor’s first language; the potentially sensitive topic of overcoming difficulties which might arise where medical professionals come from abroad to multi-cultural Britain, to find themselves working for the first time with ethnic minorities they have not worked with in their home countries, for example due to ethnic conflict or historical bias which may exist in the countries they come from; and the cases of unrepresented doctors, or those with limited funds to fight an appeal, or thos e which do not get media attention. Will there be any review of the fairness of those decisions? Deepika Raino, Head of Professional Regulation & Healthcare, Adkirk Law, and Selva Ramasamy QC, Joint Head of Chambers, QEB Hollis Whiteman
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