National Working Group on Women in Medicine · rising number of women doctors needs to be...

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Women doctors: making a difference�

Report of the Chair of the National Working Group on Women in Medicine

Presented to Sir Liam Donaldson, Chief Medical Officer

October 2009

DH INFORMATION READER BOX

Policy Estates HR/Workforce Commissioning Management IM&T Planning Finance Clinical Socialcare/Partnershipworking

Document purpose Policy

Gateway reference 12718

Title Womendoctors:makingadifference

Author BaronessDeech

Publication date 13October2009

Target audience SHACEs

Circulation list RoyalColleges,Deaneries,PMETB,GMC,BMA, EqualityandHumanRightsCommission,ACCEA, ConferenceofPostgraduateMedicalDeans

Description InAugust2008,theChiefMedicalOfficerasked BaronessDeechtochairanindependentNational WorkingGrouptolookatthepositionofwomen inthemedicalprofession.Theirreportconsiders thecurrentsituation,reviewsexistingworkand recommendsaprogrammeofactiontoimprove opportunitiesforwomeninmedicine.

Cross-reference N/A

Superseded documents N/A

Action required N/A

Timing N/A

Contact details DavidWinks CMOPrivateOffice Room114,RichmondHouse 79Whitehall LondonSW1A2NS 02072105853

For recipient’s use

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Contents

Foreword 2

OpenletterfromtheChairoftheNationalWorkingGrouponWomeninMedicine 4

Chapter 1: Executivesummaryofrecommendations 7

Chapter 2: Thecurrentsituation 11

Chapter 3:Barrierstosuccess 23

Chapter 4: Recommendationsandtheirrationale 36

Annex 1: Recommendationsofpreviousreports 46

Annex 2:TermsofreferenceoftheNationalWorkingGrouponWomeninMedicine 52

Annex 3: ChairoftheNationalWorkingGroup 53

Annex 4: MembershipoftheNationalWorkingGroup 54

Annex 5: Evidencecollected 66

Glossary 67

References 68

Foreword�

Since1997therehasbeenaradicalexpansionofthemedicalworkforceintheUnitedKingdom.Asoutlined intheNHSPlanin2000,thiswasinitiallyachievedbywelcomingqualifieddoctorsfromabroadtowork withintheNHS.However,itwasalwaystheintentionthat,inthelongerterm,domesticsupplywouldbe increasedthroughanexpansioninthenumberofplacesatmedicalschoolswithintheUK.Thisexpansionis nowcomplete,andthenumberofplacesatmedicalschoolshasincreasedfrom5,062in1997/98to8,148 in2008/09.1Thefirsttrancheofthisnewgenerationofdoctorshasnowenteredthemedicalworkforceas juniordoctors.

Thenumberofwomenenteringmedicalschoolhasincreasedsignificantly–from492(24.4%ofthetotal admissions)in1960/61to4,583(56.2%ofthetotaladmissions)in2008/09.2Thisisaremarkableachievement consideringthatwomenwereactivelypreventedfrombecomingdoctorsafewdecadesago.Despitethis increaseinwomenenteringtheprofessionoverthelast20years,fewhavereachedseniorleadership positions.Theissuesthathavetraditionallybeenassociatedwithwomenintheworkplacearegoingto becomeincreasinglypronouncedfortheNHS,anditisofparamountimportancethatweaddressthemnow.

Manyoftheissuesfacedbytheprofessionareequallypertinenttootherhealthcareworkers.Indeed,they arenotuniquetomedicine.However,unlikeotherprofessions,theconstantlychangingnatureofpractice– aswellasthedemands,bothphysicalandemotional,ofcaringforpatients–bringsadditionalconcernsfor thoseresponsibleforensuringastableworkforce.Ifwedonotmakeprovisionstoensurethatthe workforceisabletomeetpatientexpectationsandprofessionalandacademicrequirements,thentheUK willfaceadramaticshortageofworkingdoctorsinthefuture.Thesedoctorsarelikelytobelosttothe professionwhentheyareatacrucialstageintheircareers–astagewhenneitherthepatientstheycarefor, northemorejuniordoctorswhorelyonthemforadviceandsupport,canaffordtheloss.

Inrecentyears,therehasbeenconsiderabledebateanddiscussion,andanumberofstudieshavelooked intotheissuessurroundingwomeninmedicine.Thesestudieshave,inthemain,focusedonthebarriersin particularspecialties,suchassurgery,orparticularworkareas,suchasacademia.Icommissionedthe NationalWorkingGrouponWomeninMedicinetoreviewallthesereportsandtodrawoutthecommon threadsinordertorecommendaprogrammeofactiontoimproveopportunitiesforwomenineveryfield ofmedicine.

Theissuesraisedarenotnew–norperhapsaretheyunexpected.Buttotacklethemisgoingtorequirea stepchangeinhowthemedicalworkforceasawholebehaves.Itwillrequireanacceptanceofalternative anddifferingpatternsofworkingandtrainingforallmedicalstaff,notjustwomen.Widerchangesin society,suchassomemenchoosingtobecometheprimarychildcarer,meanthattherecommendationsin thisreportareproposednotjusttoprovideopportunityforwomenbuttoofferbetteroptionstotheentire medicalworkforce.Inmy2006AnnualReportIidentifiedthat‘theproblemisnotaccesstomedicalschool butratherhowweensurethatthefemalemedicalworkforceisabletofulfilitspotentialoncein employment’.Ithasbecomeclearduringthedeliberationsofthisgroupthatitisnotjustwomenwhoare affectedbytheseissues.Itismyhope,therefore,thatthisreportwilladdressthesituationforbothmenand womendoctorstocreateamoreequitablepatternofwork,recognitionandreward.

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IamgratefultohavereceivedthereportandrecommendationsoftheNationalWorkingGrouponWomen inMedicinefromBaronessDeech,thegroup’sChair.IwouldliketothankBaronessDeechandherworking groupcolleaguesfortheeffortthattheyhaveputintoacomplexarea,theenthusiasmwithwhichthey tackledthechallengeandthehardworkinvolvedinproducingsuchacomprehensivereview.

Thereportcontainsasummaryofthecurrentsituationfacingdoctors.Therecommendationsarefocused, andthepotentialbenefitsarecleartosee.Greateraccesstomentoring,recognitionbythemedicalRoyal Collegesthattimealonedoesnotindicatecompetencetopractiseindependently,andimprovedfeedback fromtheClinicalExcellenceAwardsschemearealldesignedtohelpeverydoctorrealisetheirpotential. Therearerecommendationsforadditionalsupportwithchildcareandforimprovementintheopportunities foralternativeworkingpatterns.Eachwillrequirecarefulconsiderationastohowtheycanbesthelpto achievegreatergenderequityattheseniorlevelsofthemedicalprofession,and,morefundamentally,how theywouldensurethatgooddoctorsarenotlosttotheNHSonaccountofproblemsthatcanandmust beresolved.

Iamverypleasedtoseethatthisreportisacelebrationofthesuccessestodateofwomeninmedicine. Inrecentyears,importantsteps,suchastheNHSChildcareStrategy,havebeentakentoaddressthe demandsincreatingaworkforcethatmeetsclinicianneedswithoutcompromisingpatientcareand, indeed,expectations.Thisreportisablueprintforhowthesepioneeringstepscanbecontinuedandtheir aimsachieved.

Itwilltaketimetobringaboutthechangesenvisagedinthereport.Asaresult,carefulmonitoringwillbe requiredtoensurethatprogressoccursandthatthedriveforimplementationismaintained,despitethe manycompetingprioritiesthatcontinuallychallengetheNHS.ItisforthisreasonthatIampleasedto announcethatIwillholdanannualreviewmeetingtoassessthelandscapeforwomeninmedicine.This meetingwillprovideanopportunitytoreviewprogressandensurethatadditionaleffortsaremadeto guaranteecontinuedsuccess.Womenfoughtlongandhardforentrytomedicine;itwillrequirecontinuous commitmentandefforttoensurethattheyfulfiltheirpotential.

SirLiamDonaldson ChiefMedicalOfficer,England

Open letter from the Chair of the National Working Group on Women in Medicine

Sir Liam Donaldson Chief Medical Officer, England

Dear Sir Liam InAugust2008youaskedmetochairtheNationalWorkingGrouponWomeninMedicine.Iwaspleased toacceptyouroffer.Thisworkinggroupdevelopedfromthechapterinthe2006AnnualReportofthe ChiefMedicalOfficer,Women in Medicine: Opportunity Blocks.Justover150yearsago,womenhadto fighttobeallowedtoentermedicalschools.Todayjustoverhalfofnewmedicalgraduatesarefemale. WehavehadtheadvantageofreadingtheRoyalCollegeofPhysicians’reportofJune2009,Women and Medicine: The Future,3whichpresentsahighqualityanalysisoftherelevantdataandpointsoutthatthe risingnumberofwomendoctorsneedstobeincorporatedintotheworkforceinaneffectiveandproductive manner.Changesinworkinghours,careerexpectationsanddemandareissuesthatcannotbeignored. Manyofthechangesthatwomenneedinordertoremaininmedicineareequallysoughtbyyoungermale doctors.Theseissuesarenotaproblemuniquetomedicine;however,itisparticularlyproblematicin medicine,becauseofpatients’needfor24-hourcare.Amoreuser-orientedserviceisalsorightlyfocusing onpatientdemandforcontinuityinsomemedicalsituations.Thiscreatesachallenge:morechoicefor doctorsmeanslesscontinuityofcareforpatients.Ouraimistomakeitmorepossibleforwomentowork fulltime,whilstmaximisingtheadvantagesofpart-timeworkandtraining,whenneedbe,alongwithparity ofesteemforit.

Youinvitedaformidableteamofmaleandfemaledoctors,fromavarietyofbackgrounds,soastocover thebroadspectrumofissuesthatgenderandmedicinecreate.YouaskedtheWomeninMedicineworking grouptoconsiderthecurrentsituation,reviewexistingworkandconsultwidely,andfromthistocreatea programmeofactiontoimproveopportunitiesforwomeninmedicine.

Astheworkforceinmedicinechanges,newchallengesarearising–atmedicalstudentlevelthereisaneed toencourageadiversityofapplicants.Astheworkforcebecomesmorefemalethereistheriskoffollowing otherprofessions,whererisingnumbersofwomenhaveledtodevaluationoftheprofessionalstatusand sometimessalarylevels.Themostrecentresearchshowsthat,withthecurrentlevelofinfluxofdoctors fromoverseas,thegenderbalanceinmedicineintheUKismovingtowardsequity.

Withaninvestmentofnearlyaquarterofamillionpoundsineverydoctor,maleandfemale,totakethem throughtofullregistrationattheendoftheirFoundation1year,itisincumbentontheNHStoadaptto ensurethatthesepreciousresourcesarenotlostbutthattheystayworkingforanorganisationinwhich theyfeelvaluedandinwhichtheycanachievetheirprofessionalambitions,providinggoodcarefortheir

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patients.Nodoctorshouldbewastedbecausetheycannotfindaplaceinthesystemthatiscompatiblewith theirotherrolesasaparentandpartner,andnodoctorshouldbelosttomedicinebecauseofobstaclesin thewayoffindingtherightprofessionalplacement.Weshouldmakeourgoalaprofessionwhereevery womanandeverymangoesasfarastheywishandasfarastheirtalentspermit.Thefinaljudgementasto thesuccessoftheimplementationoftherecommendationsofthisreportwilllieinretentionofdoctors withinthesystem,bothmenandwomen.

Ourreporttracestheobstaclestothefullexerciseofeverydoctor’spotential–fromthedecisionatschool tostudymedicine,throughtraining,work,maternityleave,childcare,progressthroughtheprofession, possiblyintopositionsofleadershipandacknowledgedexcellence,toretirementandpensions–withspecial emphasisonthechoicesandproblemsthatwomenface,thoughincreasinglyintoday’sworldtheyare sharedbymen.Muchofwhatwedescribeisnotnewlydiscovered.Therehavebeenseveralreportsonthe progressofwomeninmedicineinrecentyears.Weaskedourselveswhythesituationhadnotchanged, whytherewasstilldiscontent,andwehavesurmisedthatpreviousreportshadfocusedonthedesired outcomesratherthanonthenecessaryleversofchangetoachievethem.Soourreportfocusesverymuch ontheimplementationofchange.Therecommendationsarenarrowandtargetedprimarilyinthreeareas:

●● Thefirstisaimedatimprovingtheexistingstructuressothatthereisbetteradvancementtocertain crucialcareerturningpointsaswellasdifferentwaysofworking.

●● Thesecondareaisconcernedwithensuringthatnewprocessessuchasrevalidationhavetheflexibility andcapacitytoaccommodatedoctorswhomaynotbeconformingtotheusualworkingpatterns.

●● Thefinalareaisconcernedwithprovidingadditionalsupportforthepracticalrealitiesofcaringfora childoradependentrelative.

Thelistmayseemshort,butchangewillnothappenovernight,andtomaintainthemomentumfor successfulimplementationwillrequireacommonlyagreedsetofgoalsthatareachievableregardlessoftheshapeofbroaderissuesinthehealthcarelandscapethatmightbefacedinthefuture.Wherepossiblewe havealsotriedtoensurethatthereisasinglebodyaccountablefortheimplementationofeach recommendationsothatthereisaclearexpectationofwhowillberesponsibleandaccountable.

WehaveworkedcloselywithcolleagueswithintheWorkforceDirectorateoftheDepartmentofHealth, theDepartmentforChildren,SchoolsandFamilies,andtheTreasury.Wehavetakenevidencefromawide rangeofpeople:academics,traineeandtrainedclinicians,regulators,patientsandNHSmanagers.All stakeholderswithwhomwehaveengagedhaveshownunderstandingofthecomplexityoftheseissues, andcommitmenttoaddressingthem.Thereisaclearrecognitionthat,howeverdifficultitistofocuson theseconcerns,theymustbetackled.

IwasimpressedbythequalityanddedicationofthewomendoctorswhomIwasprivilegedtomeetduring thecourseofcompilingthisreport.Isawhowtheymadedifficultchoicesincareerandfamilysituations, andIadmiredtheircommitmenttomedicineandtheirresilience.Itwashearteningtorealisethatsome seniormeninthemedicalprofessionappreciatethistoo.

IrealisethatthesituationintheUKisnotunique.Ourextensiveexaminationoftheinternational experiencehasshownclearexamplesofbestpractice,butnosinglecountryhassolvedthisissuetodate. GiventheillustrioushistoryofwomeninmedicineintheUK,itisfittingthattheUKisseentoleadtheway onthisissueatanationallevel.IthereforecommendtoyouthisreportoftheWomeninMedicineworking groupanditsrecommendations.

BaronessDeech Chair,NationalWorkingGrouponWomeninMedicine

October2009

IamdeeplyindebtedtoDrVivianTang,DrClaireLemerandJamesEwingfortheirworkonthisreport.

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Chapter 1:

Executive summary of recommendations

1.1 Recommendation 1: Improve access to mentoring and career advice 1.1.1 Inthenextroundofcontractnegotiationthereshouldbeanexplicitfacilityforappropriately

trainedandskilleddoctors(usuallyconsultants)toundertakementoringorcareercounsellingas aprogrammedactivitywithintheirjobplan.

1.1.2 Tofacilitateaccessingmentoringorcareermanagementsupport,thefuturecommissionersof medicaleducationshouldmaintainaregisterofalldoctorswhoareskilledandarewillingto undertakethesetasksandmakeitmoreaccessibletootherdoctors.

1.2 Recommendation 2: Encouraging women in leadership 1.2.1 AppointmentstoNHS,academicandclinicalcommitteesandboardsshouldbeadvertisedwidely

andhaveatransparentanddemocraticprocessratherthansimplyanappointmentbynomination.

1.2.2 Committeesshouldbeencouragedtodeveloptheirwaysofworkingtoenablegreater participationbydoctorswhoareparentsorcarers.

1.2.3 Thereshouldbeincreasedaccessforwomentothecommitteesandboardsofmajormedical institutions,includingthemedicalschools,postgraduatedeaneries,medicalRoyalColleges, NHStrustsandotherNHSbodies.TheEqualityandHumanRightsCommissionshouldconsider auditingtheappointmentsprocessforallsuchpostsattheseinstitutions,astheyconsider appropriate,toassesswhethersufficientopportunityhasbeencreatedtoincreaseaccessfor womentotheserespectiveorganisations’committeesandboards.

1.3 Recommendation 3: Improve access to part-time working and flexible training

1.3.1 Thepostgraduatedeaneriesshouldmaintainalistofdoctorswishingtotrainparttimeina slot-sharearrangement.

1.3.2 NHSEmployersshoulddevelopguidanceformeetingthecostsofcontinuingprofessional development,includingforthosewhoareworkinglessthanfulltime.

1.3.3 Thedevelopmentofcredentiallingshouldbeexpedited,andthereshouldbefullrecognitionby themedicalRoyalCollegesthattimealonedoesnotindicatecompetencetopractise independently.

1.3.4 Theaspirationalquotaforpart-timetrainingshouldbeabandonedinfavourofaneeds-assessed availabilitybystrategichealthauthorities(SHAs).ThenewlyformedCentreforWorkforce IntelligenceshouldbecommissionedbyeachSHAtoprovidethisneedsassessmentonaregional basis,andprovisionshouldbemadetomeetit.

Professor Stephanie Amiel RDLawrenceProfessorof DiabeticMedicine,thefirstChair inthisfield

1.4� Recommendation 4: Ensure that the arrangements for revalidation are clear and explicit

1.4.1� TheGeneralMedicalCouncil(GMC)andtheappropriatemedicalRoyalCollegesshouldensure thattheyhaveaclearsetofre-licensingandrecertificationstandardsandassessmentprocessesin placefordoctorswhohavetakentimeoutoftrainingortheprofessiontoreturntowork.

1.4.2� Responsibleofficersshouldcoordinaterefreshertrainingforthosewhohavetakentimeoutof trainingtomeetthesestandards.ThereshouldbefundingforthiswithintheNHSbudget.

1.4.3� Trustsshouldoffer‘back-to-work’and‘taster’sessionswherethosewhohavetakenacareer breakcanshadowworkingdoctorstore-familiarisethedoctorwithproceduresandworkpatterns, sothattheyareconfidentonreturn.

1.4.4� ThePostgraduateMedicalEducationandTrainingBoard(PMETB)andtheGMCshouldensure thatwomeninnon-traininggradesreceivesupportinapplyingforentrytothespecialistregister.

1.5� Recommendation 5: Women should be encouraged to apply for the Clinical Excellence Awards scheme

1.5.1� TheAdvisoryCommitteeforClinicalExcellenceAwards(ACCEA)shouldprovidegreaterfeedback toapplicantsandadviceastowhereadditionaldevelopmentmightbenecessary.

1.5.2� ACCEAshoulddevelopanetworkofmentorswhocanbeapproachedforadvice.Thisshouldbe coordinatedwiththewidercareeradviceprogramme.

1.5.3� Selectionpanelsshouldbegenderbalancedwhereverpossible;dueconsiderationshouldbegiven toparttimeapplicants,andACCEA’sprocessesshouldbemonitoredforgenderequality.

1.5.4� Thesameencouragementshouldbeappliedtolocalawards,ifany,andmonitoringinformation fromalltrustsshouldbecollectedcentrallyforgenderanalysis.

1.6� Recommendation 6: Ensure that the medical workforce planning apparatus takes account of the increasing number of women in the medical profession

1.6.1� NHSMedicalEducationEngland(NHSMEE)andtheCentreforWorkforceIntelligenceshould ensurethatworkforcemodelsforthefutureclearlydelineatetheeffectofarisingnumberof womenintheworkforcesothatappropriateadvicefortheworkforceplanningapparatuscan begiven.

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1.6.2 Fortraining,NHSMEEshouldcommissionthemedicalRoyalCollegestodevelopinnovative solutionstothesechallenges.ItisalsonotedthatNHSMEEisconductingareviewintothe challengesthatarepresentedbytheEuropeanWorkingTimeDirective,toimprovethequalityof traininginreducedtrainingopportunitycircumstances,andthisshouldaddresstheparticular issuesforwomen.

1.6.3 TheCentreforWorkforceIntelligenceshouldapproachtheGMCtodiscusswaysoftracking careerseffectivelythroughGMCnumberstoallowaccuratedatatobecollectedtoinform workforcemodelling.

1.7 Recommendation 7: Improve access to childcare 1.7.1 TheConferenceofPostgraduateMedicalDeansoftheUnitedKingdomandtheDepartmentof

HealthshouldconsiderwhetherthemodelsuchasthatinplaceintheNorthWesternDeanery, whichcommissionsaleademployerforallspecialtytraineesinthedeanery,wouldbeapractical anddesirablemodelintheneweducationcommissioner/providerlandscape.Theadditional benefitofbetterfacilitatingaccesstogovernmentassistanceformaternitybenefitsandchildcare ofthismodelisclear.

1.7.2 Postgraduatedeaneriesortheirleademployersshouldplanaheadforthechildcareneedsoftheir traineesandfacilitatearrangementsbetweenatraineeandthetrustsduringhisorherrotationfor accesstochildcareprovision.

1.7.3 Trustsshouldappointachildcarecoordinatorwithintheirhumanresourcesdepartmentifthey havenotyetdoneso.

1.7.4 Childcarecoordinatorsshoulddevelopinternetresourcestoactasbothaninformationresource andmessageboardsonlocalchildcareoptions,includingemergencycover.

1.7.5 NHStrustsshouldengagewithlocalauthoritiesaskeyemployerstoensurethatlocalauthorities fulfiltheirlegalresponsibilitytoensurethatthechildcareneedsoftheirpopulationaremet.NHS EmployersshouldbeginaprogrammeofworktoadviseandcoordinateNHStruststoachievethis andhelpspreadbestpractice.

1.7.6 NHSEmployersshoulddrawupguidanceongoodpracticeonwhatadditionalprovisionNHS trustsshouldmakeforchildcareallowancesforunavoidableunsocialhoursofwork.

1.7.7 Hospital-basedchildcareshouldmovetoextendedopeninghours.NHSEmployersshouldhosta conferenceofchildcarecoordinatorswiththeobjectiveofidentifyinghowthisandthespecific needsofdoctorscanbeachieved.

Dame Josephine Barnes Firstfemalepresidentofthe BritishMedicalAssociation andleadingobstetricianand gynaecologist

1.7.8 TheDepartmentofHealthshouldexplorethecostsandbenefitsofdoctors(andother healthworkersinsimilarcircumstances)whoareparentspayingforfull-timeorpart-timechildcare asavalue-for-moneysolutionforenablingdoctorstoprogresstheircareers.Onthebasisofthis analysistheDepartmentshouldsubmitacasetotheTreasurytoallowdoctorstopayforchildcare fromtheirgrossearnings.Inaddition,itshouldestablishwhetheranycentralfundingmightbe availableforchildcareassistance.Theworkinggroupbelievesthatthisisfundamentaltoensuring thatalldoctorscanfulfiltheirpotential.

1.7.9 TheCentreforWorkforceIntelligenceshouldurgentlymodeltheeffectsofgreaterfemale participationingeneralpracticeandthepotentialcostsofmaternitycover.Contractualchanges shouldbeconsideredbasedonthismodellingtocompensatematernityleaveshoulditbe required.

1.8 Recommendation 8: Improve support for carers 1.8.1 AllpostgraduatedeaneriesortheirnominatedleademployersandNHStrustsshouldhavealead

personresponsibleforsupportingcarers.

1.8.2 TheNHSshouldjoinEmployersforCarersandbenefitfromthefinancialadvantagesconferred whenadoptingcarer-friendlyemploymentpractices.Doctorswhoarefamilycarershaveparticular difficultieswithlong,unpredictableandinflexiblehoursofwork.

1.9 Recommendation 9: Strenuous efforts should be made to ensure that these recommendations are enacted through the identification of champions

1.9.1 Trustsshouldidentifyanon-executivedirectortohaveresponsibilityatalocallevelforimproving workingpatterns,givingadviceandhandlingcomplaints.Thedirectorshouldworkcloselywitha leadconsultantforworkforceplanning.

1.9.2 RoyalCollegesshouldfollowtheexampleoftheRoyalCollegeofPsychiatristsanddevelop genderequalityplans.

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Chapter 2:

The current situation

2.1 Meetingthefuturewithanincreasinglyfemaleworkforcepresentsuswithaseriesofchallenges; however,manyofthesearenotuniquetomedicine.Lessonscanbelearntfromotherprofessions thathaveundergoneorareundergoingsimilardemographicshifts.Evidencefromother professionsthathaveseensimilardemographicchange,suchasteachingorlaw,suggeststhatthis workforcechangemaybeaccompaniedbyadeclineintheesteeminwhichtheprofessionisheld andthatitisoftencoupledwithareductioninremuneration,asevidencedbytheexistenceofa genderpaygap.ResearchfromtheLawSocietysalarysurveyin2007showsthatfemalesalaried partnersearnedanaverageof£46,999,whereastheirmalecolleaguesearned£80,000.4In addition,only45%ofwomensolicitorsof10years’standinginprivatelawpracticearepartners, comparedwith65%ofmen.5AreportfromtheNewZealandCouncilforEducationResearchalso raisesanimportantissue:thatthemostlyfemaleteachingprofessionmayhaveledtothe professionbecominglessattractivetomen.6Evidencealsosuggeststhat,withanincreasing numberofwomen,theprestigeandincomeassociatedwiththeprofessionislowered.7

2.2 InmanyrespectsthestoryofwomeninmedicineintheNHSisasuccess.In1948,women accountedforlessthanafifthofthemedicalworkforce;todaytheyaccountforapproximately 41%oftheworkforce,andthatfigureisrising.Overthepast10years,womenhavebeen increasinglycompetitiveandsuccessfulinthemedicalworkforce.Withintheoverallbubbleof expansionofthemedicalworkforce,thetotalnumberofwomenhasnearlydoubled.With57% ofmedicalschoolentrantsnowwomen,themedicalprofessionislikelytobethefirstpreviously male-dominatedprofessiontoachieveparity.

2.3 Womenwithscientificinterestsseemincreasinglykeenonmedicine.Similarlyqualifiedmen chooseotherscientificcareers,particularlyinformationtechnologyandengineering.The proportionofworkersinscience,technology,engineeringandmathematicswhoarewomenhas barelyrisen,from18.4%in2001to18.5%in2006.8Furthermore,only25%ofwomenwith degreesinthesesubjectsareemployedintherespectiveprofessions.9Inengineering,women makeuponly3%ofModernApprenticeships.10

2.4 Furtheruptheladderinmedicalspecialties,thenumberofwomenbecomingconsultantsis increasinginlinewiththeoverallriseinthetotalnumberofwomenjoiningthemedical profession.Nevertheless,whereasatlowergradeswomenaccountforbetween44%and59% oftheworkforce,atconsultantleveltheyaccountforonly28%.Anattritionratebetweenthe gradesisevident,whichhasremainedstable(seeFigure 1).Thisispartlyduetothefunctionof time,inthatasthepoolofwomengrowssotoowillthenumberofwomenatthemoresenior grades,butgiventhatwomenhaverepresented50%ofmedicalstudentssince1991theimpact shouldhavebeengreaterbynow.

Dr Elizabeth Blackwell FirstfemaledoctorintheUnited States

Figure 1: Attrition rates between grades of female doctors as a percentage of the workforce

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Consultants 60 Registrars

SHO/F2 50 HO/F1

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30

20

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0

Perc

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ge

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Source:TheNHSInformationCentreforHealthandSocialCare,NHSStaff1998–2008(MedicalandDental)

2.5 Oneexplanationisthatin2007themeanageofamotherintheUKforallbirthswas29.3years, theagecoincidingwiththetimeframeatwhichafemalejuniordoctormightbeexpectedtobe reachingthefinalstagesofachievingherCertificateofCompletionofTraining(CCT).Women graduatingintheearly1990swouldthereforebeatthestageoftheirliveswheremanyaretaking careerbreaksorworkingparttimetocareforchildren.Itmaythusbethattheeffectofthe1987 expansionwouldnotbeseenforanother5–10years.11

2.6 However,whatdoesseemtobeclearisthatdespitetheglobalincreaseinthemedicalworkforce, sometrendspresentworryingevidenceofaseriesofobstaclesinthesystemforwomen.These obstaclesseemtobeleadingwomentomakedecisionsregardingtheircareersthatareperhaps compromisesratherthanchoices.Thesecompromisesmightwelldenythemedicalprofessionand theNHSofvaluabletalentandskillsinmorespecialistareasbecausethoseobstacles,orperceived obstacles,havenotbeenaddressedbythosewhohavethepowertoaddressthem.

2.7 Lookingatthenumberofadditionalspecialistregistrarsoverthelast10years,forexample,shows thatthenumberofadditionalmenappointedandthenumberofadditionalwomenappointedis roughlythesame.However,thenumberofnewlyappointedconsultantsinthesameperiodshows amuchgreaterdisparity.Theincreaseindoctors’numbershasnotbeenevenlydistributed betweenthesexesatconsultantleveldespiteparityhavingbeenachievedatthespecialistregistrar level(seeFigure 2).

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Figure 2: Comparison of the number of additionally appointed male and female specialist registrars and consultants, 1997–2007

SpRs

Consultants Women

Men

0 1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000 9,000 10,000


2.8 Simultaneously,inthestaffandassociatespecialist(SAS)gradesthenumberofwomenis disproportionatelyhigh.Asof2007,womenwhograduatedfromUKmedicalschools outnumberedtheirmalecolleaguesand,indeed,femaleinternationalmedicalgraduates(IMGs). TheRoyalCollegeofPhysicians’reportWomen and Medicine: The Future12explainsinparagraph 3.60howthepercentageofwomenintheUKmedicalworkforcemaybeaffectedbythenumbers ofIMGsintheNHSworkforce.

2.9 Ingeneralpracticethesituationisslightlydifferent.Manywomenseemtohavechosentomove intothespecialtyinthelast10years,andtheglobalriseisalmostexclusivelyfemale.Thereare alsofarmorewomenGPregistrarsthanmen.Generalpracticeisinmanywaysasuccessstoryfor womeninmedicine,withincreasingnumbersofwomenchoosingthisspecialtyandsucceeding.13 However,withinthisoverallstorylurksamorecomplexandlesspositiveone.Currentlyonly46% ofGPsarepartners;ofthosewhoarenotpartners,76%wouldliketoachievepartnership. DespitethemajorityofGPsinpartnershipsbelievingthattheyhavearesponsibilitytomakethis happen,66%ofGPsbelieveitisnowmoredifficulttotakeonnewpartners.Thisisborneoutby thefactthatamajorityofGPpartnerships(69%)havenooronlyonepartneragedunder40.

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Dame Fiona Caldicott FirstfemalepresidentoftheRoyal CollegeofPsychiatrists

Figure 3: Comparison of the total GP and GP registrar population, 1997 and 2007

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

1997 2007

Women Men

0

500

1,000

1,500

2,000

2,500

3,000

1997 2007

Women Men

Total GP population GP registrar population Source:TheNHSInformationCentreforHealthandSocialCare,NHSStaff1998–2008(GeneralPractice)

2.10 Equally,thenumberofGPprovidershasremainedthesameandthenumberofGPpartnerswho arewomenhasincreasedonlyslightly(seeFigure 4).GPprovidersincludeGPpartners,single-handedGPsandGPshareholders.

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CASE STUDY: A GP PARTNER MANAGING MATERNITY LEAVE

IjoinedmypracticewhenIwaspregnantwithmyfirstchild.Iwasinthe‘rightplaceatthe righttime’asIwasdoingalocumforaGPwhothentookearlyretirement,sothepracticewas keentoappointanewpartnerassoonaspossible.Thereweretwopartnerswhowere definitelyvitalinmysuccessinbecomingapartnerandgoingontohavefourmaternity leaves.Themaleseniorpartnerwasadelightfulman,muchlovedbypatientsandcolleagues, andvery‘prowomen’.Therewasonefemalepartner,whohadmanagedtwopregnanciesin generalpracticeandwasextremelysupportive.Istartedasahalf-timepartner,doingfive sessionsaweekandhalftheon-callcommitment.Itookfourmonths’maternityleaveforeach babyandmadeitclearthatIwouldbecomingback.Atthattime,thematernitypayment coveredthreemonthsofalocumandIpaidfortheothermonth.Theothertwomalepartners seemedtohavenoobjections.

Itwasinvaluablehavinganotherfemalepartnerasrolemodel,asaprecedenthadbeensetfor maternityleave.Shewasalwayshelpful,onanymatterhoweverbigorsmall.Afterthefirst maternityleavecameandwentfairlyuneventfully,thepartnersseemedtomanagethenext threewithoutaproblem.Sincethen,ourpracticehasseenatleastsixmorematernityleaves, inpartners,traineesandsalariedGPs.Iwasalwaysupfrontfromthebeginning,sayingthatmy husbandandIwantedtohavelotsofchildren,ratherthanbeingcoyorsecretiveaboutit.

ThefinancialbarrierswerenothugeasIwashalftimeandthemaximumgrantcovereda locumforthreemonths.IwasabletofeelthatIwasnotafinancialburdenonthepractice. Imanagedtheinevitableproblemsofsmallchildrenbeingillbyhavinganannyanda husband,who,asanacademic,couldbefairlyflexiblewithhisworkinghours.Thankfullymy childrendidnothaveanyspecialneeds,andtherewerenocomplicationsleavingthemwitha nanny.Inthedaysofon-callatnight,thetimingcouldgowrongifavisitclashedwith breastfeeding,butweseemedtomanage.Iamgratefultomyhusbandforholdingthefort singlehandedlywithfoursmallchildrenonnumerousoccasions.

Mydaughterhasjustfinishedherfirstyearasamedicalstudent,sowhatshehasseenhasnot putheroff!

15

Professor Yvonne Carter YoungestprofessorofGeneral PracticeandPrimaryCareinthe UnitedKingdomwhenshetook upherpostin1996

Figure 4: Comparison of the gender breakdown of GP providers, 1997 and 2007

Women Men

0

5,000

10,000

15,000

20,000

25,000

30,000

1997 2007

Source:TheNHSInformationCentreforHealthandSocialCare,NHSStaff1998–2008(GeneralPractice)

2.11 Foranyoneingeneralpractice,beingasalariedGPmeansthatemploymentbeyondoneyear leadstoentitlementtofullNHSworkingrights.Toavoidbearingresponsibilityforthis,manysuch practicescommonlygivecontractsforjustunderayear.Short-termcontractssuchasthisarevery disruptive,particularlyforthosewithfamilies.Thereisadditionalanecdotalevidencethatwomen arefindingitharderthantheirmalecounterpartstoobtaineventheseshort-termposts.

2.12 Furthermore,throughschemessuchastheRetainerScheme,andindeedforthosecomingbackto workthroughtheReturners’Scheme,generalpracticewasattractiveforwomenworkinglessthan fulltime,aswellastoemployingpractices.Withthereductionoffundingthatbothschemeshave seen,theseopportunitieshavedwindled.

2.13 Choosingmedicineis,ofcourse,onlythefirstofanumberofcareerchoicesthatarefacedduring thecourseofamedicalcareer.Oneofthemostcrucialdecisionsthatwilldictatethesubsequent courseofacareeristhatofspecialty.Breakingdownthehospitalconsultantspecialtiesbygender revealsawidedisparitybetweenthevariousspecialtiesinfemaleparticipation,rangingfromless than10%insurgerytoaround40%oftheworkforceinpaediatrics,pathologyandpsychiatry (seeFigure 5).

16

Figure 5: Gender divide (percentage) by specialty amongst the hospital consultant workforce, 2007

Surgery

Radiology

Psychiatry

Public and community health

Pathology

Paediatrics

Obstetrics & gynaecology

General medicine

Clinical oncology

Anaesthetics

Accident & emergency

Female Male

0 20 40 60 80 100


2.14 Formen,strongdeterminantsofcareerorspecialtychoicearerolemodelspriortomedicalschool, andtheopportunityforpersonalandprofessionalsuccess.Women,however,tendtobe influencedmorebypersonalfactorssuchasfamilyobligations,fixedhoursandasenseof altruism.14Thisinturnmeansthatdifferentspecialtiesappearattractivetowomen.Researchfrom theRoyalCollegeofPhysiciansidentifiedthatwomentendtooptforthe‘people-oriented’and ‘plan-able’.Nevertheless,thisisnotalwaysthecase,ascanbeseenbythehighpercentageof womenoptingforobstetricsandgynaecology.Conversely,mentendtogravitatetowardsthe moretechnologicallyorientedandunpredictableoptions.Foramoredetailedexplanation,see Chapter4oftheRoyalCollegeofPhysicians’reportWomen andMedicine: The Future.15Whilst thereisnoevidencetosupportthetheorythathasbeenraisedfromtimetotimethatsome specialtiesaremoresuitedto‘male’or‘female’attributes,itistruethatsomespecialtiesseemto attractproportionatelymorementhanwomen.Thistopiccouldbenefitfrommoreresearchthan thegroupwasabletoundertakeforthisreport.

17 17

Miss Eleanor Davies-Colley FirstfemalefellowoftheRoyal CollegeofSurgeons

Figure 6: Female share (percentage) of consultant posts by specialty

More people oriented

(General practice) 44.1

Paediatrics 44.0 Obstetrics and 32.8 gynaecologyPsychiatry 37.7

Public health 48.8 More

More technology oriented

More ‘planable’ unpredictable

Medical group 25.0 A&E 23.2

Pathology 38.5 Anaesthetics 28.8

Radiology 31.3 Surgical group 8.4


2.15� Surgeryisanareaofparticularconcern,giventherelativelylowpercentageofwomeninsuch alargespecialty(just8%).However,lookingatthedatainadifferentway,thereareasmany womenbecomingsurgicalconsultantswhenincludingobstetricsandgynaecology,wherewomen representathirdofthespecialty.Somecautionisthereforerequiredininterpretingthedata,and thereasonsforlowernumbersofwomeninsurgeryarenoteasilydiscernible,especiallyasthese genderdifferencesarenotpronouncedattheearlystagesofamedicalcareer.Indeed,evidence showsthatearlyintheircareers,womenwereaskeenonsurgeryasmen;however,menwere morelikelytofollowthisthroughtosucceedinbecomingfullyqualifiedsurgeons.Conversely, lookingatspecialtiesintheUnitedStatesthathavemorewomen,althoughonly8%ofwomen studentsexpressedapreferenceforpaediatrics,athirdenteredapaediatricresidency.16 Accountingforthesechangingattitudesthroughthecourseofacareerisnotsimple.

18

CASE STUDY: A FEMALE SURGICAL CONSULTANT

Iworkfulltimeasaconsultantsurgeon.Idonothaveprivatepracticecommitments,which meansIhaveahugeamountofflexibility(mostofmycolleagueshave1.5–2daysaweekfor theirotherinterests).ThenewNHSConsultantContractallowsyoutonegotiate‘supporting professionalactivities’(egpreparingauditsorteachingmaterials)athome,oncethechildren areinbed.Myclinicsstartat9.15am,afterIhavedroppedthechildrenatschool.Ihavefour children.Irecommendlivingclosetowork,asyoucanbeon-callfromhome,withteenage neighboursonstandbyforchildcareifIgetcalledin.Itendtobeon-callonThursdays,somy husbanddoestheschoolrunsonthosedays.

Myparentsandin-lawsareveryhelpfulforschoolholidays.Ihavetobeorganised–on-line supermarketscandelivergroceriesintheevenings.Thesalaryisgoodenoughtopaysomeone todoironingandcleaning.MysituationasaconsultantisbetterthanwhenIwasatrainee, whenthehourswerestilllong.AsatraineeIhadtocopewithtravelling,exams,usinga breast-pumptoexpressbreastmilkwhenon-call,andhavingtofitinwithaseriesofdifferent bosses’timetables.Hopefully,theEuropeanWorkingTimeDirectivewillmakeiteasierfor womentodecidetheirspecialtywithoutworryingaboutthehours.Youcanstillthinkand studywhenoff-duty!

Figure 7: Gender divide of registrars by specialty as a percentage of the total registrar workforce, 2007

Surgery

Radiology

Psychiatry

Public health and community health

Pathology

Paediatrics

Obstetrics & gynaecology

General medicine

Clinical oncology

Anaesthetics

Accident & emergency

Female Male

0 2 4 6 8 10 12 14 16 18


19

Mrs Linda de Cossart Pastvice-presidentoftheRoyal CollegeofSurgeonsEngland

2.16� Thepatternsofcareerchoiceinspecialtytrainingyear1(ST1)traineesarestartingtochange. Firstly,overallpercentagesofwomeninallspecialtiesarenowconsiderablyhigher.AtST1–apart fromsurgery,whichasof2007was27%female,andradiology,whichis42%female–allthe specialtiesare50%ormorefemale,withtheaveragebeing55%.Theparadigmistherefore shiftingnaturally,slowlytowardsequilibrium.Womenarenowbetterrepresentedintheformerly maledomainsofemergencymedicineandanaesthetics,whichsitfirmlywithinthebracketof unpredictableworkingpatternsandmoretechnologicallyorientedfields.17,18

2.17� Ifthesechangesaremaintainedthroughspecialtytraining,thentheworkforcewillshifttohaving afemalemajority.However,ashasalreadybeenobserved,thiscreatesthepossibilityofalarge attritionrateamongstfemaledoctorsinthenext5–10yearsaschoicestofavourfamilyaremade. Theimpactonindividualspecialtieswillvary,anditisimportanttonotethatthecontextinwhich womenaremakingthesechoicesisalsochangingandthatitisnotentirelypredictablehowthis willaffectspecialtychoice.Inparticular,thedevelopmentofcredentiallingoutlinedinHigh Quality Care for All: NHS next stage review19maywellincreasethenumberofwomencapable ofperforming,forexample,asurgicalprocedure,butitmayreducethenumberofconsultant surgeons.Theeffectofamajorityfemaleworkforce,combinedwiththismoreflexibleapproach totrainingandcertification,mayimpingeoneffortstocreateamoreconsultant-deliveredservice.

2.18� Inadditiontothechoiceofspecialtyandwhethertotakeupatrainingornon-trainingpost,many womenarechoosingtoworkparttime.In2006,34%offemaleconsultantsworkedparttime comparedwith15%oftheirmalecounterparts.Ingeneralpractice,wherepart-timeworkis perceivedtobeeasier,asmanyas49%offemaleGPsbutonly12%ofmaleGPsworkparttime. Amongsttrainees,part-timeworkingislesseasilyavailable,andonly8%ofwomenand2%of menareinlessthanfull-timetraining.

2.19� Academicmedicinealsorevealssomeconcerningstatistics.In2007,oneinfivemedicalschools hadnofemaleprofessoratall,andonlytwoofthe32medicalschoolshadafemalehead.Intotal, 23.6%ofclinicalacademicsarewomen,whereaswomenrepresent28%oftheseniorhospital workforceand36%ofgeneralpracticeproviders.

2.20� Indeed,withintheinternationalcontexttheUKisamongstthecountrieswiththeworst representationofwomenatsenioracademiclevel(13%offullclinicalprofessorsintheUKare women,comparedwith20%inFinlandandPortugal).Thismayrepresentanextremesubsetofthe issuesoutlinedearlierinthischapter.Thosewhoenteracademiatakeevenlongerthanmentoreach seniorlevelsbecauseacademicmedicine,withitsneedforaPhD,isgenerallyworkedatconcurrently withclinicalmedicine,therebylengtheningtraining.Thiscanposeadditionalhurdlesforwomen.

2.21� However,thereareanumberofotherconsiderationsthatmaymeanthatthebroadlypositive visionformedicineingeneraldoesnotsitneatlywiththisgroup.Inparticular,thereisapaucityof womeninacademicpositionswhocanactasrolemodels.Thelimitednumberofwomenin

20

21

positionsofauthorityinmedicalschoolsmaymeanthatgeneraltrendstakelongertoreachthis subset.Datafromsomeacademiccentresshowthateffortstocreatenetworkingopportunities andtosupport,encourageandactivelyprogresswomen,suchasthoseseeninSheffieldUniversity (theWomen’sNetwork)andQueen’sUniversityBelfast(theWomen’sForum),candramatically changethesepatterns.AtQueen’sUniversity,therehasbeenagenderinitiativethatincludes mentoring.TheWomen’sForummeetsmonthlytoexamineprogress.Since2000,the representationofwomenontheacademiccouncilhasincreasedby58%andasconvenersof appointmentpanelsby900%.AtSheffield,awomen’sacademicreturnerschemehasbeenin placesinceJanuary2006thatprovidesfinancialsupporttowomenreturningtowork.Thissupport includesfundingshort-termback-upandawomen’snetwork.

2.22 Similarly,recentchangestotheacademiccareerladdermayhelptoprovideaclearcareer structure.TheintroductionofformalisedcareerpathwaysthroughtheNationalInstituteforHealth Research’sacademicclinicalfellowshipsandacademicclinicallectureships,withtheirclearentry criteriaandoversight,maymakesomeoftheseconsiderablebarrierslessimposing.20

2.23 Manyofthemoresubtlebarriersthatseemtobeinthewayoftheprogressionofwomenare particularlyapparentinacademicmedicine.Womenhavefewerfailedpromotionattemptsthan men,yettheyprogressmoreslowly,implyingthatwomenarehesitanttotryforpromotionand endupwaitinglongerthanperhapstheyneedto.

2.24 In2009,theMedicalSchoolsCouncilreportedthatonly13%ofprofessorsintheUKarewomen, comparedwith40%ofclinicallecturers.Itssurveyshowedthatwomenoftenfelttheywere passedoverforpromotionandthatmalecolleaguesweregivenprojectsthatare‘more interesting’.Womenneededtobemoreassertiveandperceivedthathavingchildrenwas consideredafurtherbarriertopromotion.21Studieshavealsoreportedthatwomenarelesslikely thanmentofindaneffectivementor.22Thisriskaversionisnotconfinedtomedicinealone,butit isclearlyapowerfulfactorwithinmedicine.

2.25 Similarly,thestructuralbarriersremaininacademicmedicine,suchasthedifficultiesthoseworking parttimehaveinfulfillingtheexpectationscarriedoverfromfull-timework,andthechallengesof findingboththetimeandmoneyforcontinuingprofessionaldevelopment.23

2.26 Thistrendappearstobereflectedinthecompositionofmedicaljournaleditorialboards.A2006 surveyreportedthatonly9%offemalerespondentssatoneditorialboards–lessthanhalfthe numberofmalerespondents–andonly2%offemalerespondentshadachievededitorship,a thirdofthenumberoftheirmalecolleagues.

Dr Elizabeth Garrett Anderson Firstwomantogainamedical qualificationintheUnited Kingdom

2.27� Thisapparentdearthofwomeninseniorrolesisalsorecognisableatnationallevel.AsofJune 2008,onlythreeofthe15medicalRoyalCollegeandfacultyleaderswerewomen.TheBritish MedicalAssociation(BMA)hasneverhadafemalechairoftheBMACouncil,theexecutivesofits consultantandseniorcommitteesareallmale,andonlythreechairsofits19committeesare women,oneofthesebeingaco-chairwithaman.

2.28� Theleadershiprolesmentionedabovearemainlyappointed.Thereisclearevidencethatwomen arelesslikelytostandfornomination,andthatthisstemsfromself-confidenceissuesand difficultyinsqueezingadditionalresponsibilitiesintoanalreadycrowdedlife.However,women oftenstepintotheserolesandindeedexcel,iftheyareappointedorstandforelection,although reluctanttodoso.Womenwilloftennotapplyforsuchpositionsunlessactivelyrecruitedand encouraged;thismaybeachievedbywomen’smedicalnetworkspublicisingvacanciesand nominatingthemforelection.

2.29� Theimportanceofhavingwomeninsuchrolescannotbeoverestimated.Notonlydoholdersof thesepositionshelptodefinethefuturepolicyanddirectionofmedicine,buttheyarepowerful rolemodelsforthosewithinmedicineand,indeed,asignaltothoseoutsidemedicine.

2.30� Despiteimportantchangestothemechanismsforprovidingrewardforservicetoseniordoctors –changesthathavemadetheprocessmoretransparentandfair–therehasyettobetranslation intogainforwomen.TheClinicalExcellenceAwards(CEA)schemeindicatesthatwomenmaynot bereaching,oratleastarenotbeingrecognisedfor,workatseniorlevels.In2008,women accountedforonly16%ofapplicantstothenationalawardschemeand17%oftheawards given.Overall,twiceasmanymenaswomenheldaCEAatlevel9orabove.Selectionpanels shouldbegenderbalancedinordertoinspireconfidence.ApplicationratesforSilver/GoldClinical ExcellenceAwardsarelowerforfemalesthanmales(49.5%comparedwith55.9%).24This,too, maybeafacetoftime,combinedwithlessthanfull-timeworkingandcareerbreaks.These observationsregardingnationalawardsapplyequallytolocalawards.

2.31� Fromthesedatawecanidentifytrendsamongstthefemalemedicalworkforce:

●● Womenaremorelikelytoworkparttime.

●● Womenaremorelikelytoenterastafforassociatespecialistpost.

●● Womenareattractedtosomespecialtiesoverothers.

●● Womenareveryunderrepresentedamongstsenioracademics.

●● Womenareunderrepresentedinnationalleadershiproles.

●● WomenareunderrepresentedintheClinicalExcellenceAwardsscheme.

22

23

Chapter 3:

Barriers to success

3.1 Pregnancy and maternity leave 3.1.1 Formanywomenthefirsttimetheirgenderaffectstheirworkinglivesisduringpregnancy.In

additiontothephysicaleffectsofpregnancy,therearethecomplicationsofchangingworking practice,bothduringpregnancyandpost-childbirth.

3.1.2 Theeffectsofpregnancyarewellstudied,andtherearegooddatashowingthatinclinicalareas wherejuniordoctorsworklonghourswithperiodsofsleepdeprivationandlongperiodsof alertnessthereisanincreasedriskofcomplicationsduringpregnancy.25Interestingly,however, theseeffectsappeartobemitigatedifmaternityleaveandtrainingpoliciesareflexible.Thereis thereforeastrongcaseforensuringthatwomenhaveaccesstoflexibleworkandmaternityleave cover,perhapsaboveandbeyondthatinotherprofessions.

3.1.3 Maternityleavearrangementsarelegalrequirements,butagainthecomplexandvaried contractualarrangementsinplaceintheNHSmeanthatthisisanareaofconfusionandanxiety forwomenand,indeed,employers.Forhospitaldoctors,thedifficultycomesinnegotiatingtheir workpatternstowardsthelatterstagesofpregnancywithoutleavingcolleaguestocarrythe additionalburden.ForGPsthesituationisevenmorecomplex.Theemploymentarrangements meanthatstoriesofpracticesnotemployingfemalesofchild-bearingage,orbeingunableor unwillingtocoverthecostsofmaternityleave,areacauseofseriousconcernamongstwomen GPs.Thesituationseemstobeworseningratherthanimproving,despiteeffortsfrommany.Those insubstantiveacademicpostsfaceissuesoverandabovethoseintheNHS,todowiththelength ofserviceinanyoneparticularhighereducationinstitution,asmaternityrightsdonottransfer withposts.CollaborationbetweentheNHSandtheuniversitiesoverthiswasrecommendedinthe Follettreportof2001.

3.1.4 Solutions discussed.

3.1.4.1 TheEuropeanWorkingTimeDirectivewillgosomewaytoreducingworkinghourstoanationally consistentstandard,butitisimportantthatasthedirectiveisimplementedtheneedforflexibility forpregnantdoctorsisnotlostintherigidityofthenewrotas.

3.1.4.2 SeriousdiscussionbetweentheRoyalCollegeofGeneralPractitioners(RCGP),theBMAandthe WorkforceDirectorateoftheDepartmentofHealthneedstobeinitiatedsothattheconcernsof GPsregardingmaternityleavecanbeunderstoodandmanaged.

Phyllis George Firstwomantobeelectedtothe CounciloftheRoyalCollegeof SurgeonsEngland

CASE STUDY: A PROFESSOR OF DERMATOLOGY

Manyofmycolleaguesinmysmallspecialty(dermatology)werescandalisedwhenIbecame anunmarriedmotherattheageof41.Itwasdifficultcombiningresearchwithbeingasingle motherandfull-timeconsultant,buttherewardshavebeengreat,withapersonalchair,a platinummeritawardandasonwhobelievesthatwomenareequalandshouldwork.

3.2� Children 3.2.1� Ofalltheissuesthathavebeenraised,themostwidespreadareaofconcernisthatofchildcare.

Anumberofindividualsandorganisationshaveraisedthisissue,nationallyandinternationally,as akeyfactorincareerdecisionsfacedbyparents,irrespectiveofprofession.Itisacceptedthatmen shouldplayanequalpartinchildcareandtherearesomeindicationsthatthispracticeisgrowing butithasnotyethappened,whichiswhytheproblemsneedtobeaddressedinthisreport.Our observationsandrecommendationsapplyequallytomothersandfathers.Fordoctors,the demandsofchildcareaffectanumberofchoices,forexamplechoiceofspecialty,transfertoa stafforassociatespecialistgrade,retraining,workingparttimeorleavingmedicineentirely. Lookingafterchildrenisanimportantphaseinlife,butitiscrucialthatdecisionsmadeatthistime donotdeleteriouslyaffectfuturecareers.

3.2.2� Partofthedifficultyconcernstheneedtobalancethedevelopmentalneedsofchildrenwiththe careerrequirementsofparentsandtherequirementofsocietytogainvalueformoney,giventhe sumsspentontrainingdoctors.Balancingdoctors’responsibilitytopatientsagainsttheir responsibilitytochildrenisalltoooftenaHobson’schoice.Anecdotesofachildbeingleftinthe careofasecretaryorintheofficewhilsttheneedsofapatientareseentobytheirdoctor-parent arealltoocommon.

3.2.3� Thereareanumberoftypesofchildcare,eachwithitsownbenefits(seetableopposite).

3.2.4� Nosingletypeofchildcarewillprovideapanacea.Childrenhavedifferentneedsastheygrow, anddoctorsalsorequiredifferentlevelsandtypesofsupportastheyprogressintheircareers. Theproblemsinobtainingchildcarearedifferentatdifferentstagesindoctors’careers,andare dependentonfactorssuchastheagesoftheirchildrenandtheirgeographiclocation.Itis interestingtonotethatdatafromNorthAmericaandAustraliaindicatethatveryshortlyhalfof allphysicianswillbemarriedtootherphysicians,makingchildcarearrangementsevenmore complex.26

24

Type of childcare Positives Negatives

Nanniesandhomehelp (live-in/live-out)

24-hoursupportavailable

One-to-onecare

Highcost

Unregulated

Employerresponsiblefor allpre-employmentchecks/ pay/tax

Nurseries Ofstedregistered

Trainingrequirement

Travelcosts

Usuallyfixedhours

Higherchild-to-carerratio

Childminders Safeenvironment

Fullyregulated

Relativelyinexpensive

Negotiablehours

Lowchild-to-carerratio

Travelcosts

Back-upchildcarevariable

Negotiatedhourslessflexible

Siteofwork

Extendedschoolprovision Goodactivitysetforolder children

Ofstedregistered

Holidayprovision

Relativelyinexpensive

Provisionvariable

Travelcosts

Usuallyfixedhours

Relatives One-to-onecare

Inexpensive

Dependentonavailability

Reliantongoodwill

Aupairs 24-hoursupportavailable

Inexpensive

Unregulated

Highturnover

Usuallyuntrained

Unsuitableforfull-timecover

Babysitters One-to-onecare

Inexpensive

Unregulated

Dependentonavailability

25

Professor Trisha Greenhalgh ProfessorofPrimaryCare Healthandleadingfigureinthe philosophicalaspectsofevidence-basedmedicine

CASE STUDY: ALTERNATIVE CHILDCARE

Iamaconsultantorthopaedicsurgeonwithfourchildren.Myhusbandisa‘househusband’. Itwasnotourintentiontohaveacomplete‘rolereversal’,butprimaryschool,withholidays and9amto3pmdays,suddenlyseemedmuchlessforgivingthannurseryhours.Mysalaryis plentyforafamilyofsix.

Theschoolissuecouldbeworkedarounddifferently:twohighearnerscoulduseprivate schoolswithlongerschooldays;alternatively,theconsultantjobplanincludeson-calldutyand 10hoursof‘supportingwork’ina40-hourweek,soyouonlyhaveafewfixedearlystartsand latefinisheseachweek,forwhichmyfriendsusebreakfastandafter-schoolclubs.

Ihaverecentlypickedupmoremanagerialroles,whichinvolvealotofeveningmeetingsor suddenchangesofpriority.Traditionally,consultants’wivesweresupposedtoacceptthis,but myhusbandknowsthatIhavedeliberatelychosenthisextraworkandresentsitalittleforthe reductioninfamilytime.Oncethechildrencancyclethemselveshomefromschool,my husbandwillbelookingtoworkagain.Itisaveryunusualpersonwhocandedicatetheirlife tobringingupchildren,andarolethatisstillundervalued–IknowIcouldneverdothis.

3.2.5� Forjuniordoctorsmanyoftheproblemsarisefromtherotationalnatureoftheirpostings,andthe necessitytoworkunsocialhours,ofteninchangeableworkingpatternsandshiftworking.For moreseniordoctors,theproblemsarisefromtheunpredictablenatureoftheiron-calland emergencydemands,andthelonghoursthatareoftenworked–notinfrequentlybeyondthose paidfor.

3.2.6� Whilstitmayseemthatolderchildrenposefewerchildcareconcernsthaninfantsandyoung children,thisisnotnecessarilythecase.Infantsandyoungchildrenrequirefull-timesupervision, whilstthoseinschoolrequirecareafterschoolandintheschoolholidaysthat,becauseofthe timings,maybemoredifficulttoachieveatreasonablecost.Foryoungerchildrenthequestions thatparentsgrapplewithconcernissuessuchaswherebesttoplacechildrentoensurethatthey receivethestimulationnecessaryfordevelopment,whetherplacementinsmallorlargergroupsis morebeneficial,andthesiteofchildcare–homevs.theworkplaceorsomewhereelse.

3.2.7� Equally,theconcernsofparentsareverymuchaffectedbylocation.Livingincitiesmaybring awiderchoiceoflocalchildcareoptions,butthecostsmaybesubstantiallyhigher;rural settingshavedifferentissues,suchastherestrictedavailabilityofchildcareandtheneedtotravel greaterdistances.

3.2.8� However,alltheproblemsfallbroadlyintofourcategories:

●● information

●● workingpractices

26

27

●● additionalprovisionofchildcare

●● funding.

Information 3.2.8.1 Thereappearstobeadearthofeasilyavailableinformation.Knowledgeseemstopassbywordof

mouth,andalthoughsometrustsandlocalgovernmentorganisationsdohavechildcarewebsites, informationisgreatlyvariable.Fortraineestheproblemisparticularlyacute,becausethe rotationalworkingpattern,involvingfrequentmoves,makesitevenhardertofindinformation aboutlocalchildcareprovisionwithinornearthetrustwheretheyareworking.

3.2.8.2 Theinformation,whereitisavailable,isalsonotnecessarilyfocusedondoctors.Trustswithgood practicehaveachildcarewebsiteandacontactnumberforthelocalchildcarecoordinator. However,informationisveryvariableandrarelyincludesthefullrangeofoptionsavailable.

Workingpractices 3.2.8.3 Oneofthekeyproblemswithchildcareistheunsocialhoursworked.Thechangingpatternsof

seniorconsultants’workhaveledtomoredoctorsworkingshifts.Seniordoctorsalsosufferfrom theproblemthattheymaybecalledonwhilstnotformally‘oncall’,andtheGMC’sGood Medical Practicerequiresadoctortoattendwhennecessary.27Forjuniordoctors,morehoursare workedoutsidethenormal9amto5pmworkingday,androtasarenowmorerigidduetothe introductionoftheEuropeanWorkingTimeDirective.

3.2.8.4 Thehighernumberofnursescomparedwithdoctorsallowsformoreflexibilityinnurses’rotas thanindoctors’rotas.Thisallowsnursingrotastoabsorbmorereadilythosestaffunabletowork unsocialhoursbecauseofchildcareandcaringcommitments.

3.2.8.5 Provisionoflongerhoursofchildcareisonemeanstoaddresssomeoftheseconcerns.Itis importanttostressthatlongerhourswouldensurethatfacilitiesaremoreavailableatthetimes requiredratherthantoallowchildrentobeinchildcareforlonger.

3.2.8.6 Asmentioned,theseproblemsarecompoundedforjuniordoctorsbytherotationalnatureof working–namely,thatinmostinstancesatrainee’sjobchangeseveryfourtosixmonths.This meansthat,inadditiontothephysicalgeographicaldifferenceinlocation,accessingemployer-basedsupport,suchaschildcarevouchers,canbeincrediblydifficult.Thissituationiscompounded bytheoftenshortnoticeatwhichjuniordoctorsarenotifiedofplacements.

Additionalprovision 3.2.8.7 Availableworkplacechildcareisrarelyprovidedoutsidenormalworkinghours,andevenwhereit

isavailablethereisrarelyafacilitytocoverall24hours.Givenincreasingmovesfordoctorsatall levelstoworkshiftpatterns,andindeedtheincreasedlikelihoodofdoctorsbeingpartneredwith

Dame Deirdre Hine FirstfemaleChiefMedicalOfficer intheUnitedKingdom

fellowdoctors,thisplacesastrainondoctorsthatisnotoftenreplicatedinotherprofessions. Similarly,thevariedworkpatternsofdoctorsmakeithardforthemtofitintomoreregimented routinesthatdemand,forexample,children’sattendanceonfixeddays.Ifadoctor’sshiftsmove fromaMondayoneweektoaWednesdaythenext,havingaplaceatnurseryonaMondayisnot helpful.Additionally,forjuniordoctorsmovingaroundonrotations,nurserywaitinglistsoften meanthattheycannotobtainwhatprovisionisavailable.

3.2.8.8� GPsfacedifferentproblems:theirworkplacemaynothavechildcareprovision,andtheyareoften self-employed.Carefulconsiderationneedstobegiventohowcurrentprovisionofchildcarecan accommodatetheirrequirements.

Funding 3.2.8.9� Thereissomeassistanceavailabletopayforchildcareintheformofvouchers;however,this

providesamaximumofonly£1,195perannum.Thecaseforadditionalfundsortaxrelieffor doctorsisdependentonclearlyexpressingthatthestaterequiresmorefromdoctorsthanfrom otheremployeesandthatthisadditionalworkimpingesonnormalchildcare.Forexample,doctors workprolongedunsocialhours,whichmaybeunusuallyrigidor,conversely,unpredictable.Both oftheseinterferewithsimplechildcarearrangements,andself-careofchildrenisdifficultbecause careerbreaksfrommedicinearedamagingduetothelossofskillsandknowledgeandlimited returntoworkschemes.Therewillbenorealprogresstowardsgainingfullvaluefromwomen doctorsuntilthecostandavailabilityofchildcareareaddressed.Thecostoftrainingalonemakes thisworthwhile.Aboveallotherconsiderations,helpwithchildcarewillbeintheinterestsof continuityofpatientcare.

3.2.8.10�Thecostsofchildcarearehigh,thehighestofallbeingemploymentofananny.Inadditiontothe purelyfinancialcost,thereareanumberofotherissuesrelatingtochildcarestaffthatapotential employerhastoconsider:

●● qualifications

●● experience

●● referencechecking

●● CriminalRecordsBureauchecks

●● workpermits.

28

3.2.9� Solutions discussed.

Informationprovision 3.2.9.1� Childcarecoordinatorsineachtrustobviouslyhaveakeyroleindisseminatinginformation.The

particularchallengeistomakethatinformationavailableasearlyaspossibletotraineeswhoare movinglocation,eitherbylinkinginthroughthepostgraduatedeaneryorbyinclusioninsome formofwelcomepackfornewjoiners.

3.2.9.2� TheDepartmentforChildren,SchoolsandFamilieshasrecentlypublishedNext Steps for Early Learning and Childcare,whichplacesadutyuponlocalgovernmentorganisationstomanage childcareprovisionintheirareaactively.Thisincludesconsultingwithkeyemployers.Itwouldbe difficulttoarguethatanNHSacuteorprimarycaretrustisnotakeyemployer,andtruststhatdo notcurrentlyhavechildcareprovisionshouldexploitthisnewavenue.Raisingawarenessofthis newdutywithtrustswillbeofkeyimportance.Childcarecoordinatorsineachtrustwillalsohave akeyroleinadvancingtheneedsofdoctors,aswellasotherhealthcarestaff,inthisnew framework.

Workingpractices 3.2.9.3� OnemodelthathaschallengedtheconstantchangesofemployerisintheNorthWest,wherethe

deaneryactsasthesoleemployerfortraineesregardlessofthetrustatwhichtheyactuallywork. Thisminimisesthedisruptioncausedbyhavingtostartagainateachnewlocationinaccessing employer-basedsupport.

3.2.9.4� Anotherproposedsolutionisringfencingofcrècheplacesfortraineedoctorswhoaremoved. However,demandisunlikelytobeconsistentandmodellingworkwouldbenecessarytoascertain whetherthiswouldbeacost-effectivesolution.

Additionalprovision 3.2.9.5� Emergencyin-trustchildcareisalsoapossiblesolutionforthoseinstanceswhereitisimpossibleto

arrangechildcareatshortnoticeforlimitedperiods.Anecdotalevidenceofchildrenbeingminded inadoctor’sofficebysecretarialorotherstaffiscommon.However,suchpracticeisnotfairon eitherthechildorstaffmembers.Iftrustshada‘drop-in’facility,thiswouldprovideasafe environmentnotdependentonthegoodwillofnon-clinicalstaff.Again,thiswouldneedtobe carefullymodelledtoensurethatitwouldbecosteffectivetomaintainsuchaservice,andit wouldneedtobereviewedastheEuropeanWorkingTimeDirectivealtersclinicalpractice.

Funding 3.2.9.6� Apotentialsolutiontothefundingproblemwouldbetoallowdoctorstopayforchildcareoutof

theirgrossearnings.Thiswouldmeanthatchildcarewastreatedliketheexpensesofasmall

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Dr Sophia Jex-Blake Oneofthe‘EdinburghSeven’,thefirstgroupof femalemedicalstudentsatauniversityintheUnited Kingdom.Leadingcampaignerformedicaleducation forwomenandinvolvedinfoundingtwomedical schoolsforwomen

business,andthattaxwaspaidonthenetamountsremainingafterpaymentofchildcare.This wouldprovideaworthwhilerelieffromtheexpense.

3.2.9.7� Thisrepresentsasignificantdeparturefromcurrentgovernmentpolicyandwouldnotproducea swiftresolution.TheprocessforchangingthispolicyistorequiretheDepartmentofHealthto undertakeadetailedbusinesscaseoutliningthebenefitsofchildcaresupporttodoctorsand whetheritrepresentsvalueformoney.Additionally,theDepartmentwillhavetodemonstratethat doctorsareaspecialcase,whichitisbelievedtheyarebyvirtueofthelengthandunpredictability oftheirworkinghours.Oncethebusinesscasehasbeencompleted,itwillhavetobepresented totheTreasuryaspartofthenextComprehensiveSpendingReviewinordertocomeintoeffect by2012.

3.2.9.8� Theargumentmightbemade–althoughitwouldbeshort-termism–that,inthecurrentfinancial climate,thecosttotheTreasuryandthecomplexityofthearrangementswouldhavetobefully exploredandproventoshowbenefittotheNHSiftheTreasuryweretoapproveachange.Ifa favourablebenefitweretobedemonstrated,itwouldnotnecessarilymeanthatitwouldobtain Treasuryendorsement.Buttheexpenditure,smallinoverallterms,wouldrepresentthemost worthwhileprotectionoftheinvestmentmadeintrainingwomendoctors.

3.2.9.9� AsecondavenueofapproachistoasktheDepartmentofHealthtomakeavailablefundingcentrally toassistdoctorswithchildcare.Thisapproachalsorequiresadetailedbusinesscasebeingmadeby theDepartment’sWorkforceDirectorateandabidformoneyinthenextComprehensiveSpending Reviewround.Again,thiswouldfacethechallengeofcompetingwithotherDepartmentofHealth prioritiesagainstabackgroundofaworseningeconomicpicture.Nevertheless,addressingthisissue isthesinglemostproductiveresponsecalledfor.*

3.3� Professional barriers Lessthanfull-timework

3.3.1� Thethrustofthisreportisaboutenablingfull-timeworkintheinterestsofpatients.Butdata clearlyshowthatbothmenandwomenincreasinglywishtoworklessthanfulltime,evenwith thereductioninhoursbroughtaboutbytheintroductionoftheEuropeanWorkingTimeDirective. Thisisparticularlytrueduringtraining,whenmanydoctorsstartfamilies.Equally,withanageing populationitmaywellbeproblematiclaterindoctors’careerstoo,eitherinrelationtothemselves orascarersforfamilymembers.Budgetstoallowthishaveincreasedbutarenotkeepingpace withdemand.Inpart,thisstemsfromtheadditionalcostofemployinglessthanfull-timeworkers, eveninjobshares.A2008surveybythePostgraduateMedicalEducationandTrainingBoard (PMETB)showedthatalmost22%offemaletraineesreportthattheywanttotrainflexiblybut arenotdoingso.28

*Althoughtheyarenotwithintheremitoftheworkinggroup,theseconsiderationsapplyequallytoallhealthcare workersinsimilarcircumstances.

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3.3.2 Lessthanfull-timeworkingisalsooftenundervalued.Previouslyitwasfeltthatthiswasbecause ofthesupernumerarystatusofmanysuchdoctors,whichgavetheimpressiontosomethatthese doctorswerelessinvolvedandcommittedtotheinstitutionshousingthem.Aresponsetothishas beentofollowthemodelsetbytheLondonDeaneryofencouragingjobshareswherepossible. Whilstthishasfullyintegrateddoctorsintohospitalsystems,itmayhaveincreasedratherthan decreasedproblemsforthosewithchildrenorinflexibletimeconstraints.Furthermore,manywork lessthanfulltimeinordertocareforothers,includingageingandinfirmparents,partnersand childrenwithlong-termconditionsorotherproblems.Theeffectofthisisthatthesedoctorshave limitedcapacitytotakeonadditionalworkresponsibilities,particularlythosespreadbetween contractedhours.Accordingly,itisoftenstillfeltthatwomeninthesepositionscontributelessto theiremployers,andthismayhampercareerprogression.Astudycomparingflexibletraineeswith full-timetraineesfoundthattheoutcomesoftrainingwerebroadlysimilar:92%offlexible traineesobtainedaCCTcomparedwith90%offull-timetrainees,althoughflexibletraineeswere morelikelytotakepart-timeconsultantposts.29

Re-enteringtheworkforce 3.3.3 Itisvitalforplanningandforthebestuseofwomen’stalentsthattheirre-entryintothe

professionbeattheforefrontofarrangementsformaternityleaveandafterwards.Manywomen arechoosingtohavechildrenatabouttheageof30,whichis,foradoctor,thelatterstageof completingtrainingandbecomingabletopractiseintheirownright.Itisvitalthatwomenhavea clearandunambiguousmechanismtostepoffandthengetbackonthespecialisttrainingladder, sothatthevalueofthetrainingtheyhavealreadycompletedisnotlostandthattheirskillscanbe toppeduponreturntofull-timepractice.Onecomplicationisthatmaternityisanemployment issue,meaningthatanNHStrustwillbearthecostofmaternityleave,andyetitisthe postgraduatedeaneriesthatcoordinatetraining.Therefore,onreturningfrommaternityleave, atraineemightnotreturntothetrustthroughwhichshewaspreviouslyrotating.Thisisnot financiallyequitablefortheemployingtrust,anditplacesanadditionalburdenanduncertainty uponthetrainee.Similarly,whilstinthepasttherehasbeensupportforreturntoworkschemes ingeneralpractice,suchschemesarenowverylimited,despitemanyefforts.

Professor Parveen Kumar Academicgastroenterologistwho startedthefirstMaster’sdegree ingastroenterologyinEngland andco-editorofKumar and Clark Clinical Medicine

CASE STUDY: A LETTER ABOUT RE-ENTERING THE WORKFORCE AFTER A CAREER BREAK

DearMedicalWoman’sFederation,

Iwouldbeverygratefulifyoucouldoffermesomeadvice.Iamkeentoreturntomedicine afteracareerbreakofsixyears.Priortostoppingworktolookaftermychildren,Igraduated in1994andsubsequentlyspentthreeyearsingeneralmedicineandfiveyearsinmyspecialty (thelastyearwasparttime,aftermyfirstchildarrived).Duetothetimingofmypregnancies, IsatPartIbutnotPartIIofmymembershipexams.Ialsohadtovoluntarilyremovemyname fromthemedicalregisterduetothehighcostoffees(unabletobemetonasinglefamily income!).Ire-registeredlastyear,butduetomyextensivetimeawayfromworkInowhave toreturntoanapprovedpracticesettingforoneyearfull-timeequivalent.

Iamcurrentlyresearchinganumberofoptions.

Iamconsideringreturningtomyformerspecialty,althoughIhavetostartagainatthe beginningwithmyexams,asthesystemhaschanged.Iamalso,ofcourse,somewhatrusty andwouldneedsomesortofrefreshertraining.

Ihavealsolookedintopublichealth,althoughitisapparentlynotpossibleformetoenteras adoctor,aspublichealthtraininglocationsarenotapprovedpracticesettings.Icouldapply asanon-medic,althoughthisfeelsstrangeasIhaveamedicalqualification,andIcan’thelp feelingthatImaybeputintoadifficultposition,havingamedicalqualification,yetnotbeing allowedtopractiseasadoctorbecauseIamnotinanapprovedpracticesetting.

TheotherdifficultyIhaveisthatoffittingmyworkaroundchildcare.Mychildrenwillbothbe atschoolfromSeptember.Unfortunately,Iliveinaruralarea,withnoavailableafter-school clubsandverylimitedavailabilityofchildminders.Ihavenofamilylivingnearbywhocanhelp.

IknowthatIcanapplyforflexibletraining,butIexpectthatIwouldberequiredtowork somefulldays–duetomylackofchildcare,thiswouldproveachallenge!

Iknowtherearenomagicanswers,butIcurrentlyfeelveryfrustratedthatmyprofessional experienceandqualificationscannotbeused,andwouldbegratefulforanyadviceasto whereIcangofromhere.Iunderstandthatthereusedtobeafantasticreturners/flexible schemerunbyNHSProfessionals,whichIbelievewouldhaveofferedtheperfectsolution, butthisdoesnotseemtobeavailableanylonger.Isthereanyalternative?

Non-traininggrades 3.3.4 Thedecisiontostepoffthetrainingladderandintoastafforassociatespecialist(SAS)gradepost

ismadefrequentlyasasolutiontobalancingthedemandsoffamilyagainstwork.SASgrades focusondeliveringcare,releasingadoctorfromthestructuredpressureoftrainingand,indeed, the‘extras’thatarerequiredofaconsultant.However,onceinanSASgradepost,career progressionbecomesmuchharderbecauseofthelackofthatstructure.Thereisamechanismby

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whichSASgradedoctorscandemonstratethattheyhaveobtainedsimilarexperiencetoadoctor onaspecialisttrainingprogrammeandthusdemonstrateeligibilitytoenterthespecialistregister. However,theprocessofconstructingasuitableportfolioistimeconsumingandexpensive.In addition,notalldeanerieshavestructuredsupportforSASgrades.Theprocesshasbeencriticised asoverlybureaucratic,and,whenthemedicalRoyalCollegesprovideexternalassessmentof applications,theyrelyonthegoodwilloftheirseniormemberstodosoontopoftheirclinical duties.ThePostgraduateMedicalEducationandTrainingBoard(PMETB)regulatesthe equivalenceprocedures,anditsworkwiththemedicalRoyalCollegestoreducedelaysand improvetheprocesshasbeenrecognised.

3.3.5 Partoftheproblemis,ofcourse,thedifficultyinstartinganynewprocess.Thesheervolumeof applicationsinitiallycausedextensivedelays.Additionalproblemshavebeenassociatedwiththe qualityofapplications,andtherehavebeenreportsofapplicantsunnecessarilysubmittingover 1,000pagesofinformation.Furthermore,onceanapplicationhasbeenrejected,thereis insufficientsupportforthatdoctortodiscoverwhatsheneedstodotoimprove–avoidthathas beenfilledbyprivatetutoringcompanies,whichaddstotheexpense.

3.3.6 However,forwomenwhohavechosentheSASgrade,theproblemisdeeperthansimply overcomingtheprocessofapplication.AchievingaCertificateofEligibilityforSpecialist Registration(CESR)givestheimpressionthatthedoctorwillapplyforaconsultantpost. ThereasonsdeterminingthedecisiontoentertheSASgradepostinthefirstplacearelikely toprecludetakingupsuchapost,deterringapplicationatall.Thereisalargepoolofstagnant talentintheSASgradeasaresult.

3.3.7 Solutions discussed.

Lessthanfull-timeworking 3.3.7.1 Workinglessthanfulltime,whethertoaccommodateacademicorotherresponsibilities,alsohas

potentialproblemsforrevalidation.Alldoctorswillbeexpectedtobeatthesamecompetence levelirrespectiveofhoursworked.Thisisimportant,asthepatientwouldnotwantsimilarly gradeddoctorswithvaryingcompetence.However,thisrequirementmeansthattheonus,cost andresponsibilityshouldnotfallontheindividualtocovertherequirements.Lessthanfull-time employeesshouldbeentitledtothesamecontinuingprofessionaldevelopmentandappraisal supportasfull-timecolleaguesiftheyaretobesimilarlyappraised.

Re-enteringtheworkforce 3.3.7.2 Withthechangesunderwayinthefundingofpostgraduatemedicaleducation,itwouldbe

extremelybeneficial,forboththetraineeandtheemployer,ifthefragmentationofresponsibility formaternityleavecouldberesolved.Asingleemployerforthedurationofpostgraduatetraining

Professor and Senator Rita Levi-Montalcini Italianneurologistwho,withcolleague StanleyCohen,receivedthe1986Nobel PrizeinPhysiologyorMedicinefortheir discoveryofnervegrowthfactor

wouldgreatlysimplifytheprocessandallowformuchbetterlong-termworkforceplanningand fortheflexibilitythatisrequiredtomakeitwork.

3.3.7.3� Inthecurrentmixedeconomyofrun-throughanduncoupledspecialtytraining,itwillalsobe necessarytoensurethatwomeninrun-throughtrainingpostsarenotdisadvantagedcompared withthoseinuncoupledtrainingpostswhohave,theoretically,agreateropportunitytoplan pregnancyduringthenaturalcareerbreakbetweenbasicandhigherspecialisttraining.However, thoseinuncoupledtrainingpostswillhavetore-competeforentrytotraining,whereasthosein run-throughretaintheirrighttore-entertrainingwheretheyleftoff.Workisalreadyunderway ontheconceptofmodularcredentialling,whichshouldmaketrainingmore‘portable’andensure thatrecognitionforachievingcompetenciesisgivenandappropriatelyrecorded.

3.3.7.4� Theintroductionofrevalidationwillalsoimposenewchallenges,particularlyformoresenior doctors,asbothre-licensingandrecertificationwillberequired.Undertheproposed arrangements,alongabsencefromworkofoverfiveyearscouldrenderadoctorunableto practise.Itisvitalthat,astheimplementationofrevalidationcontinues,thereisclearand unambiguousguidancefordoctorsonhowtheycanregisteras‘non-practising’andonthe requirements,onaslidingscaledependentonthelengthofabsence,toresumepractisingagain. Foraparentoftwochildrenitisnotinconceivablethatafive-yearcareergapmaybenecessary. Provisionsfor‘continuation’trainingandback-to-workexperiencewillbenecessarytoassist parentsreturningtoworktodemonstratethattheyareuptodateandfittopractise.The postgraduatedeaneries,inconjunctionwiththeGMCandthemedicalRoyalColleges,willplay akeyroleinthis,evenforthemoreseniordoctors.

3.4� Psychological barriers 3.4.1� Theworkinggroupheardconvincingevidencethatwomenarenotreachingthepoststheyaspire

to,notbecauseofstructuralbarriersbutratherbecauseofinternalpsychologicaldifferencesfrom theirmalecounterparts.Theevidencesupportsthesestatements,withwomenseemingtobe restrictedbytheirtendencytoberiskaverse,non-self-promotingandnotaswellnetworked. Theselesstangiblepersonalityfacetscannotbealteredbyrecommendations,butratherbylocal effortsandsupportiveorganisationalstructures.Atthesametime,manywomentoldthegroup thattheywerehappywithapositionthatfellshortofwhattheymighthaveaspiredto,because theyhadachievedawork–lifebalancethatsuitedthemandgavethemfulfillingcontactwith patients.

3.4.2� ExperienceattheHarvardBrighamandWomen’sHospitalinBoston,Massachusetts,clearly demonstratesthatlocalactioncanameliorateinmanywaysthesemoresubtlebarriers.Bycreating anOfficeforWomen’sCareers,whichisactivelyengagedinthepromotionofwomentosenior positions,theyhaveseendramaticimprovement.Indeed,thenumberoffemaleprofessorshas doubled.30,31

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3.4.3� Solutions discussed.

3.4.3.1� Astrustsandacademicinstitutionscoalesceintoacademichealthsciencecentres,theremaybe opportunitiesforsimilarofficesintheUK.However,evenwithouttheseformalstructures,the mechanismsthattheyhaveusedtoachievesuccesscanbeinstituted:identifyingfemalerole modelswhochampionlocalwomen;providingopportunitiestonetwork;mentorship;andactive supportofpromotions.Theseaimscanbesimplytranslatedatalocallevel:

●● Itisimportantthateverydoctorshouldhaveherownwebpageonthetrust’ssite,inorderto highlightherprofileandmakeherselfknown,andinordertohelpherfocusonthe achievementsthatshouldberecorded.

●● Prospectusesandinformationaboutthetrustshouldfeaturewomenwhohavesucceeded, andtheyshouldbeputforwardasspokeswomenwhenthetrustispublicisingitswork.

●● Thepracticeofhangingportraitsofdoctorsinhospitalsandsurgeriesandlearnedsocietiesshould includethoseofwomen,andthereshouldbearchivesoftheachievementsofwomeninthepast.

●● Womenshouldbeselectedmorefrequentlytodelivernamedlecturesandkeynotespeeches atconferencesoftheBMAandtheRoyalColleges,andtheyshouldbeincludedindue proportiononeditorialcommittees.

●● Committeesshouldmeetonlyatsuitablehours,ienotintheearlymorningorlateafternoon whenchildrenneedcollectionfromschool,noratnightwhenfamilydutiesmayprevent attendance.

●● Mentorsshouldbetrainedandthereshouldbetrustfundingfortraining.Beingamentor shouldbeapositivefactorinseekingappointmentsandawards.

●● Aleadershipprogrammesuchas‘Springboard’shouldbeofferedtoalldoctorsduringtheir earlycareer,freeofcharge.

●● Womenshouldbeencouragedtoputthemselvesforwardforawards,locallyandbymentors andwomen’snetworksaswellasintheusualways.Selectioncommitteesshouldhavea genderbalance,andproperconsiderationshouldbegiventopart-timeapplicants.

3.5� The older doctor 3.5.1� Olderwomendoctorsoftenfindthattheyfinallyhavemoretimetodevotetoprofessionalduties

oncetheirfamilydutiesarebehindthem.Inkeepingwithnewlawsrelatingtoagediscrimination, thereshouldbenoagelimitsonapplicationsforposts,prizesandfellowships.Agelimitsand criteriasuchas‘nomorethanfiveyearsfromqualification’attachedtopositionsaregender discriminatory,becausewomenaremorelikelythanmentohavetakensomeyearsoffduring theircareersforfamilyduties.Itshouldbeconsideredwhetherthereshouldbeinducementsto womendoctorstoretireatalaterage.

35

Chapter 4:

Recommendations and their rationale�

Recommendations Nominated lead*

4.1 Recommendation 1: Improve access to mentoring and career advice

4.1.1 Inthenextroundofcontractnegotiationthereshouldbeanexplicit facilityforappropriatelytrainedandskilleddoctors(usuallyconsultants) toundertakementoringorcareercounsellingasaprogrammedactivity withintheirjobplan.

4.1.2 Tofacilitateaccessingmentoringorcareermanagementsupport,the futurecommissionersofmedicaleducationshouldmaintainaregisterof alldoctorswhoareskilledandarewillingtoundertakethesetasksand makeitmoreaccessibletootherdoctors.

DepartmentofHealth WorkforceDirectorate

DeanforMedical Education Commissioning

Rationale

●● Accessingmentoringorcareercounsellingiscurrentlydifficultforanumber ofreasons.Firstly,thesetasksareseenas‘ontheside’activities,whichare oftensubsumedbyday-to-dayclinicalconcerns.Owingtoitsinformal nature,doctorsareonlyabletoaccessmentoringorcareercounsellingfrom seniorcolleaguestheyknowonanalmostrandombasis.Whencombined withgenderissues,thiscanmeanthatjuniorfemaledoctorsoftengravitate towardsthemoreheavilyfemale-representedspecialties,andmutatis mutandisformen.

●● Amorecoordinatedapproachisneededtoensurefairerandmoreequitable accesstomentoringandcareercounsellingsothatitiseasierforalldoctors toaccess.

●● CreatingprotectedtimeforconsultantsandGPstoundertakethese activitiesaspartoftheirjobplanwouldtackletheimmediateproblemof supply.Placingacoordinationroleonthefuturecommissionersof educationwouldallowaregionalsinglepointofaccessaswellasallowinga strategicviewoftalentmanagementtobetaken.Whilstthecommissioners ofeducationareprimarilyconcernedwithdoctorsintraining,itwillbe importantthatthisisalsoavailabletodoctorspost-CCTtoensurethat accesstocareercounsellingandmentoringcanbeobtainedthroughouta doctor’scareer.

* Inacademicmedicine,forNHSleadsthejointemployersincludeuniversitiesasdescribedintheFollettreport (www.academicmedicine.ac.uk/uploads/folletreview.pdf).

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http://www.academicmedicine.ac.uk/uploads/folletreview.pdf

Professor Valerie Lund Firstprofessorofrhinologyinthe UnitedKingdom

●● Byprovidingconsultantswiththetimeandspacetoundertakethesetasks, aswellashavingaregionallybasedcoordinationfunction,thetwokey outcomeswouldbeasfollows:

– Healthcareproviderorganisationswillbeabletosupplycareer counsellingandmentorshiptodoctorsthroughouttheircareers.

– Careernetworkscanbedevelopedtoenhancetalentmanagementand developmentprogrammesfurther.

●● Aspartoftheannualworkforceplanningcycle,healthcareprovidersshould declaretoSHAshowmuchmentoringandcareercounsellingcapacityis availablewithintheirorganisationandhowmanydoctors,andatwhat grade,haveaccessedthefacility.

4.2 Recommendation 2: Encouraging women in leadership

4.2.1 AppointmentstoNHS,academicandclinicalcommitteesandboards shouldbeadvertisedwidelyandhaveatransparentanddemocratic processratherthansimplyanappointmentbynomination.

4.2.2 Committeesshouldbeencouragedtodeveloptheirwaysofworkingto enablegreaterparticipationbydoctorswhoareparentsorcarers.

4.2.3 Thereshouldbeincreasedaccessforwomentothecommitteesand boardsofmajormedicalinstitutions,includingthemedicalschools, postgraduatedeaneries,medicalRoyalColleges,NHStrustsandother NHSbodies.TheEqualityandHumanRightsCommissionshould considerauditingtheappointmentsprocessforallsuchpostsatthese institutions,astheyconsiderappropriate,toassesswhethersufficient opportunityhasbeencreatedtoincreaseaccessforwomentothese respectiveorganisations’committeesandboards.

Presidentsor equivalentofRoyal Colleges,other professional institutionsand universities

Presidentsor equivalentofRoyal Colleges,other professional institutionsand universities

EqualityandHuman RightsCommission

37 37

Rationale

●● Whenpositionsoncommitteesandboardswithinmedicalinstitutionsarise, theyshouldbeadvertisedaswidelyaspossibleandwomenshouldbe activelyencouragedtoapplywithinaframeworkofanopenappointments procedure.

●● Committeestendtooperateintheearlyevening,makingitdifficultfor parentswithchildcarecommitmentstoattend.Asimplesolutionistoalter theirwayofworkingsothatcommitteesmeetduringtheday.

●● Neitheroftheseproposalscanbemanagedorenforcedfromthecentre. However,theEqualityandHumanRightsCommissionshouldauditthe arrangementsthatmedicalinstitutionshaveinplaceforcommitteesand boardsandpublishtheresults,usingopennessasaleverforchange.

4.3 Recommendation 3: Improve access to part-time working and flexible training

4.3.1 Thepostgraduatedeaneriesshouldmaintainalistofdoctorswishingto trainparttimeinaslot-sharearrangement.

Deansofpostgraduate deaneriesand universities

4.3.2 NHSEmployersshoulddevelopguidanceformeetingthecostsof continuingprofessionaldevelopment,includingforthosewhoare workinglessthanfulltime.

Trusts

4.3.3 Thedevelopmentofcredentiallingshouldbeexpedited,andthere shouldbefullrecognitionbythemedicalRoyalCollegesthattimealone doesnotindicatecompetencetopractiseindependently.

PresidentsofRoyal Collegesandother professional institutions

4.3.4 Theaspirationalquotaforpart-timetrainingshouldbeabandonedin favourofaneeds-assessedavailabilitybystrategichealthauthorities (SHAs).ThenewlyformedCentreforWorkforceIntelligenceshouldbe commissionedbyeachSHAtoprovidethisneedsassessmentona regionalbasis,andprovisionshouldbemadetomeetit.

Chiefexecutivesof SHAs

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Professor Averil Mansfield Firstfemaleprofessorofsurgery intheUnitedKingdom

Rationale

●● Part-timetrainingandworkingisperhapsthebestsolutiontobalancework andfamily.Thecurrentpart-timearrangementsareextremelyvariableand largelydependondoctorswhowishtoworkparttimehavingthegood fortunetomeetanotherdoctorinthesameposition.Amorecoordinated approach,withthepostgraduatedeaneriesbeingableto‘match’doctors wishingtoworkparttime,willgreatlyimprovethesituation.

●● Theprogressofmedicaleducationtowardsmodularcredentiallingisan importantandextremelywelcomemove.Itwillfacilitatemovementinand outoftraining,whichwillbeofgreatbenefittowomenwhoareplanning tobecomemothers.

●● Currentpart-timeworkingarrangementsarebasedonanaspirationalquota ofavailability,whichisneitherachievablenorrealistic.Differentworkforces willhavedifferentdemographics,andthekeyistoensurethatanydemand forpart-timeworkingcanbefacilitated,sothatdoctorsdonothaveto makechoicessuchaschangingspecialty,movingintotheSASgradeor leavingtheprofessionentirely.Byassessingtheneedineachregion,SHAs willthenbeabletoincludeplanningforpart-timetrainingintheirannual workforceplanningcycle.

4.4 Recommendation 4: Ensure that the arrangements for revalidation are clear and explicit

4.4.1 TheGeneralMedicalCouncil(GMC)andtheappropriatemedicalRoyal Collegesshouldensurethattheyhaveaclearsetofre-licensingand recertificationstandardsandassessmentprocessesinplacefordoctors whohavetakentimeoutoftrainingortheprofessiontoreturntowork.

4.4.2 Responsibleofficersshouldcoordinaterefreshertrainingforthosewho havetakentimeoutoftrainingtomeetthesestandards.Thereshould befundingforthiswithintheNHSbudget.

4.4.3 Trustsshouldoffer‘back-to-work’and‘taster’sessionswherethosewho havetakenacareerbreakcanshadowworkingdoctorstore-familiarise thedoctorwithproceduresandworkpatterns,sothattheyare confidentonreturn.

4.4.4 ThePostgraduateMedicalEducationandTrainingBoard(PMETB)and theGMCshouldensurethatwomeninnon-traininggradesreceive supportinapplyingforentrytothespecialistregister.

GMCandpresidents ofRoyalCollegesand otherprofessional institutions

Chiefexecutives(CEs) oftrusts

CEsoftrusts

PMETBandGMC

39

Rationale

●● Revalidationwillpresentanewchallengefordoctorswhotaketimeoutof work.Whilstashortcareerbreak,suchasayear,isunlikelytoimpingeon thefive-yearlyrevalidationcycle,alongerbreakmaywellpresent difficulties.ItwillbeimportantthattheGMCandthemedicalRoyal Collegeshaveaclearlylaidoutprocessfordoctorswhodotakelonger careerbreakssothattheycanre-enterpracticesafely.

●● Thiswillneedtobesupportedlocallywiththeappropriateretrainingor supervisoryarrangements,sothattheGMC,theNHSorganisation,patients andthepubliccanbeassuredthatreturningdoctorsareuptodateandfit topractise.

●● Doctorswhoarethinkingaboutreturningtoworkafteracareerbreak shouldbesupportedinthatdecisionbytheprovisionof‘back-to-work’or ‘taster’sessions,wheretheycanshadowaworkingdoctorsothattheycan refreshtheirskillsandunderstandtheprocesstheywillneedtoundergoin ordertoreturntoworksuccessfully.

4.5 Recommendation 5: Women should be encouraged to apply for the Clinical Excellence Awards scheme

4.5.1 TheAdvisoryCommitteeforClinicalExcellenceAwards(ACCEA)shouldprovidegreaterfeedbacktoapplicantsandadviceastowhereadditional developmentmightbenecessary.

4.5.2 ACCEAshoulddevelopanetworkofmentorswhocanbeapproached foradvice.Thisshouldbecoordinatedwiththewidercareeradvice programme.

4.5.3 Selectionpanelsshouldbegenderbalancedwhereverpossible;due considerationshouldbegiventoparttimeapplicantsandACCEA’s processesshouldbemonitoredforgenderequality.

4.5.4 Thesameencouragementshouldbeappliedtolocalawards,ifany,and monitoringinformationfromalltrustsshouldbecollectedcentrallyfor genderanalysis.

ACCEA

ACCEA/trusts/ universities

ACCEA/trusts/ universities

Trusts

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Miss Clare Marx Firstfemalepresidentofthe BritishOrthopaedicAssociation

Rationale

●● TotackletheunderrepresentationofwomenapplyingforaClinical ExcellenceAward,moresupportisneededtoprovideadvicebothonhow tomakeanapplicationand,followingafailedapplication,onwhere developmentisneeded.Bydevelopingafeedbackfunctionthatgivesa detailedappraisaloftheapplicationaswellasanonymisedcomparatordata,doctorswillbeabletoascertainwheretheyneedtodeveloptheirpractice. Bycombiningthiswithsignpostingastowhereadoctorcanfindfurther advice,doctorswillbeencouragedtorevisittheirapplicationinsteadof simplygivingup,andtoimprovetheirpracticeswherenecessary,providing thespurtoimprovementofthequalityoftheirservice.Thiswillbenefitall doctorsattemptingtoobtainaClinicalExcellenceAwardaswellasthe patientstheytreat.Womenarereceivingfewerawardsthantheyshould; agenderbalanceonthepanelwouldinspiremoreconfidenceintheresult.

4.6 Recommendation 6: Ensure that the medical workforce planning apparatus takes account of the increasing number of women in the medical profession

4.6.1 NHSMedicalEducationEngland(NHSMEE)andtheCentrefor WorkforceIntelligenceshouldensurethatworkforcemodelsforthe futureclearlydelineatetheeffectofarisingnumberofwomeninthe workforcesothatappropriateadvicefortheworkforceplanning apparatuscanbegiven.

DepartmentofHealth WorkforceDirectorate toworkwithNHS MEEandtheCentre forWorkforce Intelligence

4.6.2 Fortraining,NHSMEEshouldcommissionthemedicalRoyalCollegesto developinnovativesolutionstothesechallenges.ItisnotedthatNHS MEEisconductingareviewintothechallengesthatarepresentedbytheEuropeanWorkingTimeDirective,toimprovethequalityoftrainingin reducedtrainingopportunitycircumstances,andthisshouldaddressthe particularissuesforwomen.

NHSMEE

4.6.3 TheCentreforWorkforceIntelligenceshouldapproachtheGMCto discusswaysoftrackingcareerseffectivelythroughGMCnumbersto allowaccuratedatatobecollectedtoinformworkforcemodelling.

CentreforWorkforce Intelligence

41

Rationale

●● Theexpansionofmedicalschoolplaceshasbroughtaboutalargeincrease inthenumberofwomenenteringtheprofession.Giventhecurrenttrends forwomenchoosingtoentercertainspecialtiesorgrades,workingpart timeortakingbreaksfromtheircareer,itisvitalthattheworkforce planningapparatustakesintoaccounttheeffectsofmorewomeninthe workforcenowandactivelymanagesthosechanges.

●● Tounderstandthisissuefully,thereneedstobeaneffectivetracking mechanismfordoctors’careers.OnepotentialmethodistousetheGMC numbertofollowadoctorthroughhercareer;however,dueconsideration needstobegiventothelegallimitationsimposedbydataprotection,and theCentreforWorkforceIntelligenceshouldapproachtheGMCtoopen adiscussion.

●● Incombinationwithotherfactors–suchastheEuropeanWorkingTime Directive,themovetowardsgreaterprovisionofcareinthecommunity,the ageingpopulationandgreaterpatientexpectationofaccessandchoice– thepressurestoensuretherightsupplyareextremelychallenging.A responsiveplanningsystemisrequired,whichiscapableofidentifying trendsandmobilisingpartners,suchasthemedicalRoyalColleges,to createinnovativewaystoequipdoctorstomeetthedemand,including thedevelopmentofsimulationtechniquesande-learning.

4.7 Recommendation 7: Improve access to childcare

4.7.1 TheConferenceofPostgraduateMedicalDeansoftheUnitedKingdom andtheDepartmentofHealthshouldconsiderwhetherthemodelsuch asthatinplaceintheNorthWesternDeanery,whichcommissionsa leademployerforallspecialtytraineesinthedeanery,wouldbea practicalanddesirablemodelintheneweducationcommissioner/ providerlandscape.Theadditionalbenefitofbetterfacilitatingaccessto governmentassistanceformaternitybenefitsandchildcareofthismodel isclear.

Conferenceof PostgraduateMedical Deans

42

Dr Edith Pechey-Phipson Oneofthe‘EdinburghSeven’, thefirstgroupoffemalemedical studentsatauniversityinthe UnitedKingdom

4.7.2 Postgraduatedeaneriesortheirleademployersshouldplanaheadfor thechildcareneedsoftheirtraineesandfacilitatearrangementsbetweenatraineeandthetrustsduringhisorherrotationforaccesstochildcare provision.

Deansofpostgraduatedeaneriesorlead employers

4.7.3 Trustsshouldappointachildcarecoordinatorwithintheirhuman resourcesdepartmentiftheyhavenotyetdoneso.

Trusthumanresourcesdepartments

4.7.4 Childcarecoordinatorsshoulddevelopinternetresourcestoactasboth aninformationresourceandmessageboardsonlocalchildcareoptions, includingemergencycover.

Trustchildcare coordinators

4.7.5 NHStrustsshouldengagewithlocalauthoritiesaskeyemployersto ensurethatlocalauthoritiesfulfiltheirlegalresponsibilitytoensurethat thechildcareneedsoftheirpopulationaremet.NHSEmployersshould beginaprogrammeofworktoadviseandcoordinateNHStruststo achievethisandhelpspreadbestpractice.


4.7.6 NHSEmployersshoulddrawupguidanceongoodpracticeonwhat additionalprovisionNHStrustsshouldmakeforchildcareallowancesfor unavoidableunsocialhoursofwork.


4.7.7 Hospital-basedchildcareshouldmovetoextendedopeninghours.NHS Employersshouldhostaconferenceofchildcarecoordinatorswiththe objectiveofidentifyinghowthisandthespecificneedsofdoctorscan beachieved.


4.7.8 TheDepartmentofHealthshouldexplorethecostsandbenefitsof doctors(andotherhealthworkersinsimilarcircumstances)whoare parentspayingforfull-timeorpart-timechildcareasavalue-for-money solutionforenablingdoctorstoprogresstheircareers.Onthebasisof thisanalysistheDepartmentshouldsubmitacasetotheTreasuryto allowdoctorstopayforchildcarefromtheirgrossearnings.Inaddition,itshouldestablishwhetheranycentralfundingmightbeavailablefor childcareassistance.Theworkinggroupbelievesthatthisisfundamentaltoensuringthatalldoctorscanfulfiltheirpotential

DepartmentofHealthWorkforceDirectorateandFinance Directorate

4.7.9 TheCentreforWorkforceIntelligenceshouldurgentlymodeltheeffects ofgreaterfemaleparticipationingeneralpracticeandthepotentialcosts ofmaternitycover.Contractualchangesshouldbeconsideredbasedon thismodellingtocompensatematernityleaveshoulditberequired.

CentreforWorkforce Intelligence

4343

Rationale

●● Improvingtheavailabilityandaccessibilityofchildcareisakeyenablerto ensurethatdoctorswhowanttoprogresstheircareersarebetterabletodo so.Nosinglechildcaresolutionwillberightforeveryone;however,there areanumberofoptionstopositiondoctorssothattheyarebetterableto exploittheprovisionthatisalreadyavailable.Byalteringwaysofworking andprovidingadditionalfunding,theremaybefurtheropportunitiesto improvethesituation.

●● Theprimaryobstaclefortraineesistherotationalpatternoftheirworking arrangements.Byforwardplanning,thepostgraduatedeaneriescangreatly reducethestressofchildcarebycoordinatingatrainee’sneedswiththe trust.Thesingle-employermodelwouldalsorealisethebenefitsofallowing traineestoaccesschildcarevouchersmuchmoreeasilyandeliminatethe needtoconstantlyreapplyeachtimetheymovepost.

●● Alldoctorswhoareparentswouldbenefitfromeasieraccesstoinformation andatrust-supportednetworkofparents.Notonlywouldthisactasafocal pointfordoctorswhoareparentsandallowad hocemergency arrangementstobemademoreeasilyandquickly,itwouldalsoensurethat parentsarenotisolated.

●● Giventhesometimesunpredictablenatureofprovidinghealthcare24hours adayand,forconsultants,thepotentialneedtoattendevenwhentheyare not‘oncall’,childcareprovisionforextendedunsocialhoursisessential.

●● Theissueoffundingchildcareshouldbeinvestigatedfullytoestablishthe costsandbenefitsofmakingessentialadditionalprovisionsinthisarea.

4.8 Recommendation 8: Improve support for carers

4.8.1 AllpostgraduatedeaneriesortheirnominatedleademployersandNHS trustsshouldhavealeadpersonresponsibleforsupportingcarers.

Postgraduate deaneriesorlead employers,NHS DirectorateandNHS trusts

4.8.2 TheNHSshouldjoinEmployersforCarersandbenefitfromthefinancial advantagesconferredwhenadoptingcarer-friendlyemployment practices.Doctorswhoarefamilycarershaveparticulardifficultieswith long,unpredictableandinflexiblehoursofwork.

44

Professor Dame Julia Polak Oneofthelongest-living survivorspost-heartandlung transplantintheUnitedKingdom andaleadingfigureinresearch ontissueengineering

Rationale

●● Withanageingpopulation,thenumberofdoctorsactingascarersatsome pointintheircareerswillincrease.Whilstasacaringprofessionmedicine inherentlyunderstandsthedemandsofsuchdualresponsibility,itwill requirespecialeffortstoensurethatdoctorsactingascarersarenot disadvantaged.Theworkinggroupexploredthechallengesthatcarersface andhowthesedemandsaffectbothcareerpatternsandday-to-daylife. Theoverwhelmingsensefromthegroupwasthatmanyofthesechallenges couldbeovercomebyincreasedawareness,flexibilityanddefinedroutes forsupport.

●● TheWorkandFamiliesAct2006givestoemployeeswhoarecarersthe righttorequestflexibleworking.Employersmustseriouslyconsidersuch requestsandcanonlyrefuseforoneofthebusinessreasonssetoutinthe legislation.TheNHSshouldfollowthebestpracticeguidelinespreparedby CarersUK.

4.9 Recommendation 9: Strenuous efforts should be made to ensure that these recommendations are enacted through the identification of champions

4.9.1 Trustsshouldidentifyanon-executivedirectortohaveresponsibilityata locallevelforimprovingworkingpatterns,givingadviceandhandling complaints.Thedirectorshouldworkcloselywithaleadconsultantfor workforceplanning.

4.9.2 RoyalCollegesshouldfollowtheexampleoftheRoyalCollegeof Psychiatristsanddevelopgenderequalityplans.

CEsoftrusts

PresidentsofRoyal Collegesandother professional institutions

Rationale

●● Withoutadesignatedindividualresponsibleforbringingthese recommendationstoboardlevel,therewillbelimitedleveragetoeffect change.Similarly,RoyalCollegescanprovidemoralweightandsetgood examplesbytheiractions.

454545

Annex 1:

Recommendations of previous reports�

Report Date Recommendations

Women and Medicine: The Future, Royal Collegeof Physicians

2009 Examinerequirementsforworkforcedesign:

●● Theorganisationalimplicationsofchangingworkforcepatternsand preferenceswithrespecttoworkinghoursandspecialtychoicesshouldbe urgentlyexaminedsothattheeffectivedeliveryandcontinuityofpatient careisnotcompromised.

Investigateeconomicimplicationsofchangingworkforcepatterns:

●● Thefundingconsequencesofapotentiallysubstantialincreaseinpart-time andotherformsofflexibleworkingrequiredetailedanalysissothatthe levelofpossiblefuturebudgetarycommitmentscanbebetterunderstood.

Addresscriticalinformationgaps:

●● Thereexiststheneedtostrengthentheadequacyandaccessibilityof cross-sectionalandlongitudinaldataontheworkingpatternsofdoctors.

●● Moreinformationandresearchareneededonentrytotheprofession.

Strengthenworkforceplanningandmodelling:

●● Theimplicationsofdifferentialworkingpreferencesofwomenandmen overtheircareerlifetimesshouldbemodelledtotestsensitivitieswith respecttochangingaverageparticipationrates,thescopeforfurther extensionofpart-timeoptions,andthecorerequirementsforcontinuityof patientcare.

●● Analysisisneededtoinvestigatethelonger-termimpactonthebalanceof supplyanddemandacrossindividualspecialtiesandontotalservicecapacity.

Enhancecareerguidanceandfeedback:

●● Moreguidanceshouldbegiventohelptraineesachieveasound assessmentoftherelativecompetitivenessofentrytodifferentspecialties.

●● Thereexistsaneedtoensurethatatlatercareerstagesappropriate counsellingandfeedbackcanbeoffered,especiallyforwomendoctors,on thedevelopmentofleadershipskills,andonthecommitmentsrequiredfor attainingthehighestlevelswithintheprofession.

46

Dame Cicely Saunders Founderofthemodern hospicemovement


Making Part-Time Work, Medical Women’s Federation(MWF)

2008 Recommendationsonattitudestopart-timeworking:

●● Themedicalprofessionneedstopromotemorepositiveattitudestopart-timeworkingthroughmentors,rolemodelsandcasestudies.

●● RoyalColleges,deaneries,theBMAandtheGMCneedtofindeffective waystoconsultwiththosedoctorsworkingparttimeonawiderange ofissues.

Recommendationsonpart-timetrainingposts:

●● EmployersandRoyalCollegesshouldworktogethertoensurethatrota designcanroutinelyincorporatepart-timeworkers.

●● Medicaldirectorsshouldsupportandpromoteinnovativejobdesign.

●● Deaneriesshouldensurethattrainingprogrammedirectorstake responsibilityforleadingintegrationofpart-timetraineesintotraining programmes.

●● Deaneriesandemployersshouldcontinuetobuildontheprogressof mainstreamingpart-timetraining.

●● Employers,deaneries,trainingprogrammedirectorsandeducational supervisorsshouldensureapromptandsympatheticresponsetothose traineeswhoexpressadesiretotrainparttime.

●● Juniordoctorsshouldbemademoreawareofsourcesofinformationand supportforpart-timetrainingatundergraduateandpostgraduatelevel.

Recommendationsonpart-timecareergradeposts:

●● RoyalCollegesshouldissueguidanceonpart-timecareergradeposts.

●● Medicaldirectorsshouldsupportandpromoteinnovativejobdesignin ordertoencouragepart-timeworkingforconsultantsandSASgrade doctors.

4747


Recommendationsoncareerdevelopmentforpart-timedoctors:

●● Employers,medicaldirectorsanddeaneriesshouldadoptaformalapproach forthereacquisitionofclinicalskillsafteracareerbreakoraperiodof extendedleave.

●● TheMWFshouldseektoworkwithkeystakeholderstopromotesuccessful examplesofpart-timeworkinginthemedicalprofession.

●● Deaneries,RoyalCollegesandtheBMAshouldworkwithPMETBtouse thenationalsurveyoftraineestoexploreanysystematicdifferencesinthe qualityoftrainingexperiencedbythoseinfull-timeandpart-timeposts.

Women in Clinical Academia: Attracting and Developing the Medical and Dental Workforce of the Future, Medical Schools Council

2007 Students:

●● Morecomprehensiveinformationtostudents

●● Mentoring

●● Experienceofresearchearlyon

●● Formalinstructiononhowtoteach

Flexibility:

●● Recognitionofneedforcareerbreaks

●● Recognitionofneedforflexibleworking

●● Dedicatedtenuretracksforclinicalacademics

●● Careertrackingthroughfundingbodies

●● Flexibletrainingreinstatedindeaneries

●● Participationinseniorleadershiptrainingencouraged

●● MonitoringbyRoyalCollegesandmedicalschoolsofrepresentationon panels,boardsandfacultypositions

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Dr Fiona Subotsky PastpresidentoftheMedical Women’sFederationand consultantchildandadolescent psychiatrist


Women in Academic Medicine: Developing equality in governance and management for career progression (Athena Project), Higher Education Funding Council for England, Medical Schools Council, Imperial College London, MWF, BMA

2007 ●● Both the promotions criteria and process need to be made explicit and transparent to all staff.

●● Appraisal should be an annual process and timed to fit in with the promotion cycle.

●● Appointments committees should reflect the diversity of staffrequired (eg women and ethnic minority groups).

●● Gender monitoring of appointments and promotions should be in place.

●● Equal opportunity and diversity training should be provided.

●● Mentoring for women should be mainstreamed and monitored.

●● Role models and networking should be recognised and encouraged.

●● Measures of gender equality should be benchmarked against European targets and exemplars.

49


Women in Hospital Medicine: Career choices and opportunities, Reportofa working partyofthe Federationof theRoyal Collegesof Physicians

2001 ●● Moreopportunitiesforpart-timeconsultantposts.

●● Moreflexibilityinthenumberofsessionsworkedoverthetimean individualholdsaparticularconsultantpost.

●● Morepart-timetrainingopportunities.

●● Increasesinjobshares.

●● Aflexibletrainingbudgetshouldbedeterminedbythepercentageof femalegraduatesandthereshouldbeinterchangebetweenthetraining budgetssoastoprovidemorepart-timetrainingpostsforalldeaneriesand movementbetweengeographicareas.

●● Trainingshouldbecompetencybased.

●● Appropriatetrainingshouldbemadeavailabletonon-consultantgrade postholderssotheycanapplyforconsultantpositions.

●● Improvedmentoringfrommedicalschoolthroughtospecialtyselection overseeninthelaterstagesbytheappropriatecollege.

●● Educationalopportunitiesshouldbeavailabletothosewhodonotwork standardhours.

●● Theintroductionofahospitalretainerschemesimilartothatofferedin generalpractice.

●● Appropriatesupportforthosewhohavesteppedoutofmedicineandwant toreturn.

●● Adequatechildcareplaceswithout-of-hoursprovisionshouldbeavailable withintheNHS.

●● Pensionrightsforpart-timeworkersandthosewithcareerbreaksshould bereviewed.

●● Grantallocationshouldbeirrespectiveofworkinghours.

●● Specificpart-timeacademicpostsarenecessary.

●● Thereshouldbeequityofrepresentationofwomenonacademicboards andgrant-awardingbodies.

●● Thereshouldbeequalopportunityfornominationsfordistinctionawards.

●● Thereshouldbeequalopportunitiesforwomentoapplytoacademicand seniormanagementposts.

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Dame Margaret Turner-Warwick FirstfemalepresidentoftheRoyal CollegeofPhysicians


ReporttotheNHS Executive, Making it happen: Part-time, flexible and portfolio careers in hospital medicine

●● Awork–lifebalanceisnecessaryforalldoctorsiftheyaretosurvive fruitfullyinclinicalworktoday:thisneedmustberecognisedbytheNHS.

●● Professionalandpersonalambitionandthedesiretoworkflexiblyarenot incompatible.

●● Mostoftheleadersoftheprofessionalreadyhavea‘part-time’clinical commitmentandcombineitwithothernationallyimportantwork.Other reasonstoworklessthanfulltimeintheNHSneedtobegivencomparable statusandrespectability.

●● Avarietyofworkingpatternsneedstobefacilitatedandactivelypromoted intheNHS.Thiswouldhelpretainhighlyskilledstaffthroughouttheir careers,whatevertheirothercommitments.Thewiderresponsibilitiesand contributionsexpectedofaconsultantneedtoberecognisedwhenjob plansareorganisedsothatallconsultantscanparticipatefullyintheclinical andmanageriallifeofadepartment.

●● Toenablemoreflexibleworkingpatternstocomeabouttherewillneedto beplanningandinvestmentofmoneyindifferentwaysofworkinganda willingnesstochangeacceptedpracticeswhilstmaintaininghigh professionalstandards.

●● Currentequalopportunitylegislationmaymakeiteasierforanindividualto getajob,butbyinhibitingdiscussionofaconsultant’sotherresponsibilities orneeds(disabilityorchronicillness),maymakeitlesspracticaltocarryit out.Itmustbecomepossibletostateandopenlynegotiatetheseinorder tomakesuccessfulcompletionofthejobareality.

●● Theretainerschemeandthepossibilityofcareerbreaksforhospitaldoctors shouldbeenhanced.

●● MakingitpossibletomovefromclinicalassistantandSASgradejobsinto consultantjobs,withappropriatespecialistregistrartraining,wouldenable betteruseofresources.

●● Inordertoretainveryseniordoctors,whonowmayreturntoworkintheir mid-50sorat60,theNHSshouldconsiderfacilitatingflexibleexitfroma consultantpostaswellasflexibleentryintoit.

●● Thecultureofmedicineischangingwithchangesinsociety.Withincreased publicexpectationsandgreaterscrutinybyoutsideagencies,doctorswill beexpectedtogivemoreofthemselvesintheirencounterswithpatients.

51

Annex 2:

Terms of reference of the National Working Group on Women in Medicine

●● Toreviewexistingworkandthemostrecentreportspublishedonindividualaspectsofthislarger problem.

●● Toconsulttheopinionsofthemedicalprofession.

●● Drawingonthiswork,torecommendaprogrammeofactiontoimproveopportunitiesforwomen inmedicine.

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Annex 3:

Chair of the National Working Group�

Baroness Ruth Deech

RuthDeechtaughtlawatOxfordUniversityandwasPrincipalofStAnne’sCollegetherefrom1991to 2004.From1994to2002shechairedtheHumanFertilisationandEmbryologyAuthority,andfrom2002to 2006shewasaGovernoroftheBBC.ShewasthefirstIndependentAdjudicatorforHigherEducationfrom 2004to2008,andsince2009shehaschairedtheBarStandardsBoard,theindependentregulatorof barristers.SheisafellowoftheRoyalSocietyofMedicine.Appointedtoalifepeeragein2005,shesits asacrossbencher.

53

Annex 4:�

Membership of the National Working Group�

Professor Dame Carol Black National Director for Health and Work

BesidesbeingaNationalDirector,DameCarolisalsoChairoftheNuffieldTrust, PresidentoftheBritishLungFoundationandPro-ChancellorattheUniversityofBristol. SheistheimmediatepastPresidentoftheRoyalCollegeofPhysiciansandhasjust steppeddownasChairoftheAcademyofMedicalRoyalColleges.Theinternationally renownedcentresheestablishedattheRoyalFreeHospital,London,isthemajorcentre inEuropeforclinicalcareandresearchonfibrosingconnectivetissuediseases,in particularsystemicsclerosis.

Sincetheearly1990s,DameCarolhasworkedatboardlevelinanumberof organisations,includingtheRoyalCollegeofPhysicians,theRoyalFreeHospital HampsteadNHSTrust,theHealthFoundation,theNHSInstituteforInnovationand ImprovementandtheImperialCollegeHealthcareCharity.SherecentlyservedasChair oftheUKHealthHonoursCommitteeandisnowonthemaincommitteeforthe Queen’sAwardsforVoluntaryService.Sheisalsoamemberofmanynational committeesaimingtoimprovehealthcare.SheisaForeignAffiliateoftheInstituteof MedicineUSAandhasbeenawardedmanyhonorarydegreesandfellowships.

Professor Jane Dacre Professor of Medical Education, leading on Women in Medicine for the Royal College of Physicians

JaneDacreisDirectoroftheDivisionofMedicalEducationwithintheFacultyof BiomedicalSciencesatUniversityCollegeLondonandViceDeanofitsmedicalschool. SheisaconsultantphysicianandrheumatologistattheWhittingtonHospitalNHS TrustinLondonandisaformerAcademicVice-PresidentoftheRoyalCollegeof Physicians.ProfessorDacretookupherfirstconsultantpostasarheumatologistin 1990andwasaleadclinicianinthedevelopmentofthefirstClinicalSkillsCentrein theUK.Shehascontinuedtodevelopexpertiseinmedicaleducation(redesigning severalclinicalexaminations)andrheumatologyinparallel.Hercurrentacademic interestisinthetrainingandassessmentofdoctorsingeneral,includingfitnessto practise,andrheumatologistsinparticular.ShehasbeenappointedtothenewGMC Councilandisanon-executivedirectoroftheWhittingtonHospitalNHSTrust.Sheis marriedwiththreechildren.

54

Professor Dame Sally Davies Director General of Research and Development, Department of Health

ProfessorDameSallyDaviesistheDirectorGeneralofResearchandDevelopmentand ChiefScientificAdviserfortheDepartmentofHealthandNHS.AsDirectorGeneral, shedevelopedthenewgovernmentresearchstrategy,BestResearchforBestHealth, withabudgetrisingto£1billion,andisnowresponsibleforimplementationofthe NationalInstituteforHealthResearch(NIHR).SheisaboardmemberoftheOfficeof theCoordinationofHealthResearchandtheMedicalResearchCouncilandchairsthe UKClinicalResearchCollaboration.

SheledtheUKdelegationstotheWorldHealthOrganization(WHO)Ministerial SummitinNovember2004andtheWHOForumonHealthResearchinNovember 2008.SheisamemberoftheWHOGlobalAdvisoryCommitteeonHealthResearch andchairedtheExpertAdvisoryCommitteeforthedevelopmentoftheWHOresearch strategy.SheisamemberoftheInternationalAdvisoryCommitteeforA*STAR, Singapore,andtheCaribbeanHealthResearchCouncilBoard,andsheadvisesmany othergroupsonresearchstrategyandevaluation,includingtheAustralianNational HealthandMedicalResearchCouncil.

Dr Clarissa Fabre Medical Women’s Federation

DrClarissaFabreisPresidentElectoftheMedicalWomen’sFederation.Sheisafull-timeGPinEastSussex.Sheinitiallytrainedinpaediatricsbutmovedtogeneralpractice afterthebirthofthreechildrenandacareergapofsevenyears.Hersurgeryhas changedfrombeingasleepysingle-handedvillagepracticetoathree-partner,part-dispensing,trainingpracticewithtworegistrarsandtwopart-timesalarieddoctors.

Shehasbeenactiveinmedicalpoliticsformanyyears,onthelocalmedicalcommittee and,foraspell,ontheProfessionalExecutiveCommitteeofthelocalprimarycare trust.ForthepastfouryearsshehasrepresentedbothEastandWestSussexGPson theBritishMedicalAssociation’sGeneralPractitionersCommittee.

ShejoinedtheMedicalWomen’sFederation(MWF)whenbarriersappearedinher career,withfewopportunitiesforflexibletraininginpaediatricsandgeographical isolation.ThemostimportantobjectiveofherinvolvementinMWFistoensurethat womendoctorsareprovidedwiththeopportunitiestocombineafulfillingfamilylife withmaximumachievementintheirprofessionalcareers.Sheismarriedtoamedical academic,andhertwodaughtersarejuniordoctors.

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Ms Helen Fernandes Women in Surgery

MsFernandesisaconsultantneurosurgeon(leadpaediatricneurosurgeon)at Addenbrooke’sHospital,thefirstfemalesurgeontobeappointedthere.Shespecialises inthetreatmentofadultandpaediatricpatientswithbrainandspinalproblems.She graduatedfromNewcastleUniversity,gainedherdoctoratein2000andwasawarded theLouisAlexanderResearchFellowshipandtheHunterianProfessorshipfromthe RoyalCollegeofSurgeons.PriortoherCambridgeappointmentshewasaMedical ResearchCouncilseniorlecturerandhonoraryconsultantneurosurgeon.Helenisa memberoftheBritishAssociationofSpinalSurgeons,BritishCervicalSpineSocietyand theEastAnglianSpinalSociety.SheisAssociateDirectorofPostgraduateMedical EducationatAddenbrooke’sandChairofthenationalbodyWomeninSurgery.

Professor Steve Field Chair, Royal College of General Practitioners

ProfessorFieldtookupthepositionofRCGPChairinNovember2007andledthe collegethroughLordDarzi’sreviewoftheNHS,successfullypromotingtheRCGP’s ‘federated’modelofpatientcare–withgeneralpracticesworkingtogethertoprovide moreservicesforpatientsintheirlocalcommunities–asaworkablealternativeto polyclinics,andrepositioninggeneralpracticeattheheartoftheNHS.ProfessorFieldis recognisedasanationalleaderinmedicaleducation.AsChairoftheRCGPEducation Network,heledthecollege’sradicalreviewofGPtraining,whichledtothe introductionofthefirstevertrainingcurriculumforGPsinAugust2007.

ApractisingGPininnercityBirmingham,ProfessorFieldisHonoraryProfessorof MedicalEducation,UniversityofWarwick,andHonoraryProfessorintheSchoolof Medicine,UniversityofBirmingham.

Hehaspublishedmanyacademicpapers,reportsandbooks–includingabestselling publicationontheGPcurriculum–andhaspresentedpapersatacademicmeetings aroundtheworld.HeisamemberofthefacultyoftheHarvardMacyInstitute’s programmeforleadinginnovationinhealthcareandeducation.

Heisco-authorofthelandmarkRCGPdocumentThe Future Direction of General Practice: A roadmap,anditsfollow-up,publishedinJune2008,Primary Care Federations: Putting patients first.

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Dr Patricia Hamilton Director of Medical Education, Department of Health

BesidesbeingDirectorofMedicalEducationattheDepartmentofHealth,DrHamilton co-chairstheModernisingMedicalCareersEnglandProgrammeBoard.Sheis responsibleforoverseeingthedevelopmentanddeliveryofmanyofthemedical educationalprojectsreferredtoinA High Quality Workforce,andworkscloselywith thenewlyformedMedicalEducationEngland.

SheisworkingattheDepartmentofHealthonsecondmentfromherpostof consultantandseniorlecturerinneonatalpaediatricsatStGeorge’s,Universityof London.ShewaspreviouslyamedicaldirectoratStGeorge’s.

Untilrecently,shewasPresidentoftheRoyalCollegeofPaediatricsandChildHealth, havingpreviouslybeenVicePresidentforTrainingandAssessment.Shehaschaired manycollegecommitteesandworkingparties,includingthosedevelopingthe paediatriccurriculumandprogrammes.Shewasinvolvedindevelopmentsin workplace-basedassessments.Shewasresponsibleforproducingtrainingpackages inchildprotectionandchildmentalhealth.

AsPresidentoftheRCPCHshewasamemberoftheAcademyofMedicalRoyal Collegesandsatonseveralofitseducationandtrainingcommittees.ShewasChair ofthesteeringgroupoftheMedicalLeadershipCompetencyFrameworkproject completedbytheAcademyofMedicalRoyalCollegesandtheNationalInstitutefor InnovationandImprovement.SheisaboardmemberofthePostgraduateMedical EducationandTrainingBoard,wasco-ChairoftheLondonChildren’sClinicalPathways groupandwasamemberoftheleadershipgroupofLordDarzi’sNextStageReviewof theNHS.

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Professor Jacky Hayden Postgraduate Medical Dean, North Western Deanery

ProfessorJackyHaydenhasbeenDeanofPostgraduateMedicalStudiesfor ManchesterUniversityandtheNorthWesternDeanerysince1997;priortothisshe wastheDirectorofPostgraduateGeneralPracticeEducation.SheistheChairofthe EnglishDeansCommitteeandViceChairoftheConferenceofPostgraduateMedical Deans,wheresheleadsonthequalityagenda,andsheisleaddeanforpsychiatryand dermatology.ShehasbeenamemberoftheMedicalProgrammeBoardsinceJanuary 2008andisamemberofMedicalEducationEngland.Herclinicalbackgroundis generalpractice,andsheisamemberoftheCounciloftheRoyalCollegeofGeneral Practitioners,aPMETBpartnerandanassociatefortheGMCaspartofitsquality assuranceteam.Sheisanaccreditedmediator.Shehasestablishedarangeof innovativeactivitiesacrosstheNorthWesternDeanery,includingaleadership programmeforyoungGPsthatstartedover20yearsago,andanintegratedmedical leadershiptrainingprogrammefordoctorsintraining.Sheismarriedtoaconsultant physicianandhastwosons.

Dr Anita Holdcroft Women in Academic Medicine, British Medical Association Reader in Anaesthesia and Honorary Consultant Anaesthetist, Imperial College London and Chelsea and Westminster Hospital

DrAnitaHoldcroft,EmeritusProfessorofAnaesthesiaatImperialCollegeLondon, isaclinicianspecialisinginacutepainmedicine,especiallyinfemales.Shewasthe Secretary,thenco-Chair,oftheInternationalAssociationfortheStudyofPainSpecial InterestGrouponSex,GenderandPainto2005.SheisPastPresidentoftheForumon MaternityandtheNewbornandPresidentoftheSectionofAnaesthesiaattheRoyal SocietyofMedicine.

HerlaboratoryandclinicalpainresearchhasattractedMedicalResearchCounciland charitablegrantsaswellasfundedstudentshipsandkeynoteinternationallectures.As authorandeditorshehaswrittenbookssuchasPrinciples and Practice of Obstetric Anaesthesia and Analgesia,Core Topics in PainandCrises in Childbirth.Other publicationsincludechaptersonsexandgenderdifferencesinpaininWalland Melzack’sTextbook of Painandpapersongendermedicine,particularlyrelatingto womenandchildbirth.

58

Asaspinofffromherresearchshechampionsacademicwomen’semploymentissues andledtheWomeninAcademicMedicineprojectfundedbytheHigherEducation FundingCouncilforEngland,theBMAandtheMedicalWomen’sFederation(MWF). Shehasco-chairedtheBMAMedicalAcademicStaffCommitteeandistheMWF Treasurer.Sheismarriedwithfourdaughters.

Professor Sheila Hollins Immediate Past President, Royal College of Psychiatrists

ProfessorHollinswasPresidentoftheRoyalCollegeofPsychiatristsfrom2005to 2008.Sheismarriedwithfourchildrenandtwograndchildren,andhereldest daughterisaconsultantpsychiatrist.Shehasanongoingroleasacarerinproviding supporttotwoofherchildrenwhohavelong-termconditions,andtheexperienceof herson’slearningdisabilitystronglyinfluencedhercareerdirection.Shetrainedpart timeinpsychiatry,sharingchildcarewithherhusband,asuccessionofaupairsand ahospitalcrèche.

Shewasingeneralpracticebeforepsychiatry,whichinfluencedherfamily-based approachandherinterestinco-morbidphysicalandmentalhealthproblems.She pioneeredtheinvolvementofpeoplewithlearningdisabilitiesasco-researchersand co-teachersinthemedicalschool,andthedisseminationthroughpicturesofbest practicetoherpatientsandtheircarers.ShehasbeenProfessorofPsychiatryof LearningDisabilityatStGeorge’s,UniversityofLondonsince1991.Untilsheretired fromclinicalpracticein2006,shehadbeenaconsultantpsychiatristinsouth-west Londonfor25years.SheiscurrentlychairingasteeringgrouptodevelopaEurope-widedeclarationandactionplanonbehalfofWHOEuropeaboutthehealthand socialcareofchildrenwithintellectualdisabilities;andsheisplanningtosetupa spin-outcompanytofurtherdevelopBooksBeyondWords,herpicture-based technology,toimprovecommunicationabouthealthandothertopicswithpeople withlearningdisabilities.

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Miss Cathy Lennox Consultant in orthopaedics and trauma surgery

MissLennox’sspecialtywastraditionallyamalespecialtybutnowhasincreasing numbersofwomencomingthroughtheranks.Apartfromaninitialproblem,backin theearly1970swhenadmissionpolicytomedicalschoollimitedthenumberof womento10%,shehasencounterednomajorobstructionstohercareer.Asurgical careerinthosedaysrequiredtrainingingeneralsurgeryasapre-fellowshipregistrarto obtainthefellowshipexam(FRCS)andthentogointohigherspecialtytraining.This involvedfiercecompetitionforaplaceonthemuchcovetedorthopaedictraining rotation.Whenshestartedafamilyshewasabletotakeadvantageofthenewly createdpart-timetrainingscheme,whichmadeitpossibletocontinueherwork. Subsequently,asseniorregistrar,shedidajobsharefortwoyears,byjoiningforces withanotheroftheveryfewwomeninorthopaedictraining.Afterthisshebecamea full-timeconsultant.Duringherconsultantyearsshehasbeeninvolvedinteaching, advisingandmentoringtrainees,bothmaleandfemale.Herstrongmessagehas alwaysbeenthat,withappropriateenthusiasmanddedication,doctorscanachievean extremelyrewardingcareerinwhicheverspecialtytheychoose,regardlessofgender.

Dr Katie Petty-Saphon Medical Schools Council

DrPetty-Saphonisthe ExecutiveDirectoroftheMedicalandoftheDentalSchools CouncilsandoftheAssociationofUKUniversityHospitals.SheisaDirectoroftheUK ClinicalAptitudeTestConsortiumandsitsontheBoardforAcademicMedicinein Scotland.Priorto2003shehadacareerintheprivatesector,foundingthreesuccessful companies.ShereadnaturalsciencesatCambridgeandhasaPhDinbiochemistry fromtheUniversityofBirmingham.SheisaformerGovernoroftheUniversityof HertfordshireandofprimaryandsecondaryschoolsinSaffronWalden.Sheisaformer ViceChairofPrincessAlexandraHospitalNHSTrust,havingbeenanon-executive directortherefor10years.SheisatrusteeoftheRoyalMedicalBenevolentFundand anassociatefellowofNewnhamCollegeCambridge,andin2007wastheChief OperatingOfficerforSirJohnTooke’sindependentinquiryintoModernisingMedical Careers.Sheismarriedwithtwochildren–and10,000treesthatsheplantedin2000. Apartfromtwosetsofthreemonths’maternityleaveshehasalwaysworkedfulltime –andsohasmuchexperienceofjugglingandmulti-tasking.

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Mr Bernard Ribeiro Former President of the Royal College of Surgeons of England

MrRibeiroqualifiedatMiddlesexHospitalMedicalSchoolandwasawardedthe fellowshipin1972.In1979hewasappointedasaconsultantgeneralsurgeonto BasildonHospital,Essex,withaspecialinterestinlaparoscopicandgastrointestinal surgery.Heintroducedtherapeuticlaparoscopicsurgerytothetrustin1991withthe aimofestablishinganadvancedlaparoscopictrainingunit.

HehasbeenaseniorexaminerinsurgeryfortheUniversityofLondonandtheUniversity ofOxfordandamemberoftheCourtofExaminersoftheRoyalCollegeofSurgeons. HeiscurrentlyanexaminerforthenewmedicalschoolinBrighton.HewasHonorary SecretaryandPresidentoftheAssociationofSurgeonsofGreatBritainandIreland (1991–2000),representedtheAssociationofSurgeonsontheSenateofSurgeryandwas ChairoftheDistinctionAwardsCommitteeoftheassociation(2000–04).Hewaselected totheCounciloftheRoyalCollegeofSurgeonsofEnglandin1998.

HereceivedaCBEforservicestomedicineinJanuary2004andhasbeenmadean honoraryfellowofseveralRoyalCollegesandacademies.HewasPresidentofthe RoyalCollegeofSurgeonsofEnglandfrom2005to2008andwasappointedKnight BachelorinDecember2008.

Dr Joan La Rovere Director of the Paediatric Cardiac Intensive Care Unit and Consultant Paediatric Intensivist at the Royal Brompton Hospital, London, and Honorary Senior Lecturer at Imperial College London

JoanLaRovereisDirectorofthePaediatricIntensiveCareUnitandconsultant intensivistattheRoyalBromptonHospital,whereshehasbeenaconsultantsince 1999,andisanhonoraryseniorlectureratImperialCollege.

RaisedinBoston,MassachusettsandeducatedatPhillipsAcademyAndover,she graduatedfromHarvardUniversityin1988,followedbyanMScingeneticsatSt Andrew’sUniversity,beforecompletinghermedicaltrainingatColumbiaUniversity CollegeofPhysiciansandSurgeonsinNewYork,graduatingin1993.Paediatric residencyatChildren’sHospitalBostonwasfollowedbyamovein1996toGreat OrmondStreetHospitalinLondonasafellowinpaediatricintensivecare,and appointmentasaconsultantattheRoyalBromptonHospitalin1999.

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Hermedicalresearchfocusesonoutcomesfollowingcardiacsurgeryandshehas beeninstrumentalindevelopinglesion-specificcarepathwaysforchildrenofallages undergoingcardiacsurgery,andtheuseofdatabasestodetailclinicaloutcomes. ShesitsontheInternationalMulti-SocietalDatabaseCommitteeforPediatricand CongenitalHeartDisease.Inadditiontoherclinicalandmanagerialrole,DrLaRovere istheRoyalCollegeofPaediatricsandChildHealth’stutorattheRoyalBrompton HospitalandisamemberoftheChiefMedicalOfficerforEngland’sExpertWorking GrouponRevalidationandMedicalEducation.Shehasorganisedandspokenat numerousmedicalconferences,bothnationallyandinternationally.

DrLaRoverewaselectedamemberoftheWindsorLeadershipTrust,anorganisation thatbringstogethertopleadersfromeverysectortoreflectonhowtheyusetheir influence,decisionsandactionstobenefittheirorganisationsandwidersociety.Deeply involvedinissuesofhealthcareleadershipandeducation,DrLaRoverealsoworksto educatethenextwaveofhealthcareprofessionalsbydevelopingmedicalcurricula, innovatinglearningprogrammesandtrainingprofessionals.Shehelpstoconceptualise andemploythemostcutting-edgetechnology,includingtheuseofvirtualeducation. Akeenadvocateofmedicaleducation,DrLaRovereisatrusteeofIMET(International MedicalEducationTrust)2000,acharityaimedatpromotinglinksandcooperation betweenthewesternanddevelopingworld,includingthedevelopmentofvirtual medicaleducation.ShealsositsontheAdmissionsCommitteeofImperialCollege MedicalSchool,aswellasteachingImperialCollegemedicalstudents.

DrLaRovereisco-founderandVice-PresidentofVirtueFoundation,apubliccharitable andnon-governmentalorganisationwithspecialconsultativestatustotheUnited Nations.TheFoundation’smissionistoincreaseawarenessofprevalentglobalissues, toinspirepeopletoactionandtorenderhumanitarianassistancethroughhealthcare, education,andempowermentinitiatives.VirtueFoundationundertakeshealthcare, educationandempowermentinitiativesforwomenandchildreninthedeveloping world.

Sheismarriedwithonechild.

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Professor Bhupinder Sandhu Chair of the British Medical Association’s Equal Opportunities Committee and former Chair of the Medical Women’s Federation

BhupinderSandhuisConsultantPaediatricianandGastroenterologistattheBristol RoyalHospitalforChildrenandanhonoraryprofessorattheUniversityofBristoland theUniversityoftheWestofEngland(UWE).SheiscurrentlyPresidentofthe CommonwealthAssociationofPaediatricGastroenterologyandNutrition.

In2002shereceivedanAsianWomenofAchievementAwardfromCherieBlair.She isbeinghonouredwithaDoctorofSciencedegreebyUWEforher‘outstanding contributiontopublicservicesandexemplaryrolemodelforwomeninscienceand medicine’.

ComingfromIndiaattheageof12in1963withlittleEnglish,shegainedaplaceat UniversityCollegeLondonandgraduatedin1974.Afterpaediatricappointmentsat UniversityCollege,King’sCollegeWestminsterandGreatOrmondStreethospitalsand aresearchfellowship,sheobtainedadoctoratefromtheUniversityofLondon.She wasappointedtotheUniversityofBristolin1988andsubsequentlydevelopedthe PaediatricGastroenterologyDepartmentthere.SheisafoundermemberoftheBritish SocietyofPaediatricGastroenterologyandNutrition,hosteditsinauguralmeeting, servedasitssecretaryandconvener,andrecentlyledonproducingnationalguidelines onthemanagementofinflammatoryboweldiseaseinchildren.Shehasheldmany committeeandboard-levelpostsinBristol,andnationallyandinternationally.Shehas servedasanexternalexaminerforuniversitiesintheUKandabroad.Shespearheaded theRoyalCollegeofPaediatricsandChildHealth/VSOFellowshipScheme(described byLordCrispasabeaconofexcellentpractice)andchairedaEuropeanresearch workinggroup.Shehaspublishedextensively,withbookchaptersandover80papers, andhaschairedandspokenatmanyinternationalmeetings,includingworkingwith andadvisingtheWorldHealthOrganization.

HerpublicserviceroleshaveincludedbeingafoundationboardmemberoftheFood StandardsAgency,boardmemberandtrusteeofVSO,DeputyChairoftheBoardof GovernorsofUWE,ChairoftheBBCWestRegionalAdvisoryCouncilandachairof schoolgovernors.ShecurrentlyservesonthegoverningCouncilofBristolOldVic TheatreSchool.Sheismarriedwithtwodaughters,bothfollowingcareersinmedicine.

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Professor Deborah Sharp Medical Schools Council and Chair of the Council of Heads of Medical Schools’ Committee on Women in Clinical Academia

ProfessorSharpisProfessorofPrimaryHealthCareandHeadoftheAcademicUnitof PrimaryHealthCareattheUniversityofBristol.Shewaspreviouslylecturerandthen seniorlecturerattheUnitedMedicalandDentalSchoolsofGuy’sandStThomas’in theDepartmentofGeneralPracticeandHonorarySeniorLecturerattheInstituteof Psychiatry.SheobtainedoneofthefirstMentalHealthFoundationGPResearch TrainingFellowships,throughwhichsheundertooktheworkforherPhDonpostnatal depressioninacommunitysampleinsouthLondon.ShetookupthefoundationChair inprimaryhealthcarein1994,thefirstwomantobeappointedtoasubstantivechair inBristol,andhasbuiltupaworld-classdepartmentoverthelast15years.Theunit hasaverystrongresearchprogramme,with70%ofitssubmissionrated3*or4*in the2008ResearchAssessmentExercise.TheyarefoundermembersoftheNIHR SchoolforPrimaryCareResearch.

ProfessorSharpisimmediatePastChairoftheSocietyforAcademicPrimaryCare, representsprimarycareattheMedicalSchoolsCouncil,andsatontheGMCEducation CommitteeandontheWalportAcademicCareersPanel.Between2000and2003she wasHeadofSchoolintheFacultyofMedicineatBristol,anditwasduringthistime thatshebecameawareoftheparticularrecruitmentandretentionissuesforwomen inacademicmedicine.SheisanactivememberoftheMedicalWomen’sFederation. In2006shechairedtheCouncilofHeadsofMedicalSchools’WomeninAcademic MedicineWorkingParty,andhascontinuedbothlocallyandnationallytobeinvolved inthecareerpossibilitiesinacademicmedicineforwomenatalllevels.

Dr Sheila Shribman National Clinical Director for Children, Young People and Maternity Services

AppointedNationalClinicalDirectorforChildren,YoungPeopleandMaternityatthe DepartmentofHealthinDecember2005,after22yearsasaconsultantpaediatrician withdiverseexperienceinchildren’shealthservices,DrShribmanhasheldpostsin NHSmanagement,asamedicaldirectorfor11yearsandasachiefexecutive.Shehas beenaseniorofficeroftheRoyalCollegeofPaediatricsandChildHealthandheld postsincontinuingprofessionaldevelopment,workforceplanning,childprotectionand policyareas.Hercurrentclinicalinterestisinneurodisability.SheismarriedtoaGPand hasthreeyoungadultchildren.

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Miss Susan Ward Medical Women’s Federation

SueWardwaselectedVice-PresidentoftheMedicalWomen’sFederationatthespring meetingin2005.Hercurrentpostisasconsultantinobstetricsandgynaecologyfor SherwoodForestHospitalsNHSFoundationTrust.ShealsoholdsthepostofAssociate PostgraduateDeanattheUniversityofNottingham,withresponsibilityforarranging theFoundationProgrammeintheTrentregion.

AgraduateoftheUniversityofNottingham,MissWarddecidedtopursueacareerin obstetricsandgynaecology.Inordertobroadenherexperience,shespentaperiodas ananatomydemonstratorandthenundertookasurgicalSHOrotationduringwhich timesheobtainedherFRCS(Edinburgh).Shethenmovedintoobstetricsand gynaecology,obtainingherMRCOGandanMD.Sheisthecollegetutorforthe RCOGatKing’sMill.Sheisanenthusiasticteacherofpostgraduates,undergraduates andparamedicalstaffbothinformaleducationalsettingsandonaone-to-onebasisin theoperatingtheatreandclinic.

DespiteworkingfulltimeasanNHSconsultantandwithallherteaching responsibilities,shehasfoundthetimetobuildanddecorateanewhousetogether withherhusband.Shehasbeenwidowedandremarriedandhastwochildren,one fromeachmarriage,aswellastwocats.Oneofthemostimportantexperiencesinher careerwasastudentelectivespentinAfrica,andthisexperiencehasinfluencedher futureplans,whichareto‘leaveacohortofwell-traineddoctorsbehindher,workin Africaandthenretiredisgracefully’.

Dr Jane Youde Consultant Geriatrician

DrJaneYoudeisaconsultantgeriatricianatDerbyHospitalsNHSFoundationTrust. SheistheLeadClinicianforMedicinefortheElderlyinDerbyandhasaspecialinterest infallsandsyncope.DrYoudeisactivelyinvolvedintheBritishGeriatricSocietyand holdsthepostsofSecretaryoftheFallsSectionoftheBritishGeriatricSocietyand SecretaryfortheTrentBritishGeriatricSociety.

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Annex 5:

Evidence collected�

TheNationalWorkingGrouponWomeninMedicinemetsixtimesbetweenOctober2008and March2009.Itreceivedoralevidencefrom15stakeholdersincluding:

LucyWarner–DepartmentofHealthRevalidationSupportTeam

DrLucy-JaneDavis–BMAJuniorDoctorsCommittee

NajetteAyadiO’Donnell–BMAMedicalStudentsCommittee

ProfessorChrisMcManus–ProfessorofPsychologyandMedicalEducation,UniversityCollegeLondon

JulieCornish–AssociationofSurgeonsinTraining

CathyWilliams–PMETB

DrSueShepherdandProfessorJaneDacre–RCP

JohnJames–DepartmentofHealthWorkforceLeadershipProgramme

DrSarahThomas–PostgraduateDeanLeadforFlexibleTraining

ProfessorJonathanMontgomery–ACCEA

DrClareGerada–RCGPandPractitionersHealthProgramme

ElizabethKelan–CentreforWomeninBusiness,LondonBusinessSchool

MikeFarrar–NorthWestStrategicHealthAuthority

AilsaDonnelly–PatientPartnershipGroup,RCGP

DrSheilaShribman–NationalClinicalDirectorforChildren,YoungPeopleandMaternity

Additionally,theChairreceivednumerousrepresentationsfromindividualfemaledoctorsandmetwith groupsofdoctorsfromtheOxfordRadcliffeHospitalsandtheRoyalBromptonHospital.

Asubcommittee,chairedbyDrSheilaShribman,wasestablishedtoexaminetheissueofchildcareinmore detail.Itmettwice,inDecember2008andJanuary2009.NHSEmployers,HMTreasuryandthe DepartmentforChildren,SchoolsandFamilieswererepresented,aswellasajuniordoctorandmotherfrom theWestMidlands,inadditiontoDrLaRovereandProfessorHaydenfromthemainworkinggroup.

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67

Glossary

ACCEA AdvisoryCommitteeforClinicalExcellenceAwards

BMA BritishMedicalAssociation

CCT CertificateofCompletionofTraining

CEA ClinicalExcellenceAward

CESR CertificateofEligibilityforSpecialistRegistration

DCSF DepartmentforChildren,SchoolsandFamilies

GMC GeneralMedicalCouncil

GP generalpractitioner

IMG internationalmedicalgraduate

MWF MedicalWomen’sFederation

NHS NationalHealthService

NHSMEE NationalHealthServiceMedicalEducationEngland

PMETB PostgraduateMedicalEducationandTrainingBoard

RCGP RoyalCollegeofGeneralPractitioners

RCP RoyalCollegeofPhysicians

SAS stafforspecialistgrade

SHA strategichealthauthority

ST1 specialtytrainingyear1

WHO WorldHealthOrganization

References�

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2 HigherEducationFundingCouncilforEngland.

3 RoyalCollegeofPhysicians.Women and medicine: The future.London:RCP;June2009.

4 TheLawSociety.Earnings and work of private practice solicitors in 2007.London:TheLaw Society;February2008.

5 TheLawSociety.Women solicitors 2004: Research findings.London:TheLawSociety;2004.

6 WylieC.Trends in feminization of the teaching profession in OECD countries 1980–95. Geneva:InternationalLabourOffice;March2000.

7 NotzerN,BrownS.ThefeminizationofthemedicalprofessioninIsrael. Medical Education1995; 29(5):377–81.

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9 DepartmentforTradeandIndustry.Maximising Returns to Science, Engineering and Technology Careers.London:DTI;2002.

10 WomenintoScience,EngineeringandConstruction.www.wisecampaign.org.uk.

11 OfficeforNationalStatistics.Birth statistics (FM1 No. 36).Table1.7b.London:ONS;2008.


13 LambertTW,EvansJ,GoldacreMJ.RecruitmentofUK-traineddoctorsintogeneralpractice: findingsfromnationalcohortstudies.Br J Gen Pract2002;52(478):364–7,369–72.

14 LevittC,CandibL,LentB,HowardM.Women Physicians and Family Medicine Monograph/ Literature Review.www.womenandfamilymedicine.com/files/pdf-documents/wwpwfm_ monograph_01-08-2008.pdf.


16 LevittC,CandibL,LentB,HowardM.Women Physicians and Family Medicine Monograph/ Literature Review.www.womenandfamilymedicine.com/files/pdf-documents/wwpwfm_ monograph_01-08-2008.pdf.

17 AllenI.Womendoctorsandtheircareers:whatnow?BMJ2005;331:569–72.

18 McManusIC,SprostonKA.WomeninhospitalmedicineintheUnitedKingdom:glassceiling, preference,prejudice,orcohorteffect?J Epidemiol Community Health2000;54:10–16.

19 DarziA.High Quality Care for All: NHS next stage review.London:DepartmentofHealth;2008.

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20 NationalInstituteforHealthResearch.NIHRIntegratedAcademicTraining.www.nihrtcc.nhs.uk/ intetacatrain.

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Photocredits: GettyImages

WellcomeLibrary

Anne-KatrinPurkiss/WellcomeLibrary(ProfessorDameJuliaPolak,page45)

JeffStultiens(DameMargaretTurner-Warwick,page51)

Report of the Chair of the National Working Group on Women in Medicine

Presented to Sir Liam Donaldson, Chief Medical Officer

October 2009

Women doctors: making a difference

© Crown copyright 2009 298315 2p Feb 10 (updated for online only) Produced by COI for the Department of Health

If you require further copies of this title visit www.orderline.dh.gov.uk and quote: 298315/Women doctors: making a difference

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