Avma’s response to the GMC’s consultation on guidance for Leadership and management & Raising and acting on concerns about patient safety

Introductory questions

Using the guidance

We have received a range of feedback about the way the current guidance is structured and the current wording. It’s vital that the guidance must be user-friendly and easy to navigate, and we want to hear your views on this.

The structure of ‘Leadership and management’

In the Leadership and management guidance, most of the paragraphs apply to all our registrants. However, there are some paragraphs that apply only to those who have extra responsibilities.

The term ‘extra responsibilities’ refers to management or leadership responsibilities at a personal, team, organisation, or policy level. This may include formal management roles (such as clinical or medical directors) or roles with responsibility for supervising and managing staff (including those from a different professional background), resources, and services.

To what extent do you think the structure of the Leadership and management guidance makes it easy to use?

If you’d like to, please explain your answer.

The title of ‘Raising and acting on concerns about patient safety’

We have received feedback that the current title of the Raising and acting on concerns about patient safety guidance could be acting as a barrier to doctors, PAs, and AAs who want to raise concerns, but don’t believe their concern is linked to patient safety. For example, their concern might be about the poor behaviour of a colleague, or the behaviour of another person such as a patient or patient’s relative. These concerns must be raised. We want to encourage doctors, PAs, and AAs to speak up when things aren’t right.

We understand there are many factors which can have a detrimental effect on patient experience, such as a poor working culture which focuses on blame rather than learning, and a lack of governance and accountability. These are some of the reasons we are thinking about updating the title of the guidance.

To what extent do you agree that the title should be updated to reflect concerns beyond patient safety?

If you’d like to, please explain your answer.

If you have a suggestion for a new title, please share this.

Overlap between the two pieces of guidance

There are a number of issues covered in both Leadership and management and Raising and acting on concerns about patient safety, including:

• the need for leaders and/or managers to create compassionate and inclusive cultures where colleagues are empowered to speak up and encouraged to learn from issues rather than assign blame,
• how leaders and/or managers must respond if a colleague raises a concern with them or if they witness inappropriate behaviour, and
• the expectations on all doctors, PAs and AAs regarding sustaining a positive culture, raising concerns, and supporting colleagues.

To help make it easier to find the relevant information, we’re considering whether to combine the two pieces of guidance, so everything is in one place.

To what extent do you agree with the suggestion to combine ‘Leadership and management’ and ‘Raising and acting on concerns about patient safety’ into a single piece of guidance?

Equality, diversity and inclusion

Inclusive working and training environments are crucial to the wellbeing of all doctors, PAs, and AAs, and to safe patient care.

Since both sets of guidance were last reviewed, public inquiries and other reports have found that systemic inequalities, discrimination and bias can lead to underreporting of concerns and unsafe care for various patient groups.

As part of this guidance review, we’re carrying out an impact assessment to help us to identify how changing the guidance could impact doctors, PAs and AAs, patients, and any others with protected characteristics. We will also consider how protected characteristics can overlap or ‘intersect’ with one another, and we will consider the compound effect when this happens.

• As an example, we know from our 2025 national training survey that some doctors in training experience disadvantages associated with their personal or protected characteristics. 56% of trainees from an ethnic minority background said they felt confident to challenge discrimination and unprofessional behaviours amongst colleagues and healthcare professionals, compared to 64% of white trainees.
• When asked about reporting discrimination without fear of adverse consequences, 50% of female surgery trainees said they felt confident, compared to 61% of male surgery trainees. Rates of confidence also differ between speciality, as 69% of female GP trainees said they felt confident compared to 80% of male GP trainees.

Everyone has the right to work and train in an environment which is fair, free from discrimination, and where they’re respected and valued as an individual. It is vital that leaders and managers create and maintain this environment to support and sustain their workforce and empower them to deliver safe, high-quality patient care. We want the updated guidance to help them achieve this.

Do you have any suggestions for guidance aimed at leaders and managers to help them foster inclusive, discrimination-free environments where all team members feel respected and valued?

Do you have any suggestions about how our ‘Raising concerns’ guidance can be improved to help to achieve this?

Thematic questions on ‘Leadership and management’

In this section, we’d like your feedback on the key themes that we identified when exploring the Leadership and management guidance during our research and pre-consultation engagement activities.

Theme 1: Terminology

The current Leadership and management guidance does not define the terms leader/leadership and manager/management. In this guidance, the words are used interchangeably. We recognise that leaders and managers are distinct roles, so in the updated guidance we want to be clearer about our expectations of doctors, PAs, and AAs who perform these roles. We want to get your views on how the new guidance should describe registrants who lead and/or manage others and what it means to lead and to manage.

Defining a leader, leadership behaviours, and leadership skills

While not all doctors, PAs, and AAs will have the word ‘leader’ in their job title, many will be demonstrating leadership behaviours every day, maybe without realising. This could be taking a ward round or reporting a concern. We want to encourage our registrants to recognise these everyday leadership behaviours and to consciously develop them. Demonstrating leadership behaviours can have a positive impact on a doctor’s, PA’s, or AA’s practice, their interactions with their colleagues and teams, and patient care.

For doctors, PAs, and AAs who want to gain a greater understanding of leadership as they progress in their career, we would encourage them to develop leadership skills. Like any skill, leadership can be studied, practised, and recognised through qualifications. We think our registrants demonstrate leadership when they do the following:

• act with integrity,
• show accountability when things go wrong,
• role-model professional and inclusive behaviours,
• create compassionate, fair, and psychologically safe environments,
• act when negative behaviour undermines the inclusive environment,
• motivate and inspire individuals and teams to perform at their best,
• show respect for and sensitivity towards others’ life experience, cultures, and beliefs,
• oversee clinical governance, risk management, and audit processes,
• set direction and have strategic vision for long term success, and
• drive positive change.

This isn’t a finalised definition of leadership; it’s simply a starting point. We want to hear from you about how we should describe a leader in the updated guidance.

To what extent do you agree that the list above is a good starting point to describe the skills a doctor, PA, or AA should have to be a leader?

Do you have any further comments or suggestions around the definition of leadership?

Defining a manager, management behaviours, and management skills

Some doctors, PAs, and AAs will have the word ‘manager’ in their job title. However, just as with the term ‘leader’, some of our registrants may be displaying management behaviours when carrying out their everyday tasks without holding a formal management title.

Some doctors, PAs, and AAs may wish to develop their management skills and may opt for further study or training so their skills are recognised through qualifications. Registrants who are managers may well act as leaders, too.

As UK healthcare continues to evolve and technology continues to advance, we also recognise that some of those registered with us will perform non-traditional management roles, such as managing colleagues remotely, which can present both opportunities and challenges.

As a starting point we think a doctor, PA, or AA who is a manager or who wants to display management skills will be demonstrating many of the skills we have listed for leadership, along with the ability to do the following:

• plan, organise, and oversee operational activities to achieve a desired outcome,
• empower and direct the people they manage by setting clear goals, providing constructive feedback, and supporting health and wellbeing,
• ensure polices are implemented, processes are followed, and standards maintained, and
• manage resources efficiently and appropriately.

To what extent do you agree that the list above is a good starting point to describe the skills a doctor, PA, or AA should have to be a manager?

Would you like to comment on how we have described managers/management behaviours and management skills? Do you have any suggestions for improvement?

Theme 2: Guidance on supervision

Good medical practice says that all doctors, PAs, and AAs must:

• make sure that all colleagues whose work they are overseeing have appropriate supervision, and
• only practise under the level of supervision appropriate to their role, knowledge, skills and training, and the task they are carrying out.

Leadership and management provides more detail about the principles guiding supervision in healthcare settings and this review is an opportunity to make sure the guidance is relevant and appropriate to how medicine is practised today.

It is important that the guidance is clear but not limiting. While doctors are more likely to be in supervisory roles than PAs or AAs, we know from our engagement activity that some PAs and AAs also have these responsibilities. Similarly, although a supervisor will usually be senior to the person being supervised, this position can sometimes be reversed if the more senior colleague is less experienced in a particular activity or procedure. Our registrants frequently work in multi-professional teams and may supervise other healthcare professionals.

Supervision expectations for all

The current guidance sets out the expectation that all doctors, PAs, and AAs must:

• ensure they are appropriately supervised for any task they perform, and
• be willing to ask for advice and support from colleagues when necessary.

Responsibility and accountability

The current guidance sets out the expectation that all doctors, PAs, and AAs should:

• establish with their employer the scope of their role and the responsibilities, and
• raise any issues of ambiguity or uncertainty about responsibilities, including in multidisciplinary teams, to clarify:
  • supervision arrangements for staff and lines of accountability for the care provided to individual patients,
  • who should take on leadership roles or line-management responsibilities, and
  • where responsibility lies for the quality and standard of care provided by the team.

Those with extra responsibilities

If they have extra responsibilities, doctors, PAs, and AAs must also do the following:

• understand the extent of their supervisory responsibilities, give clear instructions about what is expected, and be available to answer questions or provide help when needed,
• make sure the people they manage have appropriate supervision,
• support colleagues they supervise or manage to develop their roles and responsibilities by appropriately delegating tasks and responsibilities, and
• be satisfied that the staff they supervise have the necessary knowledge, skills, and training to carry out their roles.

To what extent do you agree that the current guidance supports safe and effective supervision?

Would you like to comment on how the guidance on supervision could be improved?

Theme 3: The role of leaders and culture

Paragraph 9 of the Leadership and management guidance states that leaders and managers “must advance equality [and] diversity by creating or maintaining a positive working environment free from discrimination, bullying and harassment, [and] must make sure that [their] organisation’s policies on employment and equality and diversity are up to date and reflect the law.”

In your experience, how well do leaders and managers actively advance equality and diversity?

In your experience, how well do doctors, PAs, and AAs who are leaders and managers create or maintain a positive working environment?

In your experience, how well do doctors, PAs, and AAs who are leaders and managers create a working environment free from discrimination, bullying, and harassment?

The current guidance states that if you are responsible for leading or managing a team, you must make sure that staff are clear about their personal and collective responsibilities for:

• patient and public safety, and
• honestly recording and discussing problems.

Leaders and managers should also:

• contribute to setting up and maintaining systems to identify and manage risks in the team’s area of responsibility,
• make sure that all team members have an opportunity to contribute to discussions,
• make sure that team members understand the decisions taken and the process for putting them into practice, and
• make sure that each patient’s care is properly coordinated and managed.

In your experience, how well do doctors, PAs, and AAs who are leaders and managers follow this guidance to create a safe working environment where people can talk about errors and concerns?

Is there anything else you wish to tell us about the ‘Leadership and management’ guidance?

Thematic questions on ‘Raising and acting on concerns about patient safety’

In this section, we’d like your feedback on the key themes that we identified when exploring the Raising and acting on concerns about patient safety guidance during our research and pre-consultation engagement activities.

Theme 1: Leaders and managers must act when concerns are raised with them

Good medical practice states if a doctor, PA, or AA in a formal leadership or management role witnesses or is informed of bullying or other inappropriate behaviours by colleagues, the expectation is clear: they must act.

It states that they must make sure that:

• such behaviours are adequately addressed,
• people are supported where necessary, and
• concerns are dealt with promptly, being escalated where necessary.

This expectation is consistent with the guidance in both the Leadership and management and Raising and acting on concerns about patient safety guidance, which state that leaders and managers have a responsibility to act when serious concerns are raised with them.

However, during our pre-consultation engagement, we heard anecdotal evidence that doctors, PAs, and AAs may choose not to report bullying or inappropriate behaviour because they have done so before, sometimes more than once, and no action was taken.

When a concern is raised to a leader or manager, they must take it seriously and address it appropriately to ensure a safe and respectful working environment. We want to support doctors, PAs, and AAs to raise concerns and help leaders and managers to handle these situations effectively.

We acknowledge there can be many reasons to explain why leaders or managers may fail to act and that these situations can be complex. However, when there has been a serious disregard for their duties, a pattern of leadership failings, or an attempt to cover up a serious event, the leader or manager should be asked to account for their actions and omissions.

To what extent do you agree with our suggested approach to doctors, PAs, and AAs who are leaders or managers who fail to act when serious concerns have been raised with them?

Were you previously aware of the expectation on doctors, PAs and AAs who are leaders and managers to act when they witness poor behaviour or are made aware of it? Do you have any comments?

Theme 2: Barriers to speaking up

We understand that there are many reasons why doctors, PAs, and AAs may be reluctant to speak up about inappropriate behaviours or patient safety concerns they have experienced or witnessed. Some fear there will be a detrimental impact to their training, employment, or career prospects. Others may believe they have more to lose — for example, doctors who have come to work in the UK from another country may fear consequences for their right to live and work in the UK.

Another reason is a lack of belief that speaking up will lead to meaningful change. This is especially true for doctors, PAs, and AAs who have previously raised concerns without resolution or action being taken. However, we recognise that in some cases, confidentiality will prevent a leader or manager from being able to share the outcome.

Do you have any suggestions on how we can reduce barriers for doctors, PAs, and AAs to raise concerns?

Have you experienced or witnessed any differences in approaches to raising and acting on concerns, for example, between medical specialities, the four countries of the UK, the NHS and the independent sector, or primary and secondary care?

Theme 3: Victimisation and detriment as a result of raising concerns

Stakeholder feedback has shown that in rare cases, doctors, PAs, AAs, or other healthcare professionals who raise concerns with leaders or managers may face victimisation. In the most serious cases, the leader or manager may seek to shift blame onto them. They may also threaten to report them to us or another regulator in an attempt to discourage them from pursuing concerns. We take this very seriously, as it is contrary to the spirit of the guidance, which seeks to offer support and reassurance to those raising concerns.

There are provisions in the current guidance to prevent a person raising concerns from being subjected to unfairness and adverse consequences. For example, in paragraphs 22–24 of Raising and acting on concerns about patient safety, there are several paragraphs that place expectations on managers investigating concerns to do so fairly, fully, promptly, and to follow the law. Managers must not try to deter colleagues from raising concerns and must not propose or condone agreements (sometimes called non-disclosure or confidentiality agreements) to restrict a colleague’s right to disclose information. Managers also have a responsibility to protect those raising concerns from unfair criticism or action, including any detriment or dismissal, and they must tell them what action has or will be taken.

Paragraphs 66–68 of the Leadership and management guidance provide advice for leaders and managers who deal with grievance procedures. The guidance explains the importance of understanding and separating a personal grievance (that is, a complaint about a registrant’s own employment situation) and a concern about a risk, malpractice, or wrongdoing that affects others. The guidance is clear that this is particularly important if patients or members of the public are at risk of harm.

We want to know your thoughts about the current guidance provisions, whether there are any gaps, and if so what we need to do to help ensure people raising concerns are protected from adverse consequences.

To what extent do you agree that the existing guidance is sufficient to protect those who raise concerns from experiencing victimisation, including being blamed or threatened by doctors, PAs, or AAs in leadership or management roles?

Do we need a new paragraph to explicitly prohibit our registrants from victimising those who raise concerns?

Operational questions

Overall comments

In this section, we’d like your views on Leadership and management (2012) and Raising and acting on concerns about patient safety (2012) overall and anything we haven’t specifically asked about already. When answering these questions, please bear in mind the criteria which the final guidance must meet and the remit of the consultation itself. Any new paragraphs must be:

• relevant to the individual registrant’s practice — not an action for employers, educators, or government,
• relevant to most, if not all, doctors, PAs, and AAs — bearing in mind that not all work in patient-facing roles, or in the NHS,
• actionable by doctors, PAs, and AAs in practice and capable of being evidenced, for example through appraisal and revalidation, and
• necessary to protect patients, maintain standards, or uphold confidence in the professions we regulate.

In particular, you might want to tell us if there’s anything we should remove from the current Leadership and management and Raising and acting on concerns about patient safety guidance or if there is anything missing?

Please provide your overall comments.

Implementing our guidance

When we update our guidance, we have a role in supporting doctors, PAs, and AAs to understand how the principles in the guidance apply in practice in their specific roles.

We’re aware there are many factors influencing the everyday practice of doctors, PAs, and AAs, and these can vary depending on their working environment. For example, how a service is organised, different workplace cultures, access to training, and availability of professional support are some of the factors that could affect how easy it is to put guidance into practice. We want to gain a better understanding of these factors, which could include:

• barriers — things that make it difficult to apply the guidance, and
• enablers — things that support or make it easier to apply the guidance. This includes any opportunities for future improvement or innovation.

Your suggestions will also help us to focus our efforts when the new guidance is published.

Please provide any comments to help us design our implementation plan.