Some GPs are partners, others are salaried and they may also work as a locum.

Executive summary Today s GPs face considerable and growing workplace pressures. Research published by leading institutions in the field of primary care have highlighted themes of: rising patient volumes 1,2 increasing complexity of patient conditions 3 and growing numbers of GPs retiring early 4 or altering their working patterns. 1 This report shows that there are strong patterns between GPs contractual arrangements and the rates of being complained about or being investigated by us. It serves to show that deeper appreciation of the different situations, contexts, and experiences of GPs is needed to help us to better support GPs in maintaining high professional standards. For example, GPs with a single full-time permanent contract were found to have the highest rate of being complained about and investigated. This contrasts with GPs with a single locum GP contract who are the lowest. Similarly, when looking at age, gender, and place of primary medical qualification (PMQ) we see that IMG * GPs aged over 50 years old and EEA graduate male GPs have the highest investigation rate. The GP population We can see a need for a more finely tuned understanding of the GP population to help develop supportive intervention. It is clear that GPs vary across a variety of dimensions including personal demographics and special interest status. Some GPs are partners, others are salaried and they may also work as a locum. A wide variety of permanent and flexible contracts are available, which may be held in a range of practice contexts, for example, a GP may be working in a single or multi-site practice that could be part of a federation or attached to an A&E. GPs have the option of holding more than one NHS contract so may also work in a wide range of positions outside their main practice or locum agency, this could include work in academia, prisons, the police or armed forces (see Figure 1). This variety of contexts is only likely to expand as new models of care are developed across the country. * International medical graduates (IMGs) are doctors who gained their primary medical qualification outside the UK, EEA and Switzerland, and who do not have enforceable community rights to work in the UK. EEA graduates are doctors who gained their primary medical qualification in the EEA, but outside the UK, and who are EEA nationals or have enforceable community rights to be treated as EEA nationals 2

Perhaps it is the diverse make-up of the GP population that has meant even large scale pieces of work, such as the British Medical Association s National Survey of GPs, have focused in on sub-samples of the population as data for GPs in Wales and Northern Ireland were unavailable (see below). It is also important to note that our data on fitness to practise has not been incorporated into a paper focused solely on GPs before. Both of these gaps are tackled in this research which looks at our data for all GPs in England and Scotland. Scope and limitations of this paper Ideally the analysis would take into account the multi-level context in which GPs work (see Figure 1) but in reality it is constrained by the available data. The following factors have been identified as relevant by the literature but for which data are not currently available: whether the GP s practice is nested within a federation grade and whether the GP is a practice partner working hours whether the GP works in a rural or urban setting In conducting this analysis we identified gaps in the data we currently access which would help future analysis non-nhs scope of practice, and NHS employment data for Northern Irish and Welsh GPs in particular and we hope this paper aids discussion of the potential benefits of improved data sharing in those areas. It is important to note that we are actively pursuing data to remedy these gaps and are committed to producing supplementary analyses for these groups once the data has been sourced. 3

Contents Executive summary... 2 Contents... 4 Introduction... 5 The GP workforce... 8 What types of working pattern can we identify within our data?... 10 Which GP contract types are more complained about or investigated by the GMC?... 13 Other GP groups with high rates of complaint or investigation... 16 Conclusions and next steps... 21 Appendix 1: Segment demographics... 22 Appendix 2: The number and percent of GPs complained about and investigated by selected demographics... 24 References... 27 4

Introduction This analysis is part of a wider programme of work, helping us to better understand parts of the medical profession where data is currently not readily available or is analysed less. The programme explores opportunities to combine our data with other sources. It will help us to understand more about the range of doctors working environments and risks faced by the profession. We can then better identify ways that regulation may be able to provide support. This particular paper combines our data with records of NHS contracts (called practice history data) to analyse patterns for general practitioners (GPs) working in England and Scotland. Data is not currently available for Wales and Northern Ireland but we are seeking suitable sources and will produce supplementary analyses when it is possible. This paper then looks into whether some types of GP have a greater risk of being complained about or investigated. The patterns described are intended to inform and create debate about the types of challenges and risks faced by GPs. From this we can identify appropriate and proportionate preventative responses. This work will inform our future research programme and discussions about the nature of GP work. We welcome any feedback at insightandresearch@gmc-uk.org. 5

Figure 1: GP context (adapted from an internal GMC rapid evidence review) This paper focuses on individual GPs and as such provides a partial picture of GPs who are a group that is nested within workplaces, in specific geographical areas serving distinct patient groups. In future as more multi-level data becomes available it will be possible to build on this paper s findings and examine the wider contexts in which GPs work. 6

Box1: Data sources This paper combines: GMC register data cross sectional snapshots taken on the 30 th June 2013 16 GMC fitness to practise data extracted 31 May 2017, each doctor is only counted once during the 2013 16 period, the most serious complaint outcome is retained. NHS practice history records for England and Scotland of contracts worked in 2013 16 GPs in Wales and Northern Ireland The practice history data for GPs in Wales and Northern Ireland was not available to the GMC for analysis at the time of publication, so this report is limited to data for Scotland and England. The GMC are actively pursuing equivalent data for GPs in Wales and Northern Ireland and there will be supplementary analyses for these groups once the data has been sourced. Missing data In 2016 there were 54,024 licensed GPs in England and Scotland (excluding licensed GPs that are also on the specialist register). 87% (47,253) of these GPs have NHS practise history records. The absence of an NHS practice history record can happen if a doctor works in the private sector or is seeking employment. Even where the GMC register is matched to NHS practice history data we cannot tell whether the doctor also holds a private practise contract. 79% (42,804) have a practice history record and valid practice history fields (type of contract and working pattern fields). We do not know why 13% of doctors on the GP register do not have a practice history record or why a further 8% have no practice history record. This missing data affects the entire report from table 4 onwards; we do not exclude these doctors from the demographic section at the beginning of the analysis. The missing data is included in the typology as we want to describe the percent of doctors in each group and this would be artificially inflated if we were to ignore the missing data; it is also relevant when looking at the fitness to practise data. 7

The GP workforce This paper considers licensed doctors on the GP Register between 2013 and 2016 in England and Scotland. It excludes doctors who are on both the GP and specialist registers. In this section we consider how licensed GPs vary by selected characteristics such as: age and gender region of primary medical qualification (PMQ) and ethnicity maximum number of contracts held on a single day Box 2: The GP Register and NHS Workforce data The GP Register shows the number of GPs who are licensed to work in the UK. The GP Register does not hold information on the contract or working time arrangements of these doctors. The GP Register shows the potential rather than actual GP workforce, as not all doctors on the GP Register work as GPs. GMC data shows there were approximately 48,000 doctors licenced on the GP Register in England in 2016 (excluding doctors on both the GP Register and Specialist Register). This is broadly in line with NHS Digital data from March 2016 that estimated a headcount of ~42,000 GPs working in general practice and hospital community health services in NHS trusts and clinical commissioning groups (excluding private practice). 5 The difference between potential and actual workforce estimates is evident when you compare: GMC data, which shows a 5% increase in the number of doctors in England on the GP Register between 2012 and 2017 6 Health Education England reports GP numbers have fallen by 1% since 2012. 7 This paper reports on licensed GPs on the GP Register. The proportion of GPs with a locum GP contract has increased since 2013 In terms of the type of the contract data we hold, 69% of GPs had a permanent contract in 2016 and 39% held a Locum GP contract. The proportion of GPs with a locum GP contract had increased from 30% to 39% of all licensed GPs from 2013 to 2016 (see Table 1). 8

A doctor working on a locum GP contract is likely to perform similar duties to a GP on a permanent contract, they are GP practitioners who provide service sessions in general practice on a temporary and ad hoc basis. Locum GPs may be used to cover maternity/paternity leave, sick leave, annual leave, suspended doctors or vacancies. 8 They may not have the stability of a permanent contract and may hold several GP locum contracts. For some GPs this offers more flexibility, while for others it may be a route to a permanent contract. Table 1: The number of licensed GPs by contract type held in 2013 and 2016* Contract type 2013 2013 16 2016 GPs % % change GPs % Locum GP 15,711 30% 33% 20,831 39% Permanent 34,377 65% 9% 37,519 69% Bank 2,817 5% 12% 3,153 6% Fixed term 1,573 3% 19% 1,873 3% *GPs who hold more than one contract are double counted in this table. Box 3: Estimating the number of locum GPs This analysis counts a GP as a locum where their NHS contract data highlights an active locum GP contract type in any given year. There are a range of methods used by different organisations in the UK to estimate the number of Locums and the number of locum GPs varies depending on the source consulted. For example, NHS Digital estimated a headcount of approximately 2,500 locum GPs in England in 2017. 9 NHS National Services Scotland used a survey and found that there were 350 whole time equivalent locum and sessional GPs in general practice in Scotland in 2015. 10 Meanwhile, in 2014 the National Association of sessional GP s and estimated that there may have been up to 17,000 locum GPs in the UK 11 which broadly matches the findings of this analysis. 9

What types of working pattern can we identify within our data? The population of licensed GPs has been split into mutually exclusive groups based primarily on the type of contract(s) they held and its associated working pattern. Seven groups, and their relative sizes for 2016, are shown on the right hand-side of Figure 2 which also shows the proportions of doctors that held no valid contract data. Figure 2: Segmentation of GPs (using 2016 data) It is clear that GPs are a heterogeneous group who do not neatly fit into a single typology. This analysis found that most typology groups have broadly similar demographic compositions but some variations are found (see Appendix 1 for details). In particular, only 35% of GPs on full-time permanent contracts are female, while 61% of GPs on parttime permanent contracts are female. 10

Box 4: Generating the typology The paper initially used multiple correspondence analysis to examine patterns in the GP data. This method clustered factors (in this case, gender, trainee status, ethnic group, PMQ, age group, type of contract) into dimensions that indicated an underlying similarity. Doctors were assigned a score for each dimension and could be associated with more than one. This method does not place doctors into mutually exclusive groups but highlights where groups of doctors differ from the average. This analysis identified some small groups such as: IMG, BME GPs aged over 60; GPs with three or more types of contract; and GPs with two contracts including a retainer. However, the dominant group identified using this method were GPs who were not trainees and did not have three or more contracts which accounts for the majority of all GPs. Following this data led exploration the analysis adopted a more pragmatic approach and developed a typology based on the type of contract held ie permanent or locum and the number of contracts held on the basis that different contractual arrangements relate to different workplace situations. Demographics are used as a lens through which to view the typology rather than a defining feature of it. All locum GP contracts are classed as part-time within the practice history data. In this typology, the doctors with unspecified working pattern data to define whether they are full or part-time are classed as missing (8% of the original sample of 54,024 in 2016). The contract types shown in Figure 2 have distinct demographic make-ups, specifically: 43% of GPs with a full-time permanent contract are men aged 50 or over. This is considerably greater than the 24% of all GPs that are men aged 50. In general women GPs have a wider range of non-full-time contract types than men: Women are more likely than men to hold both locum and GP contracts (66% relative to 34%). Women aged less than 50 make up 42% of GPs with a single part-time permanent contract which is higher than the 36% average across all the contract types. They are also the largest proportion of GPs to hold three or more contracts (37%), with the next largest group: men under 50 accounting for 29%. 11

The demographic make-up of locums is markedly different from other types of GP in that there are proportionately fewer UK qualified white doctors among those with a single locum GP contract than overall (36% compared to 49%). BME doctors (including both those who qualified in the UK and those who qualified abroad made up 34% of these locums, a greater proportion than for other types of GP. The group with the largest proportion of BME doctors holding an IMG PMQ were in the 1 locum GP contract group, which also had the largest proportion of BME doctors holding a UK PMQ. However, these two groups added to only 34% of the total number of 1 locum GP contract doctors, and were still outnumbered by white UK doctors (36%). Please see table 5 in Appendix 1 for more. White UK PMQ doctors make up particularly large proportions of the GPs on permanent contracts, accounting for 54% and 45% of the part-time permanent and full-time permanent contracts respectively. Part-time and locum working has increased from 2013 to 2016 Table 2 shows the change in the distribution of licensed GPs among the different contract type groups between 2013 and 2016. The number of GPs with a single part-time permanent contract only has increased 18% to 11,441 doctors. GPs with a single full-time permanent contract only have decreased by 20% to 8,341 from 2013 to 2016. During the same period 1 locum contract GPs also increased from 5,586 to 7,811 (a 40% increase). These insights are consistent with increasing locum and part-time working patterns amongst GPs, and decreasing full-time permanent working. * Table 2: The percentage of licenced GPs by group, 2013 16 GP segment 2013 2013 16 2016 GPs % % change GPs % 1 part-time permanent contract 9,688 18% 18% 11,441 21% 1 full-time permanent contract 10,375 20% -20% 8,341 15% 2 contracts 1 locum GP & 1 permanent 6,415 12% 26% 8,077 15% 1 locum GP contract 5,586 11% 40% 7,811 14% Other combination of contracts 3,292 6% 18% 3,900 7% 3+ contracts 3,097 6% -5% 2,942 5% Missing contract data 14,645 28% -21% 11,512 21% Grand Total 53,098 2% 54,024 The number of licensed GPs for whom contract data was missing decreased over this period. But even when doctors with missing data are excluded from the figures, the * All locum GP contracts are recorded as part-time but it is not clear form our data whether they are working less than full-time hours. NHS Digital estimates suggest a headcount of 2,630 GP locums in June 2017 and a full-time equivalent of 970 GP locums, which suggests that many are working less than full-time hours. 5 12

increase in the share of part-time and locum doctors within the GP population is still evident. Which GP contract types are more complained about or investigated by the GMC? Box 5: Pooling data To examine whether selected GP contracts are more complained about and investigated than others we pool data from the four snapshots of licenced doctors on the GP register on the 30 th June between 2013 and 2016. There were 61,554 unique GPs in the data set during this time period, of which, 8,814 (14.3%) were complained about and 2,549 (4.1%) were investigated. Some GPs changed contract type between 2013 and 2016, so the sum of the unique number of GPs in each contract group is greater than the unique count of all GPs. For the fitness to practise component of the analysis the segments are based on the working pattern at the time of the complaint, so there is a degree of approximation necessarily used given doctors can move between contract types over time. GPs are complained about more than other groups of doctors A quarter of licensed doctors were on the GP register in 2017 (including those on both the GP and Specialist registers). 12 Between 2012 and 2016 doctors on the GP Register were more likely to be complained about compared to doctors on the Specialist Register or on neither the GP nor Specialist Registers. GPs received a greater proportion of their complaints from the public relative to doctors on other register types. In total 42% of all complaints received between 2012 and 2016 were made about GPs and approximately three quarters of complaints about GPs were made by the public. This figure is notably higher than for other groups of doctors presumably because GPs have more patient interactions than other groups. It is estimated that there are over 1.3 million GP consultations every day and that a typical GP appointment lasts 10 minutes. 13 Complaints from the public were far less likely to result in an investigation and in a sanction or a warning when compared to complaints from other sources such as an employer or the police. In recent years we have introduced provisional enquiries to see if certain complaints can be closed quickly on an initial examination of evidence. In 2016, 92% of provisional enquiries in about GPs originated from the public and of nearly all of were closed. As a result, GPs are the groups of doctors with the lowest rate of complaints investigated (32% compared to 34% for doctors on the Specialist register and 55% for doctors on neither the GP nor Specialist Register). 13

Complaints that we investigate are usually assigned an allegation which we have divided into 10 types (see State of medical education and practice in the UK 2017, page 85 for details of these groups). The most common investigations of GPs between 2012 and 2016 involved their clinical competence only, meaning they were solely about a doctor s failure to deliver good-quality clinical care to patients. This made up over a quarter (27%) of investigations about GPs but only 3% of these investigations resulted in a sanction or warning. In contrast allegations about a GPs health made up only 7% of investigations but half of these resulted in a sanction or warning 14. GPs with a locum GP contract had the lowest rate of being complained about, and GPs with a single full-time permanent contract the highest. GPs with a single full-time permanent contract had the highest rate of being complained about when compared to the other groups (21% compared to 11% of their part-time counterparts). This may be due to a greater number of patient interactions amongst those working full-time. Meanwhile, the contract group with the lowest rate of complaint was GP s with a single locum GP contract 7% were complained about, which is very similar to the rate of complaints for GPs who held both locum GP and permanent contracts (8%) (see Figure 3 on next page for details of all contract groups). GPs with a single full-time permanent contract have the highest rate of investigation Over the four years from 2013, 4% of GPs were investigated. 6% of GPs with a single permanent full-time were investigated compared to 3% of their part-time counterparts. This is perhaps unsurprising given one might expect a part-time GP to have fewer patient contacts than a full-time GP. 2% of GPs with a single locum GP contract were investigated as were 2% of GPs with both a locum GP and permanent contract. This pattern bears further discussion it may be consistent with locum GPs having fewer patient contacts, or the nature of their work and employment may mean fewer complaints are raised with the GMC. 14

Figure 3: The percentage of GPs complained about and investigated by group, 2013 to 2016* Group and number of GPs per group 61554 19935 6597 11541 12789 7551 14722 11194 1 full-time permanent contract 1 part-time permanent contract 3+ contracts 2 contracts 1 locum GP & 1 permanent 1 locum GP contract Other combination of contracts Missing contract data All 6% 3% 8% 2% 8% 2% 7% 2% 9% 2% 7% 3% 4% 11% 14% 21% 0% 5% 10% 15% 20% 25% % of GPs % complained about % investigated *Individual groups do not sum to the All group due to doctors moving between contract groups over the 2013 to 2016 time frame (see Box 5) A greater proportion of complaints against single locum contract GPs were investigated than for any other group. The state of medical education and practice in the UK 2017 report showed that GPs are more likely to be complained about than other groups of doctors but they are not more likely to be investigated. Overall 29% of GPs who were complained about between 2013 and 2016 were also investigated. This rate was highest for GPs with a single locum GP contract, 36% of complaints made about this group were investigated. The rate of complaints being investigated was lower for other types of GP contract, ranging from 23% for GPs with a single part-time contract to 27% for their full-time counterparts (see Figure 4). It is also noteworthy that GPs with missing contract data had higher rates of having complaints investigated (38%) than any identified contract type. 15

The pattern of GPs with a single locum GP contract being the least likely to be complained about and the most likely to have a complaint investigated is interesting. We invite comments, insight and further discussion on this. Figure 4: The percentage of complaints investigated, by GP group, 2013 to 2016* Group and number of GPs complained about 8814 1453 1,690 605 1019 2,312 612 796 1 locum GP contract 3+ contracts 1 full-time permanent contract 2 contracts 1 locum GP & 1 permanent Other combination of contracts 1 part-time permanent contract Missing contract data All 28% 27% 26% 23% 23% 29% 36% 38% 0% 10% 20% 30% 40% 50% % of GPs *Individual groups do not sum to the All group due to doctors moving between contract groups over the 2013 to 2016 time frame (see Box 5) Other GP groups with high rates of complaint or investigation The analysis also considered whether there were any additional GP groups at high risk of being complained about or investigated by examining the proportion of GPs complained about and investigated by selected demographics and contract arrangements (see Appendix 2). This analysis highlighted two smaller groups of interest that do not neatly overlap with a typology based on contract types. Older IMG male GPs GPs working alongside a small number of licensed doctors 16

Older IMG male GPs and EEA male GPs have a relatively high rate of complaint and investigation Our analysis shows that male IMG GPs aged 50 or over had the highest rate of being complained about (27%) compared to the overall average for GPs of 14%. The proportion of male IMG GPs aged 50 or over investigated was also higher for this group (11%) compared to 4% overall. Table 10 in Appendix 2 shows this data. A similar, albeit less pronounced, pattern is found for male EEA GPs, where 22% of male EEA GPs aged 50 or over were complained about (compared to 17% for those under 50) and 8% were investigated (6% for those under 50). Male IMG GPs aged over 50 have a range of employment contracts; the most common contract type arrangement for this group is a single full-time permanent contract. In 2016, 30% of Male IMG GPs aged over 50 had a single full-time permanent contract compared to 15% of the overall GP population. GPs working alongside fewer licensed doctors are more complained about and investigated Most GPs with an identified location (95%) work in a location that has 3 or more licensed doctors. Among these are 12% who work in locations with 25 or more licenced doctors. Only 5% (2,415) work in a location where there are less than 3 licensed doctors. Doctors working in places with only one or two licensed doctors had a higher rate of complaint and a higher rate of being investigated. Figure 6 shows this pattern a clear trend where GPs working alongside fewer licensed doctors tend to be more complained about and investigated. There could be a wide range of reasons for the emergence of this pattern and further research and discussion is required to better understand the challenges faced by doctors working in smaller institutions. 17

Box 6: How we identified the number of doctors working at a location The number of licensed doctors working at any given location has been estimated using the postcode location of all licensed doctors contracts as at 30 th June each year from 2013 to 2016. The average number of licensed doctors at each location across those four snapshots is then used to give the numbers of licensed GPs working at such locations is shown in Figure 5. Where a GP holds concurrent contracts at more than one location, the largest location has been selected. Locum doctors are excluded from the count of all licensed doctors at each location due to their work address being potentially unreliable indicators of their place of work. For the same reason, locum GPs have been omitted from the counts of licensed GPs at each location. An average of 2,978 licensed GPs held contracts without a valid level three postcode meaning that they could not be attached to a specific location ( Unknown in Figure 5). Figure 5: Average number of licensed GPs working at each size category (2013 to 2016) Licensed doctors at location Unknown > 25 11-25 6-10 3-5 1-2 2,978 2,415 5,631 8,915 10,452 16,882 0 2,000 4,000 6,000 8,000 10,000 12,000 14,000 16,000 18,000 Average number of licensed GPs Figure 6: Rates of complaints and investigations for GPs by the number of licensed doctors at their work place when the complaint was made Licensed doctors at location > 25 11-25 6-10 3-5 1-2 % complained about % investigated 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% % of GPs 18

Box 6: Summary of insights GP population There has been a 2.4% increase in the number of licensed doctors on the GPs register between 2013 and 2017. The number of female GPs has increased by 9% between 2013 and 2016. The number of UK BME GPs has increased since 2013 by 32% to 6,583 in 2016. GP working arrangements GPs have a mix of employment contracts and working arrangements often combining more than 1 contract. In 2016 a third of GPs had 2 or more contracts on the same day. Over 20,000 GPs had a locum GP contract in 2016, an increase of 33% since 2013. Between 2013 and 2016, more doctors worked in larger locations than in smaller practices. Only 5% (2,415) of GPs worked in a location of 1 or 2 licensed doctors. GP segments In 2016: 21% of GPs had single part-time permanent contract, 15% had a single full-time permanent contract, 14% had a single locum contract, 15% held 2 contracts 1 locum GP contract and 1 permanent contract, 5% had 3 or more contract types The number of GPs working a single part-time permanent contract has increased 18% since 2013, while GPs working a single full-time permanent contract has decreased by 20% over the same period. 19

The number of GPs with a single locum GP contract and GPs with both a locum GP and permanent contract has increased between 2013 and 2016 (40% and 26% respectively). Fitness to practise The proportion of GPs complained about between 2013 and 2016 was twice as high for GPs with a single full-time permanent contract (21%) compared to those with a single locum GP contract (7%) GPs with a single full-time permanent contract are more investigated (6%) than other groups of doctors (4% overall). 36% of complaints made about GPs with 1 locum GP contract were investigated compared to 27% of GPs with a single full-time permanent contract. GPs with a single locum GP contract had the highest proportion of their complaints attributed to another doctor (9%) or an employer (7%), compared to for GPs with a single full-time permanent contract (5% from another doctor and 3% from an employer). Older IMG male GPs have a relatively high risk of complaint and investigation compared to GPs with a different PMQ, gender and age combination. GPs working alongside fewer licensed doctors are more complained about and investigated 20

Conclusions and next steps For the first time, we have examined the risk of complaint and investigation of GPs according to their contractual arrangements and strong patterns have emerged. A better appreciation of the different situations, practice contexts and experiences of GPs could help us to better support them in maintaining high professional standards, and to better protect patient safety. One example highlighted in this paper is that GPs with a single full-time permanent contract are at the highest risk of being complained about and investigated whereas GPs with a single locum GP contract are the lowest. Further work is required to investigate this further. Another example of the different work patterns having different relationships to complaints and investigations is that complaints about GPs with a permanent full-time contract are less likely to reach the threshold for a full investigation when compared to GPs with a single GP locum contract. This is consistent with our published research on referrals made by employers which highlighted a perception amongst acute trusts that concerns were more likely to be raised against locums. 15 When looking at age, gender and where GPs qualified we see that IMG GPs aged over 50 years old and EEA male GPs have the highest investigation rate. We are currently carrying out a series of research to improve our understanding of primary care including a paper examining the challenges facing GPs as covered by policy literature and corroborated by our liaison teams. We will need to use these insights to motivate discussions and further evidence gathering about the challenges faced by different groups of GPs. It is notable that the absence of non-nhs contract data limits the conclusions we can draw from this paper, as GPs may also hold one or more private sector contracts. The availability of NHS employment data for Northern Irish and Welsh GPs in the practice history data is variable as well, limiting the applicability of this analysis across the f countries of the UK. It is our view that better quality non-gmc data would help our understanding of the doctors most at risk of complaint and investigation, and would consequently help design better supportive interventions to reduce those risks. 21

Appendix 1: Segment demographics Table 3: The percentage of licensed GPs by selected primary medical qualification (PMQ) and ethnic group, 2013 to 2016 PMQ and ethnicity 2013 2013 16 % change 2016 GPs % GPs % EEA BME 293 1% 15% 338 1% IMG BME 6,532 12% -1% 6,489 12% UK BME 4,998 9% 32% 6,583 12% EEA white 1,708 3% -1% 1,698 3% IMG white 714 1% -3% 694 1% UK white 26,723 50% -1% 26,524 49% EEA not recorded 662 1% -6% 619 1% IMG not recorded 1,962 4% 6% 2,083 4% UK not recorded 9,506 18% -5% 8,996 17% Total 53,098 2% 54,024 Table 4: The percentage of licensed GPs by age and gender, 2013 to 2016* Gender and age 2013 2013 16 2016 GPs % % change GPs % Men (less than 50 years old) 12,660 24% 0% 12,617 23% Men (more than 50 years old) 14,411 27% -10% 12,961 24% Women (less than 50 years old) 17,953 34% 9% 19,614 36% Women (more than 50 years old) 8,074 15% 9% 8,832 16% Total 53,098 2% 54,024 22

Table 5: GP contract type group by place of primary medical qualification and selected ethnic group (2016) PMQ * Ethnic group 1 part-time permanent contract 1 full-time permanent contract 1 locum GP contract 2 contracts 1 locum GP & 1 permanent 3+ contracts Other combination of contracts Missing contract data EEA BME 0% 1% 1% 1% 1% 1% 1% 1% EEA missing 1% 1% 1% 1% 1% 1% 1% 1% EEA white 3% 3% 3% 3% 3% 4% 4% 3% IMG BME 11% 13% 17% 12% 13% 12% 9% 12% IMG missing 3% 4% 6% 4% 4% 3% 3% 4% IMG white 1% 2% 2% 1% 2% 1% 1% 1% UK BME 11% 11% 17% 16% 12% 12% 8% 12% UK missing 16% 20% 16% 13% 13% 16% 19% 17% UK white 54% 45% 36% 50% 51% 50% 54% 49% All 100% 100% 100% 100% 100% 100% 100% 100% All Table 6: GP contract type group by gender and age (2016) Gender * Age 1 part-time permanent contract 1 full-time permanent contract 1 locum GP contract 2 contracts 1 locum GP & 1 permanent 3+ contracts Other combination of contracts Missing contract data All Men (less than 50 years old) 21% 22% 26% 25% 29% 28% 21% 23% Men (more than 50 years old) 18% 43% 21% 9% 19% 27% 29% 24% Women (less than 50 years old) 42% 16% 40% 55% 37% 31% 31% 36% Women (more than 50 years old) 19% 19% 13% 11% 15% 15% 19% 16% All 100% 100% 100% 100% 100% 100% 100% 100% 23

Appendix 2: The number and percent of GPs complained about and investigated by selected demographics Table 5: The number and percent of complaints and investigations by GP gender and age, 2013 to 2016 Gender * Age Number Number complained about % Complained about Number of complaints investigated % Investigated % of Complaints investigated Men (less than 50 years old) 15,665 2,399 15% 724 5% 30% Men (more than 50 years old) 16,898 3,349 20% 1,103 7% 33% Women (less than 50 years old) 23,114 1,811 8% 397 2% 22% Women (more than 50 years old) 10,732 1,255 12% 325 3% 26% All 61,554 8,814 14% 2,549 4% 29% 24

Table 8: The number and percent of complaints and investigations by GP ethnic group and place of primary medical qualification, 2013 to 2016 PMQ * Ethnic group Number Number complained about % Complained about Number of complaints investigated % Investigated % of Complaints investigated EEA BME 373 79 21% 28 8% 35% EEA missing 730 135 18% 50 7% 37% EEA white 2,016 304 15% 102 5% 34% IMG BME 7,544 1,533 20% 524 7% 34% IMG missing 2,417 509 21% 189 8% 37% IMG white 799 156 20% 51 6% 33% UK BME 6,899 948 14% 285 4% 30% UK missing 10,157 1,537 15% 460 5% 30% UK white 30,619 3,613 12% 860 3% 24% All 61,554 8,814 14% 2,549 4% 29% Table 9: The number and percent of complaints and investigations by the maximum number of contracts held on the same day per year, 2013 to 2016 Maximum number of contracts on a single day Number Number complained about % complained about Number of complaints investigated % Investigated % of complaints investigated Missing 14,288 1,487 10% 600 4% 40% 1 32,868 4,414 13% 1,113 3% 25% 2 22,348 1,905 9% 556 2% 29% 3+ 9,796 1,008 10% 280 3% 28% All 61,554 8,814 14% 2,549 4% 29% 25

Table 6: GPs complaints and investigations by gender, age and PMQ from 2013 to 2016 PMQ Gender and age GPs GPs complained about % complained about Complaints investigated % investigated % of complaints investigated EEA Men (< 50 years) 821 136 17% 53 6% 39% EEA Men (> 50 years) 952 207 22% 76 8% 37% EEA Women (< 50 years) 1100 103 9% 26 2% 25% EEA Women (> 50 years) 595 72 12% 25 4% 35% IMG Men (< 50 years) 3,281 565 17% 192 6% 34% IMG Men (> 50 years) 3,596 984 27% 389 11% 40% IMG Women (< 50 years) 3,066 326 11% 85 3% 26% IMG Women (> 50 years) 1,536 323 21% 98 6% 30% UK Men (< 50 years) 11,563 1,698 15% 479 4% 28% UK Men (> 50 years) 12,350 2,158 17% 638 5% 30% UK Women (< 50 years) 18,948 1,382 7% 286 2% 21% UK Women (> 50 years) 8,601 860 10% 202 2% 23% All 61,554 8,814 14% 2,549 4% 29% 26

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