Under-representation of women on governing bodies: women general practitioners on Clinical Commissioning Groups in England

Introduction

The Health and Social Care Act (2012) has re-shaped the way that primary care is organized in the English National Health Service (NHS). General practitioners (GPs) through their practices are grouped together in 211 Clinical Commissioning Groups (CCGs), now responsible for roughly 60% of the total NHS budget. ¹ CCGs plan, choose and procure services for their local communities. This is not a voluntary arrangement; GPs are compulsorily members of CCGs and are represented by CCG governing bodies. In the course of attending a number of these meetings as a researcher, I became increasingly aware of the dearth of women GPs seated at the ‘top table’. We know that women are well represented in general practice, so their absence on CCG governing bodies seemed noteworthy.

The question of the representation of women on boards has been publicized by the continuing government review tracking and promoting the numbers of women on Financial Times Stock Exchange (FTSE) boards. The original report notes that in 2010 only 12.5% of FTSE board members were women and examines the challenges facing women in the boardroom. ² By 2014, encouragement to improve these figures resulted in an increase of 22.8% in the number of women on these boards. ³ The original report notes similar patterns and trends in business boardrooms in Europe, America and other industrialized countries. Away from the corporate world, the question of diversity on NHS hospital boards has been raised by Kline. ⁴ While reporting that 40% of London NHS hospital board members are women, he points out that approximately 80% of non-medical health service staff are women, so board membership does not represent the gender mix of the workforce.

Our observations of CCG boards took place in the context of research examining the early workings of newly formed CCGs. ⁵ Only 146 out of 721 (20.2%) GP governing body members were women. In addition, 28 out of 110 CCGs (25.5%) reported no women GPs on their boards at all, and 45 out of 110 (40.9%) governing bodies contained only one woman GP. ⁶ These figures need to be set against the fact that women represent 60% of medical school entrants and 60% of GP registrars in England. Women GPs now make up almost exactly half of the GP workforce, 48.5%.^7,8

Why are there few women on CCG governing bodies?

Dig a little deeper into these statistics and some pointers begin to emerge that may account for the disparity described above. Although numbers of women joining the profession have been growing steadily, so too have the numbers of women becoming sessional or salaried GPs (rather than partners). In 2013, 70% of ‘salaried/other GPs’ were women concentrated in the age range mid–20s to mid–30s. ⁷ The category ‘other’ includes part-time workers, and these jobs are attractive to women with child care responsibilities, responsibilities which still rest largely on the shoulders of female parents. Sessional or part-time GPs work for particular sessions, while salaried GPs may work full-time, but they are not partners in their practices. So there are two issues that are relevant here: the first is that women GPs make up the majority of salaried and part-time positions; the second is that the numbers of salaried and part-time positions are growing in relation to the numbers of partner positions. ⁹

Significantly, some CCGs preclude the possibility of electing non-partners onto the governing body ¹⁰ while in others salaried or part-time GPs are not encouraged to put themselves forward for election. The upshot is that there are few non-partner GPs on CCG governing bodies. ¹¹ The Royal College of General Practitioners (RCGP) survey found that 9% of sessional GP respondents had a role on a CCG, while our own survey showed that 27% of participating CCGs had a salaried GP on the governing body. ⁶

Thus, there are clear structural reasons to explain the low numbers of women on CCG governing bodies: women predominate in the group of salaried and part-time GPs, and these GPs are under-represented on the governing bodies. However, work on the nature of leadership raises other issues. It is suggested that women and men tend towards different management and leadership styles – usefully summarized by Claes ¹² who talks about masculine and feminine poles of behaviour. She notes the association of masculine management skills with dominance, assertiveness and decisiveness, and that relationship building, collaboration and supportive behaviour are associated with women. Others have referred to a leadership style characterized in terms of military metaphors (e.g. ‘leading from the front’, ‘being on the front line’ and ‘leading the rank and file’) as ‘heroic’ leadership. The more collaborative styles of leadership are perhaps less flatteringly referred to as ‘post-heroic’. In general terms, heroic leadership styles are more often associated with men and post-heroic styles are more commonly employed by women. This characterization may oversimplify a more nuanced reality, but women GPs already facing structural disadvantages may also find it difficult to make headway in an environment that favours masculine management styles.

The NHS has long espoused the image of heroic leader, but in recent years, especially in the business community, this style of leadership has been questioned. In particular, the image of leader as superhero or goal scoring sports star has been challenged by a more diffuse and co-operative view of leadership. ¹³ However, it remains unclear the extent to which such thinking has permeated the Service, and whether those electing CCG governing body members see leadership in this way.

Does it matter?

There are a number of reasons why this issue is important. The first concerns justice and fairness. There are few who would argue that women GPs are less talented than their male counterparts, and few who would contend that women are not able to manage and lead others. From a moral perspective then, conditions that prevent women from taking leadership positions ought to be redressed. Secondly, the need for leadership to reflect the broader community is important. Many women choose to consult women GPs (particularly on ‘women’s issues’) and in turn it is likely that women GPs will have both different and overlapping priorities and interests from their male colleagues. Linked to this is a third issue – the government has been keen for primary care clinicians to take on leadership and management roles because they are in daily touch with patients. GPs, through their CCGs, now make far ranging decisions about commissioning services and spending budgets. These roles are not trivial and are set to expand in the near future. Finally, there is a well-made argument that points to the importance of role models for upcoming generations; in this case, women GP leaders who will inspire and encourage other women to take on roles on CCG governing bodies and other leadership positions. ⁸

Wait or act?

The question now is should we wait for change, noting that women continue to swell the ranks of general practice and hoping that in time their growing numbers will be reflected in CCG governing bodies? On the other hand, CCGs are new organizations; why not take action now to ensure a better representation of women on these bodies? Affirmative action refers to policies or programmes whereby groups who have been previously discriminated against are compensated or promoted by virtue of being part of a disadvantaged group. Such methods are controversial and may be complicated. The most straightforward approach is to employ quotas: stipulate that a certain proportion of those who are hired or enrolled come from a group previously disadvantaged and under-represented. Such schemes have waxed and waned in popularity with concerns being raised about reverse discrimination.

Two recent examples highlight positive views about affirmative action in the form of gender quotas. The first notes how the implementation of legal gender quotas in several European countries has boosted the number of women on boards of directors of top companies. ¹⁴ This approach has speeded the progress of women onto boards which was previously described as ‘glacial’. ‘The proportion of women on the boards of all French Global 200 companies has shot up to 29.7% since legislation setting a target of 30–40% was enacted in 2010. A decade ago the figure was 7.2%. Likewise in Italy, which passed a quota law in 2011, the proportion has jumped to 25.8% from 1.8% in 2004.’ Quotas can provide a radical solution with the hope that this kind of move can kick start wider change within an organization.

The second example refers to the UK Supreme Court, ¹⁵ and the observation that the upper echelons of the UK judiciary are dominated by white males from socially advantaged backgrounds. Malleson notes that gender quotas have been successfully used in the Belgian Constitutional Court, The International Criminal Court and the European Court of Human Rights. Such quotas have brought about rapid and effective change while the UK Supreme Court has the lowest proportion of women on the bench of any Organisation for Economic Co-operation and Development (OECD) country. Malleson argues that two common objections to this kind of affirmative action can be rebutted. The first is that quotas will lead to less qualified people being appointed to high-level jobs. In a field such as law with many well-qualified women in a potential candidate pool, she believes that this is not a problem. The same argument can be made for women GPs, especially as we recall that 60% of GP registrars are now women. There are plenty of women GPs who are fully qualified, who have jobs and are therefore part of the candidate pool for CCG leadership positions. A second common worry is that quotas are inflexible; but quotas can be flexible, Malleson describes a variety of schemes that employ short lists, gender ratios or gender targets, all of which can be reviewed and adapted.

What if CCGs were committed to a quota of 40% women on their governing bodies? Not only would this be more representative of the general population, fairer to women GPs and possibly bring fresh leadership styles to governing bodies, but it would also oblige CCGs to look more closely at the position of salaried and part-time GPs who happen to be predominantly women. Isn’t it time that more women were sitting at the ‘top table’?