The NHS reforms may herald a revolution in the way healthcare is conceived and delivered, but they have so far failed to effect much change in gender politics.
Following the pattern set by male-dominated PCTs, women currently occupy only one in three CCG board positions, according to an investigation by our sister paper Pulse.
Its analysis of 100 new CCG boards found only 35% of 1,153 identifiable board positions are held by women. And women occupy only 21% of chair posts, the investigation found. Among GPs on the boards, the disparity was even more marked. GPs hold fewer than half of the seats on the new boards, with only 21% of GP board positions taken by women.
The statistics look especially startling when seen in the context of the medical profession, where around half of GPs are women and female entry rates into medical school are now running at 56%.
But CCGs appear to be no different to other ‘industries’. A recent BBC report found women occupied less than a third of senior positions in 11 key sectors including business, politics and policing.
Long hours and family unfriendly cultures were cited as the barriers for women to occupy the top positions in the UK. So does this finding transfer to the low numbers of women GPs on CCG boards? Or is there a CCG glass ceiling?
Dr Clarissa Fabre, the former president of the Medical Women’s Federation, thinks not.
‘There are no barriers to women who want to get involved with CCGs. If they want to apply they can,’ she says.
‘There are just fewer women who want to take things like this on. The doctors involved in CCGs tend to enjoy it, but it’s not for everyone. A lot of grassroots GPs just couldn’t care less and my impression is that they struggle to fill these posts in any case.’
Dr Fabre, a former GPC and LMC member and a GP in Uckfield, East Sussex, has plenty of experience of committees but says CCGs are not for her: ‘CCGs are terribly constrained by budgets and cutting referrals. Personally, I wouldn’t touch it with a barge pole.’
A Tough environment
Dr Niti Pall, the only woman on the eight-strong board of NHS Sandwell and West Birmingham CCG, admits it can be ‘tough’ in the CCG boardroom.
‘It’s a very male environment. Meetings, often held in evenings and at weekends, are not seen as core work and women find that harder to fit into their working lives,’ she says.
‘I’m pretty despondent about what’s been going on – not seeing women coming through. And when we air it, it becomes a gender war. But I work in a very diverse and underprivileged area and in order to change things for my patients, you have to be at the table. Some 50% of my patients are women, after all.’
Dr Elizabeth Gill, chair of the 164,000-patient High Weald, Lewes and Havens CCG, admits the boardroom can be challenging – but is worth it.
‘It’s the most exciting time of my career. There’s a lot of hard work, but I’m passionate about this organisation,’ she says. ‘I got involved in commissioning because I saw the potential for changing things. When my youngest child had gone to school, there was a bit of leeway. I was a part-time partner working three days a week, but the practice released me from one day. So I still do two clinical days, my CCG days and one day clinical training – plus all the rest!’
Dr Gill adds: ‘I got involved because I was a GP – not because I was female or male. Women bring different leadership qualities, and I think the way to get more women involved is just to encourage them. It’s seen as potentially boring, but it’s anything but.’
RCGP chair Dr Clare Gerada believes the continued presence of what she terms the ‘old guard’ presents a barrier to female GPs within CCGs: ‘If you got the full list of names and mapped them against the list of those involved in commissioning under PCTs, you’d find a lot of overlap – most of them men.’
But she believes the main reason women are under-represented on CCG boards is because general practice is a ‘people-friendly’ profession and that many GPs – especially women – are more interested in providing care than commissioning it.
‘I’m leading for our area looking at integrated care for the elderly,’ Dr Gerada says. ‘At our first meeting, it was all women. It’s what we’re interested in. The commissioning end doesn’t excite me. It’s very different from how you can provide the best quality care for your patients. Most of commissioning is about transactions and contracts. Women on the whole are more inclined to look at services.’
For Dr Pall, a GP in Smethwick, the key issue is that few CCGs are offering board positions to salaried and part-time GPs: ‘There’s a glass ceiling for women within clinical leadership due to the fact that so many of them are not partners. They’re sessional and salaried doctors.’
Some CCGs are offering board positions to sessional GPs, but they are a minority, despite the proportion of salaried GPs having increased by almost 10-fold in the past decade.
To counter this, Dr Pall believes CCG boards should ‘take a leaf out of industry’s book’ and follow in the footsteps of countries such as Norway and Iceland and introduce quotas for women.
‘We’ve got to have positive discrimination for women, otherwise we’re going to have the wrong mix on the boards,’ says Dr Pall. ‘The best boards in the world are doing this. They’re saying publicly: “We will recruit more women” and sticking to it.’
Dr Pauline Brimblecombe, a GP in Cambridge and a pioneer GP commissioner, has withdrawn from the flagship CCG she helped set up because of an ‘inability to effect change.’
But she agrees positive discrimination in the form of quotas for women on CCG boards would work: ‘Gender is not an issue in the Cambridgeshire and Peterborough CCG, where several of the lead clinicians are women GPs. This is probably linked to the high percentage of women GPs and especially women partners locally.
‘And as with most boards, once you have a critical number of women – say 25%, or at least more than one – gender becomes less of an issue. This is why there should be a percentage quota of women on CCG boards.’
But Dr Nicola Burbidge, chair of Great West CCG, says the reason more women are not on CCG boards is simply that women generally spend more time with their children and families and so quotas wouldn’t work: ‘I had four kids and didn’t become a PEC chair until one had left school and the others were well into their teens.
‘My CCG has nine GP posts – three of them are women. I think also that women hate politics more than men do. They are not so interested in all the argy-bargy that goes with leadership. I do it because I can’t stand seeing things being done badly. But I don’t think quotas will work. You have to let those people who are right for these roles bubble up through the system.’
The view of the NHS Commissioning Board is that CCGs are still in development and the gender balance will change as the fledgling organisations progress.
It has commissioned the RCGP to explore how sessional GPs, 70% of whom are female, can be more involved in commissioning.
With male GPs set to be in the minority in just a few years time, will more female GPs take on clinical leadership in the future, through sheer weight of numbers?
Dr Pall thinks not: ‘I think women will tend to stay in the surgery while men carry on doing the commissioning.’
Which begs a final question: does the gender balance on boards make any difference to patient care?
Dr Gerada is doubtful: ‘I think men get more excited about things like urgent care and diagnostics, but there’s no reason to believe that commissioning would be any different if more women were involved.’
But for Dr Pall, it’s crucial: ‘If CCGs are going to be effective, you need the different styles men and women bring to the table. An effective board has to be a diverse board.’
Alisdair Stirling is a freelance journalist