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Overview
In March 2024, the Royal College of Physicians (the College) held an Extraordinary General Meeting (EGM) of fellows, arranged to debate issues relating to physician associates. Several members of the College raised significant concerns following the EGM, in relation to the presentation of information at the EGM and the conduct of participants. In response to these concerns the College commissioned The King’s Fund to examine: the events leading up to the EGM, from the point at which the initial communication was received from the petitioners; the running of the EGM; and the relevant activities after the EGM.
This learning review considers:
the context leading up to the EGM and the handling of survey data presented as part of the EGM
the application of the current governance framework of the College, including its leadership and internal processes as relevant to the EGM
areas of strength and opportunities for improvement in data management, governance practices and procedures
relevant reflections on culture, behaviours and relationships within the College as manifested in relation to the EGM.
It is important to note that this learning review was not directly concerned with the policy and implementation issues in relation to the rollout of physician associates.
In conducting this review, we interviewed a range of College staff and officers, members of the Council of the College (the Council) and other interested individuals who had played a direct role in the EGM or were involved in the governance surrounding it. As we were not able to interview all Council members or trustees, we also received a number of written submissions from those groups. We watched the recording of the EGM and reviewed the formal documentation relating to the EGM and a range of emails and other correspondence relevant to the period. We also reviewed samples of relevant social media.
Overall, we identified a range of collective failures in leadership across the College, and our findings and recommendations are focused on the learning for groups within the College – the Council, the Board of Trustees, senior officers and executive leaders – and for the relationships between those groups both internally and with the wider College membership. There was a clear lack of accountability and due process.
It was clear that all those who participated in the review, whatever their role, were keen to ensure learning from the events surrounding the EGM. It was also clear that, although undoubtedly individuals took actions that, with hindsight, they recognised to be inappropriate or unhelpful in relation to the outcome of the EGM, this was in the context of significant organisational dysfunction that was described to us during the course of this review. This review does not seek to point the finger of blame at any individual, but rather to identify the underlying issues that the College needs to address in order to rebuild relationships internally, with the wider College membership and with external stakeholders – and through doing so, to deliver effectively its mission of educating, improving and influencing for better health and care.
Summary of findings
Governance
With regard to the calling of the EGM, the College followed relevant bye-laws closely. We did, however, identify that it may have been possible for the EGM to have been called sooner by following other aspects of relevant bye-laws.
More generally, there is a pervasive lack of trust and confidence in the College’s governance. There is concern that the lay trustees are too distant from the activities of the College, and that the Board of Trustees does not operate as a single board with lay and clinical trustees acting collegiately.
The Council is not operating effectively. Decision-making processes are unclear and this both creates inefficiency in the way in which the College operates and puts individuals at risk of challenge where decisions are not seen to be undertaken transparently.
Survey of members
There was a lack of due process in the survey of members: it was conducted without clear processes in relation to design, sign-off and quality assurance.
We found no collective ownership of the survey by College officers: there was a lack of collective responsibility throughout the survey process, leading to individuals feeling blamed and isolated when the survey was criticised.
There was ineffective use of expertise: survey design, questionnaire development and analysis and the dissemination of the results require specific skillsets and expertise, which were either lacking at the College or, where they did exist, they were not used.
There was a perceived lack of transparency: the process around the survey’s development was opaque and this meant that when it was criticised, the College could not show clearly how conclusions had been reached, further fuelling accusations of bias.
There appeared to be organisational bias. A survey should not be carried out with the aim of proving a pre-determined point of view. Instead, it should be seen as contributing to an evidence base without preconceived ideas of what the results should show. When the evidence did not meet the aims of the survey or match the apparent pre-conceived views of those behind the survey, it led to the results being presented in a biased way.
Broader culture and behaviour issues
We found poor interpersonal relationships within the College, which affected staff and officers across the organisation. This was one of the contributory factors to the lack of confidence in governance noted above.
We also found poor behaviours across the organisation and in particular surrounding Council meetings and other interactions with and between Council members. These included shouting and the use of intimidatory language on both open and closed social media.
Communications with fellows and members appeared reactive rather than proactive. The College leadership team appeared to be lacking the bandwidth to listen and respond effectively to member issues.
There was limited support for senior officers and at least some executives in carrying out their roles effectively in times of pressure, and they also lacked the time to meet their responsibilities fully at such times.
Many participants in this review perceived the College not as an organisation that sets policy, but rather as one that reacts to others and is driven by other organisations’ agendas rather than driving its own.
Recommendations
Leadership, management and culture
It is clear that all participants recognised the significant cultural issues within the College and wanted to see change and improvement. We strongly recommend that the College seeks external support to the president and chair of the College for a programme to help implement the desired changes identified in this review. The programme should support individuals and groups within the College to develop a culture that is trusting, collaborative and forward-looking, making the best use of the skills and experience brought to the College by each part of the organisation. This would need to be aligned to any governance review commissioned in response to our recommendation below, but does not need to wait for it to conclude.
We understand that there is an intention for a further review of governance within the College. We recommend within that further work:
a review of the way in which the Council operates, in particular to consider whether it is appropriate to bring greater public transparency to at least some parts of Council discussions
an externally commissioned review of the effectiveness of the Board of Trustees, to include the effectiveness of the relationship between the Board and the Council
a further review of the bye-laws to reduce ambiguity, in particular to provide greater clarity on the criteria by which either the president or the Council may judge that an EGM is required
consideration of the relationship between the full membership of the College and its governance arrangements, in particular how the membership of the College is engaged on policy issues
consideration of the appropriate threshold number of fellows required to trigger an EGM should the president or Council not deem that the criteria have been met.
Structure and processes
The College should develop a Standard Operating Procedure for EGMs or any meeting involving discussion with large numbers of fellows or members.
The College should have a clear Standard Operating Procedure for surveys of fellows and members.
The College should consider whether College officers and executives have sufficient time commitment and support to undertake the duties asked of them, especially during workload peaks, and to ensure training enabling them to discharge their duties in respect of the different governance structures and processes in which they are involved.
The College should review the arrangements it has in place to provide support to the physical and mental health needs of both staff and officers.
We understand that the College is already taking some actions relevant to these recommendations.
Given the importance of this learning to the College as a whole we recommend that this report is considered in full by both the Board of Trustees and Council, and that the chair of the College Board of Trustees and the president (currently the senior censor acting as president) take joint accountability for responding to the recommendations.
Read the full report now: Royal College of Physicians (RCP) Independent Learning Review
Further information
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