For the Global Majority of the National Health Service (NHS) workforce, the concept of “institutional courage” offers social justice and empowerment. Institutional courage is important because it embodies commitment of healthcare institutions and leaders to challenge biases and dismantle systemic barriers. It acts as a mechanism that approaches a more equitable and inclusive workplace. Therefore, its absence, typically manifests as “institutional betrayal” which fundamentally undermines trust and perpetuates inequity. In this blog, I describe three examples of institutional betrayal, explore the role of courageous individuals, and conclude by listing 11 key elements associated with institutional courage.

Institutional betrayal is in all reality, wrongdoings by an institution upon individuals that are dependent on the institution. This includes failure to prevent or respond supportively to:

• Interpersonal injustice,
• Discrimination,
• Harassment, or
• Assault.^1,2

Contextual cases in the media have shown that institutions often respond in ways where their intended action represents a lack of understanding of the transgression. Outwardly, sending out a loud message that this action is rather to protect itself by effectively silencing the survivor. This has far-reaching and long-lasting impact resulting in determinate harm to the survivors psychological and physical health.¹

In November 2021, Dr Farah Jameel, a General Practitioner (GP) and international medical graduate (IMG), was elected as the first female Chair in the British Medical Association (BMA) GP committee of England’s (GPCE) 100-year history. That in itself is a formidable achievement, and she set her three-year key priorities to reset the relationship with the Government and begin to rebuild general practice. However, soon after commencement of her role, it was reported that Dr Jameel faced sexism. Sadly, this transpired only two years after the 2019 investigation by Daphne Romney QC into allegations of sexism, bullying and harassment at the BMA. The Romney report labelled the BMA as ‘toxic’ with an ‘old boys’ club culture’ which treats women ‘as of less importance and ability.’ By March 2022, Dr Jameel had taken sick leave and then in November 2022, BMA staff made a complaint against Dr Jameel for unspecified reasons which resulted in the organisation placing her under temporary suspension.

Further to the Romeny report, a 2022 report by Ijeoma Omambala QC described an ‘old boys’ network’ within the BMA GP Committee, and concluded that ‘bullying’ within the committee continues to contribute to the ‘marginalisation of women, ethnic and other minorities’.

More recently, on 20^th July 2023, Dr Farah Jameel received a ‘vote of no confidence’ from members of the GPCE and she lost her Chair position. Due to widespread coverage and support from colleagues and the public, one day prior, a petition calling for withdrawal of the ‘vote of no confidence’ in the BMA GPCE Chair was generated that has received more than 800 signatures to date in support of Dr Jameel. On 4^th August 2023, an open letter was sent to the new GPCE Chair, BMA leadership and BMA UK Council members raising concerns about intersectional discrimination and inequity within the BMA with a call to action. At this time of writing, Dr Jameel remains under suspension whilst she is on maternity leave.

In the second case that I highlight in this blog, Dr Kayode Oki was suspended from the BMA council because of a complaint related to old tweets published in the newspapers that had been taken out of context. The BMA issued a public statement of suspension. Immediately, a silent vigil in protest against the suspension of Dr Oki convened outside BMA house, an on-line petition was generated and an open letter with 114 signatories was sent to the BMA asking them to lift the suspension and stop the investigation. Dr Oki, a foundation year one doctor in South Thames presented motion 43 at the annual representative meeting of the BMA in June 2022. He described the failure of the BMA to learn from the Romney report, highlighting evidence of lack of value and support for female members as well as members from marginalised groups including Black, Asian, minority ethnic, IMGs and locum doctors. Dr Oki alleged a hostile environment existed in some of the committees with a ‘culture of politics by complaints’ and ‘political statements taken as personal attacks’. Whilst Dr Oki was successfully elected as a medical students’ representative and is one of only three Black people on the 69-member BMA Council, within one year, unfair reporting appeared against him in national newspapers. Whilst the suspension was subsequently removed, due to confidentiality of the processes there is lack of clarity about the timing of events and the reason for the investigation, which is still in progress at the time of writing. On 14^th August 2023, the final petition with more than 3,000 signatures was delivered to BMA House in conjunction with a letter which asked two questions of the BMA: “What specific grounds underlie the complaint lodged against Dr Oki, leading to his suspension?” and “Were experts with a comprehensive understanding of racial dynamics and equity involved in the investigation process?”

The third case is of Dr Valentine Udoye, an international qualified GP, who had high hopes and dreamed of working in the UK. However, this dream soon turned to a nightmare when he was referred to the General Medical Council (GMC) for fitness to practice based on dishonesty. Dr Udoye had sought advice on how to practice as a UK GP from the Head of Continuing Practice who advised him in 2016 to join the NHS Induction and Refresher (I and R) Scheme. Unfortunately, Dr Udoye was not eligible to join the scheme and incorrectly completed the application form after further advice, which turned out to be incorrect, from the GP National Recruitment Office (GPNRO), NHS England (NHSE) and Health Education England. Dr Udoye was subsequently referred by NHSE to the GMC for dishonesty arising from an error in completing the I and R application form. Although two Medical Practitioners Tribunal Services agreed that there was an honest mistake, the GMC appealed the decision and pursued him through the high court. A petition asking the ‘GMC Stop the Witch-Hunt of Dr Valentine Udoye’ was generated and for 19 consecutive weeks from 22^nd October 2022, a silent vigil took place outside the GMC in solidarity with Dr Udoye. Letters signed by 175 doctors of African heritage, Doctors Association UK and seven major medical organisations for Global Majority doctors were sent to the GMC asking them to reconsider their case against Dr Udoye. Five years later, on 2^nd March 2023, Dr Udoye eventually cleared his name at great cost to his health, wealth and family. Note that this case of Dr Udoye occurred five years after that of Dr Hadiza Bawa-Garba and recommendations by the Williams review that the GMC should be relieved of their ability to appeal against the findings of doctors’ disciplinary hearings by the MPTS.

There is perhaps a sad truth that unites the cases above, namely that those (institutions) who should be supporting individuals are not. These dedicated doctors have made profound sacrifices, whether by leaving their homeland or venturing far from family, embodying a commitment to public service that transcends borders and distances. Consequently, amidst all the clear injustice at play, defensive organizational behaviours are the detrimental choice and preferred method of handling such cases where fear and caution take precedence over collaboration and innovation.

Described above are cases that have a common reaction and action from colleagues and the public. It is representational of how grassroots collective action in the form of petitions, signed letters and protests, can apply external pressure on institutions to do the right thing! This is sadly, a public communal method to accessing justice to effect meaningful change that can lead to systemic improvement. Whilst individual courage is commendable, it is paramount that reorientation of the institutions, from betrayal to courage ought to be transformational.

Professor Jennifer Freyd describes 11 general principles of institutional courage.

1. Comply with civil rights laws and go beyond mere compliance
2. Educate the institutional community (especially leadership)
3. Add checks and balances to power structure and diffuse highly dependent relationships
4. Respond well to victim disclosures
5. Bear witness, be accountable, apologise
6. Cherish the whistle-blowers; cherish the truth tellers
7. Conduct scientifically-sound anonymous surveys
8. Regularly engage in self-study
9. Be transparent about data and policy
10. Use the organisation to address the societal problem
11. Commit on-going resources to 1-10

I feel, like the public, evidence and other colleagues, that institutional courage is an ongoing process that requires dedication, commitment to creating positive change, cultural competency and educated leadership. It’s a pledge to protect and care for those who depend on the institution and look towards them for moral support, and institutional support at times of injustice. A moral compass orientated to the common good of individuals within the institution can transform organisations to be more accountable, equitable and effective places for everyone. It is without doubt now that institutional courage requires leaders that are willing to take risks rather than maintain the status quo because systems that do nothing cause more harm.

References

1. Smith, C. P. & Freyd, J. J. Dangerous Safe Havens: Institutional Betrayal Exacerbates Sexual Trauma. J. Trauma. Stress 26, 119–124 (2013).
2. Smith, C. P. & Freyd, J. J. Institutional betrayal. Am. Psychol. 69, 575–584 (2014).

Author

Evelyn Mensah

Evelyn (Evie) Mensah is a Consultant Ophthalmologist at Central Middlesex Hospital, London North West University Healthcare NHS Trust where she’s the Clinical Lead for Ophthalmology and Co-Lead for the North West London Ophthalmology Clinical Reference Group.

Evie obtained her medical degree from Imperial College and ophthalmology training was at Moorfields. Her expertise includes the management of medical retinal disease and complex cataract surgery. She’s a previous educational supervisor and college tutor to Ophthalmology Specialist Trainees (OSTs) in her unit and has trained and accredited a multi-professional workforce to take on extended roles. Evie has been the recipient of two ‘Best Trainer in Ophthalmology’ Health Education England awards over the past four years nominated by London OSTs.

Evie is a trustee of the Moorfields Lions Korle Bu Trust and has developed an innovative diabetic retinopathy management course for West African Ophthalmologists underpinned by input from educators at University College London and the West African College of Surgeons. She also runs an innovative Laser simulation course for London OSTs.

Evie is the Workforce Race Equality Standard (WRES) Expert for her Trust that comprises a 69% global majority workforce. She is also the new Chair for EDI (equity, inclusion and diversity) at the Royal College of Ophthalmologists.

Evie is active on social media where she is an advocate for antiracism and social justice.

Declaration of interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None

Correction: The original blog posted on the 19th of October has been edited for clarity and to avoid ambiguity.