BMJ

Confidential: For Review Only Bend it like Beckham or Fix them like Florence: Is a career in healthcare Honourable?

Journal: BMJ

Manuscript ID BMJ-2019-052419.R3

Article Type: Christmas research

BMJ Journal: BMJ

Date Submitted by the 18-Nov-2019 Author:

Complete List of Authors: Emelifeonwu, John; Western General Hospital Department of Neurology and Neurosurgery, Hazelwood, James; Chelsea and Westminster Hospital NHS Foundation Trust Nolan, Oscar; The University of Edinburgh Edinburgh Medical School Sharland, Emma; The University of Edinburgh Edinburgh Medical School O'Donald, Anna; The University of Edinburgh Edinburgh Medical School Peet, Alison; NHS Lothian, General Practice Frazer, Ricky; Velindre Hospital

Keywords: Phaleristics, New Year's Honours, healthcare

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1 2 3 4 Bend it like Beckham or Fix them like Florence: Is a career in healthcare 5 Honourable? 6 7 John A. Emelifeonwu MRCS (corresponding author) 8 Neurosurgery Registrar 9 Western General Hospital 10 Edinburgh 11 EH4 2XU 12 Confidential: For Review Only 13 14 James E Hazelwood (MBChB, BMedSci) 15 16 FY1 doctor 17 Chelsea and Westminster Hospital 18 London 19 SW10 9NH 20 21 22 Oscar Nolan 23 24 Medical Student 25 University of Edinburgh Medical School 26 47 Little France Crescent 27 Edinburgh 28 EH16 4TJ 29 30 31 Emma Sharland 32 33 Medical Student 34 University of Edinburgh Medical School 35 47 Little France Crescent 36 Edinburgh 37 EH16 4TJ 38 39 Anna O’Donald 40 41 Medical Student 42 University of Edinburgh Medical School 43 47 Little France Crescent 44 Edinburgh 45 EH16 4TJ 46 47 48 Alison Peet MBChB MRCP 49 GP Registrar 50 Stockbridge Blue Medical Practice 51 1 India Place 52 Edinburgh 53 EH3 6EH 54 55 56 Ricky Frazer MBChB MRCP 57 Consultant Medical Oncologist 58 Velindre Hospital 59 Velindre Road, Cardiff 60 CF14 2TL

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1 2 3 Abstract 4 5 6 Objectives 7 8 To compare the proportional representation of healthcare workers in receipt of New 9 10 Year Honours (NYH) to workers in other industries and to determine whether there are 11 12 Confidential: For Review Only gender or geographical biases in the NYH system 13 14 15 16 17 Design 18 19 Observational study of the UK Honours system with a comparative analysis of 20 21 22 proportional representation of the UK workforce and subgroup analyses of gender and 23 24 geographical representations. 25 26 27 28 29 Participants 30 31 Recipients of the NYH from 2009 to 2018. 32 33 34 35 Main outcome measures 36 37 38 Citations in recognition of excellence in industry were compared to the size of that 39 40 industry’s workforce to determine the absolute risk of receiving an award in that 41 42 industry. The relative risk changes between receiving a NYH for services to healthcare 43 44 45 was compared to other industries. We further performed subgroup analyses to 46 47 determine whether there were gender or regional differences in NYHs awarded. 48 49 50 51 52 Results 53 54 There were a total of 10,989 NYHs bestowed from 2009 to 2018 of which 47% were 55 56 awarded to women. There were 832 awards (7.6%) for services to healthcare. There 57 58 was no significant difference between the absolute risks of receiving honours for 59 60

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1 2 3 services to healthcare compared with services to science and technology industries 4 5 6 (p=0.22). However, in relation to the sizes of their workforces, people working in sports 7 8 and in the arts and media had a relative risk increase of 2106% and 486%, 9 10 respectively, compared to healthcare. Two-fifths of awards were issued to people 11 12 Confidential: For Review Only living in London and counties in the Southeast of England, and only one-third of the 13 14 15 Higher Order awards (knighthoods, damehoods, Companions of Honour and 16 17 Commanders of the Order of the British Empire (CBEs) were received by women. 18 19 20 21 22 Conclusions 23 24 In relation to the size of its workforce, a career in Healthcare is not as ‘Honourable’ as 25 26 27 careers in certain other industries. Geographical and gender biases may also exist in 28 29 the Honours system. 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 Introduction 50 51 In the UK, the Honours system recognises people who have “committed themselves 52 53 54 to helping and serving Britain”. The New Year Honours (NYH) are appointments in 55 56 recognition and reward of excellence in the work and/or charity of citizens of the UK 57 58 and Commonwealth countries. They have been awarded as part of the New 59 60

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1 2 3 Year celebrations since 1890 by or in the name of the reigning monarch1. Nominations 4 5 6 are suggested by the general public and nominees are overseen by the Cabinet 7 8 Office’s Honours and Appointments Secretariat. There are 8 main citations for which 9 10 a person may be honoured: 1) community, voluntary and local services, 2) arts and 11 12 Confidential: For Review Only media, 3) health, 4) sport, 5) education, 6) science and technology, 7) business and 13 14 15 the economy, and 8) civil or political services. 16 17 18 19 20 The Honours system has often been criticised for being biased especially in favour of 21 22 23 those in ‘Royal circles’ including politicians and civil servants. It has been assumed 24 25 that as the reigning Monarch is the ‘fountain of Honour’, those around the fountain are 26 27 more likely to be ‘splashed’. In recent years, there have been suggestions that this 28 29 30 bias may extend to connected people, particularly celebrities. There have been high 31 32 profile examples of famous people coveting or receiving honours2 3. Amidst concerns 33 34 of cronyism and a broken system, the government has in recent years vowed to review 35 36 the Honours system to ensure that it “rewards genuine public service”4. The national 37 38 39 health system (NHS) is a genuine public service that employs approximately 1.5 40 41 million people and is ranked amongst the best in the world in terms of its quality, 42 43 accessibility and efficiency5. The health sector provides approximately 7% of the entire 44 45 6 46 UK workforce . Most are unable to influence the fountain’s splashes. The aim of this 47 48 observational study was to determine how the proportion of NYHs awarded for 49 50 healthcare compared to the proportions awarded to workers in other industries in the 51 52 53 UK, and to determine whether there were any gender or geographical differences in 54 55 the NYHs awarded. 56 57 58 59 60

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1 2 3 Methods 4 5 6 Data 7 8 NYH List 9 10 A list of the recipients of the NYH is available on the Cabinet Office’s website7. The 11 12 Confidential: For Review Only list, which is updated yearly, contains the names of all recipients of an Honour, the 13 14 15 Order of the Honour being bestowed including its title, a citation stating the sector or 16 17 categories to which the recipient has provided outstanding services and the county of 18 19 the UK that the recipient represents. There were 6 main Orders awarded: Companion 20 21 22 of Honour (CH), knighthoods or damehoods (of varying Orders), Commander of the 23 24 Order of the British Empire (CBE), Officer of the Order of the British Empire (OBE), 25 26 Member of the Order of the British Empire (MBE) and the British Empire Medal (BEM) 27 28 29 (see Box 1). 30 31 32 33 UK workforce estimates 34 35 To calculate the proportion of Honours received by each industry, we collated data on 36 37 38 the number of people working in that industry’s workforce. This information was 39 40 available in the ‘workforce jobs’ database of the Office of National Statistics (ONS)8. 41 42 The ONS is the executive office of the UK Statistics Authority, a non-ministerial 43 44 45 department of the UK Government. The workforce jobs database is a quarterly 46 47 estimate of jobs in various industries in the UK. 48 49 50 51 52 A spreadsheet was created to record data on all recipients of NYH from 2009 to 2018. 53 54 We collected data on the gender of each recipient, type of honour, which county of the 55 56 UK they represented and the citation for which they received the Honour. We 57 58 dichotomised NYHs into CH, CBEs and the various Orders of knights and dames 59 60

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1 2 3 (‘Higher Order” awards) versus all other Orders of awards to determine whether there 4 5 6 were any differences between industries in the proportion of ‘higher’ Orders bestowed. 7 8 This was based on a recent cabinet office report in which awards of CBEs or higher 9 10 were considered “Higher order award”9. 11 12 Confidential: For Review Only 13 14 15 16 17 Analysis 18 19 We matched each citation to the relevant industry as follows: 20 21 22 1. Honours received for services to arts and media were matched with the art, 23 24 recreation and entertainment category of the ONS report; 25 26 2. Honours for civil and political services were matched with the ONS category public 27 28 29 administration and defence; compulsory social security; 30 31 3. Honours for services to health was matched with the ONS category human health 32 33 activity; 34 35 4. Honours for services to science and technology was matched with the ONS 36 37 38 category “Professional scientific and technical activities”. 39 40 5. Honours for services to education was matched with the ONS category “teaching 41 42 and education professions”. 43 44 45 6. Honours for services to sports were matched with “fitness and sports occupations” 46 47 section of the ONS database. 48 49 50 51 52 Honours for voluntary and community services were omitted from this analysis as 53 54 there were no direct matches with ONS workforce figures. 55 56 57 58 59 60

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1 2 3 We extracted workforce data from the final quarter of each year (2009-2018). Five 4 5 6 authors (JH, ON, ES, AJ, JAE) independently extracted ONS and NYH data from 2 7 8 years each and data was then cross checked by a different author. Disputes were 9 10 resolved by consensus. 11 12 Confidential: For Review Only 13 14 15 The relative risk (RR) of receiving a NYH for each industry compared to healthcare 16 17 was calculated using the equation: 18 19 20 21 22 23 24 25 26 27 28 29 30 Where AR is the absolute risk or the number of NYHs for a citation divided by the 31 32 33 number of people employed in the industry (size of workforce). A similar equation was 34 35 used to compare industry differences in the proportion of ‘Higher Order’ awards 36 37 received. 38 39 40 41 42 We calculated the relative risk reduction or increase of receiving a NYH in other 43 44 industries compared to healthcare using the equation: 45 46 47 (1-RR) x 100 48 49 RRs and 95% confidence intervals were calculated using the Epitools package in R10 50 51 11. The significance level was set at P < 0.05 (2-tailed) when comparing workforces 52 53 54 and when comparing proportions of ‘Higher Order’ awards. 55 56 57 58 59 60

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1 2 3 Pearson Chi-square test was used to compare gender differences in the proportion of 4 5 6 ‘Higher Order’ awards received. We determined the gender of recipients either by their 7 8 name or by the gender prefix used in the NYH list. Rarely, internet searches were used 9 10 to determine gender. 11 12 Confidential: For Review Only 13 14 Patient involvement 15 16 17 No patients were involved in setting the research question or the outcome measures, 18 19 nor were they involved in developing plans for design, or implementation of the 20 21 22 study. No patients were asked to advise on interpreting or writing up results. There 23 24 are no plans to disseminate the results of the research to patients or study 25 26 participants. 27 28 29 30 31 32 Results 33 34 A total of 10,989 NYH awards were bestowed between 2009 and 2018 (table 1). Based 35 36 37 on the information available, we were able to determine gender in 10,979 recipients. 38 39 There were 5,166 female recipients (47.1%) and 5,813 male recipients (52.9%). There 40 41 were 17 CHs, 81 Orders of the Bath, 343 damehoods and knighthoods, 3 Orders of St 42 43 44 Michael and St George, 1,006 CBEs, 2,353 OBEs, 5,310 MBEs and 1,876 BEMs. 45 46 47 48 The proportions of awards bestowed for each of the 8 citations for each year is shown 49 50 in figure 1. The most common citations were community services (27% of all awards) 51 52 53 and voluntary and local services (18%). Of the rest of the awards, 11% were bestowed 54 55 for services to education, 9% for services to business and the economy, 9% for civil 56 57 and political services, 8% for services to health, 7% for services to media and the arts, 58 59 60 6% to services to sports and 4% for services to science and technology. Notably, there

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1 2 3 was a spike in the proportion of sports citations in the years after Olympic games (2013 4 5 6 and 2017) (figure 1). 7 8 9 10 11 12 Confidential: For Review Only Differences in percentage between receiving a citation for services to health 13 14 15 compared to other industries 16 17 A total of 832 NYHs were awarded for service to health between 2009 and 2018 of 18 19 which 54% of recipients were female. Healthcare honours constituted 7.6% of all 20 21 22 awards received in that period. Doctors received 34.4% of these awards whilst nurses 23 24 and allied health professionals each received 14.5% of the awards. The rest (36.7%) 25 26 were awarded to healthcare support staff such as management staff. The ONS 27 28 29 estimates for the total UK healthcare workforce in the final quarters of each year 30 31 ranged from 3,846,000 in 2009 to 4,340,000 in 2018. 32 33 34 35 The relative risk (RR) of receiving a NYH for services to sports compared to healthcare 36 37 38 was 22.01 [95% CI 19.91-24.34; p<0.001), corresponding to a 2101% reduction in the 39 40 relative risk of receiving a NYH for services to healthcare compared to sports citations. 41 42 The RR of receiving a NYH for services to arts and media compared to healthcare was 43 44 45 5.84 [95% CI 5.31-6.44; p<0.001) and this corresponded to a 484% reduction in 46 47 relative risk of receiving a NYH for healthcare compared to arts and media citations. 48 49 The RR of receiving a NYH for services to business and the economy compared to 50 51 52 healthcare was 3.9 [95% CI 3.59-4.28; p<0.001], corresponding to 290% reduction in 53 54 the RR of receiving a healthcare citation compared to business and the economy. The 55 56 RR of receiving a NYH for civil and political services compared to healthcare was 2.66 57 58 [95% CI 2.43-2.91;p<0.001]. There was a 166% RRR of healthcare citations compared 59 60

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1 2 3 to civil and political services citations. The RR for education citations compared to 4 5 6 healthcare was 1.87 [95% CI 1.72-2.04; p<0.001], corresponding to a RRR of 87% of 7 8 healthcare citations compared to education. Finally, there was a RRR of 7.6% for 9 10 healthcare citations compared to science and technology citations but this was not 11 12 Confidential: For Review Only significant (RR = 1.08 [95%CI 0.95-1.21; p=0.22]). 13 14 15 16 17 18 19 Differences in the proportion of ‘higher Order’ Honours bestowed? 20 21 22 There were 58 ‘Higher Order’ awards issued for service to healthcare (CHs, 23 24 knighthoods and damehoods and CBEs). This was 6.9% of the total number of NYHs 25 26 given for services to healthcare. This proportion of ‘Higher Order’ awards was 27 28 29 comparable to the proportion of ‘Higher Order’ awards issued for services to arts and 30 31 media (6.3%, p=0.58), education (5.1%, p=0.08) and science and technology (8.3%, 32 33 p=0.4). 34 35 36 37 38 Nearly 11% of awards received for services to civil and political services were ‘Higher 39 40 Order’ and this corresponded to a 56% RR increase for receiving a ‘Higher Order’ for 41 42 this citation compared to receiving a ‘Higher Order’ NYH for healthcare (RR 1.56 [95% 43 44 45 CI 1.15-2.11; p=0.03]). Conversely, only 2.8% of sports citations were ‘Higher Order’ 46 47 NYHs and there was a 59% reduction in the relative risk of receiving a NYH for this 48 49 citation compared to healthcare (RR 0.4 [95% CI 0.25-0.67; p <0.001). 50 51 52 53 54 In the period covered (2009-2018), there has been an improvement in the 55 56 proportional representation of women recipients of NYH (figure 2). However, only 57 58 59 60

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1 2 3 one-third of the ‘Higher Order’ NYH recipients were female. The ‘Higher Order’ 4 5 6 award recipients were significantly more likely to be male (p<0.001). 7 8 9 10 Geographical differences in awards 11 12 Confidential: For Review Only We calculated the total number of NYHs received in each region of the UK (including 13 14 15 health and non-health citations) and compared the average number of awards for 16 17 persons living in each region over the last decade. Figure 3 shows a geographic heat 18 19 map for the distribution of NYH over the last 10 years. In England, London and the 20 21 22 Southeast received the highest number of NYHs with 18% and 16% of all NYHs, 23 24 respectively, corresponding to an average of 23 NYHs per 100,000 persons and 20 25 26 NYHs per 100,000 persons, respectively. The southwest of England was also well 27 28 29 represented compared to the rest of England. East England received the lowest 30 31 number of per population NYHs and there was no significant difference between the 32 33 number of NYH recipients in East England, Yorkshire and the Midlands. The relative 34 35 risk of receiving a NYH in other regions of the UK was significantly higher than for East 36 37 38 England (figure 3). People in Scotland received approximately 9% of the NYHs, 39 40 corresponding to an average of 19 NYHs per 100,000 population. People in Wales 41 42 received approximately 5% of all NYHs, corresponding to approximately 18 NYHs per 43 44 45 100,000. Finally, Northern Ireland received the highest number of per population 46 47 recipients with approximately 38 NYHs per 100,000. Approximately 0.6% of NYHs 48 49 were awarded to non-UK residence (in our data this included residents of the Channel 50 51 52 Islands and the Isle of Man). 53 54 55 56 Discussions 57 58 59 60

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1 2 3 In this phaleristic study, we compared the proportional representation of various 4 5 6 industries in the NYHs from 2009 to 2018. We found that the risk of receiving an award 7 8 were significantly higher for people working in the sports, arts and the media and to a 9 10 lesser degree, people working in the civil and political services and business compared 11 12 Confidential: For Review Only to people working in healthcare and those working in science and technology. We also 13 14 15 found geographical differences, with nearly two-fifths of awards bestowed on people 16 17 living in London or the Southeast of England. Finally, although proportional 18 19 representation has improved for women over the past decade, the proportion of 20 21 22 women receiving the ‘Higher Order’ awards was significantly lower than men. 23 24 25 26 27 Is the Honours system biased? 28 29 30 In the period examined, the proportions of recipients from various industries each year 31 32 has remained roughly similar (with the exception of sports citations which increased 33 34 markedly after each Olympic year). This may suggest that overseers in the Cabinet 35 36 Office may use quotas to determine how many awards are received by people in each 37 38 39 citation. Use of a quota system negatively biases groups with larger workforces due 40 41 to dilution. The NHS is the fourth largest employer in the world with approximately 42 43 1.5million employees and many more people work in private health in the UK12. 44 45 46 Therefore, assigning the same proportion of NYHs to the health industry as other 47 48 smaller industries in the UK will reduce the chances of people in healthcare receiving 49 50 an award because of dilution of the awards amongst a larger population. The higher 51 52 53 risks of receiving a NYH in other industries compared to healthcare may therefore be 54 55 due to dilution rather than bias. The science and technology sector however are 56 57 underrepresented. This group had a similar workforce compared to civil and political 58 59 60

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1 2 3 services, and nearly double the amount of people working in sports but were less likely 4 5 6 to receive a NYH than both industries. 7 8 9 10 11 Gender differences may be due to bias. This has been addressed to some extent by 12 Confidential: For Review Only 13 the increased proportion of women recipients over the last 10 years (figure 2). 14 15 16 However, the low number of women receiving the ‘Higher Order’ awards compared to 17 18 men suggests that more needs to be done to address this bias. Gender inequalities 19 20 are not unique to the Honours system. International evidence shows persisting female 21 22 13 14 15 23 under-representation in the film industry , corporate leadership , and in 24 25 medicine16. In a recent analysis of the recipients of awards by the American Academy 26 27 of Physical Medicine and Rehabilitation (AAPM&R) over the past 48 years, women 28 29 30 were significantly under-represented and strikingly, no female physician received an 31 32 award in the most prestigious categories in 40 of the 48-year history of the ceremonies. 33 34 Initiatives have been developed to target gender inequity in different industries17 18 19. 35 36 Clearly, more needs to be done and the cabinet office have recently published 37 38 39 initiatives to improve female representation In a recent report from the cabinet office, 40 41 there was recognition of underrepresentation of women and a vow to “step up efforts 42 43 to in it outreach work, targeting women’s business and community networks to raise 44 45 9 46 awareness of the [Honours] system and encourage nominations from those groups” . 47 48 The Parliamentary Public Administration Select Committee (PASC) 2012 report 49 50 51 criticised the Honours system as being too geared towards rewarding people for 52 53 simply ‘doing their day job’20. In particular, it was noted that Whitehall bureaucrats and 54 55 other senior figures such as council chief executives, traditionally made a strong 56 57 58 showing in the Honours rounds. The report stated that too few Honours were being 59 60 awarded to ordinary citizens for the extraordinary contributions they make to their

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1 2 3 communities, which is what the Honours system should be for. The report went on to 4 5 6 recommend that there should be no automatic Honours for people who hold a certain 7 8 post, or for celebrities and sports stars at a certain level, which “too often seemed to 9 10 still be the case”. Our results show that this over-representation probably exists, 11 12 Confidential: For Review Only particularly for the sports, arts and media and the civil and political services compared 13 14 15 to healthcare workers, those working in science and technology and to a lesser extent 16 17 those working in education. 18 19 20 21 22 23 24 25 Weaknesses 26 27 The ONS workforce data which we used to determine the proportion of NYHs in each 28 29 30 industry are estimates that are based on surveys of businesses and may not be 31 32 entirely accurate. They are therefore a potential source of variation. Furthermore, 33 34 citations for NYH may not correlate with the industry that the person works for. For 35 36 example, someone with a voluntary role in healthcare who works in a different industry 37 38 39 may receive an award for services to health. It is therefore likely that some of the 40 41 statistics attained from the workforce database and the NYH lists are inaccurate. 42 43 Secondly, the workforce data for each year has been treated independently of the 44 45 46 other years. This approach does not take into account the proportion of the people 47 48 who already have a NYH in each industry and therefore may underestimate the 49 50 proportion of recipients in each industry. 51 52 53 Finally, NYHs are awarded based on nominations from the public and it is possible 54 55 that the differences in the proportions of recipients from different industries simply 56 57 58 reflects the referral practices of that industry. Therefore, industries that work closest 59 60 with the government and Cabinet Office (civil servants, politicians, those in media and

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1 2 3 celebrities) are more likely to refer a colleague for Honours than people in healthcare. 4 5 6 We contacted the cabinet office for a breakdown of nomination statistics, but this 7 8 information was unavailable because of the rolling nature of nominations (a person 9 10 may receive an award at a later round to the one they were nominated) which makes 11 12 Confidential: For Review Only it difficult to calculate the nomination-to-award ratio for different citations. It may be 13 14 15 useful for completeness to conduct a survey of Honours’ nomination practices 16 17 between different industries to determine whether people in certain industries are more 18 19 likely to nominate a colleague than others. 20 21 22 23 24 Conclusion 25 26 27 We found that the relative risk of receiving a NYH are higher in certain industries 28 29 compared to healthcare. The NHS is persistently voted amongst the best in the world. 30 31 This is possible because of the extraordinary contributions being made by ordinary 32 33 34 people working in healthcare – the very reason the Honours system is alleged to exist. 35 36 This needs to be reflected in the NYHs and may increase morale within the struggling 37 38 NHS. 39 40 41 42 43 What is already known on this topic 44 45 46  The Queen and Government’s Cabinet Office are the ‘fountains of Honour’ in 47 48 the United Kingdom 49 50 51  Those closest to the fountain are most likely to get splashed 52 53 54 What this study adds 55 56 57  The fountain appears to disproportionally splash politicians, those in arts and 58 59 60 media and sportspeople over healthcare workers and people working in

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1 2 3 4 5 6 7 8 References 9 10 11 1 Morrison J. Essential Public Affairs Oxford, 2015 12 Confidential: For Review Only 13 14 15 2 Liddle R. At least David Beckham has exposed the honours system for the sham it really is: 16 17 The ugly attitude revealed in his emails is surely shared by any number of celebrities. 18 19 Accessed 31 August 2017. www.spectator.co.uk/2017/02/at-least-david-beckhams-shame- 20 21 22 shows-up-the-honours-system-too 23 24 25 26 27 3 28 McCartney M. Margaret McCartney: Dishonourable New Year honours. 29 30 BMJ.2016;4;352:i28. 31 32 33 34 4 https://www.telegraph.co.uk/news/2017/05/18/theresa-may-vows-overhaul-honours-system-ensure-rewards- 35 genuine/ 36 37 5 Schneider EC, Sarnak DO, Squires D, Shah A, Doty MM. Mirror, Mirror: How the Performance of the U.S. 38 Health Care System Compares Internationally at a Time of Radical Change. The Commonwealth Fund, July 39 2017. 40 https://interactives.commonwealthfund.org/2017/july/mirror-mirror/ 41 42 6 43 How many NHS employees are there? The full facts team. Accessed 31 August 2017 44 45 https://fullfact.org/health 46 47 7 https://www.gov.uk/honours/honours-lists 48 49 8https://www.ons.gov.uk/employmentandlabourmarket/peopleinwork/employmentandemploy 50 51 52 eetypes/datasets/employeejobsbyindustryjobs03 53 54 55 56 9 The Cabinet Office. (2019). Fourth report on the operation of the reformed honours system. 57 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data 58 /file/807228/Report-on-the-Operation-of-the-Honours-System-Final-for-Publication-1.pdf 59 60

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1 2 3 4 10 Team RDC (2008) R: A language and environment for statistical computing. In: 5 6 Computing RFfS, editor. Vienna, Austria. 7 11 8 Aragon TJ (2012) EpiTools: R Package for Epidemiologic Data and Graphics. pp. 9 EpiTools: R Package for Epidemiologic Data and Graphics. 10 11 12 NHS Digital (2018), NHS Workforce Statistics – September 2018; NHS Digital 12 (2018), Confidential:General Practice Workforce, For Final 30Review September 2018, Only Experimental 13 14 Statistics. NHS Digital 15 13 16 Lauzen MM. It’s a Man’s (Celluloid) World: On-Screen Representations of Female 17 18 Characters in the TOP 100 Films of 2014. Accessed 30 August 2017. 19 20 http://fontanar2.cubadebate.cu/wpcontent/uploads/2015/02/2014_Its_a_Mans_World_Report. 21 22 23 pdf 24 25 26 27 14 Hesse-Biber S, Carter G. Working Women in America. New York: Oxford University 28 29 Press, 2005 30 31 32 33 34 15 Catalyst (2011) Women CEOs and Heads of the Financial Post 500. Accessed 30 August 35 36 2017 http://www.catalyst.org/publication/322/women-ceos-of-the-fortune-1000 37 38 39 40 41 16 Silver JK, Bhatnagar S, Blauwet CA, Zafonte RD, Mazwi NL, Slocum CS, et al. Female 42 43 physicians are underrepresented in recognition awards from the American Academy of 44 45 PM R.2017.pii:S1934-1482(16)31042-5. 46 Physical Medicine and Rehabilitation. 47 48 49 50 17 Kuhlmann E, Ovseiko PV, Kurmeyer C, Gutiérrez-Lobos K, Steinböck S, von Knorring M 51 52 et al. Closing the gender leadership gap: a multi-centre cross-country comparison of women 53 54 55 in management and leadership in academic health centres in the European Union. Human 56 57 Resources for Health 2017;15(2):2-7 58 59 60

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1 2 3 4 18 Cook A, Glass C. Women and top leadership positions: Towards an institutional analysis. 5 6 7 Gender, Work and Organization 2014;21(1):91-103. 8 9 10 11 19 Ovseiko PV, Greenhalgh T, et al. A global call for action to include gender in research 12 Confidential: For Review Only 13 14 impact assessment. Health Research Policy and Systems 2016;14(50):1-12 15 16 17 18 20 The Honours System. House of Commons Public Administration Select Committee. 19 20 21 Accessed 29 August 2019. 22 23 https://publications.parliament.uk/pa/cm201213/cmselect/cmpubadm/19/19.pdf 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 Conflicts of Interest 51 52 53 None 54 55 56 57 Licencing statement 58 59 60

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1 2 3 4 I John Emelifeonwu The Corresponding Author of this article contained within the original manuscript which 5 includes any diagrams & photographs within and any related or stand alone film submitted (the 6 Contribution”) has the right to grant on behalf 7 of all authors and does grant on behalf of all authors, a licence to the BMJ Publishing Group Ltd and 8 its licencees, to permit this Contribution (if accepted) to be published in the BMJ and any other BMJ Group 9 products and to exploit all subsidiary rights, as set out in our licence set out at: http://www.bmj.com/about- 10 bmj/resources-authors/forms-policies-and-checklists/copyright-open-access-and-permission-reuse. 11 12 Confidential: For Review Only 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

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1 2 3 About the UK Honours System 4  The UK honours system is a series of awards of varying levels of significance that are awarded by the monarch to reward achievements in public life, conveying 5 upon the recipient public recognition for the achievement in question, and the use of the appropriate post-nominals. 6  Recipients are notified in the biannual honours lists, at New Year or Birthday Honours, and have the honour bestowed by a member of the royal family at one of 7 approximately 60 investiture ceremonies throughout the year. 8  Nomination forConfidential: an award can only be made by someone else, and must For include details Review of the work deemed rewardable, Only and any recognition previously received. 9  A nomination must be further supported by letters from two individuals who know the nominee personally. 10  Nominations are assessed by the Honours Committees, comprised of senior civil servants and members independent from government. 11  There are individual committees for each specific activity (eg arts and media, sport etc) who approve awards within their field, before sending for the final approval 12 of the Main Committee. 13 14 15 Honours (and post-nominals) in descending Description 16 order of magnitude 17 Companion of Honour (CH) CH Major contribution to the arts, science, medicine or government, lasting over a long 18 period of time. Only 65 may ever be concurrently awarded. 19 Knight or Dame Commander of Kt or DBE Major contribution, usually at national level. Those working in the nominee’s area will 20 the Order of the British Empire see their contribution as inspirational and significant, requiring commitment over a long 21 period of time 22 Commander of the Order of CBE Prominent but lesser role at national level, or leading role at regional level. Or, for 23 the British Empire distinguished, innovative contribution to any area. 24 Officer of the Order of the OBE Major local role in any activity, including those whose work have made them known 25 British Empire nationally in their chosen area 26 Member of the Order of the MBE Outstanding achievement or service to the community with a long-term significant 27 British Empire impact and stands out as an example to others. 28 British Empire Medal BEM For “Hands-on” service to local community through long-term charity work, or 29 30 innovative work for a short duration making a significant difference. 31 32 There are alternative Orders in which select groups may receive awards for achievements. These include the Order of the Bath for senior civil servants and military officers, 33 the Order of St Michael and St George for Diplomats and those serving the UK abroad, and the Royal Victorian Order for those who have served the Queen or monarchy in 34 a personal way. 35 36 37 38 39 40 41 42 43 https://mc.manuscriptcentral.com/bmj 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Page 21 of 25 BMJ

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1 2 3 Number 4 5 Gender of NYHs 6 male 5813 7 female 5166 8 9 Gender undetermined 10 10 11 Average workforce Absolute risk (AR) of 12 CitationConfidential: For Review(2009-2018) Only receiving NYH 13 -4 14 Arts and media 795 6651000 1.19 x 10 15 Business and economy 975 12221000 7.98 x 10-5 16 Civil and Political service 1038 19089000 5.44 x 10-5 17 NA NA 18 Community services 2989 -5 19 Education 1203 31890000 3.83 x 10 20 Health 832 40701000 2.04 x 10-5 21 Science and Technology 419 19084000 2.20 x 10-5 22 -4 23 Sport 703 1560000 4.5 X 10 24 Voluntary and Local services 2025 NA NA 25 26 27 Order of Honour 28 Companion of honour 17 29 Knights/Dames 343 30 31 Orders of Bath 81 32 Orders of St Michael and St George 3 33 CBE 1006 34 35 OBE 2353 36 MBE 5310 37 BEM 1876 38 39 40 CBE=Commander of the Order of the British Empire; OBE=Officer of the Order of the British Empire, 41 Member of the Order of the British Empire (MBE); BEM=British Empire Medal. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

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1 2 3 a. 4 5 6 Proportional represenation of female and male recipients 7 8 70 9 10 60 11 12 Confidential: For Review Only 13 50 14 15 40 16 17 30 18 % of recipients 19 20 20 21 22 10 23 24 0 25 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 26 27 % Male % Female 28 29 b. 30 31 32 Proportions of female and male recipients of 'Higher' order awards 33 34 80 35 36 70 37 38 60 39 40 50 41 42 40 43 30 44 % of recipients 45 20 46 47 10 48 49 0 50 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 51 52 male female 53 54 55 56 57 58 59 60

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1 2 3 4 5 6 7 8 9 10 11 Confidential: For Review Only 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 Figure 3a. Heat map showing the number of NYH recipients per 100,000 in regions of the UK. 3b. 46 Proportions of NYH recipients in regions of the UK and relative risks (and 95% CI) of receiving a NYH 47 compared to East England 48 225x270mm (96 x 96 DPI) 49 50 51 52 53 54 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj