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.R2

Article Type: Christmas research

BMJ Journal: BMJ

Date Submitted by the 04-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 relative risk of receiving an award in that 41 42 industry. The relative differences (percentage difference) between the risks of 43 44 45 receiving a NYH for services to healthcare was compared to other industries. We 46 47 further performed subgroup analyses to determine whether there were gender or 48 49 regional differences in NYHs awarded. 50 51 52 53 54 Results 55 56 There were a total of 10,989 NYHs bestowed from 2009 to 2018 of which 47% were 57 58 awarded to women. There were 832 awards (7.6%) for services to healthcare. There 59 60

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1 2 3 was no significant difference between the relative risks of receiving honours for 4 5 6 services to healthcare compared with services to science and technology industries 7 8 (p=0.22). However, in relation to the sizes of their workforces, the risk of receiving an 9 10 award was greater for other industries: people working in sports and in the arts and 11 12 Confidential: For Review Only media were 20 times and 6 times more likely to receive a NYH respectively, compared 13 14 15 to people working in healthcare. This corresponds to a 2106% and 486% increased 16 17 risk of receiving a NYH in these industries compared to healthcare. Two-fifths of 18 19 awards were issued to people living in London and counties in the Southeast of 20 21 22 England, and only one-third of the Higher Order awards (knighthoods, damehoods, 23 24 Companions of Honour and Commanders of the Order of the British Empire (CBEs)) 25 26 were received by women. 27 28 29 30 31 Conclusions 32 33 34 In relation to the size of its workforce, a career in Healthcare is not as ‘Honourable’ as 35 36 careers in certain other industries. Geographical and gender biases may also exist in 37 38 the Honours system. 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 Introduction 59 60

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1 2 3 In the UK, the Honours system recognises people who have “committed themselves 4 5 6 to helping and serving Britain”. The New Year Honours (NYH) are appointments in 7 8 recognition and reward of excellence in the work and/or charity of citizens of the UK 9 10 and Commonwealth countries. They have been awarded as part of the New 11 12 Confidential: For Review Only Year celebrations since 1890 by or in the name of the reigning monarch1. Nominations 13 14 15 are suggested by the general public and nominees are overseen by the Cabinet 16 17 Office’s Honours and Appointments Secretariat. There are 8 main citations for which 18 19 a person may be honoured: 1) community, voluntary and local services, 2) arts and 20 21 22 media, 3) health, 4) sport, 5) education, 6) science and technology, 7) business and 23 24 the economy, and 8) civil or political services. 25 26 27 28 29 30 The Honours system has often been criticised for being biased especially in favour of 31 32 those in ‘Royal circles’ including politicians and civil servants. It has been assumed 33 34 that as the reigning Monarch is the ‘fountain of Honour’, those around the fountain are 35 36 more likely to be ‘splashed’. In recent years, there have been suggestions that this 37 38 39 bias may extend to connected people, particularly celebrities. There have been high 40 41 profile examples of famous people coveting or receiving honours2 3. Amidst concerns 42 43 of cronyism and a broken system, the government has in recent years vowed to review 44 45 4 46 the Honours system to ensure that it “rewards genuine public service” . The national 47 48 health system (NHS) is a genuine public service that employs approximately 1.5 49 50 million people and is ranked amongst the best in the world in terms of its quality, 51 52 5 53 accessibility and efficiency . The health sector provides approximately 7% of the entire 54 55 UK workforce6. Most are unable to influence the fountain’s splashes. The aim of this 56 57 observational study was to determine how the proportion of NYHs awarded for 58 59 healthcare compared to the proportions awarded to workers in other industries in the 60

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

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1 2 3 A spreadsheet was created to record data on all recipients of NYH from 2009 to 2018. 4 5 6 We collected data on the gender of each recipient, type of honour, which county of the 7 8 UK they represented and the citation for which they received the Honour. We 9 10 dichotomised NYHs into CH, CBEs and the various Orders of knights and dames 11 12 Confidential: For Review Only (‘Higher Order” awards) versus all other Orders of awards to determine whether there 13 14 15 were any differences between industries in the proportion of ‘higher’ Orders bestowed. 16 17 This was based on a recent cabinet office report in which awards of CBEs or higher 18 19 were considered “Higher order award”9. 20 21 22 23 24 25 26 Analysis 27 28 29 We matched each citation to the relevant industry as follows: 30 31 1. Honours received for services to arts and media were matched with the art, 32 33 recreation and entertainment category of the ONS report; 34 35 2. Honours for civil and political services were matched with the ONS category public 36 37 38 administration and defence; compulsory social security; 39 40 3. Honours for services to health was matched with the ONS category human health 41 42 activity; 43 44 45 4. Honours for services to science and technology was matched with the ONS 46 47 category “Professional scientific and technical activities”. 48 49 5. Honours for services to education was matched with the ONS category “teaching 50 51 52 and education professions”. 53 54 6. Honours for services to sports were matched with “fitness and sports occupations” 55 56 section of the ONS database. 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 was calculated using the 16 17 equation: 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Where n is the number of NYHs for a citation and w is the number of people employed 32 33 in the industry (size of workforce). A similar equation was used to compare industry 34 35 differences in the proportion of ‘Higher Order’ awards received. We calculated the 36 37 38 percentage change in risk of receiving a NYH in other industries compared to health 39 40 care (the percent relative effect) using the equation: 41 42 43 44 45 46 10 47 RRs and 95% confidence intervals were calculated using the Epitools package in R 48 49 11. The significance level was set at P < 0.05 (2-tailed) when comparing workforces 50 51 and when comparing proportions of ‘Higher Order’ awards. 52 53 54 55 56 Pearson Chi-square test was used to compare gender differences in the proportion of 57 58 ‘Higher Order’ awards received. We determined the gender of recipients either by their 59 60

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1 2 3 name or by the gender prefix used in the NYH list. Rarely, internet searches were used 4 5 6 to determine gender. 7 8 9 Patient involvement 10 11 12 Confidential: For Review Only 13 No patients were involved in setting the research question or the outcome measures, 14 15 nor were they involved in developing plans for design, or implementation of the 16 17 study. No patients were asked to advise on interpreting or writing up results. There 18 19 are no plans to disseminate the results of the research to patients or study 20 21 22 participants. 23 24 25 26 27 Results 28 29 30 A total of 10,989 NYH awards were bestowed between 2009 and 2018 (table 1). Based 31 32 on the information available, we were able to determine gender in 10,979 recipients. 33 34 There were 5,166 female recipients (47.1%) and 5,813 male recipients (52.9%). There 35 36 37 were 17 CHs, 81 Orders of the Bath, 343 damehoods and knighthoods, 3 Orders of St 38 39 Michael and St George, 1,006 CBEs, 2,353 OBEs, 5,310 MBEs and 1,876 BEMs. 40 41 42 43 44 The proportions of awards bestowed for each of the 8 citations for each year is shown 45 46 in figure 1. The most common citations were community services (27% of all awards) 47 48 and voluntary and local services (18%). Of the rest of the awards, 11% were bestowed 49 50 for services to education, 9% for services to business and the economy, 9% for civil 51 52 53 and political services, 8% for services to health, 7% for services to media and the arts, 54 55 6% to services to sports and 4% for services to science and technology. Notably, there 56 57 was a spike in the proportion of sports citations in the years after Olympic games (2013 58 59 60 and 2017) (figure 1).

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1 2 3 4 5 6 7 8 Relative risks for receiving a citation for services to health compared to other 9 10 industries 11 12 Confidential: For Review Only A total of 832 NYHs were awarded for service to health between 2009 and 2018 of 13 14 15 which 54% of recipients were female. Healthcare honours constituted 7.6% of all 16 17 awards received in that period. Doctors received 34.4% of these awards whilst nurses 18 19 and allied health professionals each received 14.5% of the awards. The rest (36.7%) 20 21 22 were awarded to healthcare support staff such as management staff. The ONS 23 24 estimates for the total UK healthcare workforce in the final quarters of each year 25 26 ranged from 3,846,000 in 2009 to 4,340,000 in 2018. 27 28 29 30 31 Figure 2 shows the RRs [with 95% confidence intervals (CI)] of receiving an award for 32 33 services to other industries compared to healthcare. The risk of receiving a NYH for 34 35 services to sports was 2106% [95% CI 1891-2335%] higher than the risk of receiving 36 37 38 a NYH for services to healthcare (RR 22.0 [95%CI 19.91-24.35], p=<0.001). The risk 39 40 of receiving a NYH for services to arts and media was 486% [95% CI 430-544%] higher 41 42 than for services to healthcare (RR 5.84 [95%CI 5.30-6.44], p<0.001), 291% [95% CI 43 44 45 255-328%] higher for services to business and the economy compared to healthcare 46 47 (RR 3.90 [95%CI 3.55-4.28], p<0.001), 167% [95% CI 143-191%] higher for those 48 49 working in the civil and political services compared to healthcare (RR 2.66 [95%CI 50 51 52 2.42-2.91], p<0.001) and 88% [95% CI 72-104%] higher for those working in education 53 54 (RR 1.87 [95%CI 1.71-2.04], p<0.001). The risks for receiving a NYH for services to 55 56 science and technology was 8% [95% CI -4-21%] higher than healthcare and this was 57 58 not statistically significant (RR 1.07 [95%CI 0.96-1.21], p=0.22). 59 60

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1 2 3 4 5 6 7 8 Differences in the proportion of ‘higher Order’ Honours bestowed? 9 10 There were 58 ‘Higher Order’ awards issued for service to healthcare (CHs, 11 12 Confidential: For Review Only knighthoods and damehoods and CBEs). This was 6.9% of the total number of NYHs 13 14 15 given for services to healthcare. This proportion of ‘Higher Order’ awards was 16 17 comparable to the proportion of ‘Higher Order’ awards issued for services to arts and 18 19 media (6.3%, p=0.61), education (5.1%, p=0.1) and science and technology (8.3%, 20 21 22 p=0.4). Nearly 11% of awards received for services to civil and political services were 23 24 ‘Higher Order’ and people working in these industries were 56% more likely to receive 25 26 a ‘higher’ award than people working in healthcare (RR 1.63 [95% CI 1.17-2.27], 27 28 29 p=0.03). The lowest proportion of ‘Higher Order’ awards were in the sports citations 30 31 (2.8%). People working in this industry were 59% [95% CI 75-35%] less likely to 32 33 receive a ‘Higher Order’ awards compared to healthcare recipients (RR 0.39 [95%CI 34 35 0.22-0.65, p <0.01). The risk of ‘higher’ awards for services to education was 26% 36 37 38 [95% CI -49-5%]less than for healthcare but this difference did not reach significance 39 40 (RR 0.67 [95% CI 0.45-1.0, p=0.055]. 41 42 43 44 45 In the period covered (2009-2018), there has been an improvement in the 46 47 proportional representation of women recipients of NYH (figure 3). However, only 48 49 one-third of the ‘Higher Order’ NYH recipients were female. The ‘Higher Order’ 50 51 52 award recipients were significantly more likely to be male (p<0.001). 53 54 55 56 Geographical differences in awards 57 58 59 60

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1 2 3 We calculated the total number of NYHs received in each region of the UK (including 4 5 6 health and non-health citations) and compared the average number of awards for 7 8 persons living in each region over the last decade. Figure 4 shows a geographic heat 9 10 map for the distribution of NYH over the last 10 years. In England, London and the 11 12 Confidential: For Review Only Southeast received the highest number of NYHs with 18% and 16% of all NYHs, 13 14 15 respectively, corresponding to an average of 23 NYHs per 100,000 persons and 20 16 17 NYHs per 100,000 persons, respectively. The southwest of England was also well 18 19 represented compared to the rest of England, whilst the east England, the north of 20 21 22 England, Yorkshire and the Midlands were comparatively underrepresented. People 23 24 in Scotland received approximately 9% of the NYHs, corresponding to an average of 25 26 19 NYHs per 100,000 population. People in Wales received approximately 5% of all 27 28 29 NYHs, corresponding to approximately 18 NYHs per 100,000. Finally, Northern Ireland 30 31 received the highest number of per population recipients with approximately 38 NYHs 32 33 per 100,000. Approximately 0.6% of NYHs were awarded to non-UK residence (in our 34 35 data this included residents of the Channel Islands and the Isle of Man). 36 37 38 39 40 Discussions 41 42 In this phaleristic study, we compared the proportional representation of various 43 44 45 industries in the NYHs from 2009 to 2018. We found that the risk of receiving an award 46 47 were significantly higher for people working in the sports, arts and the media and to a 48 49 lesser degree, people working in the civil and political services and business compared 50 51 52 to people working in healthcare and those working in science and technology. We also 53 54 found geographical differences, with nearly two-fifths of awards bestowed on people 55 56 living in London or the Southeast of England. Finally, although proportional 57 58 59 60

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1 2 3 representation has improved for women over the past decade, the proportion of 4 5 6 women receiving the ‘Higher Order’ awards was significantly lower than men. 7 8 9 10 11 Is the Honours system biased? 12 Confidential: For Review Only 13 In the period examined, the proportions of recipients from various industries each year 14 15 16 has remained roughly similar (with the exception of sports citations which increased 17 18 markedly after each Olympic year). This may suggest that overseers in the Cabinet 19 20 Office may use quotas to determine how many awards are received by people in each 21 22 23 citation. Use of a quota system negatively biases groups with larger workforces due 24 25 to dilution. The NHS is the fourth largest employer in the world with approximately 26 27 1.5million employees and many more people work in private health in the UK12. 28 29 30 Therefore, assigning the same proportion of NYHs to the health industry as other 31 32 smaller industries in the UK will reduce the chances of people in healthcare receiving 33 34 an award because of dilution of the awards amongst a larger population. The higher 35 36 odds for receiving a NYH in other industries compared to healthcare may therefore be 37 38 39 due to dilution rather than bias. The science and technology sector however are 40 41 underrepresented. This group had a similar workforce compared to civil and political 42 43 services, and nearly double the amount of people working in sports but were less likely 44 45 46 to receive a NYH than both industries (Figure 2). 47 48 49 50 51 Gender differences may be due to bias. This has been addressed to some extent by 52 53 54 the increased proportion of women recipients over the last 10 years (figure 3). 55 56 However, the low number of women receiving the ‘Higher Order’ awards compared to 57 58 men suggests that more needs to be done to address this bias. Gender inequalities 59 60

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1 2 3 are not unique to the Honours system. International evidence shows persisting female 4 5 13 14 15 6 under-representation in the film industry , corporate leadership , and in 7 8 medicine16. In a recent analysis of the recipients of awards by the American Academy 9 10 of Physical Medicine and Rehabilitation (AAPM&R) over the past 48 years, women 11 12 Confidential: For Review Only were significantly under-represented and strikingly, no female physician received an 13 14 15 award in the most prestigious categories in 40 of the 48-year history of the ceremonies. 16 17 Initiatives have been developed to target gender inequity in different industries17 18 19. 18 19 Clearly, more needs to be done and the cabinet office have recently published 20 21 22 initiatives to improve female representation In a recent report from the cabinet office, 23 24 there was recognition of underrepresentation of women and a vow to “step up efforts 25 26 to in it outreach work, targeting women’s business and community networks to raise 27 28 9 29 awareness of the [Honours] system and encourage nominations from those groups” . 30 31 The Parliamentary Public Administration Select Committee (PASC) 2012 report 32 33 34 criticised the Honours system as being too geared towards rewarding people for 35 36 simply ‘doing their day job’20. In particular, it was noted that Whitehall bureaucrats and 37 38 other senior figures such as council chief executives, traditionally made a strong 39 40 41 showing in the Honours rounds. The report stated that too few Honours were being 42 43 awarded to ordinary citizens for the extraordinary contributions they make to their 44 45 communities, which is what the Honours system should be for. The report went on to 46 47 recommend that there should be no automatic Honours for people who hold a certain 48 49 50 post, or for celebrities and sports stars at a certain level, which “too often seemed to 51 52 still be the case”. Our results show that this over-representation probably exists, 53 54 particularly for the sports, arts and media and the civil and political services compared 55 56 57 to healthcare workers, those working in science and technology and to a lesser extent 58 59 those working in education. 60

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1 2 3 4 5 6 7 8 Weaknesses 9 10 11 The ONS workforce data are estimates that are based on surveys of businesses and 12 Confidential: For Review Only 13 may not be entirely accurate. Furthermore, citations for NYH may not correlate with 14 15 the industry that the person works for. For example, someone with a voluntary role in 16 17 18 healthcare who works in a different industry may receive an award for services to 19 20 health. It is therefore likely that some of the statistics attained from the workforce 21 22 database and the NYH lists are inaccurate. Secondly, the workforce data for each year 23 24 has been treated independently of the other years. This approach does not take into 25 26 27 account the proportion of the people who already have a NYH in each industry and 28 29 therefore may underestimate the proportion of recipients in each industry. 30 31 32 Finally, NYHs are awarded based on nominations from the public and it is possible 33 34 that the differences in the proportions of recipients from different industries simply 35 36 reflects the referral practices of that industry. Therefore, industries that work closest 37 38 39 with the government and Cabinet Office (civil servants, politicians, those in media and 40 41 celebrities) are more likely to refer a colleague for Honours than people in healthcare. 42 43 We contacted the cabinet office for a breakdown of nomination statistics, but this 44 45 46 information was unavailable because of the rolling nature of nominations (a person 47 48 may receive an award at a later round to the one they were nominated) which makes 49 50 it difficult to calculate the nomination-to-award ratio for different citations. It may be 51 52 53 useful for completeness to conduct a survey of Honours’ nomination practices 54 55 between different industries to determine whether people in certain industries are more 56 57 likely to nominate a colleague than others. 58 59 60

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1 2 3 Conclusion 4 5 6 We found that the odds of receiving a NYH are higher in certain industries compared 7 8 to healthcare. The NHS is persistently voted amongst the best in the world. This is 9 10 possible because of the extraordinary contributions being made by ordinary people 11 12 Confidential: For Review Only working in healthcare – the very reason the Honours system is alleged to exist. This 13 14 15 needs to be reflected in the NYHs and may increase morale within the struggling NHS. 16 17 18 19 What is already known on this topic 20 21 22  The Queen and Government’s Cabinet Office are the ‘fountains of Honour’ in 23 24 25 the United Kingdom 26 27 28  Those closest to the fountain are most likely to get splashed 29 30 31 What this study adds 32 33 34  The fountain appears to disproportionally splash politicians, those in arts and 35 36 37 media and sportspeople over healthcare workers and people working in 38 39 science and technology. 40 41 42 References 43 44 45 46 1 Morrison J. Essential Public Affairs Oxford, 2015 47 48 49 2 Liddle R. At least David Beckham has exposed the honours system for the sham it really is: 50 51 52 The ugly attitude revealed in his emails is surely shared by any number of celebrities. 53 54 Accessed 31 August 2017. www.spectator.co.uk/2017/02/at-least-david-beckhams-shame- 55 56 shows-up-the-honours-system-too 57 58 59 60

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1 2 3 4 3 McCartney M. Margaret McCartney: Dishonourable New Year honours. 5 6 7 BMJ.2016;4;352:i28. 8 9 10 11 4 https://www.telegraph.co.uk/news/2017/05/18/theresa-may-vows-overhaul-honours-system-ensure-rewards- 12 genuine/ Confidential: For Review Only 13 14 5 Schneider EC, Sarnak DO, Squires D, Shah A, Doty MM. Mirror, Mirror: How the Performance of the U.S. 15 Health Care System Compares Internationally at a Time of Radical Change. The Commonwealth Fund, July 16 2017. 17 https://interactives.commonwealthfund.org/2017/july/mirror-mirror/ 18 19 6 20 How many NHS employees are there? The full facts team. Accessed 31 August 2017 21 22 https://fullfact.org/health 23 24 7 https://www.gov.uk/honours/honours-lists 25 26 8https://www.ons.gov.uk/employmentandlabourmarket/peopleinwork/employmentandemploy 27 28 eetypes/datasets/employeejobsbyindustryjobs03 29 30 31 32 33 9 The Cabinet Office. (2019). Fourth report on the operation of the reformed honours system. 34 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data 35 /file/807228/Report-on-the-Operation-of-the-Honours-System-Final-for-Publication-1.pdf 36 37 10 Team RDC (2008) R: A language and environment for statistical computing. In: 38 Computing RFfS, editor. Vienna, Austria. 39 40 11 Aragon TJ (2012) EpiTools: R Package for Epidemiologic Data and Graphics. pp. 41 42 EpiTools: R Package for Epidemiologic Data and Graphics. 43 44 12 NHS Digital (2018), NHS Workforce Statistics – September 2018; NHS Digital 45 (2018), General Practice Workforce, Final 30 September 2018, Experimental 46 Statistics. NHS Digital 47 48 13 Lauzen MM. It’s a Man’s (Celluloid) World: On-Screen Representations of Female 49 50 51 Characters in the TOP 100 Films of 2014. Accessed 30 August 2017. 52 53 http://fontanar2.cubadebate.cu/wpcontent/uploads/2015/02/2014_Its_a_Mans_World_Report. 54 55 pdf 56 57 58 59 60

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1 2 3 4 14 Hesse-Biber S, Carter G. Working Women in America. New York: Oxford University 5 6 7 Press, 2005 8 9 10 11 15 Catalyst (2011) Women CEOs and Heads of the Financial Post 500. Accessed 30 August 12 Confidential: For Review Only 13 14 2017 http://www.catalyst.org/publication/322/women-ceos-of-the-fortune-1000 15 16 17 18 16 Silver JK, Bhatnagar S, Blauwet CA, Zafonte RD, Mazwi NL, Slocum CS, et al. Female 19 20 21 physicians are underrepresented in recognition awards from the American Academy of 22 23 Physical Medicine and Rehabilitation. PM R.2017.pii:S1934-1482(16)31042-5. 24 25 26 27 17 Kuhlmann E, Ovseiko PV, Kurmeyer C, Gutiérrez-Lobos K, Steinböck S, von Knorring M 28 29 30 et al. Closing the gender leadership gap: a multi-centre cross-country comparison of women 31 32 in management and leadership in academic health centres in the European Union. Human 33 34 Resources for Health 2017;15(2):2-7 35 36 37 38 39 18 Cook A, Glass C. Women and top leadership positions: Towards an institutional analysis. 40 41 Gender, Work and Organization 2014;21(1):91-103. 42 43 44 45 46 19 Ovseiko PV, Greenhalgh T, et al. A global call for action to include gender in research 47 48 impact assessment. Health Research Policy and Systems 2016;14(50):1-12 49 50 51 52 20 53 The Honours System. House of Commons Public Administration Select Committee. 54 55 Accessed 29 August 2019. 56 57 https://publications.parliament.uk/pa/cm201213/cmselect/cmpubadm/19/19.pdf 58 59 60

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1 2 3 4 5 6 7 8 9 10 11 12 Confidential: For Review Only 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Conflicts of Interest 28 29 30 None 31 32 33 34 Licencing statement 35 36 37 I John Emelifeonwu The Corresponding Author of this article contained within the original manuscript which 38 includes any diagrams & photographs within and any related or stand alone film submitted (the 39 Contribution”) has the right to grant on behalf 40 of all authors and does grant on behalf of all authors, a licence to the BMJ Publishing Group Ltd and its licencees, to permit this Contribution (if accepted) to be published in the BMJ and any other BMJ Group 41 products and to exploit all subsidiary rights, as set out in our licence set out at: http://www.bmj.com/about- 42 bmj/resources-authors/forms-policies-and-checklists/copyright-open-access-and-permission-reuse. 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 BMJ Page 20 of 25

1 2 3 4 5 6 7 8 Confidential: For Review Only 9 10 11 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 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

1 2 3 Gender 4 5 male 5813 6 female 5166 7 8 9 Citation 10 Arts and media 795 11 Business and economy 975 12 Confidential: For Review Only 13 Civil and Political service 1038 14 Community services 2989 15 Education 1203 16 17 Health 832 18 Science and Technology 419 19 Sport 703 20 21 Voluntary and Local services 2025 22 23 Region 24 London 1944 25 26 SE 1797 27 SW 896 28 East England 709 29 30 West Midlands 713 31 East Midlands 607 32 Yorkshire 640 33 34 NW 943 35 NE 366 36 Scotland 1019 37 38 Wales 562 39 NI 704 40 Outlying islands 43 41 42 International 35 43 44 Order of Honour 45 Companion of honour 17 46 47 Knights/Dames 343 48 Orders of Bath 81 49 Orders of St Michael and St George 3 50 51 CBE 1006 52 OBE 2353 53 MBE 5310 54 55 BEM 1876 56 57 58 59 60

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1 2 3 4 5 6 7 8 Confidential: For Review Only 9 10 11 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 https://mc.manuscriptcentral.com/bmj 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Page 23 of 25 BMJ

1 2 3 4 5 6 7 8 Confidential: For Review Only 9 10 11 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 https://mc.manuscriptcentral.com/bmj 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Page 24 of 25

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 Figure 4. Heat map of number of NYHs per 100,000 population received in different parts of the UK 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 https://mc.manuscriptcentral.com/bmj