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 https://mc.manuscriptcentral.com/bmj Page 1 of 25 BMJ 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 https://mc.manuscriptcentral.com/bmj BMJ Page 2 of 25 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 https://mc.manuscriptcentral.com/bmj Page 3 of 25 BMJ 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 https://mc.manuscriptcentral.com/bmj BMJ Page 4 of 25 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 https://mc.manuscriptcentral.com/bmj Page 5 of 25 BMJ 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 https://mc.manuscriptcentral.com/bmj BMJ Page 6 of 25 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.