‘The excellence of BME doctors isn’t rewarded’

The British Association of Physicians of Indian Origin (BAPIO) has much to celebrate on its 20th birthday this year. A small organisation, operating above a restaurant in Bedford, it has punched above its weight and has genuinely improved the profession for black and minority ethnic (BME) GPs.

At the helm is its president, Dr Ramesh Mehta, a consultant paediatrician in the town. He rose to prominence by spearheading a legal challenge against the RCGP in 2014, which claimed the MRCGP examination discriminated against international medical graduates (IMGs) and BME trainees, after huge disparities were noticed in pass rates.

This was not upheld by the High Court, but the judge praised BAPIO and instructed the RCGP to reform the exam. Meanwhile, Dr Mehta has strongly highlighted problems encountered by BME GPs failing CQC inspections and undergoing GMC investigations. And with the NHS attempting to address the GP shortage by looking abroad – including possibly to India – the importance of removing anything that acts as a barrier to BME doctors will be even more pressing.

Even though BAPIO’s judicial review of the MRCGP was ultimately unsuccessful, you have been involved in talks with the RCGP. Has the exam improved?

Since the judicial review, we’ve been meeting the college on a regular basis, and we know it is very keen to improve things. However, in real life we haven’t seen any change. The pass rate for international medical graduates is still very low, and it doesn’t have to be.

What would you like to happen next?

The question is, how do you assess doctors’ competence? That’s what the RCGP is trying to do. There are hundreds of doctors who are failing the clinical skills assessment exam. In practice their tutors are very happy with them and their patients are very happy, but in the artificial environment of the college where they are tested, they are failing by a few marks.

Are we saying that those doctors, who have been trained for three years at a cost of nearly half a million pounds, are no good as GPs? It doesn’t make sense. Years ago there was no MRCGP, people were practising and were doing extremely well. They were competent.

Professor Clare Gerada, the previous RCGP chair, is now saying the CSA is not right (‘Former RCGP chair claims CSA should be scrapped’, pulsetoday.co.uk/news) – and she is correct. The college needs a rethink. Hundreds of these doctors who could not clear the CSA are going to greener pastures, like New Zealand and Australia and Canada, and are highly respected and very happy. This is a loss to the country. It doesn’t need to be like that.

What are you going to do if you don’t see any improvements?

We’re on good terms with the college at the moment. We’re talking to them and we hope things will change. I do understand that it’s not just up to the college – the deaneries and Health Education England need to give support. So it’s a long-term issue and we will continue to try our best. However, the issue is not just with the RCGP. Differential attainment of international medical graduates is an issue with almost all the royal colleges. And some of them are worse than the RCGP.

Since our judicial review, there has been a lot of interest in sorting this out. The GMC is very keen, the Academy of Medical Royal Colleges is doing some work and the BMA is trying to assist. However, over the past two years we have hardly seen any change.

What we are going to do about it? We are going to consult our members. We will talk to the Department of Health again. We have been talking to the GMC, and we need to see definite change.

You mentioned losing doctors from the profession. Now it seems that HEE is considering filling in this gap by bringing in trained GPs from abroad, including India. Are you concerned about this plan?

I don’t think the DH has much choice. I’m concerned that if it is not done properly, it will create problems for the NHS and for these doctors’ countries of origin.

Historically, the NHS has never done without doctors from overseas. The backbone of the NHS since its inception has been overseas doctors, especially from the Indian subcontinent. For now, we know that the UK is in acute need of many, many doctors, especially in general practice, and in some other specialties. We need a win-win scenario for everybody.

What pitfalls must HEE avoid in taking this approach?

The worst it could do is to bring doctors here and just put them in general practice. Incoming doctors must have an induction before they come here, for several months. After arriving, they must be supervised at least for six months. They must be given a mentor and be looked after properly, and they should not be treated as cheap labour.

We, as an organisation, would be more than happy to help HEE in this venture. We understand the situation in India and here, and we also understand the trouble that doctors from overseas can get into when they come to this country.

IMGs are more likely to find themselves subject to a GMC investigation. Is this something you’ve discussed with the GMC?

We have been talking to the GMC for many years now. To be fair to the GMC, it is trying to find a solution, but I don’t think this is easy.

The problem, we believe, is not the competency of these doctors; the problem is cultural differences, issues of communication.

We know that for similar issues, IMGs are referred to the GMC five times more frequently than white doctors. Why is that happening? This is because of the cultural difference.

The problem with the GMC is the early screening process [the panel that decides which complaints go to a fitness-to-practise hearing]. We know that every year, nearly 2,700 doctors are referred and 40% of those go through an investigation. We have a big problem with the GMC’s screening process – there are lots of issues to sort out at that stage before going into detailed investigation.

Practices run by singlehanded BME doctors are more likely to fail CQC inspections. Have you taken this up with the CQC?

We are meeting with the CQC, which has been very generous in explaining what it is doing. For our part, we do not want any compromise with patient safety. However, when you’re looking at inspecting a surgery, you need to understand the background of how these surgeries are run.

Singlehanded doctors – especially BME doctors working in inner-city or remote areas – have been there for years and years. They provide a service where nobody else wants to go. Patients are happy. And then the CQC goes there and finds the tap is not working or the table is not clean, or things like that. For stupid things the doctors are punished.

We know that, in one part of London, four doctors have been suspended for such simple things. So, instead of providing support for these doctors and their surgeries, especially when there is such a shortage of doctors, the CQC is suspending them. It doesn’t make sense.

So, we have been talking to the CQC and I am pleased it is taking some steps and has reassured us it is not going after singlehanded BME doctors. However, the proof of the pudding is in the eating, so we’re watching how things are going.

Finally, in the past there has been well-documented discrimination against IMGs in the NHS. Do you think it’s as bad as ever, or has it improved?

There is some improvement. About 30 years ago, there was direct discrimination and it was pretty bad. I think the new generation is getting much more multicultural. There is certainly direct discrimination but it’s fading slowly but steadily.

However, unconscious bias and indirect discrimination are still there. And that is, I think, the main reason why BME doctors are not able to progress in their career in spite of being excellent. They don’t get rewarded or noticed; progression is hindered.

In the US, overseas doctors are able to progress to the highest level and the country is benefitting from their talent. I hope that in this country, we don’t waste the huge amount of talent among BME doctors.