Welcoming the publication of the Independent Review of the Membership of the Royal College of General Practitioners (MRCGP) and the Clinical Skills Assessment (CSA) examination
Niall Dickson, Chief Executive of the General Medical Council, said:
‘The report by Professor Aneez Esmail found that while there are significant differences in pass rates between different groups of doctors, the way they are assessed in the CSA is not the cause of those differences.
‘In particular Professor Esmail found that the pass rates for doctors sitting the computer marked applied knowledge test mirrored their performance in the CSA exam.
‘As the regulator, we commissioned this review following concern about the fairness of the exam run by the Royal College of General Practitioners (RCGP). The concerns focused on whether failure rates were higher among doctors who qualified outside the UK or Europe, as well as those UK-trained doctors from black and minority ethnic backgrounds.
‘We asked Professor Esmail of the University of Manchester to lead this independent work given his experience and expertise in general practice. His report draws a clear conclusion: “the method of assessment is not a reason for the differential outcomes” in the pass rates.
‘We welcome his conclusions, which we hope will both provide some assurance and help find better ways to support doctors undertaking GP training.
‘Professor Esmail’s report also makes a number of important observations about the nature of the examinations. He says that “the CSA exam is not a culturally neutral examination and nor is it intended to be. It is not and nor should it be just a clinical exam testing clinical knowledge in a very narrow sense. It is designed to ensure that doctors are safe to practice in UK general practice.”
“The cultural norms of what is expected in a consultation vary from country to country. So for example a British graduate will have difficulty in practising in a general practice setting in France or India until they have become acculturated to that system of care.”
‘However, this report should not be a cause for complacency and we need to understand more about why “there are significant differences in failure rate between different groups in the CSA examination”. The report says that Black and Minority Ethnic (BME) UK graduates are nearly four times more likely to fail the CSA examination at their first attempt than their White UK colleagues; although Professor Esmail points out that the difference disappears at the second attempt. On the other hand BME International Medical Graduates (IMG) candidates are nearly fifteen times more than likely to fail this exam than their White UK colleagues and the difference between the two groups persists at subsequent sittings.
‘Professor Esmail has made a number of important recommendations for the GMC and the RCGP. As he has proposed, we will publish exam results of the GMC’s Professional and Linguistic Assessments Board (PLAB) exams and International English Language Testing (IELT) results, and how they link to College exam results. We are already working with Colleges to ensure that examiners have suitable equality and diversity training, and that their performance is monitored and that best practice is followed in setting standards for exams.
‘The RCGP - and other colleges - will want to consider their response to the recommendations - including his proposal that international medical graduates should be made explicitly aware of the differential outcomes with clear advice on how to better prepare for examinations. Professor Esmail also suggests that it may be better to focus on reasons for success rather than reasons for failure.
‘The exams are very important for all involved and it is right that, because of the nature of general practice, they are rigorous, demanding and specific to the UK health system. The health service relies on the skill and dedication of doctors who trained outside the UK - we want all doctors in training to succeed.
‘I am grateful to Professor Esmail for his careful consideration of the evidence and thoughtful recommendations in what is a complex and difficult area of work. We want to work closely and constructively with all those involved in this area and do everything we can to maintain high standards and make sure doctors have the support they need to develop their skills and provide high quality care to their patients. Patients, employers and doctors must be confident that the exams doctors sit to become a GP in the UK are fair, robust and meets the high standards we have set.