There is a hierarchy of opportunity based on melanin

Dr Naureen Bhatti on why primary care needs to do more to support diversity, equity and inclusion in medical training and workforce development

Black and ethnic minority doctors have a poorer experience of medicine than their white colleagues. And despite the recent acceleration of equity, diversity and inclusion efforts, discrimination and disadvantage prevail across all stages of their careers.

Sadly, there is no evidence that the attainment gap between doctors of different ethnicities and their white peers is narrowing significantly. Particularly worrying is the differential attainment we have seen in all specialty postgraduate exams, although comparisons have so far been between those whose primary medical qualification is from the UK and those who got theirs elsewhere.

For the first time, the newly released GMC report shows the data split by ethnicity in a more detailed way. Data from medical royal colleges and postgraduate training bodies collated by the GMC suggest that UK medical graduates of Black or Black British heritage have lower pass rates in specialty exams (62%) than UK white (79%), Asian (68%) and mixed heritage trainees (74%).

Other factors such as socio-economic status compound the poorer outcomes seen in some groups, with UK Black trainees from areas with a higher level of deprivation having a 59% pass rate compared with 76% for UK white trainees from an equivalent socio-economic background. 

Race is not the only factor that can disadvantage medical training, with UK Asian Muslim trainees having lower exam pass rates than those from a Hindu or Sikh faith and those who do not follow a religion.

In the MRCGP exam, international medical graduates (IMGs) have lower pass rates compared with their UK trained peers in the AKT (48% v 82%) and RCA exam (45% v 93%), but there is no granular breakdown of ethnicity given in this data, particularly of the UK graduate GP trainees.

A recent paper in the British Journal of General Practice concludes that ethnic minority doctors performed no worse in licensing exams when the Multi-Specialty Recruitment Assessment (MSRA) and demographic factors were considered. But without granular stratification of ethnicity in the MSRA scores at entry to GP training, there is no way of excluding racial bias because the same differential attainment applies to MSRA exams and exit exams.

Tackling institutional racism in the NHS

The increase in support for our IMG GP trainees is highly welcome, but the results of these interventions will not yet be seen as these trainees have not been supported through a full three-year GP training programme. However, the recommended support initiatives continue to focus mainly on the individual, not institution or policy.

While we are (rightly) supporting individual trainees, we are not tackling the institutional racism in the NHS. As we already know from work by Professor Katherine Woolf at UCL Medical School and others, this results in less supportive and less positive learning environments for ethnic minority learners, as well as discrimination and racism.

Unfortunately, recruitment into GP training is still based on candidates with the highest scores having first choice of where they go, which makes the unhelpful assumption that everyone arrives at this point with equivalent experiences and resources. This introduces ‘an inverse care law in education’ – meaning that those who are international medical graduates, or diaspora of migrants from more deprived areas, continue to be placed where other trainees, predominantly white, don’t want to be.

This also changes nothing from the early years of the NHS, when those from the Commonwealth arrived and were placed in less desirable specialties and areas. And as we know, this often reduces the support these trainees might otherwise have from family and friends if they are placed further from home.

It is also essential to ensure that examinations, including workplace-based assessments, are unbiased and fair. Not to mention that expectations of proficiencies in language fluency and literacy do not override knowledge and skills, disadvantaging not only those for whom English is a second language but advantaging those with the fluency that often comes to those from middle-class homes and schools. The current focus on trying to ‘fix’ trainee deficits in examinations risks further stigmatising learners and misallocating resources.

We need to do more to ensure that equality and diversity is fully supported in education and workforce development, as is being done in the implementation of the London Workforce Race Equality Strategy (WRES) in Primary Care. The first pan-London survey of the primary care workforce showed that the experience of staff was no different from our colleagues in hospital trusts. A third of respondents said they had experienced racial discrimination from patients in the previous year, and one in five from colleagues or managers. The strategy aims to support NHS primary care employers with tools to implement and embed anti-racist initiatives as well as enable meaningful, long-term cultural change.

Respect, dignity, compassion and care should be at the core of how patients and staff are treated. Not only because that is the right thing to do but because patient safety, experience and outcomes are all improved when staff are valued, empowered and supported. To quote Yvonne Coghill, director of WRES Implementation for NHS England, there is a ‘hierarchy of opportunity based on melanin’.

The NHS was established on the principles of social justice and equity but the treatment of our colleagues from minority groups often falls short, with those in primary care to date often excluded from initiatives and resources. And we don’t seem to be tackling it just yet.

Dr Naureen Bhatti is a GP in East London who led on the development of the London Workforce Race Equality Strategy in Primary Care