Best of British: the NHS was celebrated at the Olympics Opening Ceremony. But is there still a white bias for doctors? Photo: Getty
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White GPs have a far higher exam pass rate than black or Asian ones

In his Health Matters column, Dr Phil Whitaker discusses how the Royal College of GPs came under attack for possible discrimination. 

The Royal College of General Practitioners (RCGP) was at the high court last month, defending itself against allegations of racial discrimination. At issue was the college’s clinical skills assessment (CSA) examination, which all doctors must pass in order to practise independently as GPs. Roughly 94 per cent of white British doctors pass the CSA first time, whereas for black, Asian and minority ethnic (BAME) British doctors the rate is only about 75 per cent. The statistics are even worse for international medical graduates (IMGs – doctors who qualified at medical schools overseas), with just over half passing at the first attempt.

A possible explanation for these stark discrepancies could have been racism. The British Association of Physicians of Indian Origin (Bapio), which sought the judicial review, argued that the way the CSA examination is conducted leaves it open to discrimination. Candidates are faced with a simulated surgery, 13 different ten-minute cases coming one after the other. The patients are actors who play out carefully crafted vignettes, designed to test specific aspects of good medical practice. However, there can be no precise script: the actors’ responses will vary according to the way each candidate conducts the consultation.

Performance is assessed by examiners who are experienced GPs. Bapio’s contention was that the actors, or the examiners, or both were biased against BAME candidates. The RCGP countered that its equality and diversity training guarded against such a possibility and cited the excellent results achieved by many BAME and IMG candidates as evidence that no discrimination exists.

The judgment went in the college’s favour, Mr Justice John Mitting ruling that the CSA was not discriminatory. However, he ordered the RCGP to investigate the reasons for the stark differences in pass rates. It seems likely that as a result the spotlight will turn from the CSA to shine more broadly on the way GPs are trained.

Two-thirds of the marks in the CSA are awarded for what might be termed the pure medicine: arriving at an appropriate diagnosis and formulating a reasonable plan of management. Any doctor sitting the CSA – which is taken towards the end of a three-year programme of postgraduate training in general practice – has already passed other written examinations that assess this academic knowledge. The other third of CSA marks reflects consultation skills, including exploring the patient’s ideas regarding the symptoms; understanding and responding to the impact the illness is having on the person’s life; and incorporating, where possible, the patient’s preferences into the management plan.

The CSA examines not just knowledge but also the doctor’s skills in applying that knowledge to “real-life” situations. This is the doctor as “knowledgeable partner” rather than didactic expert – no decision about me without me.

Such “patient-centred” practice is relatively new and requires highly developed communication skills to pick up the nuances behind what people say. Britain has been at the forefront of its development but around the world much of medical education is still very “doctor-centred”, with the expectation that patients will gratefully fit in with how their physician chooses to do things. IMGs, whose basic training is likely to have been in medical schools rooted in doctor-centred cultures, may find patient-centred practice profoundly alien; and this goes equally for British-trained BAME doctors raised in doctor-centred subcultures.

The CSA may be exposing a fundamental problem with GP training. Every trainee has an experienced trainer who oversees their development. Trainers are expected to conduct frequent workplace-based assessments of patient-centred consultation skills and to review progress every six months. Ultimately, if a trainee is experiencing intractable difficulties, the trainer is expected to report this for further action.

There should, in theory, be ample opportunity to remedy problems well before the CSA. The current discrepancies in pass rates suggest that this isn’t always happening.

This may indicate that grass-roots training hasn’t universally evolved to match the expectations of the RCGP or there may be more difficult issues. The relationship between trainer and trainee is forged over a relatively long timescale and many trainers find the collision of roles – friend, colleague, mentor, assessor and, ultimately, police person – to be uncomfortable.

Difficulties that have their roots in cultural differences and language skills are particularly sensitive and there may well be a reluctance to escalate them (the Bapio action illustrates how the spectre of racism allegations hovers over these issues). If a trainee is medically competent but is failing to consult in the expected manner, a trainer may find this too potentially explosive to raise, and rely on others to tackle the problem instead.

While finding for the RCGP, Mr Justice Mitting praised Bapio for bringing the action, saying that he believed it would ultimately benefit medicine. At present, some doctors are being failed by the system, which is ruinous to their careers and emotional health. In resolving this, a better, more open system of GP training and assessment must surely result.

This article first appeared in the 01 May 2014 issue of the New Statesman, The Islam issue

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Labour to strip "abusive" registered supporters of their vote in the leadership contest

The party is asking members to report intimidating behaviour - but is vague about what this entails. 

Labour already considered blocking social media users who describe others as "scab" and "scum" from applying to vote. Now it is asking members to report abuse directly - and the punishment is equally harsh. 

Registered and affiliated supporters will lose their vote if found to be engaging in abusive behaviour, while full members could be suspended. 

Labour general secretary Iain McNicol said: “The Labour Party should be the home of lively debate, of new ideas and of campaigns to change society.

“However, for a fair debate to take place, people must be able to air their views in an atmosphere of respect. They shouldn’t be shouted down, they shouldn’t be intimidated and they shouldn’t be abused, either in meetings or online.

“Put plainly, there is simply too much of it taking place and it needs to stop."

Anyone who comes across abusive behaviour is being encouraged to email

Since the bulk of Labour MPs decided to oppose Labour leader Jeremy Corbyn, supporters of both camps have traded insults on social media and at constituency Labour party gatherings, leading the party to suspend most meetings until after the election. 

In a more ominous sign of intimidation, a brick was thrown through the window of Corbyn challenger Angela Eagle's constituency office. 

McNicol said condemning such "appalling" behaviour was meaningless unless backed up by action: “I want to be clear, if you are a member and you engage in abusive behaviour towards other members it will be investigated and you could be suspended while that investigation is carried out. 

“If you are a registered supporter or affiliated supporter and you engage in abusive behaviour you will not get a vote in this leadership election."

What does abusive behaviour actually mean?

The question many irate social media users will be asking is, what do you mean by abusive? 

A leaked report from Labour's National Executive Committee condemned the word "traitor" as well as "scum" and "scab". A Labour spokeswoman directed The Staggers to the Labour website's leadership election page, but this merely stated that "any racist, abusive or foul language or behaviour at meetings, on social media or in any other context" will be dealt with. 

But with emotions running high, and trust already so low between rival supporters, such vague language is going to provide little confidence in the election process.