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

Photo: Getty
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After Richmond Park, Labour MPs are haunted by a familiar ghost

Labour MPs in big cities fear the Liberal Democrats, while in the north, they fear Ukip. 

The Liberal Democrats’ victory in Richmond Park has Conservatives nervous, and rightly so. Not only did Sarah Olney take the votes of soft Conservatives who backed a Remain vote on 23 June, she also benefited from tactical voting from Labour voters.

Although Richmond Park is the fifth most pro-Remain constituency won by a Conservative at the 2015 election, the more significant number – for the Liberal Democrats at least – is 15: that’s the number of Tory-held seats they could win if they reduced the Labour vote by the same amount they managed in Richmond Park.

The Tories have two Brexit headaches, electorally speaking. The first is the direct loss of voters who backed David Cameron in 2015 and a Remain vote in 2016 to the Liberal Democrats. The second is that Brexit appears to have made Liberal Democrat candidates palatable to Labour voters who backed the party as the anti-Conservative option in seats where Labour is generally weak from 1992 to 2010, but stayed at home or voted Labour in 2015.

Although local council by-elections are not as dramatic as parliamentary ones, they offer clues as to how national elections may play out, and it’s worth noting that Richmond Park wasn’t the only place where the Liberal Democrats saw a dramatic surge in the party’s fortunes. They also made a dramatic gain in Chichester, which voted to leave.

(That’s the other factor to remember in the “Leave/Remain” divide. In Liberal-Conservative battlegrounds where the majority of voters opted to leave, the third-placed Labour and Green vote tends to be heavily pro-Remain.)

But it’s not just Conservatives with the Liberal Democrats in second who have cause to be nervous.  Labour MPs outside of England's big cities have long been nervous that Ukip will do to them what the SNP did to their Scottish colleagues in 2015. That Ukip is now in second place in many seats that Labour once considered safe only adds to the sense of unease.

In a lot of seats, the closeness of Ukip is overstated. As one MP, who has the Conservatives in second place observed, “All that’s happened is you used to have five or six no-hopers, and all of that vote has gone to Ukip, so colleagues are nervous”. That’s true, to an extent. But it’s worth noting that the same thing could be said for the Liberal Democrats in Conservative seats in 1992. All they had done was to coagulate most of the “anyone but the Conservative” vote under their banner. In 1997, they took Conservative votes – and with it, picked up 28 formerly Tory seats.

Also nervous are the party’s London MPs, albeit for different reasons. They fear that Remain voters will desert them for the Liberal Democrats. (It’s worth noting that Catherine West, who sits for the most pro-Remain seat in the country, has already told constituents that she will vote against Article 50, as has David Lammy, another North London MP.)

A particular cause for alarm is that most of the party’s high command – Jeremy Corbyn, Emily Thornberry, Diane Abbott, and Keir Starmer – all sit for seats that were heavily pro-Remain. Thornberry, in particular, has the particularly dangerous combination of a seat that voted Remain in June but has flirted with the Liberal Democrats in the past, with the shadow foreign secretary finishing just 484 votes ahead of Bridget Fox, the Liberal Democrat candidate, in 2005.

Are they right to be worried? That the referendum allowed the Liberal Democrats to reconfigure the politics of Richmond Park adds credence to a YouGov poll that showed a pro-Brexit Labour party finishing third behind a pro-second referendum Liberal Democrat party, should Labour go into the next election backing Brexit and the Liberal Democrats opt to oppose it.

The difficulty for Labour is the calculation for the Liberal Democrats is easy. They are an unabashedly pro-European party, from their activists to their MPs, and the 22 per cent of voters who back a referendum re-run are a significantly larger group than the eight per cent of the vote that Nick Clegg’s Liberal Democrats got in 2015.

The calculus is more fraught for Labour. In terms of the straight Conservative battle, their best hope is to put the referendum question to bed and focus on issues which don’t divide their coalition in two, as immigration does. But for separate reasons, neither Ukip nor the Liberal Democrats will be keen to let them.

At every point, the referendum question poses difficulties for Labour. Even when neither Ukip nor the Liberal Democrats take seats from them directly, they can hurt them badly, allowing the Conservatives to come through the middle.

The big problem is that the stance that makes sense in terms of maintaining party unity is to try to run on a ticket of moving past the referendum and focussing on the party’s core issues of social justice, better public services and redistribution.

But the trouble with that approach is that it’s alarmingly similar to the one favoured by Kezia Dugdale and Scottish Labour in 2016, who tried to make the election about public services, not the constitution. They came third, behind a Conservative party that ran on an explicitly pro-Union platform. The possibility of an English sequel should not be ruled out.  

Stephen Bush is special correspondent at the New Statesman. His daily briefing, Morning Call, provides a quick and essential guide to British politics.