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

Picture: ANDRÉ CARRILHO
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Leader: Boris Johnson, a liar and a charlatan

The Foreign Secretary demeans a great office of state with his carelessness and posturing. 

Boris Johnson is a liar, a charlatan and a narcissist. In 1988, when he was a reporter at the Times, he fabricated a quotation from his godfather, an eminent historian, which duly appeared in a news story on the front page. He was sacked. (We might pause here to acknowledge the advantage to a young journalist of having a godfather whose opinions were deemed worthy of appearing in a national newspaper.) Three decades later, his character has not improved.

On 17 September, Mr Johnson wrote a lengthy, hyperbolic article for the Daily Telegraph laying out his “vision” for Brexit – in terms calculated to provoke and undermine the Prime Minister (who was scheduled to give a speech on Brexit in Florence, Italy, as we went to press). Extracts of his “article”, which reads more like a speech, appeared while a terror suspect was on the loose and the country’s threat level was at “critical”, leading the Scottish Conservative leader, Ruth Davidson, to remark: “On the day of a terror attack where Britons were maimed, just hours after the threat level is raised, our only thoughts should be on service.”

Three other facets of this story are noteworthy. First, the article was published alongside other pieces echoing and praising its conclusions, indicating that the Telegraph is now operating as a subsidiary of the Johnson for PM campaign. Second, Theresa May did not respond by immediately sacking her disloyal Foreign Secretary – a measure of how much the botched election campaign has weakened her authority. Finally, it is remarkable that Mr Johnson’s article repeated the most egregious – and most effective – lie of the EU referendum campaign. “Once we have settled our accounts, we will take back control of roughly £350m per week,” the Foreign Secretary claimed. “It would be a fine thing, as many of us have pointed out, if a lot of that money went on the NHS.”

This was the promise of Brexit laid out by the official Vote Leave team: we send £350m to Brussels, and after leaving the EU, that money can be spent on public services. Yet the £350m figure includes the rebate secured by Margaret Thatcher – so just under a third of the sum never leaves the country. Also, any plausible deal will involve paying significant amounts to the EU budget in return for continued participation in science and security agreements. To continue to invoke this figure is shameless. That is not a partisan sentiment: the head of the UK Statistics Authority, Sir David Norgrove, denounced Mr Johnson’s “clear misuse of official statistics”.

In the days that followed, the chief strategist of Vote Leave, Dominic Cummings – who, as Simon Heffer writes in this week's New Statesman, is widely suspected of involvement in Mr Johnson’s article – added his voice. Brexit was a “shambles” so far, he claimed, because of the ineptitude of the civil service and the government’s decision to invoke Article 50 before outlining its own detailed demands.

There is a fine Yiddish word to describe this – chutzpah. Mr Johnson, like all the other senior members of Vote Leave in parliament, voted to trigger Article 50 in March. If he and his allies had concerns about this process, the time to speak up was then.

It has been clear for some time that Mr Johnson has no ideological attachment to Brexit. (During the referendum campaign, he wrote articles arguing both the Leave and Remain case, before deciding which one to publish – in the Telegraph, naturally.) However, every day brings fresh evidence that he and his allies are not interested in the tough, detailed negotiations required for such an epic undertaking. They will brush aside any concerns about our readiness for such a huge challenge by insisting that Brexit would be a success if only they were in charge of it.

This is unlikely. Constant reports emerge of how lightly Mr Johnson treats his current role. At a summit aiming to tackle the grotesque humanitarian crisis in Yemen, he is said to have astounded diplomats by joking: “With friends like these, who needs Yemenis?” The Foreign Secretary demeans a great office of state with his carelessness and posturing. By extension, he demeans our politics. 

This article first appeared in the 21 September 2017 issue of the New Statesman, The revenge of the left