Career Focus

Circumventing racism in the NHS

BMJ 1997; 314 doi: (Published 01 March 1997) Cite this as: BMJ 1997;314:S2-7081
  1. Douglas Carnall, editor
  1. Career Focus

    Douglas Carnall reviews the scene for those who can't wait for the policy debate because they've got to advance their careers right now

    “After I'd got the job, I asked the consultant how he normally shortlisted for the post. He told me that he put all the CVs with English names into one pile, and all those with non-English names into another pile, and looked at the English pile first.” Hardly a method of shortlisting likely to find approval with the commissioners for racial equality, yet when Aneez Esmail took his observation a step further in his groundbreaking study, he found that his paired CVs - differing only in the ethnicity of the name on the front sheet - were twice as likely to be shortlisted with an Anglo-Saxon name as with an Asian one.1 How much has changed since the publication of the study in 1993? Speakers at last week's BMA conference held to discuss racism in the NHS were not optimistic that much progess has been made.

    The present policy debate is entirely laudable and necessary if matters are to improve. It may be that the newly reorganised NHS Executive Equal Opportunities Unit headed by Elizabeth Al-Khalifa will succeed in achieving policy that breaks down the barriers to advancement within the NHS where others have failed. We certainly know that the problem is endemic: 23% of all hospital doctors in the NHS are from an ethnic minority, for example, yet while doctors from ethnic minorities are under-represented in the consultant grades, 63% of doctors in staff grade posts are from an ethnic minority. It's a big problem, and it is fair to say that many of the causes can be addressed only at societal level; though those who work in the NHS have a duty to lead as well as to follow. But where does that leave doctors who feel that they may be experiencing discrimination? If you are in the process of applying for a job it only takes one act of racism to send you on the slow track to a place that all the working parties in the world can't pull you back from.

    You need to be able to tell whether employment procedures are non discriminatory, you need to know how you can challenge employment decisions, and how to be able to work your way around a system in the full knowledge that it is sexist, racist, and dominated by patronage and the old boy network.2

    Where to apply

    There is little published work on the likely success of candidates from ethnic minorities in each institution. Indeed, lack of systematic audit is the progenitor of the status quo. Research which examined medical schools' admission rates by ethnic grouping found considerable disparities between the schools.3 On the face of it, applicants to St Andrews were almost four times more likely to get a place if they were white than if they were from an ethnic minority, with Cambridge and several of the London medical schools not far behind. These data have been criticised4 but if differing institutional cultures does mean that selection procedures for medical students are racist it seems likely that applications further down the line in your career may also run into similar problems.The NHS is a huge organisation; employment practices will be correspondingly diverse.

    Beating the shortlist barrier

    Both the research and the anecdotes of those who have suffered at the hands of the system show that much of the problem lies in the shortlisting process: it's a lot easier to throw away a piece of paper than a human being. If you can get a face to face interview you at least have a fighting chance of selling yourself and your talents. When you apply for a job you should receive two key documents describing the post - a job description and an accompanying person specification.5 These should clearly state the objective criteria by which candidates will be shortlisted for the post; if you meet them, and are not shortlisted, you are on much stronger ground if you decide to pursue a complaint.

    Ideally, standard forms which record potentially discriminatory details such as name, sex, and ethnic origin would be entered on a detachable front sheet, which would be removed by a personnel clerk before the shortlisting process begins. We plan to publish suitable model forms on the BMJ's Web page soon, which will be available for any organisation to download and use.

    Many job advertisements still call for a CV, though this is not good equal opportunities practice. Most high flying candidates from ethnic minorities have found that the solution to ensuring a place on the shortlist lies in visiting the unit personally, and pointing out that they are not just another name on a piece of paper, but a real human being. Although informal visits could potentially be construed as not favouring equal opportunities, it seems that the balance favours the keen candidate who is willing to make the effort to get over the prospective unit and start to build relationships.

    Getting shortlisted is more than half of the battle, and is perhaps the area that good employment practice is best equipped to address. Candidates will have to pursue their own strategies at interview,6 though they should not have to field discriminatory questions. Dealing with openly racist remarks may be personally difficult (see box). It's easy for me to write, but unless individuals have the courage to stand up and say “The rot stops here” then the person who dealt out the racist remarks or attitude will continue to exert his or her pernicious influence. Part of the reason why racism is so endemic in Britain may be our difficulty in being open about the issue. It's embarrassing to make an unconsciously racist remark, and the person who does so may want to change: perhaps you will be the person to help them.

    After the interview

    It may be that you don't get the job. This may be for good reasons, or it way not. It would certainly focus the attention of personnel departments on their equal opportunities procedures if the unsuccessful candidates wrote to the personnel department after the selection process and asked for a breakdown by ethnicity of the number of applications for the post, the numbers shortlisted, and the numbers successful. Such data are supposed to be routinely collected and analysed by trusts, but researchers who request the data say that in many trusts they are hard to track down and access, disorganised when they finally get them, and obviously have not been used to inform policy or practice in the trust. Your letter should focus their minds. Follow it up. Racial discrimination is against the law.


    Pursuing a claim for racial discrimation during employment selection procedures has been hitherto considered impractical by most candidates. The potential for legal costs, and the potential for acquiring a troublemaker label, seems risky compared with the maximum compensation of £10,000 available. However, recent changes have lifted the ceiling on the compensation potentially obtainable to infinity, which may make suing seem a lot more worth while.

    Senior doctors are inevitably involved in appointments procedures. While it is clear that some have felt able to disregard the moral imperatives against racist conduct, the business case for reform is now unassailable. The BMA produces useful guidelines7 on good employment practice: it is encumbent on everyone involved in selection procedures to ensure that they are followed.

    Useful addresses

    NHS Executive Equal Opportunities Unit,

    Department of Health,

    Human Resources Division,

    Room 2E58,

    Quarry House

    Quarry Hill,

    Leeds LS2 7UE

    Commission for Racial Equality,

    Elliot House,

    10-12 Allington Street,

    London SW1E 5EH

    (0171 828 7022)


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