Intended for healthcare professionals


Tackling racism in the NHS

BMJ 1997; 314 doi: (Published 01 March 1997) Cite this as: BMJ 1997;314:618

We need action not words

  1. Aneez Esmail, Vice president, Medical Practitioners' Uniona,
  2. Douglas Carnall, Editor, Career Focusb
  1. a 50 Southwark Street, London SE1 1UN
  2. b BMJ, London WC1H 9JR

    A BMA conference held last week to discuss racial discrimination in the medical profession highlighted a range of reports and publications written since 1987 that have documented the problem. Racial discrimination occurs at all levels in the medical profession, from applications to medical school,1 2 3 through the examination process,4 to job applications.5 6 It also affects the manner in which complaints are made against doctors.7 8 Our problem is not a lack of evidence but the lack of political will to tackle the problem.

    That racial discrimination within the medical profession is widespread is a view many doctors may find hard to accept. But it is an accusation that must be taken seriously. With 23% of the medical workforce and, in some medical schools, 30% of the current intake classifying themselves as ethnic minorities, the issue is not necessarily one of under-representation of ethnic minorities but of equal opportunities–potentially affecting a quarter of doctors in Britain.

    The problem of discrimination in the profession is first and foremost an ethical and moral issue, and, as a profession, we should be setting an example to society. The health service reflects society, but it is false to argue that we can make progress only if we solve society's problems first. The medical profession is an important leader of opinion in society–both at a national and local level9 –and must take the lead in dealing with discrimination in its own ranks. As a profession, we tend to deny that there is a problem, and, with a few exceptions, our leaders have failed to make the fight against discrimination a top priority.

    If research evidence has been available for many years, why has there been so little progress? The General Medical Council's ethical guidance for doctors10 makes it clear that doctors must not themselves discriminate against patients or their colleagues on racial grounds. The council's president, Sir Donald Irvine, argued at the BMA conference that, as a profession, we have sometimes concentrated our efforts on quality standards for professional care and services to patients at the expense of considering the ethical context in which we deliver and practice our care.

    The moral case against discrimination is surely unassailable. But there is a good business argument too. In a meritocracy we should not be arguing about the numbers of people from ethnic monitories applying for medical school or working in the profession but about equal opportunities to enter the profession and progress within it. The NHS loses if the best teachers, researchers, and clinicians are prevented from achieving their potential because of bigotry.

    So what can be done? Recent legislation which removes the upper limit for compensation in cases where discrimination can be proved means that employers could face huge bills if found guilty. This will increase pressure on employers to ensure that they have systems in place that minimise the possibility of discrimination. It is no longer acceptable, for example, for consultants to shortlist and select junior doctors without following established guidelines on good personnel practices.

    Applicants who feel they may have been discriminated against in job applications should be more willing to challenge the system using the established legislative framework. Unfortunately, most general practices, because they are classified as small businesses, are exempt from the provisions of the Race Relations Act; the professions' leaders should take a lead in arguing for this anomaly to be corrected.

    Huge amounts of data are currently collected for ethnic monitoring of admissions to medical schools, job applications, and complaints against doctors, but existing processes fail to make these data available for public scrutiny and research. More openness and transparency is essential. The Council of Deans for Britain's medical schools could take a lead by making available existing data on the ethnicity of applicants to medical schools so that researchers can compare schools and the effects that their admissions policies have on ethnic minorities.

    The General Medical Council should publish on a regular basis the outcome of complaints against doctors, by ethnicity, the number investigated, and the number eventually brought before its professional conduct committee. The NHS Executive should make it a management objective for chief executives of trusts and health authorities to monitor personnel practices so that poor practice is highlighted and acted on.

    Basics of good practice in equal opportunities

    • Applications should have all references to age, gender, and ethnicity removed before being assessed

    • Shortlisting should be done using a standardised form (an example of which will be posted on the BMJ's web site)

    • Interviews should follow a standardised objective format so that every candidate is asked the same questions and answers can be graded objectively

    The BMJ also has its part to play. In its launch edition, Career Focus (carried each week in the classified advertising section) promised “to shine a light amidst the darkness of rumour, gossip, and individual preferment that so often characterises doctors' current experience of career advancement in Britain today.”11 Openness, transparency, and review of employment practice are the tools with which we will begin to tackle the serious injustice and waste that racism represents. With Career Focus, the BMJ dedicates two pages each week to publishing the best available information on how doctors can develop their careers. We look forward to using this space to disseminate good practice in equal opportunities; but we will also publish the experiences of those who have not been so fortunate. What is required in this European Year Against Racism is fewer excuses and a lot more action.


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