Discrimination in the discretionary points award scheme: comparison of white with non-white consultants and men with womenBMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7391.687 (Published 29 March 2003) Cite this as: BMJ 2003;326:687
All rapid responses
Following the comments to our article we carried out a further analysis of data made available to us to assess the distribution of discretionary points by specialty and ethnicity. The data on the distribution of consultants by specialty was not available to us at the time of publication. The further analysis that we carried followed the same methods described in the original article.
Table 1 shows the difference in distribution of discretionary point awards (DPA) by specialty and ethnicity. This shows a marked variation between the specialties with for example 9% of non-white consultants in trauma & orthopaedics having a DPA compared to 43% of white consultants (ratio of white to non white 4.59 (CI 3.11-6.76). At the other end of the scale 30% of non-white consultants in geriatric medicine had a DPA compared to 54% of white consultants (ratio of white to non-white 1.84 (CI 1.48-2.30).
It is difficult to explain the wide differences between specialties - why for example are only 9% of ethnic minority consultants in trauma & orthopaedics successful in obtaining DPA compared to 30% of their colleagues in Geriatric Medicine? Lack in his rapid response (1 April 2003) suggests that it may be due to lack of emotional intelligence or reduced hours worked in the NHS. There is of course no evidence for this assertion. Our analysis seeks to highlight differences so action can be taken to make the system fairer and it is surprising that not a single awards committee or the Department of Health has carried out an analysis to assess whether the system is operating fairly. We believe that it is a disgrace that consultants sit on committees which allocate these awards without insisting that the outcomes are audited or the process monitored in an attempt to ensure that the system appears to be fair. I have sat through enough employment tribunals to see the charade that operates in some trusts in the allocation of these awards. Perhaps the comments of one tribunal chair will suffice to make my point. In Nasr Vs Salisbury NHS Trust, the Chairman in his ruling stated:
"....Such a high level of subjectivity (in the awards of discretionary points) is anathema to the successful application of equal opportunity guidelines since it works to the disadvantage of ethnic minorities, both in operation and perception...... (The case fell) into the worst category of racial discrimination against a senior medical professional..."(1)
It is true as Cave states in his rapid response (29 March 2003) that DPAs have to be applied for. For this to be an explanation for the discrepancies that we have highlighted suggests that female and ethnic minority consultants do not apply for awards which could potentially enhance their salary by over £21,000. I know many ethnic minority and female consultants who are very committed to the NHS, but I know of none who are prepared to forego such a salary increase. Applying for discretionary points is not the prerogative of white consultants only.
Joseph (4 April) argues that our title suggests that we have come to the conclusion that discrimination is responsible for the discrepancies that we have highlighted. The editors chose the title and as our text makes clear, we only offer discrimination as a possibility in the absence of any other convincing explanation. The question that Joseph and others have to ask themselves is why these discrepancies exist? He is obviously grateful for the opportunity to practice medicine in this country and he may be more willing accept that the discrepancies that we have highlighted in virtually all areas of the NHS between ethnic minority doctors and their white colleagues are due to some sort of benign neglect. The implied suggestion is that the problem of alleged discrimination will go away if we make some minor changes. I beg to differ. It is true that I do not have direct proof that differences that I have highlighted in job applications(2), GMC complaints(3), medical school admissions(4), distinction awards(5) and discretionary points between white and ethnic minority doctors is due to racial discrimination, but I think I make a pretty good case. We can carry out all sorts of studies to control for explanatory factors (data which will never be collected when only 2% of trusts even bother to keep records of their performance related pay scheme in relation to monitoring of ethnicity)(6) but why do we have such difficulty in accepting that racial discrimination may be an explanation?
Table 1 Discretionary Points: selected ratios of awards to consultants by ethnicity and speciality. (England at 30th September 2001) Specialty Percentage of White consultants with a Discretionary Point award Percentage of Non White consultants with a Discretionary Point award Ratio of a white consultant receiving a Discretionary Point award compared to an ethnic minority consultant. Plastic surgery 49 10 5.25(1.76-15.64) Trauma & orthopaedic surgery 43 9 4.59(3.11-6.76) General Surgery 70 16 4.36(3.26-5.83) Clinical neurophysiology 49 11 4.38(1.14-16.84) Neurosurgery 60 14 4.17(1.14-15.21) Obstetrics & Gynaecology 62 16 3.95(2.94-5.32) Dermatology 54 15 3.68(1.92-7.04) Histopathology 55 17 3.25(2.31-4.56) Anaesthetics 41 13 3.23(2.6-4.0) Cardio-thoracic Surgery 50 17 3.03(1.5-6.09) Neurology 46 15 2.91(1.45-5.84) Ophthalmology 43 16 2.7(1.85-3.96) Urology 64 24 2.66(1.84-3.84) Rheumatology 53 22 2.43(1.48-3.97) Chemical Pathology 60 26 2.32(1.15-4.69) Haematology 65 29 2.26(1.56-3.28) General psychiatry 57 28 2.05(1.73-2.45) Clinical radiology 54 25 2.15(1.75-2.65) Accident & Emergency medicine 45 20 2.17(1.49-3.17) Geriatric medicine 54 30 1.84(1.48-2.30) Child & adolescent psychiatry 54 40 1.35(1.01-1.81) Med microbiology & virology 55 48 1.15(0.85-1.55)
1. www.positive-equality.co.uk/downloads/section2_case6.doc (accessed 17 July 2003)
2. Esmail A,.Everington S. Racial discrimination against doctors from ethnic minorities. BMJ 1993;306:691-2.
3.Esmail A,.Everington S. Complaints may reflect racism. BMJ 1994;308:1374.
4. Esmail A, Primarolo D, Nelson P, Toma T. Acceptance into medical school and racial discrimination. BMJ 1995;310:501-2.
5. Esmail A, Everington S, Doyle H. Racial discrimination in the allocation of distinction awards? Analysis of list of award holders by type of award, specialty and region. BMJ 1998;316:193-5.
6. Racial Equality and NHS Trusts. Commission for Racial Equality (2000).
Competing interests: Table 1Discretionary Points: selected ratios of awards to consultants by ethnicity and speciality. (England at 30th September 2001) Specialty Percentage of White consultants with a Discretionary Point awardPercentage of Non White consultants with a Discretionary Point awardRatio of a white consultant receiving a Discretionary Pointaward compared to an ethnic minority consultant. Plastic surgery 49 10 5.25(1.76-15.64) Trauma & orthopaedic surgery 43 9 4.59(3.11-6.76) General Surgery 70 16 4.36(3.26-5.83) Clinical neurophysiology 49 11 4.38(1.14-16.84) Neurosurgery 60 14 4.17(1.14-15.21) Obstetrics & Gynaecology 62 16 3.95(2.94-5.32) Dermatology 54 15 3.68(1.92-7.04) Histopathology 55 17 3.25(2.31-4.56) Anaesthetics 41 13 3.23(2.6-4.0) Cardio-thoracic Surgery 50 17 3.03(1.5-6.09) Neurology 46 15 2.91(1.45-5.84) Ophthalmology 43 16 2.7(1.85-3.96) Urology 64 24 2.66(1.84-3.84) Rheumatology 53 22 2.43(1.48-3.97) Chemical Pathology 60 26 2.32(1.15-4.69) Haematology 65 29 2.26(1.56-3.28) General psychiatry 57 28 2.05(1.73-2.45) Clinical radiology 54 25 2.15(1.75-2.65) Accident & Emergency medicine 45 20 2.17(1.49-3.17) Geriatric medicine 54 30 1.84(1.48-2.30) Child & adolescent psychiatry 54 40 1.35(1.01-1.81) Med microbiology & virology 55 48 1.15(0.85-1.55)
This is not the first time that Esmail and Everington have
highlighted the discrepancies between the relative numbers of awards held
by white and non white consultants. On the last occasion the title
appeared to question the existence of discrimination in the allocation of
distinction awards1, although the text and the authors’ replies to
correspondence left no one in any doubt. This time however the authors
categorically state in the title that there is discrimination in the
discretionary points award scheme although in the text they concede that
the concentration of non-white consultants in specialties which are less
likely to receive awards is a possible explanation. I am certain that many
would join me in warmly acknowledging the contribution that these authors
have made over the past several years in highlighting the discrepancies
with a view to improving the position of the ethnic minorities, but
equating the discrepancies to discrimination without proof is
In the authors' reply to the letters following the publication of the
article1 the authors state that no one including the senior members of the
profession is exempt from bearing the responsibility for the
discrimination in the distinction awards scheme. The responsibility
appeared to be fairly and squarely placed on the shoulders of the ACDA. I
was surprised at the relatively passive reception that this comment
received from the then chairman of the Advisory Committee on Distinction
Discrimination is defined in law. It can two forms. One is direct
discrimination where differential treatment may occur directly due to
racial bias and the other is indirect discrimination through the use of
criteria which even if applied universally places ethnic minorities at a
relative disadvantage. Both forms are unacceptable in law. There is little
doubt that individuals in the NHS have been guilty of direct
discrimination. During my membership of the regional advisory committee
for distinction awards I however did not observe any ethnic minority
consultant being deprived of a distinction award as a result of direct
discrimination. There was however undeniable statistical evidence of
proportionately fewer awards being held by the ethnic minority consultants
and this had to be explained. I made representations to the Commission for
Racial Equality (CRE) that the criteria in use at the time, specially the
weight given to work of national and international significance may in
practice make the awards less achievable by ethnic minority consultants
who may be concentrated in specialties and smaller district general
hospitals. Further “bearing the heat and burden of the day” did not
qualify for an award higher than a B award. This could pssibly have had a
detrimental effect on the ethnic minority consultants who were more likely
to be in these hard pressed posts. The results of the investigations
conducted by the CRE were included in the Annual report of the ACDA
published in March 1998. The Commission reported that it found no evidence
of direct discrimination at work within the scheme. The CRE however upheld
the view that one of the explanations for the discrepancy may be indirect
discrimination arising from the application of the above stated criteria.
Changes were made on the lines recommended by the CRE.
In view of the fact that the CRE has investigated the matter and
exonerated the scheme of direct discrimination and has offered a possible
alternate explanation it is not appropriate for individuals to continue
with allegations of discrimination and for the BMJ to publish articles
without adequate proof of the claims made. Admittedly the current article
deals with discretionary points and not distinction awards. Claims of
discrimination are still however being made without proof or serious
attention being paid to alternate explanations. Alternate explanations
applicable to the distinction awards, as it was known then, may be
relevant to the discretionary points scheme as well.
Dr. Notcutt in his rapid response has suggested several other
possible explanations which are more plausible than an act of deliberate
discrimination against a colleague. It is also heartening to know that the
ACDA have at last commissioned an independent analysis of the figures,
applying a multivariate analysis to model the relationship of a number of
factors such as age, seniority, sex, specialty, ethnicity, place of
training to granting of an award as reported in the ACDA Report on
Distribution of Awards – February 2003. Lady Valence, the present chairman
of the ACDA should be congratulated on taking this bold step which seems
to have been treated as a taboo subject hitherto by the ACDA. I hope that
this investigation is expedited and the results published as soon as
Unsubstantiated allegations of discrimination does not help the cause
of the ethnic minorities or the credibility of the scheme. These just
promote polarisation within the profession. Discrimination should only be
invoked if other plausible explanations are fully investigated and
1. Racial discrimination in the allocation of distinction awards?
Analysis of list of award holders by type of award, specialty and region.
Aneez Esmail, Sam Everington, Helen Doyle. BMJ 1998;316:193-195
A award holder at retirement. Former member of the regional advisory committee on distinction awards. Sri Lankan by birth, now a British citizen and grateful for the opportunity to practice medicine in this country.
Competing interests: No competing interests
The authors of this paper state that they 'assessed whether any
disparity.... was associated with ethnic origin and sex'. They concluded
that non-white and female consultants may be disadvantaged under the
(present) award scheme.
Their paper has not demonstrated this.
They looked superfically at ethnicity and sex, with no evidence of
causation. To prove their premise, they would have had to show that other
relevant factors were equal; other factors deserving consideration might
be hours actually worked on behalf of the NHS per week,or Emotional
Intelligence (as described in the BMJ in recent weeks, which is related to
With the advent of scoring systems now widely used in awards, there
is perhaps good reason to check that applicants with equal scores were not
disadvantaged by sex or ethnicity. That is what this paper could have
done, and such an analysis would be valuable as an audit.
An analysis as superficial as presented in this paper however does no
service to the medical profession or to those attempting to reward fairly
those who have gone the extra mile in the service of the NHS.
Competing interests: No competing interests
It is of no great surprise that this study shows that female and non-
white consultants fare worse in the race for discretionary points.
However, the conclusion that the cause is discrimination is simplistic.
The authors do not provide a breakdown in terms of speciality or age. For
example, I strongly suspect that anaesthesia does less well than general
medicine. However, the age, ethnicity, and sex profiles are different , as
are the work patterns. Anaesthesia has grown rapidly in recent years and
has often been attractive to women who have to juggle a career at home and
at hospital. Often the opportunities for extra-mural hospital activity may
be impossible for them to take up.
I have sat on the local Discretionary Points committee and the
Regional Higher Awards committee for several years (thankfully ended now).
I believe that our local DP committee has worked hard to fulfil its
obligation to the Consultant body with a structured approach to each
individual's application. Ultimately value judgements have to be made,
particularly when trying to balance the worth of one consultant's efforts
against another from a different speciality with a different profile of
activity. The local DP scheme allows reward in different ways for both the
steady, low level contributor and the higher flier. In this, the system
can probably work reasonably well, although it is labour intensive.
Failure for an individual in one year can be reversed by recognition in
In talking to colleagues from elsewhere I have learnt that other DP
committees vary considerably in their rigour and method of assessment.
Perhaps some remain in the clutches of the local "establishment". An
analysis of the number of trusts with anaesthetists (for example)
appearing on the committee and the points awarded to the speciality for
each trust could be an interesting survey. (Or any other speciality that
is low in the pecking order).
The Regional Higher Awards Committee was a contrast to the DP
Committee. I became progressively disillusioned with it over my 3-year
term. I think the committee I sat on struggled to achieve fairness and
balance between speciality, ethnicity, sex, geography, academia v DGH etc.
However, the large number of applicants compared to the small number of
awards (10:1), meant that each individual gets far less attention than
they deserve and that they might get locally. Success often depends on the
oratory of the various representatives as well as some implicit horse-
trading. Scoring systems help a little to provide some robustness to the
evaluations. Publications, committee service and luck remain the prime
determinants of success. The medical pecking order remains, as a glance
at the overall numbers of awards to different sexes, specialities, ethnic
origins etc. will demonstrate.
This is not racism. The primary problems are the awards system
themselves and the complex demography of the consultant body. Whether the
proposed re-structuring of the committees will work is debatable. Perhaps
the methodology for selection could be substantially improved. Doubling
the number of awards particularly regional level would be of greatest help
for there is no doubt that half the applicants are deserving of such
Maybe we should dump the DP and Higher Awards systems and develop
new and better methods for rewarding the hard-working.
Male. Anaesthetist. White. Mixed race marriage. DGH Consultant. B Award
Competing interests: No competing interests
The authors are to be commended for publishing the data showing that merit
awards are less commonly given to non-white and female consultants. They
surmise that this phenomenon may be related to racial and sex-
Perhaps they could now turn their attention to the far larger
discrepancies in merit awards between specialties? Can they explain this
on the basis of some other, even more pervasive kind of discrimination?
Perhaps they would also like to look at the significant geographical
variability in merit awards in the UK? And come up with a suggestion for
Competing interests: No competing interests
By using as their denominator figure the number of
consultants eligible for discretionary points, the authors
introduce a flaw to their hypothesis. Not all eligible
consultants apply for discretionary points. Those that do
not apply will not be considered and will not receive them.
Their finding that non-white and female consultants have
fewer points could be because more of these categories do
not apply for
Competing interests: No competing interests