Racism In The NHS

Black and Minority Ethnic Doctors within the British National Health Service: What can History tell us?
{Centre for the History of Science, Technology and Medicine, University of Manchester}

In Britain, current estimates suggest that up to 33% of doctors practicing within the National Health Service (NHS) are from Black and Minority Ethnic Backgrounds (BME). This is contrasting to the number of BME individuals within the background population, which stands at just 7.9%. From 1948, when the NHS was first founded, to the 1980s the number of BME clinicians steadily increased.

Within British medical schools BME applicants are less likely than their white counter-parts to succeed in their applications despite equivalent qualifications. This has been shown since 1982 and persists into the most recent analysis in 2008. Once at medical school BME students are more likely to fare worse in both undergraduate and postgraduate examinations than their white counterparts.

The aim of this essay is to illustrate the integral role BME doctors have and continue to play within the NHS, from its inception, with the migration of thousands of doctors from the Indian subcontinent in the 1950s onwards, to the present application of British-educated BME applicants to medical school. It is only from learning from our past that we can progress towards the egalitarian ideal that current law would have us aspire to.

Introduction

In Britain, current estimates suggest that up to 33% of doctors practicing within the National Health Service (NHS) are from Black and Minority Ethnic Backgrounds (BME). This is contrasting to the number of BME individuals within the background population, which stands at just 7.9%. From 1948, when the NHS was first founded, to the 1980s the number of BME clinicians steadily increased. The number of BME clinicians in managerial positions and positions of authority, did not, increase proportionately. Currently, less than 1% of NHS chief executives are from a BME background. (Esmail 2007, Snow 2010, BMA 2009)Within British medical schools BME applicants are less likely than their white counter-parts to succeed in their applications despite equivalent qualifications. This has been shown since 1982 and persists into the most recent analysis in 2008. Once at medical school BME students are more likely to fare worse in both undergraduate and postgraduate examinations than their white counterparts. (Collier & Burke 1986, BMA 2009)

These figures are of course disturbing as they indicate a failure of the NHS as an employer and British Medical Schools as Higher Education Institutions (HEIs) to address the discrimination that the BME population of Britain faces. Regardless of a particular moral standpoint, in the light of the Race Relations Amendment Act (2000), a legal statutory right has been placed on the employer/HEI to promote equality within their institution. Failure to do so could result in a potential prosecution. However, indirect discrimination, which is the most likely mechanism of discrimination within these organisations, is diffuse and often intangible meaning it is a difficult concept to both identify and redress when it occurs. (BMA 2009, Esmail 2006)

The aim of this essay is to illustrate the integral role BME doctors have and continue to play within the NHS, from its inception, with the migration of thousands of doctors from the Indian subcontinent in the 1950s onwards, to the present application of British-educated BME applicants to medical school. It is only from learning from our past, and acceptance of some of the mistakes that may have been made, that we can progress towards the egalitarian ideal that current law would have us aspire to.

Post-War Britain; Labour Shortages & the Creation of the NHS

The Second World War ended in 1945 and with it came a host of challenges, the most relevant of which to this topic being the chronic labour shortage. The armed forces retained much of Britain’s male population and suffered much loss of life as a consequence. Many members of the population retired due to their age and the school leaving age was raised to 15. These and various other factors contributed to the labour shortage which post-war Britain faced. (Snow 2010).

Under the guidance of the Labour PM Clement Attlee and Minister of Health Aneurin Bevan the NHS was conceived and was by no means exempt from the labour shortage. Health care was being offered to those who had previously no access to such resources inevitably increasing demand. From 1949 – 1953 the number of hospital inpatients rose by 600,000. As a consequence of this increase in patient numbers, hospitals were required to increase the numbers of doctors and nurses. In its first decade the number of medical staff employed by the NHS rose by 30% in England and 50% in Scotland. The number of nursing and midwifery staff rose by 26% across Britain. Many of these new doctors and nurses came from overseas to face new challenges in their host country, however, this essay will primarily discuss the experiences of the former. (Kyriakides 2003, Snow 2010)

The Goodenough Committee, in 1944, had predicted the shortage of doctors within the medical profession at the time, recommending the expansion of all British medical schools to accommodate for the perceived shortfall. These recommendations were unfortunately superseded by recommendations put forward by the Willink Committee, who published in 1957. (Snow, 2010) The Willink Committee recommended a decrease in the intake of British medical schools by 10% to prevent overproduction. They failed to take into account the increasing demands of the growing British population upon the NHS and the idea that some British doctors may not wish to stay in Britain but themselves emigrate, an idea that may have undermined the NHS as; ‘a symbol of Britishness’ (Kyriakides 2003)

Due to the Willink Committee’s underestimation of the requirement of British-educated doctors medical recruiters were forced to search further afield to fulfill the demand placed on the NHS. Thankfully, due to the close relationship the British Empire had shared with India until it’s independence in 1947, doctors from the Indian subcontinent were willing and able to migrate to Britain. (Esmail 2007)

Why The Indian Subcontinent?

By 1960 the number of Junior doctors from the Indian subcontinent (India, Pakistan, Bangladesh and Sri Lanka) was between 30-40% of the total workforce. These are unprecedented numbers and the question as to why so many doctors from the Indian subcontinent chose to emigrate must be asked. (Snow 2010) Britain first colonised India over 400 years ago and along with the ‘creation’ of many other public services, spawned the Indian Medical Service (IMS). Upon it’s creation the IMS was exclusively available for Europeans only to enter, this exclusion criteria, was however, lifted in 1855 enabling Indian citizen’s to enter also. (Esmail 2007)

The IMS was not without controversy. During the 19th century there was much debate regarding Orientalist versus Anglicist views of how medicine should be practiced and taught. Orientalists maintained the indigenous culture of Indian medicine should remain intact whilst being simultaneously assimilated with that of western culture. Anglicists fought for the eradication of Indian culture and traditional medicine and its replacement with Western medical education and values. The anglicist perspective prevailed and by 1892 Indian medical degrees were recognised by the General Medical Council (GMC), tailored to the needs of the British. This was not, perhaps, the best outcome for a developing nation. The health service of India became reliant on doctors as opposed to non-medically trained health workers and assistants who were easier to train and more populous in number. (Esmail 2007)

England was held in high esteem by contemporary Indian society at the turn of the previous century. Esmail (2007) states that; ‘coming to England was like a badge of honour…in the 1800s’, whilst R. Madhok, Medical Director of NHS Manchester states;

‘From a very early age, two things were clear in my life. One, that i would become a surgeon and two, that i would go to England to train…My family had lived under the British Raj in what became Pakistan after the partition of the country. As refugees in India….they had fond memories under the ‘fair sahibs’…going to England was a given for me.’ (Snow 2010: Foreword XV)

These quotations illustrate the pedestal that England and English society was placed upon. They may go some way to understanding the desire of many doctors from the Indian sub-continent to train here and fulfil the shortage of doctors that the NHS was facing post-Willink committee. Unfortunately, the reception they received upon arrival was less than savoury. (Esmail 2007, Snow 2010)

Reception of Migrant Workers in Britain

The medical profession can not be viewed through an isolated lens when describing the reception given to overseas doctors. Attention must be paid to the treatment of all migrant workers as a whole, rather than within the medical community specifically, if a fair appraisal of the social and political climate of the time is to be sought.

Due to the labour shortages discussed above, 1948 saw the introduction of the Nationality Act which granted British citizenship to citizens of the British colonies and former colonies. Waves of thousands of migrants from the West Indies and South Asia settled in Britain. Prior to 1948 5% of the British population had been born overseas. The first waves of migrants to enter Britain faced considerable discrimination in all aspects of day to day life. Quotas were enforced by trade unionists, limiting the numbers of BME workers a given employer could hire. Housing allocations were unofficially biased in favour of white British people leaving black and Asian people to cluster in poor and often squalid conditions in inner city wards. (Snow 2010)

These tensions came to a head in the summer of 1958 when rioting broke out in Notting Hill, London and Nottingham. In a community that had been marginalised and unsupported: it was an era when the newly settled waves of Caribbean immigrants had had enough and responded to unacceptable racial bigotry.’ (Jan-Khan 2003)

These were not the first riots caused by a deep sense of discontent ingrained within a community that were in need of social and political representation. The storming of the Bastille in Paris, 1789, with the subsequent revolution that occurred is but one early example of the power of a mob. Unfortunately this outburst of both aggression and frustration from the Afro-Caribbean community only served to further perpetuate their alienation from British society, politicians in general and the governing Conservative party of the time. Kyriakides argues that it was not, in fact, the fault of the migrant population of Britain at the time but a consequence of the growing racism and discrimination that was apparent in British society. (Kyriakides, 2003, Jan-Khan 2003)

Four years after the first ‘race riots’ in Britain, as the media gleefully labelled them, 1962 saw the introduction of the first piece of legislation designed to halt the influx of migrants from the former British colonies. The Commonwealth Immigrants Bill was passed, restricting the entrance of citizens of the commonwealth to those who had been issued with employment vouchers. This, as Paul (1998) observes, created a change in dynamic from the right that a citizen of the new Commonwealth had to become a citizen of Britain, to one of a contract worker, employed by the state with the state holding an ability to terminate that contract of employment. (Paul 1998, Kyriakides, 2003)

Employment vouchers were issued in three categories; A – to workers that had already secured employment within Britain, B – to workers whose skills were required within Britain and C – for other migrants from the commonwealth that did not meet the criteria for either A or B vouchers. It was migrants who were coming to staff the British NHS that obtained working vouchers in the A & B categories. (Kyriakides 2003)

1968 saw the Labour government of the time, led by Harold Wilson, introduce another measure to combat the migration of people from the former colonies, the Commonwealth Immigration Act. The trigger for this was the expulsion of tens of thousands of Asian Kenyans from their home country by ‘africanisation’ policies forced to seek refuge in Britain, the country of which they were passport holders for. This mass of refugees did not ignite within British politicians a sense of injustice and of wrongdoing, but caused quite the opposite; the hastening of the Act through Parliament in an attempt to block refugee’s from arriving. (Kyriakides 2003)

The Commonwealth Act 1968 was to set in motion the institutionalisation of the concept of ‘patriality’; the idea that in order to avoid immigration controls an individual migrating from the commonwealth had to have either a parent or grandparent born in Britain. Kyriakides states “Only possession of ‘British Blood’ could guarantee entry into the UK.” A position that was starkly contrasting to that held by Britain 20 years prior, when the state required migrant labour to prevent the collapse of major industries. It was soon after the introduction of this policy that Enoch Powell made his, now infamous, ‘Rivers of Blood’ speech.

Reception of Migrant Doctors

From the introduction of the Commonwealth Immigration Bill in 1962 – 1972 well over 16,000 migrants from the new Commonwealth (India and Pakistan in particular) came to work in Britain as doctors. This was by no means a co-incidence; the Ministry of Health worked in close contact with the Ministry of Labour throughout the duration of the 1960s to ensure a constant inflow of doctors, ready to staff, as juniors, the fledgling NHS. Within the British Medical Association (BMA), however, the attitude towards migrant doctors was that of antagonism and restriction of rights. A view somewhat influenced by the current social climate of the time but in opposition to the needs and requirements of the institution the BMA was serving. (Kyriakides 2003, Esmail 2007)

The dichotomous relationship which medical migrants faced was spoken of in a debate in the House of Lords in 1961. Lord Cohen of Birkenhead politely reminded the house that ”the health service would have collapsed had it not been for the enormous influx of junior doctor’s from countries such as India and Pakistan” (Email 2007)

Whilst Lord Taylor of Harlow was less forgiving in his comments: ”they are here to provide hands in the rottenest, worst hospitals in the country because there is no-one else to do it.” (Esmail 2007)

Despite the obvious need of migrant doctors, the reception given to them was not one of welcoming. Esmail (2007), demonstrated through a search of British Medical Journal (BMJ) articles from 1961-1975 what would now be construed as “offensive and racist” language used in numerous letters from British clinicians complaining in regards to the standards of their Indian colleagues medical training, their language abilities and difficulties in understanding the intonation of Indian speech. The reality, as demonstrated by Smith (1980) in an objective assessment of migrant doctors language skills, was that the vast majority of migrant doctors possessed a good grasp of the English language, along with good communications skills, not the inverse, as Esmail illustrated was thought by their British counter-parts. (Esmail 2007, Smith 1980)

The Saviour Pariah Construct

The migrant doctor as a ‘savior’ has already been illustrated by reference to the discussion that occurred in the House of Lords. The idea of the migrant doctor being a pariah has been alluded to and will be further discussed here.

Migrant doctors entering Britain were exempt from the Commonwealth Immigration Act of 1968 but were not exempt from its legal ramifications. They were categorised, upon entry, as ‘non-patrials’ otherwise seen as ‘non-British’ a description based solely upon the colour of their skin, irrespective of the degree to which they were committed to their employment within the NHS, one of the ‘great British institutions.’ (Kyriakides 2003)

As reflected in the discussion of the social climate of the time with respect to migrants and employment, employment within the NHS was no different. There may not have been quotas introduced by hard line trade-unionists but there was a disproportionate number of overseas doctors working within the ‘Cinderella services’ of the NHS. (Esmail 2007)

Between 1968-1975 general practitioners (GPs) from overseas accounted for a 78% increase in the number of practicing GPs. The vast majority of these GPs were concentrated in deprived inner city areas or very remote areas, both of which white doctors chose not to work within. (Kyriakides 2003)

It was not exclusively GPs that were allocated less than first preference. Overseas doctors seeking to further their careers in their chosen subjects came across significant difficulties in accessing training opportunities such as rotations within teaching hospitals. This was due to the informal networks developed during training as a student in the locality, the development of an ‘old boys club’ to which entry was impossible without prior exposure, thus creating a vicious cycle of foregone opportunities. Because of this, one survey of hospital medical staff by grade and ethnicity in 1975 showed an incongruous proportion of doctor’s who had been born outside of Britain concentrated in the House Officer and Senior House Officer positions when compared to others. (Snow 2010, Esmail 1993, 1997, Kyriakides 2003)

Overseas doctors were also highly represented in what were seen as the ‘less desirable’ specialties or those which did not appeal to white British doctors such as the predominately social specialties; geriatrics, facilities for the mentally handicapped and mental illness. What have now become Old Age Medicine and Psychiatry. The strong tradition of Indian and Pakistani doctors entering these specialties persists to this day. Is it not an indictment upon British doctors that the most vulnerable individuals in British society were considered too inferior to be treated by Britains own doctors? Smith (1980) also demonstrated that over 60% of Asian doctors settled within a specialty that was not their first choice.

Esmail, controversially argues, that Asian doctors had become ‘indentured labourers’ of the NHS. Much in the same way that Indians were promised better lives by the ruling British powers during the 20th Century if they agreed to migrate to other British colonies, Asian doctors were promised the same. Although Asian doctors were paid adequate wages, unlike their ancestral counterparts, they were not given adequate opportunities for career progression or to obtain further medical qualifications. Smith (1980) illustrated that half of all overseas doctors were disappointed with the experiences they had gained whilst working and studying in Britain. They were ‘indentured labourers’, of a kind. (Esmail 2007, Smith 1980)

The Merrison Committee Report

The Merrison report (Siebert 1977) on the regulation of the medical profession was to end mass migration of Asian doctors. It gave authority to the GMC to remove the right of registration of all Indian graduates. The justification of the GMC for the removal was given as follows;

‘[it] was no longer able to effectively satisfy itself as to the standards of qualifications currently granted in India, although this did not reflect on the standards of earlier years’ (Parkhouse 1979: 92)

The Merrison Committee gave their justification to the GMC as follows;

‘The problem in relation to doctors educated overseas is the extent to which the GMC ought to accept the standards of educational institutions overseas…it must ensure that the overseas doctor has reached a standard of competence which is at least equivalent to that of the minimum standard required for the registration of a doctor trained in the UK’ (Parkhouse 1979: 72)

There was concern from the Merrison Committee as to the standards of overseas doctors and HEIs overseas. However, there was no withdrawal of recognition of European medical schools by the GMC, the withdrawal was solely focused on HEIs within the new Commonwealth; with non-white doctors. The inference that can be drawn from the Merrison Committee’s recommendations, and which Kyriakides makes very eloquently;

‘low standards were a danger to the public, low standards being synonymous with overseas doctors from the new commonwealth…Only those who  practiced in British or European standards would be accepted, all else would provide an inferior quality of service.’ (Kyriakides 2003)

From 1975 onwards all Indian graduates had to complete an assessment of professional and linguistic capacity in order to register temporarily with the GMC, to avoid the perpetuation of ‘low standards’ and ensuring a superior ‘quality of service.’ The justification for the treatment of overseas doctors was based on a report created by a panel on which not one was a member of an BME group, no member had experience in working with overseas doctors and there was no representation given to overseas doctors themselves. (Roy, 1975)

The discrimination that overseas doctors faced was not simply due to the perception that their home universities had ‘low standards’ as a report published by the Commission for Racial Equality in 1987 suggested that British trained doctors from ethnic minority groups had difficulties getting the best jobs. Esmail (1993) sought to confirm this with a prospective study analysing the shortlisting rates of applicants with both European and non-European surnames who had received education in British medical schools and had equivalent qualifications. This showed, at shortlisting there was a two fold bias towards those candidates that had European surnames over those that did not. (Commission for Racial Equality 1987)

What can be inferred from the results of this study and the report is that discrimination by surname took place during the 1980s and 1990s, regardless of the particular HEI you were educated within. ‘Low standards’ had become synonymous with non-white skin, with non-European surnames.

British Born Ethnic Minorities and their Application to Medical School

Without the influx of migrants from the commonwealth during the post war era BME would not be an abbreviation that we use today. Equally, without the establishment of initial migrant communities there would be no ‘second generation’ of which the remainder of this essay will focus on. Britain has been blessed with a multicultural and multi-ethnically diverse society, the latest 2001 Census figures (Office of National Statistics, Census 2001) are shown in the table below;

Table 1. Percentage of population within each ethnic group as recorded by the National Census 2001 (Office of National Statistics, Census 2001)

Within both applicants to medical school and medical students there is an over-representation of BME students, the most recent 2008 figures show 36% of applicants and 28% of acceptances were non-white. Why there is such a strong tradition of medical education within BME communities can be observed by the; ‘high esteem for medical careers in particular minority ethnic groups, especially those from Asian backgrounds’ (BMA Equal Opportunities Committee, Equality and diversity in UK medical schools, 2009: 51)

However, this has not always been the case. In 1981, for example, BME applicants occupied 11.2% of the total number. BME applicants have since then steadily increased in number. Prior to 1989 the Universities Central Council on Admissions (UCCA) did not collect data from applications regarding their ethnicity and as such it is difficult to quantitatively analyse any data relevant to BME medical applicants prior to 1989. The collection of data regarding applicants ethnic identity was prompted by an investigation by the Commission for Racial Equality into the admissions procedure at St. George’s Hospital Medical School in 1987 where there was found to be discrimination occurring due to both race and gender. (BMA 2009, MacManus 1995)

The issue of ethnic diversity within medical schools is one that requires addressing as a recent American Medical Association (AMA) study has found that students who attended more ethnically diverse medical schools were better prepared to meet the needs of an ethnically diverse population. (Saha 2008)

The purpose of the latter section of this essay is to address the current treatment of BME applicants to medicine and their subsequent progression through medical school. Discrimination in regards to race is illegal and has been since 1976 saw the introduction of the Race Relations Act. This was extended in 2000, becoming the Race Relations Amendment Act which placed a statutory duty on all public service organisations to promote equality of opportunity and elimination of racial discrimination. The Act was introduced in the wake of the MacPherson Report (1999), highlighting institutional racism within the Metropolitan Police resulting in the failure to prosecute the killers of Stephen Lawrence, a black teenager murdered in a racist attack. Institutional racism has no place in British society or the NHS. (Esmail 2006, Lea 2000)

Before an analysis of the application process to medicine is made in respect to BME students it is sensible to take a brief look at the selection criteria used to differentiate between candidates. There are 23 medical schools within the UK with an average ratio of 1:7 in terms of applicants to offers. As medicine is an oversubscribed course some measures have to be taken in order to reduce the pool of applicants. This occurs by two main mechanisms; short listing, usually by the appraisal of the UCAS (universities and central admissions service) application form for either academic or non-academic attributes or both, and via the interview process. (Parry 2006)

The academic attributes that are sought via the UCAS application are usually either obtained or predicted a-level results (or equivalent Scottish highers/ international baccalaureate). The non-academic criteria sought via the UCAS application in 21 of 23 schools are; evidence of motivation for the study of medicine, team working, leadership skills and evidence of extracurricular activities. These criteria are then used to short-list candidates. Short listing of candidates is perhaps the most brutal of decisions as this admissions tutor writes;

‘the problem was excluding people from interview…because they were all so good…it’s terribly difficult and quite unfair…people would joke we should throw them all up in the air and the first 40 you pick for interview, it would have been just as fair.’ (Parry 2006)

The short listing process is followed by interviews; usually by a panel of both academic and clinical members of staff of varying number but always between two and five. The panelists are usually trained in how to adequately appraise potential students and comprised of both male, female and ethnic minority panelists. Questions which are asked at interview are a combination of both predetermined (from a bank) and interviewer-led in the vast majority of schools. The duration of interviews varied between 15-45 minutes, the majority however, are 15-20 minutes long. (Parry 2006)

Selection of students is a controversial topic and therefore requires the utmost transparency. The first study into the selection of medical students was conducted by Collier and Burke in 1986. As has already been noted the UCCA did not collect statistics on the ethnicity of applicants to university prior to 1989 and as such the data used in the study was collated from the surnames of final year examinations students during the summer of 1982, 1983 and 1984. Judgement on the ethnicity of the candidate was based on the nature of their surname; either European or non-European. Below is an adaptation of the original tabled produced outlining the percentage of non-European candidates within each London medical school.

Table 2. Percentage of non-European students taking final exams in London medical schools.

As outlined in the table above Westminster medical school had a mean of 5% of non-European students taking final exams whilst The Royal Free had a mean of 16% across the three years studied. It is acceptable for there to be differences within each individual school as to the year on year percentage of non-European students but what is not acceptable and difficult to account for is the statistically significant difference between each medical school in the number of non-European students. Furthermore, the inter-school differences should not remain consistent year-on-year. The data collected by Collier and Burke was the first to illustrate racial discrimination within the admissions process to British medical schools. In their own words;

‘Our evidence suggests that the admissions arrangements at some of the London medical schools have failed to provide the equal opportunities defined by the race relations act.’

The first in-depth look at selection of BME applicants to medical school was facilitated by the release of data collected by the UCCA in regards to applicants ethnicity in 1989. It was conducted by McManus and analysed data from applicants to medical school in 1990. The results of this study showed that BME applicants were less likely to be accepted, partly due to lower educational qualifications and partly due to late application. However, even when these elements were controlled for BME applicants were still 1.46 times less likely than their white counter-parts to gain a place at medical school. The greatest cause of disadvantage itself was not ethnic origin but having a non-European surname. This implied that in the short listing process there was an inherent bias towards European surnames. (McManus 1995)

McManus undertook the same study in 1996/7 with a more detailed data set and was able to draw specific conclusions in regards to each university and the rates of acceptance of BME applicants. Below is an adaptation of the the data he produced. (McManus 1998)

As can be seen from the above table only 9 of all the medical schools within the uk were statistically shown not to have disadvantaged a BME applicant. The difference between discrimination (as an active consequence of racism) and disadvantage needs to be considered thoroughly, with a robust definition of racism in place. The definition given by the Commission for Racial Equality surrounds attitudes towards BME people with other definitions centring around racism as an ideology. McManus asks the question; can the obvious disadvantage experienced by BME applicants be due to racism?

To answer this question a global view of BME doctors history within the NHS has to be taken into account. McManus rightly concludes that from statistical analysis of the numbers of BME students entering the profession in ’96 and ’97 a link can not be drawn between disadvantage and discrimination. However, when other literature such as that which has been discussed in this essay is considered a more sinister picture may be drawn from the treatment of BME students by individual medical schools.

British Born Ethnic Minorites and their Performance in Undergraduate and Postgraduate Exams

In the summer of 1994 ten medical students at the University of Manchester failed the clinical but not the written element of their final exams. All were male and all had Asian surnames. This prompted various analysis into the performance of BME medical students both in undergraduate and postgraduate exams within the University of Manchester itself and across all medical schools in the UK.

Wass (2003) published one of the first in depth quantitative and qualitative studies into BME performance in undergraduate examinations. The study group was the cohort of a London medical school (n=179) sitting their final exams in 1999. The results of the study were perhaps the most interesting published so far due to the inclusion of a qualitative analysis in addition to the usual quantitative number crunching.

The study revealed differences in the mean performance of BME students in the communication stations of their observed structured clinical examinations (OSCE’s) when compared to their white colleagues. There were no overt breakdowns of communication or discriminatory comments as witnessed by video recording of each interaction, but there were two subtle differences between the communication styles of BME students and white students. (Wass 2003)

BME students were more likely to adopt a medical model of communication, distancing themselves from the patient, whereas the model of communication favoured by OSCE examiners is a social or patient centred one, in which the patient and student are required to ‘work together’ in order to come to a join conclusion. There are a variety of reasons why BME students may be more likely to adopt this method of communication. Primary socialisation naturally occurs differently in different communities and as such the communication styles of each community are assimilated by the student concerned. Communication styles also naturally differ between communities with what some consider to be impolite others considering to be normal discourse. The quote below illustrates this. (Wass 2003)

‘Our culture is different. In India we don’t use the words like ‘please’ and ‘thankyou’ in our day-to-day language. They are formal words…In 1982, I was told by a senior nurse that I was rude, and I was shocked!’ Umesh Prabhu, Consultant Paediatrician Pennine Acute Hospitals NHS Trust (Snow 2010: 77)

Socialisation within the medical school itself is also an important factor in the generation of an appropriate rapport with patients. Professional communication is quite different to the communication that is used day-to-day between friends and family therefore immersion within the professional environment is necessary to foster an appropriate dialogue between patients. (Wass 2003)

Due to the qualitative nature of the study Wass revealed an interesting nuance in the examiners marking styles when compared to that of the simulated patient (SP) in communication scenario’s. There were several instances where examiners awarded top marks but BME SPs awarded lower marks, with the students concerned tending to use a communication style in which explicit guidance was deferred; there was more ‘talk about talk.’ This observation fits with the use of the medical model of consultation employed more regularly by BME students, which is rated more highly by some SPs from ethnic minorities. (Wass 2003)

Other quantitative analysis of BME students performance in undergraduate exams have been conducted, all showing BME students performing less well than white peers. However, Wass conducted the only study that attempted to address the reasons why there was a deficit in the examination results of BME students. (Haq 2005, Woolf 2007, McManus 2008)

Conclusion

The post-war period of British history is one that can be looked upon with great shame in relation to the treatmement of BME communities. Despite victory over Nazi Germany and the anti-semitism associated with it British people entered into a dialouge of distain with the migrant workers that emmigrated to Britain due to the creation of the Nationality Act 1948. This very same law was created to save Britain from the drastic labour shortage threatening to engulf it, yet there was no compassion from the host community. (Snow, 2010)

Within the medical profession this is best surmised as the ‘savior/pariah construct.’ Without doctors with dark skin, with non-european surnames, to staff the ‘rottenest, worst hospitals in our country’ ‘the NHS would have collapsed.’ Yet in the same breath the BMA during the 1960s and 1970s was berrating doctors from the Indian subcontinent, accusing them of ‘low standards’ and poor communication skills, the later of which, was proved to be untrue in the vast majority. Eventually, the BMA through the GMC succeeded in withdrawing registration rights to all medical schools within the Indian-subcontinent to protect ‘members of the public’ against the ‘low standards’ that had now become associated not just with the country from which the doctor graduated but with the colour of thier skin and with thier surname. (Esmail 2007, 1993, 1997, 1996, Kyriakides 2003)

The Collier & Burke study confirmed that there was statistically significant discrimination due to ethnicity occuring within London medical schools during the early 1980s. The discrimination that overseas doctors had faced within the medical profession had been passed down a generation to those educated and most likely born within the UK; not only had ‘low standards’ been assimilated into the perception of a dark skinned doctor but the very same ‘low standards’ were preventing BME people from even entering the medical profession. (Collier & Burke 1986, Kyriakides 2003)

Despite current over-proportional representation of BME students in medical school cohorts white students with equivilent grades are still more likely to be accepted than thier BME counterparts. Studies have shown that this bias may be due to surname alone causing indirect discrimination during the short listing process but anonymisation of UCAS application forms has not been shown to be effective in eliminating this bias. (McManus 1998, BMA 2009)

Within medical school BME males in particular have been shown to under perform in clinical examinations. This may be due to intrisic inter-community differences in communication style as no obvious bias is present during OSCEs. (Wass 2003)

With the commissioning of the MacPherson report and the subsequent introduction of the Race Relations Ammendment Act 2000 it is clear in that no organisation whether public or private should be privy to institutionalised racism, nor should they allow the priority of equal opportunities to be lost. (Lea 2000)