Charu Chopra looks at how knowledge of our shared past and present could help the NHS to challenge workplace inequalities and discrimination
“If you know your history, then you would know where you’re coming from.”
Bob Marley sang these words in the song Buffalo Soldier 40 years ago, but they capture the essence of much that underpins the current thinking around decolonisation. If we all understood each others’ and our histories, then we would not discriminate against those whose backgrounds are different to ours, even unintentionally. Although a lot of work is being done around decolonising medical education in undergraduate courses (for example, at Bristol University), ideas about how to apply this in the NHS workplace and implement it within postgraduate medical training are less well developed.
Attention has been drawn to the differential attainment or “award gaps” seen in doctors from ethnic minority backgrounds. For many years we have also seen evidence of representation gaps; for example, although doctors from ethnic minority backgrounds make up 41.9% of the NHS medical workforce, they only occupy around 20.3% of senior medical director roles (2020 data). Discrimination and microaggressions are common experiences described by ethnic minority doctors in the NHS, and these acts of bias can create an environment where even more harms are perpetuated. In the first two months of the covid-19 pandemic, for example, 94% of the NHS doctors reported as dead were from ethnic minority backgrounds.
For many migrant doctors, factors associated with acclimatising in new working environments are thought to contribute to the award gap, as well as the effects of discrimination and bias. Initiatives like cultural competence training, equality and diversity training, enhanced induction programmes, and unconscious bias training have endeavoured to remove some of these obstacles. However, these factors cannot fully explain the award gaps that UK graduate doctors from ethnic minority backgrounds still face.
To unpick the root causes of these inequalities, I’d argue that we need to look closer at the social determinants of learning in postgraduate medical education. The learning that occurs formally and informally from peers, mentors, cross-professionals, and medical supervisors forms essential and deep learning experiences for doctors during their training. This was aptly reflected in the GMC report What supported your success in training?, which found that support from colleagues and supervisors underlies many doctors’ success stories. I’d argue that the relative lack of such social support and professional encouragement in the workplace for doctors from ethnic minority backgrounds contributes to award gaps and the excess GMC referrals seen for doctors from ethnic minority backgrounds.
Research has found that many managers in NHS organisations struggle to provide feedback to those from different ethnic backgrounds to themselves. This has a whole host of negative implications, meaning that some trainees may not be provided with feedback that is critical to learning and development, and won’t take up coaching and mentoring opportunities. Social barriers like these between those of different backgrounds may manifest overtly as bullying and harassment, or as covert/unconscious biases that operate discreetly, and guide our day to day actions.
To “know our history” is to also accept that the concepts underpinning historical racial hierarchies were born out of a need to legitimise practices like slavery and colonial rule, and that “othering” people of colour was essential to this. Pseudosciences like phrenology, where skull size and shape were linked to race and thereby used to prop up beliefs of racial superiority, stoked these ideas. While these scientific theories have been debunked, sentiments around racial hierarchies are still deeply rooted in some parts of our society, and acknowledging this is perhaps the first step towards “decolonising” our current clinical learning environments.
Since its inception, the NHS has relied on migrant doctors and nurses, particularly those from Commonwealth countries—indeed, their migration was intentionally facilitated in the twilight years of the British Empire. Yet an awareness of this history is often missing from public memory and in contemporary social and political debates. Commentators have described this erasure of the role of migrants in providing essential NHS workforce requirements as a “collective amnesia” and it continues today.
Around 37% of doctors are medical graduates from outside the UK, with 26% coming from outside the European Economic Area, yet the continued, valuable, and essential contribution of this workforce to the NHS is not the predominant narrative that surrounds this group of doctors. In the 2000s, the government’s plan to restrict immigration to the UK by capping the number of non-EU migrants, along with a Department of Health requirement that EU doctors be preferentially recruited over non-EU doctors, seemed to deny this history and even undermine it. This led to many migrant doctors from outside the EU feeling undervalued and unwelcomed in the NHS—sentiments that were relived more recently when Dido Harding pledged to end England’s reliance on overseas doctors during her bid to become head of NHS England.
Engendering a sense of belonging is essential for all doctors’ wellbeing, and is likely lacking for many doctors from ethnic minority backgrounds in the NHS workplace, who experience discrimination and lack the professional backing extended to other colleagues. Further research would help us to better understand these narratives, and may provide solutions to remedy this.
Only by first knowing our history can we develop compassionate and inclusive learning environments for our doctors of diverse backgrounds. This knowledge of our shared past and present helps us to challenge discrimination and promote a sense of belonging in our doctors from ethnic minority backgrounds. NHS leadership must show compassion and humility in this learning journey, exercised through the lens of history, allowing trainees’ own individual stories to emerge, which we all need to listen to openly.
Charu Chopra is associate postgraduate dean for equity, diversity, and inclusivity at Scotland Deanery. She is also a consultant immunologist at the Royal Infirmary of Edinburgh. Twitter @_DrCharu
Competing interests: none declared.