Blog by Sharon Yip
Talk of access to public institutions such as healthcare has been amplified in recent months, due to the Black Lives Matter movement. However, less discussion has been focussed on internal access for staff members working within medicine. Many initiatives aim to improve access to medical education and reduce differential attainment for trainees, yet such initiatives remain difficult to fund and evaluate.
In my local area at Buckinghamshire Healthcare NHS Trust, the Workforce Race Equality Standard (WRES) Action Plan 2020 details that the relative likelihood of staff being appointed from shortlisting is 1.98 times higher for white candidates.1 There is also a perceived barrier to career progression, as 23.3% of ethnic minority staff do not believe the Trust offers equal opportunities for career progression. The Trust reports key goals in altering the make-up of the Board and leadership positions, with a clearly measurable aim to have over 24% ethnic minority individuals in these positions by 2022.
In 1956, V.F. Ridgway noted the importance of judicious measurement: “what gets measured gets managed”. This is especially relevant when evaluating interventions to address differential attainment (DA), the phenomenon of performance differences in medical training between individuals grouped by age, gender, and race. This piece focuses on measuring the impact of interventions on Black, Asian and minority ethnicity (BAME) trainee experience which influences training outcomes yet is difficult to quantify.2 Such difficulty contributes to the scant literature on postgraduate interventions, even as anecdotally many organisations implement interventions to support trainee doctors.3
Numerous NHS trusts use Training the Trainers workshops to develop skills for supervising clinicians from diverse cultural and linguistic backgrounds. Trainee experiences are often measured quantitively, eg. frequency of trainer-trainee meetings is recorded in the National Training Survey (NTS). Whilst this generates an accessible overview, qualitative measures are necessary to explore nuances of trainee experience while interfacing with trainers. Trusts employing BAME networks to reduce DA often cite social support and mentoring as benefits, shown through interviews and focus groups.4 Variations shaping trainee experience are intangible and multi-dimensional, thus requiring qualitative approaches to capture lived experiences. Such reliance on qualitative data disadvantages these projects due to complexity of data interpretation, negative perceptions of data validity, and a preference towards quantifiable outcomes reflected in funding decisions.
One must also consider mixed-method approaches. For example, bullying and discrimination are reported in macro-level surveys such as the WRES data, NTS and NHS staff survey. However, this requires respondents to self-identify their experiences, reported numbers are restricted, and figures reflect long-term effects. Qualitative interviews offer opportunity for experiences to be iterated, bypass a need to self-identify experiences, encourage sharing in a safe setting and highlight immediate impact. Large-scale qualitative methods consume substantial time and resources and require organisational support to analyse data. Hence organisations must act to develop both long and short-term measures to evaluate interventions. Afterall, trainee experiences of racial discrimination, bullying and disengagement are also related to patient satisfaction.5
So far there is a paucity of robust evidence for any single intervention to reduce DA related to racial inequality.6 As there are no one-size-fits-all solutions, this is perhaps to be expected. Leaders who intervene locally and evaluate outcomes in a holistic manner are likely to find solutions. This can come in the form of locally scalable career development programmes such as Bradford’s “Moving Forward”, which aims to equip BAME healthcare professionals such as nurses in band 5 or 6 with leadership and management skills to support them in applying for more senior positions. Or this can come in the form of subtle cultural shifts which build an inclusive workplace that values diversity. A strategy that many NHS Trusts employ is forming BAME networks. For instance, East London NHS Foundation Trust has five separate staff networks for marginalised groups, including BAME individuals. Notably, the network leads have access to dedicated sponsors, financial channels, and protected time to organise events and meetings. This provides further opportunity to measure and evaluate the impact of their work locally.
Local initiatives to reduce barriers for BAME trainees have the power to respond to local needs. However, these often face the largest obstacles for assessment of their short-term impact. Education providers must endeavour to support and fund pragmatic, reliable and relevant measures which capture initiatives’ multi-dimensional impact. The summative effect of interventions may meaningfully reduce DA and increase access to “success factors”.7 Therefore, despite the challenges of evaluation, continued commitment to wide-ranging approaches and valid measures of trainee experience are essential for education providers to understand and evidence effectiveness of such interventions.
Sharon Yip is a foundation year doctor working in the Oxford deanery, UK. She is currently studying for a PG Certificate in Medical Education, with an interest in BAME representation and differential attainment.
 Buckinghamshire Healthcare NHS Trust. October 2020. Workforce Equality Plans. Available at: https://www.buckshealthcare.nhs.uk/For%20health%20professionals/workforce-race-equality-standard.htm
 Work Psychology Group. 2018, Evaluating the Impact of Interventions Aimed at Addressing Variation in Progression Associated with Protected Characteristics Known as ‘Differential Attainment,’ Available at: www.gmc-uk.org/-/media/documents/gmc-differential-attainment-final-report-13_08_18-76652679.pdf.
 Regan de Bere, Sam, et al. General Medical Council, 2015, Understanding Differential Attainment across Medical Training Pathways: A Rapid Review of the Literature, Available at: www.gmc-uk.org/-media/documents/GMC_Understanding_Differential_Attainment.pdf_63533431.pdf.
 Ross, Shilpa et al. The Kings Fund, 2020, Workforce Race Inequalities and Inclusion in NHS Providers, Available at: www.kingsfund.org.uk/sites/default/files/2020-07/workforce-race-inequalities-inclusion-nhs-providers-july2020.pdf.
 Dawson, Jeremy. NHS England, 2018, Links between NHS Staff Experience and Patient Satisfaction: Analysis of Surveys from 2014 and 2015, Available at: www.england.nhs.uk/publication/links-between-nhs-staff-experience-and-patient-satisfaction-analysis-of-surveys-from-2014-and-2015/.
 Woolf, Katherine. “Differential Attainment in Medical Education and Training.” British Medical Journal, 11 Feb. 2020, doi: https://doi.org/10.1136/bmj.m339 .
 Roe, Victoria, et al. GMC, 2019, “What Supported Your Success in Training?” A Qualitative Exploration of the Factors Associated with an Absence of an Ethnic Attainment Gap in Post-Graduate Specialty Training. Available at: www.gmc-uk.org/-/media/documents/gmc-da-final-report-success-factors-in-training-211119_pdf-80914221.pdf.