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Why This Matters in General Practice

General practice is the frontline of modern Britain. You will see patients from every background, every faith, and every possible combination of language, culture and family structure. Your ability to meet each person where they are — without assuming, without flattening, without performing — is a core clinical skill, not a soft extra.

It also matters because the evidence is uncomfortable. BAME patients receive different investigations, different referrals, and in some cases, worse outcomes. BAME trainees face higher exam failure rates, more GMC referrals, and slower progression. If we do not talk about this honestly, we cannot fix it.

The 9 Protected Characteristics

It is against the law to treat someone unfairly because of any of these nine things. They are called protected characteristics, and they are shielded by the Equality Act 2010. Every GP trainee should know them.

Our children are quietly trained into the social hierarchies around them, long before they know what they are being taught.

Race, Ethnicity, Nationality

These three words are often used as if they mean the same thing. They do not. Understanding the difference helps us speak about people more accurately — and more respectfully.

The Danger of a Single Story

Please watch this beautiful TED talk by Chimamanda Ngozi Adichie. She explains what happens to a whole group of people when the world only hears one story about them — and how powerful it is when more stories are told.

Her talk on feminism, given from a Nigerian perspective, is also worth your time. It opens a window into the thinking of some of our trainees and trainers. Not everything transfers to the UK, but many of the unspoken cultural signals she describes certainly do.

One of her most important points is that change begins with children — and with us. Young people need to believe that more is possible for them, and that someone will support them in reaching for it. We must help people step out of the cage of pre-set ideas — that being a girl, or Black, or middle-aged and barely comfortable with computers, does not mean your life has to look a certain way.

Change has to start inside each of us. And when we see it happening around us, we need the courage to name it.

"White Privilege"

Peggy McIntosh's essay "White Privilege: Unpacking the Invisible Knapsack" is one of the clearest pieces ever written on this subject. Please read it. You will understand far more about what white privilege actually means after twenty minutes with her words than after any lecture.

Privilege here does not mean that white people have had easy lives. It means the absence of certain obstacles — not unearned riches, but unearned protection from particular hardships. The numbers below help show what that looks like in Britain.

This short video by John Amaechi gives the clearest explanation of white privilege you are likely to hear. He describes it as "the lack of impediment" rather than "unearned riches" — and he is kind about it. We all face hardship, he says, and some of that hardship comes from the absence of privileges that others are given automatically. It is not about blame or shame. It is about awareness, so we can begin to close the gap.

Notions of Deficit

The deficit theory of education used to argue that students who were different from the "norm" — in race, class, gender or ability — should be treated as deficient. The job of education, this theory said, was to correct them.

For example, by the age of five, Black children living in poverty in the UK are around a year behind their wealthy peers in vocabulary. Deficit theory would treat this as the child's problem, rather than a symptom of the conditions they were born into.

Most of us would reject this theory if it were spelled out to us plainly. But it has not fully gone. It lingers in quieter places — in the low expectations some educators hold for students of colour, or for international medical graduates. It shows up in the gentle surprise when someone "unexpected" does well. That, too, is deficit thinking.

What is Racism?

Two definitions worth sitting with:

But perhaps the single most useful way to think about racism is this:

This is important, and it is not limited to race. It applies to any group dynamic where power meets prejudice — including caste and colourism within communities of colour themselves.

Unconscious Bias

Unconscious bias is about the individual, not the institution.

We gravitate towards people who look and think like us (Boliver, 2016). Burgess and colleagues put it plainly: even consciously egalitarian people may hold negative ethnic and racial stereotypes of which they may not be fully aware.

The consequence is that unintentional bias can be just as damaging as overt bias. We may not mean harm. Harm still happens.

What is Institutional Racism?

You may think racism is the fault of a few "bad apples" — and that is not you. But there is something bigger going on. There are structures built into our organisations that quietly deny fair opportunity to people from diverse backgrounds. Saying "I'm not racist, I'm not a bad apple" misses the point entirely.

The Macpherson Report, published in 1999 after the murder of Stephen Lawrence, gave us the landmark definition of institutional racism. It is still the definition we use today.

Critical Race Theory & Microaggressions

Critical Race Theory (CRT) began in American legal studies. It argues the following:

(Gilborn, 2008)

The Iceberg of Racism

A useful way to picture racism is as an iceberg. The part above the water — the overt, aggressive part — is what everyone talks about. But the much larger part sits below, quietly shaping lives every day.

Colour Blindness & Whiteness

Colour blindness

"Colour blindness" is often presented as a virtue — "I don't care what colour they are. I treat everyone the same." In reality, it can be just as harmful as overt racism, because it keeps the existing power relationships intact. It sounds generous but reflects ignorance, and sometimes superiority.

When we claim not to see difference, stereotypes do not disappear — they go underground. They still shape the quiet assumptions people carry. Black children are "the ones who underachieve", or "the aggressive ones", or "the ones who are good at sport". None of that leaves the room just because we say we don't see it.

Whiteness — and moving forward

Progress is not about militancy. It is not about shame. It is about moving forward — together.

Brené Brown makes a beautiful distinction between shame and guilt. Shame says "I am bad", and it freezes us. Guilt says "I did something bad", and it moves us. We need the second, not the first.

What helps?

• Developing racial literacy — the language and knowledge to talk about race clearly.
• Working parties that include diverse voices — not as tokens, but with real power.
• Sharing pastoral work — making sure the emotional support of diverse trainees is not quietly dumped onto educators of colour.
• Scenarios and training exercises that bring trainers and trainees into the conversation together.

Injustice in the NHS — Real Examples

These are real reflections from doctors and trainees. Click each question to read the examples. They are shared here not to shame anyone, but to help us recognise what injustice and microaggressions actually look like — and to practise what to say next time.

The DDDD Framework

When you witness poor behaviour, it can be hard to know what to do in the moment. The DDDD framework — from the Active Bystander programme — gives you a simple sequence of steps. It helps you challenge unacceptable behaviour in a way that opens the door to change, rather than shutting it.

The beauty of DDDD is that you always have at least one option available, even when the others feel too risky. The aim is not to win an argument. The aim is to reinforce, gently but firmly, where the line is.

But Talking About Race Feels Like Walking on Eggshells

Yes. It does. And we need to breathe through that discomfort, because how else do we get to the other side? Tackling inequality is everyone's responsibility.

Peggy McIntosh offers a helpful image. She says she was born into a white, privileged background — and it is like being handed a bank account with money in it, without asking for it. What she chooses to do with that account is her responsibility. She can use it to reduce the inequalities around her.

It is easier to stay with people who feel familiar — birds of a feather flock together, as the saying goes. That is unconscious bias at work. We don't look because we are not the ones causing harm directly. But we are complicit the moment we look the other way.

You may see yourself as not racist. You don't hurl abuse. But there are things life has given you that others have not been given — simply because of where and how you grew up. Most of us end up where we are not purely through merit. Many of us were given a quiet head start, at the expense of people from different backgrounds who were never given the same. That is the inequality we are talking about.

Racial Inequalities in Medicine & Healthcare

This is not abstract. The effects of racism in medicine are measurable, and they are measured. Here is a selection of what the evidence shows.

For doctors and students in training

For patients

Other things worth knowing

• Medical students from ethnic backgrounds other than White British are less likely to get a First or Upper Second class degree. There is an attainment gap that runs from medical school through to postgraduate exams.
• Doctors from ethnic backgrounds other than White British apply for more posts on average than White doctors to reach the same outcomes — and are less likely to be shortlisted or appointed (GMC data).
• Doctors from ethnic backgrounds other than White British are more likely to be referred to the GMC by employers. The GMC has acknowledged this disparity and committed to reducing it in its published Fair to Refer? and follow-up programmes.
• There is limited ethnic diversity in medical research — most study participants are white, which has implications for the evidence base.
• Dermatology has historically been taught predominantly on white skin. Textbooks and teaching resources are slowly being updated, but the gap remains.
• The higher you climb the medical hierarchy, the whiter the room tends to become — particularly at consultant, partner and board level.
• Racist abuse still happens — from patients and from colleagues — and is now recognised formally in BMA, GMC and NHS England guidance.
• Ethnicity data is often missing from records of disease and death, which makes inequalities harder to see and harder to act on.
• The question of how NHS services are experienced by ethnic communities beyond the White British majority — and whether they feel listened to — is still not asked often enough.

Differential Attainment — What the Data Shows

"Differential attainment" is the term for the gap in exam and progression outcomes between different groups of trainees — a gap that persists even after controlling for other factors. The numbers below come from UK primary care research and the General Medical Council. They are uncomfortable. They are also the starting point for change.

Source: General Medical Council and RCGP data, summarised across multiple BJGP analyses (e.g. Woolf 2019; Esmail & Roberts 2013). Specific percentages vary by year and exam diet — check GMC/RCGP annual reports for the latest figures.

Why does the gap exist?

The research is clear on one point: the gap is not explained by ability. After controlling for A-level results, school type, socio-economic status, parental occupation, language, motivation, study habits and personality, a difference remains. The causes are multiple and structural:

• Relationships matter. BME trainees describe feeling they have to work harder to prove themselves, and finding it harder to get support from senior colleagues when things go wrong.
• Isolation is real. UK qualitative research finds trainees from minority backgrounds can feel more isolated, especially when there is a difficulty with the trainer themselves.
• IMGs face a steeper induction. Cultural and consultation-style differences, unfamiliar NHS systems, separation from family, and a learning culture that rewards assertiveness all add up.
• Unconscious bias shows up in workplace-based assessment. Less well-evidenced than exams, but harder to audit — and where much of the quiet gap lives.
• The deficit framing still lingers. Educators sometimes see "at risk of failing" trainees through a lens of what they lack, rather than what the system is not giving them.

What is being done

Since 2020, a national response has taken shape. NHS England, NHS Education for Scotland, the RCGP and the GMC have launched a coordinated programme — and outcomes are already improving where targeted support has been offered:

The GP Action Framework

Understanding race and culture is one thing. Putting it into practice in your consulting room is another. Here is a simple, usable sequence for every consultation.

Handling a Racist Patient

Racism from patients towards doctors and staff from different ethnic backgrounds is not rare. Successive NHS Staff Surveys have consistently shown significant proportions of staff from different ethnic backgrounds reporting discrimination from patients, relatives or members of the public. The good news: there is a clear, sanctioned pathway, drawn from BMA, GMC and NHS England guidance. You do not have to figure this out alone.

The IMG Consultation Shift

If you trained outside the UK, your consultation style was almost certainly shaped by a different system — one that was entirely appropriate for where you practised. UK general practice asks for something different, and the SCA is built around that different expectation. The table below captures the most common adjustments trainees describe having to make.

The "Broken Mirrors" story — a cautionary tale

Not all adjustment advice is good advice. Sometimes trainees are told, in the name of "improving communication", to change something they should never have to change. The following is a real, published case from UK general practice — and it is essential reading for trainers as well as trainees.

Insider Pearls — What Nobody Tells You Early

The following insights come from recurring themes across UK GP trainee blogs, training forums, deanery newsletters, and UK GP training YouTube content. They are the kinds of things experienced trainees wish someone had told them in ST1. Each one has been checked against RCGP, GMC and NICE guidance before being included here.

Teaching This Topic — Trainer Pearls

Race, ethnicity and culture are not easy topics to teach. Trainees may feel defensive, anxious, or unsure what is safe to say. Your job is to make the conversation possible — not perfect.