Equality & Diversity in GP Training
Because fair care isn't just good ethics — it's good medicine. And good training. And, frankly, good humanity.
📥 Downloads
Handouts, teaching scenarios, flashcards, and presentations — ready when you are. Perfect for tutorials, half-day releases, and self-directed learning.
path: Click on a folder for specific resources...
- dddd framework - challenging unnacceptable behaviour.pdf
- discrimination scenarios for gp trainers.docx
- diversity - behaviours that create an inclusive environment.doc
- diversity - terminology.pdf
- diversity amongst gp trainees.ppt
- diversity flashcards (TEACHING RESOURCE).doc
- diversity images (TEACHING RESOURCE).ppt
- diversity images worth looking at (TEACHING RESOURCE).doc
- diversity in practice.ppt
- diversity professional capabilities with descriptors.pdf
- diversity scenarios 1 (TEACHING RESOURCE).doc
- diversity scenarios 2.pdf
- diversity tutorial plan (TEACHING RESOURCE).pdf
- diversity within GP training.pptx
- equality and diversity - understanding key points.doc
- health inequalities and diversity teaching in medical student training.pdf
Web Resources
A hand-picked mix of official guidance and real-world GP training resources. Because sometimes the best pearls are not hiding in the official documents.
⚖️ Legal & Official Guidance
Equality Act 2010 — Protected Characteristics (EHRC) Equality Act 2010 Full Guidance (Gov.uk) Direct & Indirect Discrimination (EHRC) Harassment & Victimisation (EHRC)🩺 RCGP & NHS Resources
RCGP Equality, Diversity & Inclusion RCGP EDI Plan 2023–2026 RCGP Health Inequalities Hub NHS England / HEE — EDI ResourcesQuick Summary — If You Only Read One Section
under the Equality Act 2010
recognised in law
came into force
between most & least deprived areas in England
(Marmot Review 2020)
🔑 The Five Things Every GP Trainee Must Know
- The Equality Act 2010 protects 9 characteristics from discrimination — you must know all 9 by name.
- There are 4 types of discrimination in law: direct, indirect, harassment, and victimisation. Each is different. Each matters.
- Unconscious bias is real — you have it, your trainer has it, your patients have it. Awareness is the first step to managing it.
- Health inequalities are not just statistical noise — they reflect deep social injustice. The Marmot Review 2020 showed healthy life expectancy can differ by up to 19 years between the most and least deprived areas of England.
- Your role as a GP goes beyond clinical care — you are a frontline witness to health inequality and have a professional duty to notice, respond, and advocate.
Legal Framework
The Equality Act 2010 is the cornerstone. It replaced several older pieces of legislation and created one unified legal framework for equality in England, Scotland, and Wales.
Clinical Relevance
Equality and diversity are embedded directly in the RCGP curriculum. They are assessed across multiple Professional Capabilities — especially Holistic Practice and Community Health.
Why This Matters in GP Training
🎓 In Your Training
Equality and diversity are not a tick-box exercise. They are assessed throughout your GP training via WPBA tools, ARCP panels, and ultimately through how you practise as a doctor.
The RCGP's 13 Professional Capabilities include Holistic Practice, Health Promotion and Safeguarding and Community Health and Environmental Sustainability — both directly relate to how you understand and respond to inequality.
The RCGP EDI Plan (2023–2026) explicitly requires that inclusion issues and health inequalities are covered in the curriculum and examined.
🏥 In Your Practice
Every consultation carries an equality and diversity dimension. Your patient's age, ethnicity, disability, religion, or sexual orientation may change their experience of illness, their access to services, and their response to your management plan — even if it changes nothing about the clinical diagnosis.
The GP who ignores this is the GP who gives a well-meaning but ultimately ineffective consultation.
⚠️ The Consequences of Getting It Wrong
- Patient harm — inequitable care leads to worse health outcomes for already-disadvantaged groups
- Complaints and fitness to practise referrals — discriminatory treatment is grounds for GMC referral
- Legal liability — the Equality Act gives patients legal recourse against discriminatory practices
- Systemic harm — individual bias, multiplied across a workforce, widens health inequalities at a population level
RCGP Curriculum Link
Promoting equality and valuing diversity are described in the curriculum as being "at the heart" of what GPs do. The knowledge and skills you develop here are "applicable across the whole curriculum and should be incorporated into all aspects of clinical, managerial and research practice."
The Equality Act 2010
What Is It?
The Equality Act 2010 is the primary piece of legislation protecting people from discrimination in Great Britain (England, Scotland, and Wales). Northern Ireland has separate equality legislation. The Act came into force on 1 October 2010, replacing several older, separate laws — including the Sex Discrimination Act 1975 and the Race Relations Act 1976 — with one unified framework.
It applies to workplaces, services, and public functions — which means it covers both how you treat your patients and how your training organisation treats you.
Who Does It Protect?
The Act protects anyone who has — or is perceived to have — a protected characteristic. It also protects people who are associated with someone who has a protected characteristic (for example, a carer for a disabled person).
This means you can experience discrimination even if the protected characteristic does not actually apply to you — if someone thinks it does, that is enough.
Example: A patient is offered fewer explanation or treatment options because the GP assumes — incorrectly — that they have a learning disability based on their speech pattern. This may constitute direct discrimination by perception under the disability characteristic.
📋 The Public Sector Equality Duty (PSED)
The NHS — including GP practices — is a public body. This means it carries the Public Sector Equality Duty, which requires it to actively:
Discrimination, harassment, and victimisation
Equality of opportunity between different groups
Good relations between people of different groups
The 9 Protected Characteristics
Under the Equality Act 2010, it is unlawful to discriminate against someone because of any of these nine characteristics. You must know all nine — they appear in multiple contexts across GP training, WPBA, and real clinical practice.
Memory Aid — "DRAG-PR(I)SMS"
Disability · Race · Age · Gender Reassignment — Pregnancy & Maternity · Religion or Belief — (Intercept bias!) — Sex · Marriage & Civil Partnership · Sexual Orientation
This is a recall aid only — always refer to the Equality Act 2010 for the authoritative list and definitions.
Beyond the Nine
As GPs, we recognise that fair care extends beyond just the legal nine. The RCGP explicitly notes that equitable practice should also consider class, socioeconomic status, and previous history — characteristics not covered by the Act but equally important in delivering truly person-centred care.
Types of Discrimination — Know the Difference
The Equality Act recognises four main types of discrimination. Each has a distinct legal definition. Trainees are expected to understand the differences — this comes up in teaching scenarios, CbD discussions, and real-life practice.
| Type | What it means | GP Example |
|---|---|---|
| Direct | Treating someone less favourably because of a protected characteristic | Offering shorter appointment slots to patients with learning disabilities because "they take too long" |
| Indirect | A policy that applies to everyone but disproportionately disadvantages a group with a protected characteristic | Offering online-only booking for all appointments — this disadvantages older patients and those without internet access |
| Harassment | Unwanted behaviour related to a protected characteristic that violates dignity or creates an intimidating, hostile, or offensive environment | A colleague making repeated "jokes" about a trainee's accent or ethnic background — even if intended as banter |
| Victimisation | Treating someone badly because they have raised a discrimination complaint or supported one | A trainee receives a poor ARCP review after raising concerns about racial bias in their assessment — if the poor review is related to the complaint, this is victimisation |
Intent Does Not Matter
You do not have to intend to discriminate for it to be discrimination. Unintentional discrimination is still unlawful. This is particularly important for harassment — a one-off "joke" can constitute harassment, even if no offence was meant.
Disability: Two Extra Protections
For disability specifically, the Act adds two further protections: discrimination arising from disability (being treated badly because of something caused by a disability, not the disability itself) and the duty to make reasonable adjustments.
🔍 Is This Discrimination? — A Quick Decision Guide
Unconscious Bias — The Hidden Influence
What Is Unconscious Bias?
Unconscious biases (also referred to in the research literature as "implicit biases") are attitudes and stereotypes that influence our decisions without us being fully aware of them. They are shaped by our upbringing, culture, personal experiences, and the social world we live in.
Importantly, unconscious bias is not a character flaw. It is a feature of how the human brain works — we make rapid judgements based on patterns we have learned over a lifetime. The problem comes when those patterns lead us to treat people unfairly.
Why Doctors Are Not Immune
Medical training does not protect you from unconscious bias. Research consistently shows that:
- Clinicians show measurable bias in pain assessment across racial groups
- Mental health diagnoses differ by ethnicity even when symptoms are identical
- Referral rates vary by patient gender and ethnicity for the same presenting complaint
- We tend to gravitate toward people who are like us — in social groups, in recruitment, and in training assessments
How Bias Manifests in GP Training
- Assessment bias — unconscious lower expectations for trainees from ethnic minority backgrounds
- Feedback bias — vague, less actionable feedback given to trainees from underrepresented groups
- Referral bias — over- or under-referring patients based on assumptions about their social circumstances
- Communication bias — adjusting the amount of information given based on perceived social class or education level
- Pain management bias — undertreating pain in certain patient groups due to stereotyping
Most bias operates below the waterline — invisible, powerful, and resistant to change without deliberate effort.
What Can You Actually Do About It?
Awareness alone is not enough — but it is the essential first step. Research suggests the following help:
- Slow down decisions — rapid, automatic thinking is where bias operates. Deliberate, structured decision-making reduces its impact.
- Use objective criteria — in assessments, referrals, and consultations, apply the same criteria to every patient or trainee.
- Seek feedback — ask trusted colleagues whether they notice patterns in your practice you may not see yourself.
- Reflect regularly — in your ePortfolio, PDP, and supervision, consider whether equality and diversity feature in your reflections.
- Cultural humility — recognise that your cultural framework is not the default. Approach every patient with openness to their worldview.
Notions of Deficit — An Educational Perspective
Based on the work of Professor Vini Lander
The following section draws on a presentation about race and education by Professor Vini Lander, Professor of Race and Education and Director of the Centre for Race, Education and Decoloniality in the Carnegie School of Education, Leeds Beckett University. Read more about her work →
The Deficit Theory
The deficit theory of education — which was influential historically — argued that students who differed from an assumed "norm" (usually white, middle-class, male, able-bodied) should be considered deficient or "less than" their peers. The purpose of education, under this view, was to fix these deficiencies rather than to value and build on difference.
We now recognise this theory as harmful and scientifically unfounded. But its legacy lingers — in the assumptions we make about students, patients, and colleagues.
Why This Still Matters Today
- Low expectations — do some educators and clinicians still unconsciously expect less from trainees or patients who differ from a perceived norm?
- The language of deficit — phrases like "disadvantaged," "hard to reach," or "non-compliant" often reflect a deficit framing rather than a systemic one
- Children are not colourblind — as Prof. Lander emphasises, children are unconsciously trained into social hierarchies from birth. The same applies to trainee doctors who grew up in those hierarchies.
- IMGs — the GP training system has historically struggled to support international medical graduates equitably. Deficit thinking — assuming IMGs need to be "corrected" rather than supported — contributes to the attainment gap
From Deficit Thinking to Asset-Based Practice
The opposite of deficit thinking is asset-based practice — recognising the strengths, knowledge, and lived experience that every trainee and every patient brings. A patient who has managed a chronic condition for 20 years has expertise you do not. An IMG who has practised in three different health systems has insights that a UK-trained doctor may lack entirely.
Cultural Competence & Cultural Humility
Cultural Competence
Cultural competence refers to the knowledge, skills, and behaviours that allow a clinician to work effectively with people from different cultural backgrounds.
This includes understanding how culture shapes:
- The meaning of illness and health
- Attitudes toward medicine, doctors, and authority
- Family roles in healthcare decisions
- Expressions of pain and emotional distress
- Dietary practice, religious observance, and lifestyle
- Acceptable physical examination and touching
Cultural Humility — Going Further
Cultural humility goes one step beyond competence. It is a lifelong commitment to self-reflection and learning about one's own cultural biases and assumptions, combined with genuine openness to other worldviews.
Cultural competence can suggest you have "learned enough" about a culture. Cultural humility recognises that:
- No one can be an expert in every culture
- Cultures are dynamic, not static
- Individuals are not defined by their cultural background
- Your job is to be curious and open, not to perform knowledge
In Practice: The LEARN Framework
Listen with empathy · Explain your thinking · Acknowledge differences and similarities · Recommend treatment, noting patient preferences · Negotiate agreement
Health Inequalities — The Bigger Picture
Understanding health inequalities is not optional for a UK GP. The Marmot Review and its follow-up have shown that health in England is deeply unequal — and the NHS sits at the intersection of that inequality every single day.
Health is shaped by factors far beyond the clinic. GPs sit at the intersection of all of these layers.
📉 The Stark Numbers
- Healthy life expectancy (years lived free from limiting illness) can differ by up to 19 years between the most and least deprived areas of England (Marmot Review 2020)
- The 2020 Marmot Review found that since 2010, health improvements in England have stalled — and worsened in the most deprived areas for women
- Black women in the UK are approximately 3.7 times more likely to die during or shortly after pregnancy than white women (MBRRACE-UK 2023)
- Ethnic minority NHS staff are significantly less likely to be shortlisted for senior leadership roles compared to white colleagues with equal qualifications (NHS Workforce Race Equality Standard data)
- The Inverse Care Law (Tudor Hart, 1971) still holds: the availability of good healthcare tends to vary inversely with the need for it
🩺 What This Means for You as a GP
- The social history matters — housing, employment, income, and social support are not optional extras; they are clinical information
- Proportionate universalism — provide services that are universal, but with a scale and intensity that is proportionate to the level of deprivation (Marmot's key principle)
- Understand the patient's context — behaviours like smoking and poor diet are strongly shaped by social conditions such as poverty, stress, and limited access to healthy options. Judging patients for behaviours driven by their circumstances is neither fair nor effective. Focus on enabling change rather than assigning blame.
- Link workers and social prescribing — know what is available in your area and use it. These are powerful equity tools in primary care.
- Advocacy is part of the job — as a GP, you are uniquely positioned to bear witness to health injustice and to advocate for your patients and communities
RCGP Health Inequalities Hub
The RCGP has dedicated significant resources to health inequalities. Their Health Inequalities Hub (rcgp.org.uk) provides practical, GP-focused guidance on how to identify and respond to inequality in daily practice. It is written by GPs, for GPs. Use it.
GP Action Framework — What Should You Actually Do?
Knowing the theory is one thing. Doing something with it is another. Here is a practical framework for how equality and diversity apply in your day-to-day GP work.
🩺 In Every Consultation
- 1
Check your assumptions
Before you form an impression, ask: am I making assumptions about this person's lifestyle, understanding, or compliance based on how they look, speak, or where they live?
- 2
Take a social history seriously
Housing, employment, income, social support, and caring responsibilities are relevant clinical information. Ask about them. Document them. Act on them.
- 3
Adjust your communication — not your expectations
Adapt how you explain things to every patient. Do not reduce the quality or quantity of care you offer. Every patient deserves the same standard of care, communicated in a way that works for them.
- 4
Use interpreters properly
When a patient needs an interpreter, use a professional one. Do not use family members, especially children, to interpret — this compromises confidentiality and accuracy, and may place the child in an impossible position.
- 5
Safety-net equitably
Ensure that your safety-netting is clear and accessible to every patient. If a patient struggles to use the phone, or does not have reliable internet, make sure your follow-up arrangements are realistic for them.
🏥 In Your Workplace
- Raise concerns early — if you witness discriminatory behaviour or language, address it. Silence is not neutral.
- Know your rights — as a trainee, you are protected by the Equality Act. If you experience discrimination, there are clear routes to raise this through your deanery, RCGP, or GMC.
- Support your colleagues — be an active bystander. If you witness a colleague being treated unfairly, say something. Allyship matters.
- Use reasonable adjustments — if you or a colleague needs reasonable adjustments to training (for example, due to disability, pregnancy, or religious observance), these are rights, not privileges. The duty to make reasonable adjustments lies with the employing and training organisation. Raise this with your Training Programme Director, Educational Supervisor, or deanery as early as possible.
📋 In Your ePortfolio (FourteenFish)
Equality and diversity should feature in your reflections, PDP, and WPBA evidence. Good evidence includes:
- Reflections on consultations with patients from diverse backgrounds
- Evidence of using interpreters, making reasonable adjustments, or adapting your approach
- CbD or consultation observation (CAT) cases involving sensitive equality issues
- Attendance at EDI training or teaching sessions
- Reflections on health inequality and what you did about it
Microaggressions — Small Cuts, Big Impact
What Are Microaggressions?
Microaggressions are brief, everyday exchanges that send negative or denigrating messages to members of marginalised groups. They are usually subtle and often unintentional — but the impact on the recipient can be cumulative and significant.
The term was coined by Dr Chester Pierce (psychiatrist) in the 1970s, and has become increasingly recognised in healthcare settings as a contributor to both workforce inequality and poor patient care.
Think of each microaggression as a small paper cut. One alone may be trivial. Hundreds over time cause real damage.
Examples in a Medical Context
- "You speak excellent English!" (to a colleague who grew up in the UK)
- "Where are you really from?" (implying someone does not belong)
- "I didn't expect you to be a doctor" (to a woman or ethnic minority colleague)
- Mispronouncing someone's name repeatedly without effort to learn it
- Assuming a female doctor is a nurse
- "You're so articulate" (said as if it's surprising)
- Asking an IMG to explain or "represent" their whole culture
- Touching a colleague's hair or body without permission — a behaviour disproportionately reported by Black colleagues as unwanted and objectifying
How to Respond to Microaggressions
If you are on the receiving end:
- You do not have to educate everyone who says something offensive — but you can choose to if you feel safe to do so
- It is always appropriate to say: "I found that comment uncomfortable — can I explain why?"
- Document incidents, especially in training contexts. You may need this record later.
- Seek support — from your Educational Supervisor, Training Programme Director, or RCGP support services
If you witness a microaggression:
- Active bystander intervention — don't look away. Even a small intervention matters.
- In the moment: "I'm not sure that came across the way you intended — could you clarify?"
- Check in with the person affected: "Are you OK? That must have been frustrating."
- Raise it through appropriate channels if it happens repeatedly or is serious
Challenging Discriminatory Behaviour — The DDDD Framework
One of the most common questions from GP trainees is: "What do I actually say when a patient is discriminatory?" This is one of the hardest situations in general practice — you have a duty to the patient and a duty not to accept discriminatory behaviour toward you or your colleagues.
The DDDD Framework
The DDDD Framework (available in the downloads) provides a structured approach to challenging unacceptable behaviour. It stands for: Describe · Disclose · Decide · Do. It is a resource available in your downloads above.
The DDDD Framework — Challenging Unacceptable Behaviour
Name the behaviour clearly. "When you said X, I felt…" Stay specific and factual.
Explain the impact. "That comment was hurtful / unacceptable / makes it difficult for me to help you."
Choose your response. Continue? Pause? End the consultation? Escalate to a colleague or manager?
Act on your decision calmly. Document it afterwards. Debrief if needed.
When a Patient Refuses a Clinician on Discriminatory Grounds
A patient who refuses to see a clinician solely because of that clinician's race, religion, or sex is expressing a preference that the practice is not obligated to accommodate. Urgent and emergency care must always be provided regardless. For non-urgent care, the practice manager or GP partner should speak with the patient, explain that all clinicians are equally qualified, and offer an appointment with an available clinician. Seek advice from your medical defence organisation if you are unsure how to proceed in a specific case, as the appropriate response depends on the individual circumstances.
Useful Phrases for Difficult Moments
- "I need to address something before we continue…"
- "I want to help you, but I can't do that if the consultation continues this way."
- "That language isn't acceptable here. Can we start again?"
- "I'm going to pause the consultation for a moment."
Trainee Voices & Real-World Wisdom
What trainees and GP educators actually say — the stuff that doesn't make it into official documents.
The insights on this page are drawn from published research with GP trainees, GP educator discussions, and UK deanery resources, compiled to be consistent with RCGP and GMC guidance. They represent patterns of trainee experience rather than prescriptive advice. Always apply your own professional judgement and seek appropriate support where needed.
📉 Differential Attainment — The Real Picture
Evidence from NHS England, NHS Education for Scotland, and published GP training research (Education for Primary Care, 2023; GMC National Training Survey data). Figures are approximate and vary by year and deanery.
Indicative figures from published research on differential attainment in UK GP training
This is not a small problem. Research from NHS England and NHS Education for Scotland consistently shows that trainees from minority ethnic backgrounds and international medical graduates (IMGs) are less likely to qualify as GPs compared to their white UK-trained peers.
This gap is not explained by differences in clinical knowledge or intelligence. It is driven by a complex mix of factors — many of which are systemic and entirely fixable.
The Good News
When NHS England provided targeted, individualised support to trainees who had previously not qualified, 76% went on to complete training successfully. The gap is real, but it is not inevitable.
What Drives the Attainment Gap? — The Real Reasons
- Assessments calibrated to UK cultural norms
- Exam language assumes British idiom
- Lack of representative role models
- Unconscious bias in assessment panels
- Isolated from peer support networks
- Less informal support from senior doctors
- Vague feedback that doesn't help
- Trainer-trainee cultural mismatch
- Communication style differences
- UK cultural and linguistic knowledge gaps
- Relocation stress and family separation
- Visa and immigration pressures
- Lower confidence in exams
An Important Distinction
None of the reasons above relate to clinical competence or intelligence. The knowledge is there. The skills are there. The gap exists because the system was not designed with everyone in mind. That is a systemic problem — and fixing it is everyone's responsibility, not just the trainees who experience it.
👥 What Trainees Actually Experience — Honest Accounts
Drawn from published qualitative research with GP trainees across multiple UK deaneries
A Common Trainee Journey — When Things Go Wrong
On Feeling Isolated
Many IMGs describe feeling very isolated when problems arise in their training — particularly when they have a difficult relationship with their trainer. Without a natural peer support network, small problems can escalate quickly. The lesson: build your support network early, before you need it.
On "Playing the Game" in Exams
IMG trainees consistently describe realising they needed to learn a different communication style for UK exams — not because their real-world skills were poor, but because exams test a culturally specific version of the consultation. Understanding this early saves a lot of heartache.
On Accent Anxiety
Trainees report worrying that their accent would disadvantage them in clinical assessments — and this worry itself becomes a barrier. The evidence shows that sociolinguistic differences (idioms, phrasing patterns) matter more than accent alone. Knowing what to target helps reduce this anxiety.
On the Value of One Good Supervisor
Trainees who overcame the attainment gap almost universally mention one person — a trainer, educational supervisor, or senior colleague — who gave them specific, actionable feedback and genuine personal support. The quality of this relationship matters more than almost anything else.
🎯 Practical Tips From Trainee Experience — What Actually Helps
These are patterns that come up repeatedly when trainees describe what made the difference. They are consistent with RCGP guidance and NHS England's differential attainment programme recommendations.
Don't wait until you're struggling. Make connections with peers, your TPD, and your deanery's Professional Support Unit from day one. In GP training, isolation is your biggest enemy.
Vague feedback like "work on your rapport" is not enough. Ask your trainer: "Can you give me a specific example of what good would look like?" The more specific the feedback, the more actionable it is.
Watch British TV (soap operas are excellent for everyday idioms). Widen your social circle beyond other doctors. Read a UK newspaper. This is not about changing who you are — it's about expanding your toolbox.
Your PLP is not just a form. It is a tool to direct your training toward your specific needs. Be honest with your educational supervisor about where you feel less confident — this is how targeted support gets built.
Being good at medicine and performing well in a UK assessment are related but not identical skills. The exam tests a specific thing. Study the format. Practise the format. Don't let exam struggles make you doubt your clinical ability.
If you experience discrimination in your training, you have rights. Your deanery has a professional support unit. The RCGP has support services. The GMC has a process. Staying silent protects no one, least of all you.
🌍 Specific Guidance for IMGs — From People Who've Been There
Drawn from BJGP Open research (2023), NHS England Equity in Training resources, and Bradford VTS IMG guidance
The consultation model is different — and that's the first thing to understand
UK general practice uses a strongly patient-centred model. This means patients expect to be involved in decisions, are less deferential to doctors, and may challenge clinical recommendations openly. This is not disrespect — it is the norm. If you trained in a more doctor-directed system, this shift is real and takes time. Recognise it early so it doesn't catch you off guard in the consultation room or the exam hall.
Sociolinguistic errors matter more than grammar in clinical settings
Research shows that native English speakers judge sociolinguistic errors (idiom, phrasing, intonation) more harshly than grammatical mistakes. What this means practically: using phrases translated directly from your first language — even when technically correct — may feel off to patients and assessors. Learning and using British idiomatic English in consultations is a professional skill, not a personality makeover.
Reflective practice is new to many IMGs — and it's central to GP training
Reflective practice — writing about your own learning, mistakes, and development — is a cornerstone of UK postgraduate training. For many IMGs, this is genuinely unfamiliar. It is not a test of weakness. It is a demonstration of professional growth. Start early, write honestly, and ask your trainer to model what good reflection looks like.
Your clinical skills are an asset — don't let the system make you forget that
The attainment gap is not primarily about clinical knowledge. IMGs bring extraordinary clinical experience, resilience, and diverse perspectives to UK general practice. When training feels hard, this is worth remembering: many of the barriers are systemic, and addressing them requires effort from both the system and the individual working within it.
The visa anxiety is real — plan for it and get proper advice early
IMGs face immigration and visa pressures that UK-trained doctors do not. This includes complexities around dependent family members, restrictions on location, and anxieties about what happens if training is extended. These pressures are real, acknowledged in NHS England's own equity reports, and can significantly affect wellbeing and performance. Seek advice early from your deanery's Single Lead Employer HR team, the BMA (which provides immigration guidance to members), or an immigration solicitor. Do not leave visa questions until a crisis — the earlier you plan, the more options you have.
✅ What Good Support Looks Like
From NHS England's differential attainment programme findings
- Targeted, specific feedback — not "improve your communication" but "here is exactly what to do differently in this part of the consultation"
- Early identification of need — proactive check-ins, not waiting for a crisis
- Holistic support — addressing wellbeing, family, and relocation stress alongside clinical development
- Peer support groups — connecting trainees who share similar experiences reduces isolation dramatically
- Sponsorship, not just mentorship — having a senior who actively champions you makes a measurable difference to career success
- Communication coaching — specific help with idiomatic English in clinical settings, available through deanery Professional Support Units
❌ What Trainees Say Doesn't Help
Patterns identified through qualitative research with trainees
- Generic advice that doesn't address specific gaps
- "You just need to be more British" — helpful in concept, useless in practice without specific guidance
- Waiting to see if things improve without proactive intervention
- Comparing trainees to one another rather than supporting each individual's development
- Advice to "not make a fuss" about discrimination — silence does not resolve discrimination, it normalises it
- Overfocusing on exam preparation without addressing underlying confidence and support needs
🔧 What the System Is Doing About It
Differential attainment is now a national priority. Here is what NHS England, NHS Education for Scotland, and the GMC are doing — so you know what support you are entitled to ask for.
Common Pitfalls — Trainee Traps
Assuming Colour Blindness Is Neutral
"I treat all my patients the same" sounds like fairness — but it can mean ignoring real differences in lived experience, risk, and need. Equitable care sometimes means treating people differently to get the same outcome.
Confusing Equality and Equity
Equality = giving everyone the same thing. Equity = giving people what they need to achieve the same outcome. These are not the same. A GP who offers every patient a 10-minute appointment regardless of need is practising equality, not equity.
Using Family Members as Interpreters
Well-intentioned but problematic. Accuracy suffers. Confidentiality is breached. Family dynamics may prevent the patient from speaking freely. Children may be placed in distressing situations. Always use professional interpreting services.
Labelling Patients as "Non-Compliant"
Non-compliance is often a structural issue. Before labelling a patient, ask: Is the medication unaffordable? Does the dosing schedule conflict with work or religious practice? Are there side effects the patient hasn't felt safe to mention?
Ignoring the Social History
Focussing only on the clinical complaint without understanding the patient's social context leads to management plans that don't work. A patient who is homeless, unemployed, or in an abusive relationship needs a plan that acknowledges their reality.
Staying Silent About Discrimination
Witnessing discrimination and saying nothing is not neutral — it normalises it. Active bystander skills are a professional duty, not an optional extra. If you see it, address it — even imperfectly.
Insider Pearls — What Trainees Wish They Had Known
The Social History Is Underrated
Trainees who consistently ask about housing, money, and social support find their management plans work better. It takes 30 seconds to ask. It can change everything about how you manage the presenting problem.
You Don't Have to Know Everything About Every Culture
The most effective approach is curiosity and openness — not expertise. "I want to make sure I understand your perspective — can you help me understand how this fits with your beliefs?" is a powerful consultation phrase.
Documenting EDI in Your ePortfolio Matters
Trainees who actively reflect on equality and diversity in their 14Fish ePortfolio — in learning log entries, CbD write-ups, and their PDP — consistently show stronger evidence for the Community Health and Holistic Practice capabilities. Don't leave this to chance.
Bias Is Not a Personal Attack — It's a System
When trainers and assessors give feedback about potential bias in practice, it is professional feedback — not a character assassination. The GP who gets defensive is the GP who fails to grow. The one who engages seriously is the one who becomes excellent.
The Equality Act Protects You Too
Many trainees — especially IMGs — don't realise that the Equality Act protects them as workers and trainees. If you experience discrimination in your training environment, you have legal rights. Do not suffer in silence. Routes for raising concerns include: your Training Programme Director, your deanery's Professional Support Unit, the BMA (for employment/legal advice), the RCGP, or the GMC's confidential support line (0161 923 6399).
Health Inequalities Show Up Every Day
You don't have to work in a deprived area to see health inequality. It walks into every GP surgery in the country. The trainee who recognises it, names it in their reflections, and acts on it — however small that action — is building one of the most important professional capabilities a GP can have.
For Trainers & TPDs — Teaching Equality & Diversity
Why This Section Exists
Equality and diversity can be difficult to teach well. It is easy to default to a checklist approach — "here are the 9 protected characteristics, now you know." The real educational value lies in helping trainees develop genuine insight, reflexivity, and practical skills for navigating complex situations.
Tutorial Ideas
Use the discrimination scenarios in the downloads section. Present a scenario and ask the trainee: What type of discrimination is this? Who is affected? What would you do? What does the law say? What does the RCGP expect?
Good scenarios to discuss: patient refuses to see an IMG doctor; trainee receives lower grades with less feedback than their peers; practice has phone-only booking for a patient who is deaf.
You may wish to direct your trainee to the Harvard Implicit Association Test (IAT), freely available at implicit.harvard.edu, as a starting point for reflection. Note that the IAT is a tool for prompting conversation rather than a definitive measure of bias — its reliability as a predictive test has been debated in the literature. Discuss what it brought up: What did you notice? What might it mean for your practice? The goal is reflection, not shame or diagnosis.
Ask your trainee to bring a patient case where social circumstances significantly affected the clinical picture. Discuss: What social factors were present? How did they affect the management plan? What resources did you use? What more could have been done? This works well as a CbD linked to Community Health (CHES) or Holistic Practice (HPHS) capabilities.
Choose a patient from your practice with a complex background (with appropriate anonymisation). Ask the trainee to map the barriers this patient faces in accessing healthcare: transport, language, cultural factors, digital literacy, employment constraints. Then discuss: what can the practice change? What can the trainee do differently in consultations?
Reflective Questions for Trainees
- Tell me about a consultation this week where the patient's background shaped the clinical outcome.
- Have you ever noticed a pattern in how your management decisions differ between patient groups?
- When did you last feel uncertain about how to navigate a cultural or religious difference in a consultation?
- Have you experienced — or witnessed — unfair treatment in your training environment? How did you respond?
- What does "equitable care" actually look like in your practice?
- How does health inequality show up in your patient population?
The Most Common Trainee Blind Spot
Many trainees intellectually understand equality and diversity but struggle to apply it reflexively in their own practice. The gap is not knowledge — it is self-awareness. Push trainees to apply these concepts to their own consultations, not just hypothetical scenarios.
🏁 Final Take-Home Points
The things to carry with you from this page into every clinic, tutorial, and consultation.
- The Equality Act 2010 protects 9 characteristics — know them all. They are not just a list; they represent real people with real rights.
- There are 4 types of discrimination: direct, indirect, harassment, and victimisation. Intent does not matter — impact does.
- Unconscious bias is universal. The GP who claims to have none is the GP who is least likely to catch it in themselves.
- Health inequalities are not background noise. They are the context in which every consultation takes place. The Marmot Review is your framework.
- Equitable care is not the same as equal care. Treating everyone identically is not always fair.
- Cultural humility — curiosity and openness — serves patients better than any checklist of cultural facts.
- The social history is clinical information. Housing, income, employment, and social support belong in your consultation.
- Silence about discrimination is not neutral. Active bystander skills are a professional duty.
- The Equality Act protects you as a trainee too. Know your rights and your deanery's duty to support you.
- Equality and diversity are embedded throughout the RCGP curriculum and assessed in your WPBA and ARCP. Document your reflections in your 14Fish ePortfolio.
Bradford VTS — free educational resource for GP trainees, trainers, and TPDs everywhere. Created by Dr Ramesh Mehay. For educational use only. Always verify information against current RCGP, GMC, and EHRC guidance. Nothing on this page constitutes legal advice. Full disclaimer →
The 9 Protected Characteristics
It is against the law to discriminate against someone because of:
- age
- disability
- gender reassignment
- marriage and civil partnership
- pregnancy and maternity
- race
- religion or belief
- sex
- sexual orientation
These are called protected characteristics. You are protected under the Equality Act 2010 from these types of discrimination. All GP Trainees should be familiar withe the Equality Act. (see web link above)
The content of this webpage has been derived from a presentation on Race and Racism by Professor Vini Lander, Leeds Becketts University. Vini Lander is Professor of Race and Education and Director of the Centre for Race, Education and Decoloniality in the Carnegie School of Education.
Click here to read more about her.
Our children are unconsciously trained into our social heirarchies.
Don’t think for one second that our children are blind to colour and race.