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Dear Professor Berne Ferry and Professor Dame Sue Hill,
The recent tragic events in the United States and the strength of the Black Lives Matter movement globally and in the UK, have sparked a shared momentum of reflection within ourselves and our society. As many individuals look introspectively during this time, doing the difficult work of acknowledging and unlearning their personal biases and prejudices, we must also take a critical look at the institutional systems we operate within.
For us, as current and former trainees on the Scientist Training Programme (STP), these institutional systems include the Healthcare Science profession and the NHS as a whole. The NHS Workforce Statistics 2018 Report published by NHS Digital shows that when comparing staff in similar roles, White staff had higher average pay than those in all other ethnic groups. A list of statistics that reveal the inequalities faced by NHS employees of Black, Asian and Minority Ethnic (BAME) background is included at the end of this letter. This list is by no means exhaustive. The NHS Workforce Race Equality Standard (WRES) 2019 Report revealed that White applicants were 1.46 times more likely to be appointed from shortlisting compared to BAME applicants. In light of this, we have been critically thinking about the STP application process, and whether there are aspects of the system that contribute to the racial inequality within the NHS, where the barriers to access may be, and where improvements can be made.
We are acutely aware that there are few other people of BAME backgrounds holding positions at Band 6 or above within our departments. This may be reflective of the region we work in or the nature of our specialisms. However, the national statistics released by the NHS WRES 2019 Report support our observations, showing that although BAME staff make up 19.7% of the total NHS workforce, BAME representation drops by 7.5% from Band 5 to Band 6, drops a further 5% at Band 7 level, and continues to decrease with each level of seniority. Given these personal observations and national statistics, we have been considering how the National School of Healthcare Science (NSHCS) can utilise its influence and opportunities to redress the current inequality of the lives, prospects and opportunities for people from BAME backgrounds.
As current and former trainees on the STP, we wholeheartedly believe in the programme and the opportunities it affords. However, we would like to know what active measures the NSHCS has in place to ensure this opportunity is also extended to a more diverse recipient cohort in the future.
To open up this conversation, we have five main requests for the National School:
- Disclose the diversity and ethnicity of total and successful applicants for each specialism and cohort;
- Disclose how interviewers are selected, and how many were from BAME backgrounds in each of the cohort years;
- Add anti-racism training and unconscious bias training as a prerequisite to performing interview duties;
- Incorporate anti-racism training to the MSc Professional Practice module and extend current Professional Practice competencies to include trainee reflections on racial discrimination;
- Facilitate a collaborative meeting with BAME trainee representatives and members of NSHCS to support policy changes.
These requests are the culmination of diverse perspectives and collaborative effort from current, former, and recently accepted trainees working across multiple STP specialisms. We believe these actions are necessary because programmes such as the STP that provide paid opportunities for individuals of any background to train in specialist areas, without necessarily needing any former experience in the field, undoubtedly have an important part to play in changing scientific fields that have historically been overwhelmingly White.
1. Disclose the diversity and ethnicity of total and successful applicants for each specialism and cohort:
The STP publishes competition ratios comparing the number of applicants to the number of awarded posts on the NSHCS website every year. We request that the diversity of each cohort is published with similar regularity. This will be an important initial step in revealing whether there is a current lack of diversity, if this is changing, and where more can be done. As part of the initial online application to the STP, all applicants are required to fill in equality and diversity demographic questions. We urge the NSHCS to release the demographic data in terms of individual statistics for Black, Asian, Mixed and other Minority Ethnic groups. This is important because the umbrella term “BAME” is reductionist, lumping together anyone of non-white heritage. The BAME umbrella can mask clear patterns seen for particular ethnic groups, such as statistics that show that our Black peers are consistently underrepresented and underpaid in leadership roles within the NHS (NHS Workforce Statistics, 2018). Should the data show disparities between groups, we wish to know what tangible steps the National School has in place to address them.
We are requesting these statistics under the Freedom of Information Act directly to you in this letter. We will also make a request to Health Education England through whatdotheyknow.com.
2. Disclose how interviewers are selected, and how many were from BAME backgrounds in each of the cohort years:
We recognise the efforts that have been made to provide equal opportunity to those from different socioeconomic backgrounds. Any individual with a relevant undergraduate science degree can apply to the programme. The shortlisting for interview stages is based on the online application and aptitude test scores, and appears to be moderated by a shortlisting panel with all personal information about applicants kept anonymous. We feel that many barriers have been considered and mitigated by this process, allowing individuals from any background an opportunity to apply for the programme. The next stage of the process is a rigorous interview day, and it is at this point that implicit biases may acutely affect the chances of applicants from BAME backgrounds receiving an offer.
In my own experience, out of the 8 interviewers, there was not a single person of colour. As individuals we all carry implicit and unintentional biases, whether this is overt or recognisable even to ourselves. We propose that the NSHCS should curate interviewer panels that reflect the ethnic diversity of the UK population. We believe it would be a positive step forward to place at least one person of colour for each set of four interview stations, so that every applicant is assessed by a senior scientist or a member of staff from a BAME background for the non-science stations. This will not only serve to balance the biases exercised (whether knowingly or unknowingly) by the collective panel, but will also show aspiring scientists that there are senior Clinical Scientists that look like them. We acknowledge that this must be balanced with maintaining the scientific integrity of the interviews and that all interviewers should be appropriately trained and qualified to assess applicants.
3. Add anti-racism training and unconscious bias training as a prerequisite to performing interview duties:
We would like to know how the interviewers are selected, and whether they are required to undertake any anti-racist training before fulfilling this role. We would like to stress the difference between training resources that aim towards multicultural tolerance and those that promote anti-racism. Anti-racism is the beliefs, actions and policies that actively oppose racism.
An initial step forward may be to include resources such as the Unconscious Bias Training handbook created by The Royal Society, as part of the mandatory training for STP interviewers. Unfortunately, changing the unconscious biases held by members of the interview panel cannot be achieved through one session of well-intentioned training (Bezrukova et al., 2016). Sustained effort and commitment to evidence-based anti-racism training will be required from the NSHCS all those involved in the interview and further training of STP applicants. Studies have shown that even individuals who explicitly state that they reject prejudiced ideas towards particular ethnic groups, were revealed to exhibit implicit bias when completing Implicit Association Tests (Dovidio and Gaertner, 2004). This inconsistency between whether individuals believe they harbour racial prejudice, and whether their actions exhibit racial prejudice is termed “aversive racism”. Aversive racism is the reason that one session of anti-racism training will never be enough to remove the effects of unconscious bias (Dobbin and Kalev, 2018) and provides a strong argument for why BAME representation on STP interview panels is necessary in order to facilitate truly equal opportunity for all applicants.
These requests focus on the STP interview process, as we believe this is one of the initial barriers to BAME individuals entering the profession. However, similar action on providing anti-racism training and unconscious bias training for Workplace Training Officers and OSFA examiners would also be prudent in tackling covert racism during our three years of clinical training.
4. Incorporate anti-racism training to the MSc Professional Practice module and extend current Professional Practice competencies to include trainee reflections on racial discrimination.
We need measures in place which actively challenge the racism and discrimination that propagate the inequalities people of BAME backgrounds face when entering, and excelling, in our scientific fields. To achieve this, a holistic approach must be taken, beginning with our university education. We feel that an essential step towards creating a Healthcare Science workforce that is truly inclusive of people of all backgrounds would be to incorporate anti-racism training into the compulsory Professional Practice MSc module. Case studies based on real trainee experiences could help new trainees recognise microaggressions and understand the negative impact they have on our colleagues of Black, Asian and other minority ethnicities. Role play activities re-enacting how to effectively challenge racism within the workplace and how to support colleagues facing discrimination from both patients and staff, would be invaluable in equipping our future scientists in becoming more tolerant, anti-racist clinicians. Creating this type of working environment will be key to attracting and retaining more BAME Clinical Scientists and encouraging representation at more senior level positions.
The current Ethics lecture given as part of the Professional Practice MSc module at the University of Manchester uses the history of tissue culture to teach the intricacies of ethical dilemmas in medicine and Healthcare Science. The case study of Alder Hey Children’s Hospital is given, where the organs of 850 infants were removed and retained after post-mortem examinations without the parents’ knowledge or consent (Royal Liverpool Children’s Inquiry Report, 2001). We are taught that this was indisputably wrong and that the Human Tissue Act 2004 was put in place to ensure that ethical breaches of this severity would never occur again.
However, within the ethical context surrounding human tissue acquisition, we are not taught about the origin of HeLa cells. There is no mention that the original HeLa cells were taken without consent from an African-American woman named Henrietta Lacks while she was receiving cancer treatment at John Hopkins Hospital. The same horror and empathy we are taught to feel for the Liverpudlian parents affected by the practices at Alder Hey are not extended to Henrietta Lacks and her family. These omissions of the contributions of Black individuals to modern medicine, and the importance of the ethical dilemmas that surround their recognition, is just one aspect that should be acknowledged and remedied in an effort towards decolonising our curriculum. Unless these educational gaps are addressed, we cannot expect our graduating trainees to have unbiased views if there are consistent biases present in the curriculum from which they are taught.
The dangers of tiptoeing around the presence of racial biases in healthcare will not only affect our competency as clinicians, but ultimately affect the patients we care for. Studies have shown that the presence of racial prejudices in any form lead to severe, negative outcomes for patients of BAME backgrounds. There is evidence of disparities in the way BAME patients are treated in all parts of the patient pathway, from initial access to services, accurate diagnoses, appropriate treatments, onwards referrals and follow up care. For example Black patients are 50% less likely to receive pain medication than White patients (Singhal et al., 2016) and are also less likely to receive additional care and support during their cancer treatment (National Cancer Patient Experience Survey).
We believe that it is essential for us to be taught these contemporary inequalities that exist for BAME patient groups before we enter the healthcare workforce. This knowledge of population inequalities will better equip us in recognising and challenging incidents of racial bias as we practice as clinicians and impact patient pathways in our specialist roles. Incorporating racial discrimination into the Professional Practice Competencies will require each trainee to reflect on how racial biases pervade their specific scientific field and encourage more conscientious, anti-racist practice.
5. Facilitate a collaborative meeting with BAME trainee representatives and members of NSHCS to support policy changes.
To stand in solidarity means to take action. Inaction will continue to promote systems that favour the majority White graduates. Change within the healthcare science community will not come if we continue to feed through trainees that look, speak, and act alike. We ask you to recognise and reach out to your BAME members to engage in candid and meaningful discussions that lead to lasting positive change.
We wish to be a part of these reformative discussions and decisions by requesting a meeting with policy makers at the NSHCS. The aim of this meeting will be to collaborate towards an achievable action plan to improve the inclusivity and diversity of the STP. We hope that by providing our insights as trainees who have gone through the STP system, you will be able to appreciate our perspectives.
Although the focus of this letter is on BAME representation, we also recognise that equality, diversity and inclusion is a much wider issue. Our focus on BAME representation does not diminish the importance of creating policies that benefit all the protected characteristics outlined in the Equality Act 2010. Transparency in publishing the equality and diversity data of STP applicants and successful trainees regarding sexuality, disability, gender and more, will highlight the disparities currently present in our workforce, and reveal gaps where more work is necessary.
The Scientist Training Programme markets itself as a springboard into a career as a Clinical Scientist. On the NSHCS website, the National School states that graduates from the STP “will be involved, often in lead roles, in innovation and improvement, research and development and/or education and training.” This statement shows in no uncertain terms that the intention of the STP is to produce leaders within the 35 scientific specialisms offered by the programme. With this intention in mind, we wish to ask the NSHCS to reassess whether their current recruitment process, education programmes and support systems, are sufficient to ensure that those accepted onto the STP – the trainees that are poised to become future leaders of our scientific fields – are truly representative of the UK population and adequately equipped to tackle the covert racism that pervades our society today.
We intend for this letter to be a first step in opening up constructive dialogue between the policy makers at NSHCS and trainees of underrepresented groups in order to move forwards towards a more diverse workforce in Healthcare Science.
We are presented with a pivotal moment to consider a different future for our profession. As the leaders and gatekeepers of the Healthcare Science profession you have the responsibility, and the power, to lead change.
We look forward to your response.
RACE INEQUALITY STATISTICS:
The NHS Workforce Statistics (January 2018) published by NHS Digital shows that:
- Across the whole NHS workforce in January 2018, Black men and women had lower average (mean) monthly basic pay than White men and women.
- Men and women from the Asian, Black, Mixed and Other ethnic groups working non-medical staff groups had lower average monthly basic pay than their White counterparts.
- The largest ethnicity pay gap was seen among managers and senior managers, where Black men were paid 80p for every £1 received by White men.
The 2019 report published by NHS Workforce Race Equality Standard showed further inequalities:
- In Band 6 roles, just 17% were from BAME backgrounds, this reduced to 14% at Band 7, and continues to reduce as band levels increase.
- The relative likelihood of white staff accessing non–mandatory training and CPD compared to BME staff was 1.15.
- Across all trusts, 29.8% of BME staff experienced harassment, bullying or abuse from patients, relatives or the public in 2018.
- In 140 NHS Trusts (61.4%), BME staff reported a higher level of harassment, bullying or abuse from patients, relatives or the public compared to white staff.
- For 188 NHS Trusts (82.4%), a higher proportion of BME staff compared to white staff experienced harassment, bullying or abuse from colleagues in 2018.
- The gap between BME and white staff experiencing harassment from colleagues has increased over the last four years, from 3.0 in 2015, to 4.8 percentage points in 2018.
- In contrast, the percentage of white staff that experienced discrimination at work from a manager, team leader or colleague in the last 12 months decreased from 6.6% to 6.4%.
- Fewer BAME employees (69.9%) believed their Trust offered equal opportunities for career progression and promotion, compared to 86.3% of White staff.
Evidence that highlights health inequalities experienced by BAME patients:
- Black patients are 50% less likely to receive pain medication than White patients (Singhal et al., 2016).
- Ethnic minorities, especially Asian and specifically Chinese patients, reported less positive experiences during their cancer care than White patients (Bone et al., 2014).
- African and African-Caribbean people who have a psychotic illness and who live in London are between 4 and 8 times more likely to be detained than their White counterparts (Audini and Lelliott, 2002).
- When comparing staff in similar roles, White staff had higher average pay than those in all other ethnic groups.
- BAME staff are significantly underrepresented in senior pay bands (AfC 8a and above). As the pay bands increase, the proportion of BME staff within those bands decreases, from 24.5% at band 5, to 6.5% at very senior management (VSM) level.
- White applicants were 1.46 times more likely to be appointed from shortlisting compared to BAME applicants.
- The percentage of BME staff that experienced discrimination at work from a manager, team leader or colleague in the last 12 months increased from 15.0% to 15.3%
Audini, B. and Lelliot, P. (2002). Age, gender and ethnicity of those detained under Part II of the Mental Health Act 1983. British Journal of Psychiatry, 280; 222-226.
Bezrukova, K., Spell, C. S., Perry, J. L. & Jehn, K. A. (2016). A meta-analytical integration of over 40 years of research on diversity training evaluation. Psychological Bulletin, 142, 1227-1274.
Bone A, Mc Grath-Lone L, Day S, et al. (2014). Inequalities in the care experiences of patients with cancer: analysis of data from the National Cancer Patient Experience Survey 2011–2012. BMJ Open; 4:e004567. doi: 10.1136/bmjopen-2013-004567
Dobbin, F. & Kalev, A. 2018. Why Diversity Training Doesn’t Work: The Challenge for Industry and Academia. Anthropology Now, 10, 48-55.
Dovidio, J. F. & Gaertner, S. L. (2004). Aversive racism. Advances in experimental social psychology, Vol. 36. San Diego, CA, US: Elsevier Academic Press
Harvard University. (2011). Implicit Association Test. Accessed via:
Hoffman, K. M., Trawalter, S., Axt, J. R., & Oliver, M. N. (2016). Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proceedings of the National Academy of Sciences of the United States of America, 113(16), 4296–4301. https://doi.org/10.1073/pnas.1516047113
NHS Digital. (2018). NHS Workforce Statistics January 2018. Accessed via:
NHS Workforce Race Equality Standard (2019) 2019 Data Analysis Report for NHS Trusts. Accessed via: https://www.england.nhs.uk/wp-content/uploads/2020/01/wres-2019-data-report.pdf
Singhal, A., Tien, Y. Y., & Hsia, R. Y. (2016). Racial-Ethnic Disparities in Opioid Prescriptions at Emergency Department Visits for Conditions Commonly Associated with Prescription Drug Abuse. PloS one, 11(8), e0159224. https://doi.org/10.1371/journal.pone.0159224
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The Royal Liverpool Children’s Inquiry Report. (2001). Ordered by the House of Commons. Accessed via: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/250 934/0012_ii.pdf