Abstract
Differential Attainment
 
 Healthcare professionals are among the most respected, valued members in any society- and also the most regulated. It attracts some of the most talented, innovative and resilient individuals who are keen to do good. Respect, job satisfaction and autonomy are fundamental to the experience of any professional, and often valued above financial or material reward. Doctors are no different.
 Education and training of the healthcare workforce is a lengthy and resource intense process. No nation-state can be truly self-sufficient. Hence workforce migration is a reality where various pull and push factors lead to professionals moving across countries and continents, in the service of populations.
 Society is divided along many lines and steeped with structural inequalities. Many of these are the result of thousands of years of history, legacy and societal wrongs. Healthcare services and professionals reflect similar patterns of the 'big society'.
 The phenomenon of differential attainment (DA), which is the subject of this report is simply a manifestation of such structural inequalities. DA or differential outcomes for doctors due to their age, race, gender, sexual orientation, ethnicity, disability, socio-economic deprivation or influenced by migrant status - rather than motivation, ability, effort or enterprise.
 DA is fundamentally unfair. Those affected by DA are either unaware or unable to counteract the influence on their careers. DA leads to demoralisation, disengagement and poor outcomes for professionals and their patients. It takes its toll not only on careers but on lives and livelihoods. DA leads to a huge under-utlisation of human resources- a true waste of talent and enterprise.
 This report- BTG21 focuses on DA in the medical profession exploring the career cycle through the themes of recruitment, assessments, career progression, research & academia, leadership roles, awards and professionalism.
 BTG21 is people-centred and in tackling inequalities offers solutions on career fulfillment and wellbeing- by an ideological shift of hearts and minds.
 
 Thematic Synthesis
 
 BTG21 summary report is the culmination of a thematic synthesis of evidence covering the full spectrum of medical careers. It presents lived experiences (collected through mixed method approaches) capturing patterns in peoples experiences through an online survey, and in-depth qualitative interviews with a purposive sample of professionals from across the career cycle, range of ethnic heritage, medical specialism and country of origin.
 Followed by consensus developed through workshops by a triumvirate of experts, stakeholders and grassroots professionals.
 There are 5 primary causes of DA- bias, social class & deprivation, immigration status, geographical and individual factors and impacts every stage of medical professional careers.
 The thematic synthesis reviews are published in the Sushruta Journal of Health Policy.
 
 Recommendations
 
 The Workshop discussions, recommendations (the 10-point plan) include policy enablers, immediate actions and research questions in the following areas;
 
 
 
 Tackling bias
 Embracing diversity & inclusion
 Celebrating the contribution of migrants
 Leveling the playing field
 Inclusive leadership & accountability
 Removing structural barriers
 Review-Reform-Rethink assessments
 Redefining professionalism
 Disaggregation-intersectionality-benchmarking of data
 Support-flexibility & Wellbeing
 
 
 
 
Highlights
1.1 Health is a fundamental human right and provision of good health for its citizens, is one of the key functions of any nation-state
Twenty—five years on we find ourselves reflecting on our journey so far
This is reflected in the medical professions where the diversity of doctors entering the register has changed, with the balance of gender and the increasing numbers of International Medical Graduates (41%)
Summary
INDRANIL CHAKRAVORTY, SUNIL DAGA, SHIVANI SHARMA, MARTIN FISCHER, SUBARNA CHAKRAVORTY & RAMESH MEHTA The British Association for Physicians of Indian Origin (BAPIO) was founded in 1996 as a nonprofit organisation to support and give a voice to thousands of doctors from the Indian subcontinent, who dedicate their working lives to the UK National Health Service. BAPIO as an organisation grew to include doctors from across the world and their progeny. At its heart the mission was and remains that of promoting equality and diversity, while supporting doctors to be educators, researchers, leaders and always to provide excellent care to our patients. BAPIO has always believed that we achieve more if we work in collaboration with all. Twenty—five years on we find ourselves reflecting on our journey so far. The UK society reflects multi-cultural identities, with over 14% of the population identifying with a non-white heritage. This is reflected in the medical professions where the diversity of doctors entering the register has changed, particularly with the balance of gender and the increasing numbers of International Medical Graduates (41%). On the surface, this is a positive story for diversity. However, equity in outcomes, opportunity and workplace inclusion are far from a reality. Seven years on from the landmark BAPIO vs Royal College of General Practitioners ruling in 2014, the differentials are still more pronounced by ethnicity and gender over other protected characteristics. This, persistent differential attainment across the career cycle has spurred BAPIO to chair the ‘Alliance for Equality in Healthcare Professions’ (AEHP). In this report (BTG21), we detail the process, outcomes and recommendations from a mammoth effort from the AEHP to bring together multiple stakeholder organisations, training providers, academics, researchers, and grass root doctors across a rigorously designed programme of exploration on the lived experience of DA and associated drivers. Over 150 professionals have made contributions to this project during last year. Together, we have critically considered what progress has been made and asked honest questions about the changing face of challenges that require intervention to make equity in medical careers a reality. The NHS Workforce Race Equality Standards and the Medical Race Equality Standards also mark progress in unearthing longstanding disparity. We hope that the outcome of the AEHP is complimentary to these but bolder in scope. We propose a series of actions to support a systematic shift over the next five years that properly values, celebrates and makes use of the talent of the diverse workforce providing medical care in the UK. This is our vision for a fair and just society. This was our dream for justice for the BTG21 team. The phenomenon of differential attainment has never been far from the collective heart of the members of BTG21 team. The kernel of the idea of a project to tackle DA may indeed have been born during discussions fueled by the buzz one feels after a successful BAPIO National Conference, as we did in 2019 in London. But, what started as an idea, then rolled on gathering over 150 people with passion, expertise, lived experiences and above all the drive to make a difference to the fellow professional. Then COVID-19 happened to the world and all the skeletons of inequalities came out of proverbial cupboards. This spurred the team on. Our mission - 'To right the wrongs'. The programme of work comprised of 6 themes with nominated leads who took on the challenge, assembled the expertise, the range of professionals and the resources needed to undertake the rigorous and expansive thematic synthesis. The teams included medical students and professionals across the spectrum, working closely and without hierarchy. Each team worked differently, but several hundred people-hours were invested in reading, debating, analysing and writing the review papers, creating the discussion questions for consensus building workshops and then poring over the thousands of words of transcripts. What was created at the end was a robust evidence base of 88,000 words. The BTG21 Team used mixed methods. We recognised the value of primary research, importantly led by researchers independent to BAPIO. The qualitative research element on lived experience of DA was therefore undertaken by researchers at the University of Hertfordshire. The 'central team' as one of us called the coordinating, facilitating and writing team - were tireless in constructing the meetings, the pre-workshop discussions, the workshops and the post-workshop facilitated debriefs and poring over 88,000 words of text. We have faced many challenges but have never been shy to challenge ourselves. For weekday evenings and almost every other weekend, the whole family (including the dog) were drafted in. Many contributed to the artwork, graphics and editing. It is incredible that this mammoth piece of work was done pro bono. If we were to apply standard research costing for a similar type of programme of activity, we estimate the value of the professional time in excess of £150,000. We have come closer as a team, as a family and put our collected views together. For all of this and more, we are grateful to each and every member of the team. We are grateful to our collaborators, our experts, our stakeholders and the healthcare leaders who have supported and joined us - challenging us to be brave and bold. Indranil CHAKRAVORTY, St George's Univ London & U of Hertfordshire Martin FISCHER, Fischer Associates Shivani SHARMA, University of Hertfordshire Subarna CHAKRAVORTY, Kings College Hospital Sunil DAGA, Leeds Teaching Hospitals Ramesh MEHTA, President BAPIO Jyothi SRINIVAS, Milton Keynes University Hospital (Recruitment) Subodh DAVE, University of Bolton (Assessment) Veena DAGA, Leeds Teaching Hospital (Career Progression) Anindita ROY, University of Oxford (Research & Academia) Rakesh PATEL, University of Nottingham (Research & Academia) Geeta MENON, University of Surrey (Leadership Roles) Vijay NAYAR, Health Education England (Leadership Roles) Ananta DAVE, University of Nottingham (Professionalism) JS BAMRAH, University of Manchester (Professionalism) Akhila PANDA (University of Buckingham Med Sch) Alison FERGUSON (Uni of Buckingham Med Sch) Anshoo DHELARIA (East & North Herts) Arvind SHAH (North Middlesex Hosp) Carlos CURTIS-LOPEZ (University of Manchester) Catherine Dominic (Bart’s & The London) Chelliah Selvasekar (Christie Hospital, Manchester) Daniel Robinson (University of Manchester) Dev Chauhan (The Hillingdon Hospital) Faisal Hassan (Royal United Hospital, Bath) Geraldine Sawney (Lister Hospital, Stevenage) Joydeep Grover (Southmead NHS Trust, Bristol) Lambrini Theocharidou (Countess Chester Hospital) Manasi Shirke (Queen's University, Belfast) Naureen Bhatti (HEE London) Neeraj Bhala (University of Birmingham) Rachel Don Bosco (University of Hertfordshire) Robert M Blizzard (HEE York's & Humber) Rosanna Geddes (Medical Defence Shield) Roshelle Ramkisson (University of Manchester) Rupal Shah (HEE London) Saba Hussein (Sirona Care & Health) Sahana Rao (Oxford University Hospital) Saif Sait (Kings College Hospital, London) Saman Zaman (St Georges University Hospital) Saraswati Hosdurga (Weston General Hospital) Sarthak Bahl (Milton Keynes University Hospital) Satheesh Matthew (Barts Health NHS Trust) Shevonne Matheiken (Manchester) Spandana Madabhushi (East & North Herts) Triya Chakravorty (University of Oxford) Umakanth Kempanna (Hull Royal Uni Hosp NHS Trust) Veeresh Patil (Milton Keynes University Hospital) Academy of Medical Royal Colleges Association of Pakistani Physicians of N Europe BAME Health Matters BME Medics British Indian Doctors Association British Indian Psychiatrists Association British Medical Association Doctors Association of United Kingdom Health Education England Health Education England (Global) Medical Association of Nigerians Across Great Britain (MANSAG) Medical Defence Shield Medical Defence Union Medical Schools Council Medical Women’s Federation Melanin Medics Nepali Doctors Association NHS England & Improvement Nursing & Midwifery Council RDME, University College London Royal College of Anaesthetists Royal College of Emergency Medicine Royal College of General Practitioners Royal College of Nursing & Midwifery Royal College of Obstetrics & Gynaecology Royal College of Paediatrics and Child Health Royal College of Pathologists Royal College of Physicians of Edinburgh Royal College of Physicians of London Royal College of Psychiatrists Royal College of Surgeons Royal Pharmaceutical Society University of Hertfordshire Andrew Goddard RCP London, President Andrew Morris, CEO, NHS E/I Andrew Foster, CEO Andy Lewington, Kidney Research UK Aneez Esmail, Univ of Manchester, UK Angharad Davies, Royal College of Pathologists Anjali Prinja, Imperial College London Ann Griffin, Dir, Research Dept MedEd, UCL Annapurna Pandravada, University of Glasgow Anshoo Dhelaria, Paediatrician, Lead for LEDs Anthea Mowat, Medical Women's Federation, UK Anton Emmanuel, Head, NHS RHO Anushka Aubeelack specialty doctor Ashok Poduval, Sherwood Forest Hospitals Asya Mussad, Faculty of Med Leadership & Mgmt Atef El-Kholy, Egyptians Doctors Association Balakrishnan R Nair, Univ of Newcastle, Australia Baroness Dido Harding, NI Health Protection Bernard Chang, President Royal College of Ophth Camilla Kingdon President, RCPCH Carol Woodhams, University of Surrey Caroline Curtin, Barking, Havering & Redbridge Trust Chaand Nagpaul, Chair, British Medical Association Clare Owen, Medical Schools Council Colin Melville, General Medical Council UK Colleen McGregor,Trainee HEE Thames Valley David Sellu, Surgeon Davinder Sandhu, Past PG Dean, Univ Bristol Deena Iskander, Academic Clinical Lecturer Deepak Rao, Associate MD London Dinesh Bhugra, Kent & Medway Medical School Farica Patel, St George's University Hospital Fatima Sulaiman, Blood Cancer UK Faye Gishen, University College London Fiona Bishop, Associate Dean, HEE Fiona Godlee, Chief Editor British Medical Journal Fiona O'Sullivan (HoS, Ophthalmology, HEE KSS) Gabrielle Finn, University of Manchester Geoff Smith, Geoff PG Dean, HEE South West Habib Naqvi MBE, Chair, NHS Race & Health Obs Hannah Barham-Brown, BMA Council Member Hannah Sharpe (PhD student) Harish Bhandari, Leeds Teaching Hospitals, UK Harveen Brar (UG applying for Med) Hatim Abdulhussein, Trainee Doctor Heidi Johansen-Berg, St Edmunds Hall Helen Rowntree, Blood Cancer, UK Helen Stokes-Lampard, Chair, AoMRC Hilary Cass, ex-President of RCPCH Husam Elbana, James Cook Univ Hospital Iqbal Singh OBE, Healthcare Commission Ivy Glavee, Dentist, London Jacqueline Stevenson, University of Leeds Jagtar Singh OBE, Chair Coventry & Warwickshire Jahangir Alom Trainee- Widening participation Jane Cannon, General Medical Council UK Jane Dacre DBE, University College London Jeeves Wijesuriya, BMA JDC Jenny Vaughan, Doctors in Distress UK Joanne Harris, Dean, Univ Bucks Med Sch John Brecknell, DME Queen's Hospital, John Chisholm, Medical Ethicist John Drew, NHS E/I John Launer, Innovation, HEE Primary Care John Norcini, FAIMER, Philadelphia, USA Julie Thacker, Univ Exeter (MSC) Justin Bice, University of Leicester Kailash Chand, Retd Chair of BMA NW Kantappa Gajanan, Chair of BAPIO SAS forum Kate Firth, BMA Policy Analyst, EIC Committee Kate Gregory, General Medical Council UK Kate Murnane (Dphil student) Kate Rush (Medical Director, Bristol) Katherine Woolf, UCL Medical School Kheelna Bavalia, Dy MD, NHS E/I, SW London Lambert Schuwirth, Flinders Univ, Australia Laura Roberts, HEE, Diversity & Inclusion Lead Lena Weber (visiting medical student) Lilian Hunt, EDIS Lisa Cotterill, NIHR Academy Mala Rao OBE, NHS Race & Health Observatory Marianne Griffiths DBE, CEO, Brighton & Sussex Hosp Marie Gabriel CBE, Chair, NHS Race & Health Obs Marimouttou Coumarassamy, Notts NHS Trust Mayur Lakhani, Past President, RCGP Megan Cosgrove, PhD-UK, now Med_NY Michael Mulholland, Vice-chair RCGP Mike Wilkinson, NE Associate Dean for SAS Mohsin Badat, Clinician scientist Monica Lakhanpaul, University College London Mumtaz Patel, VP, Global Health, RCP London Nadeem Moghal, CMO, Independent Health Sector Nader Francis, University of Bath, UK Nagina Khan, University of Tauro, Nevada Natasha Matthews, Faculty of Med Lead & Mgmt Navaneeth N Navina Evans DBE, CEO, HEE Neena Bodasing Lead QA, Keele University Neena Modi OBE, President, MWF Nisha Nathwani, DME, L&D Hosp Nithya Krishnan, Univ Coventry Olamide Dada, Melanin Medics Ouseyi Adesalu,King's College Hospital Pali Hungin, Durham University Parveen Kumar DBE, QMUL Patrick Baughan, Advance HE Prasanth Patel, Univ Hosp of Leicester Pushpinder Mangat (MD HEI, Wales) Rachel Davies (Med student) Radhika Gulati, Medical Student Raees Lunat. Clinical Fellow, HEE Rafey Faruqui, Kent & Medway Med Sch Raj Gupta, BMA Academic Group Raj Mattu, BAPIO Patient Safety Forum Rakshitha Pabathi, Medical Student Rani Bains Rebecca Barnard, GMC UK Rishika Sinha, GP Robert Brunger, Mid-Essex NHS Trust S Gajanan (SAS Doctor) Sam Weber, University of Oxford Samira Anane, BMA rep Sanjiv Ahluwalia, Reg Dean, HEE, London Sarah Siddiqui, HEE London, DA Fellow Sarah Wideman (PhD student) Sharon Burton, General Medical Council UK Shevonne Matheiken (ST4 Psychiatry) Shreya Verma, Medical Student Simon Gregory, Health Education England Sonali Kinra, RCGP Soosan Romel, SAS doctor Stella Vig, Vice President, RCS London Stephen Powys, MD, NHS England Stuart Hood, AMD, MRCPUK Sue Russell, Cancer Research UK Sunil Dasan, St George’s Univof London Taj Hassan, Past-President, RCEM Terence Stephenson, Sir, Past Chair, GMC, UK Thomas Charlton, Trainee Doctor Tinaye Mapako, BMA Students CMTE TJ Lasoye, DME, Kings College Hosp, London Tom Baggaley, Assoc Med Res Charities Toyin Wokoma, Med Assoc Nigeria across GB Tricia Barlow (Paeds SpR, Disability Lead) Tricia Campbell Trainee rep, BOTA Usha Parvathy, U of Newcastle, Australia Veena Patel, University Hospitals of Leicester Vidushi Golash, Trainee Doctor Vijay Kumar, Association of Surgeons UK Vinita Shekar, SAS Cmte, RC Surgeons England Waleed Arshad, RCP London/AoMRC SAS Lead Yaa Achampong (ST5 trainee in O&G) Yuvaraj Venugopal GP, LNC Rep Zoe Penn, MD, NHS E/I London, Prof Standards
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