Recommendations

Selection and assessment practice

• A consistent, national approach to benchmarking the GP selection process, in terms of diversity statistics and final numbers selected within different demographic groups, against other medical specialities is recommended. This would allow comparison of the patterns and trends in group performance differences across medical specialities; the patterns are unlikely to be unique to GP. Data could be collected and collated for each deanery.
• The involvement of external equality advisors in the design and review of the selection process is recommended to ensure the process is free from any cultural bias. Diversity specialists can identify cultural impact of the language used and the structure of selection exercises.
• There is a wealth of information and guidance resources available via recruitment, deanery, speciality and general NHS websites for all applicants, including overseas doctors, looking to work in the NHS. The volume and large distribution of this information may make it difficult to sift through and navigate and it may be useful to draw all relevant information sources together for non-UK qualified doctors so they have one point of reference.
  • Alternatively it may be useful to offer some form of mentoring or advisory support to assist international doctors with accessing and navigating these sources to ensure they familiarise themselves with the necessary information, both process and context related.
• Implicit Association Tests may be a practical way of understanding individuals’ unconscious biases. Making use of them in a confidential, developmental manner for selectors may be a useful way of assisting them in understanding their own subconscious biases, contributing to more objective and conscious assessments of candidates during selection.

Selection process

The key recommendations, based on this research, in terms of delivering a robust and objective selection process which reduces adverse impact against minority groups, are as follows:

• Matching selectors and candidates based on ethnic background or nationality and equal representation of ethnic groups during pilot phases and within the selector group.
• Slower processing of information by candidates whose first language is not English could be mitigated by ensuring there is not an undue time pressure in completing selection tests/exercises. It should be noted however that this effect can also be mitigated by the inclusion of behavioural assessments within a selection process, in addition to cognitively loaded tests, as in the current GP selection process.
• The inclusion of equality and diversity awareness training as part of selector training is critical. Standardised face-to-face verification of a selector’s completion and understanding of the equality and diversity training, whereby they are required to demonstrate their skills and knowledge, is highly recommended.
• Selector training should be highly standardised and regulated and it would be beneficial to support any online equality and diversity training with face-to-face workshops to consolidate learning.
• Based on a job analysis and best-practice competency modelling techniques, a selector competency framework has been developed for use in the national GP selection process. This competency mode enhances the quality of selector training, providing the national process with further credibility. It is recommended that selector training continues to emphasise the importance of achieving and maintaining effectiveness in these competency areas in order to deliver objective assessment and selection processes. Formal assessment of individuals against these competencies may further assist with the selection of highly competent selectors for use in the national process.

Equal and diversity

• In terms of future monitoring and analysis of group differences, it is recommended that validation and evaluation of selection processes continues. In addition equal opportunities monitoring and equality assessments of the process should continue on an annual basis.
  • Analysis of scores and performance at a very detailed level based on ethnicity and / or place of medical qualification may provide additional insight into differences in performance.
  • More detailed case level analysis of the SC exercises may also be useful in further explaining performance differences (e.g. analysing differences in performance for different cases used within the three Simulation exercises).
  • More in-depth analysis of performance for each of the ‘Mixed’ ethnic origin sub-groups may, for example, contribute to further understanding of the differences between ethnic groups.
• Organisational policy in relation to equality and diversity should be routinely reviewed and updated; equal opportunities data monitoring should reflect such changes and additional data should be collected as indicated by these policies.
• Raising awareness of newly developed GP competency (identified by GP Job Analysis project, 2011) ‘Respect for Diversity and the Law’ for selectors and candidates. Stakeholder consultation indicated that measurement of behaviours relevant to equality and diversity can raise awareness and improve practice in this area.
• Evidence shows that organisational familiarisation can contribute to greater confidence in candidates during selection. It is recommended that material provided on national recruitment and deanery websites is continually reviewed to ensure it is relevant and provides accurate information or signposting which allows all candidates, including international candidates, to familiarise themselves with organisations, the GP role and selection processes.
• Promoting cultural sensitivity enables people to work more effectively when interacting with individuals from other countries and also assists with making transactions between cultures more effective. Raising awareness of cultural differences (e.g. using models such as Hofstede, 1984; 2001) with both selectors and candidates may be a useful stage in equality and diversity practice. Online training tools specifically for raising awareness of cultural differences and sensitivities may be a useful and accessible resource.

Additional research and evaluation

• Findings in the equalities impact reports (2009-11) indicate that candidates attending Foundation Programmes (FP) are more successful in GP selection. In addition the current literature suggests overseas doctors who enter speciality training without having attended a UK FP have greater difficulty adapting to the UK healthcare system. Links between these two findings could be explored to determine how the FP contributes to more effective performance in selection.
• Consultation with ethnic minority groups and doctors trained overseas to understand their needs in more detail i.e. what they are seeking from employment and the support they need as well as what they find particularly challenging about GP selection processes within the UK.
• Continued research, across medical specialities at postgraduate level, is required to understand the nature and cause of group differences, particularly in relation to ethnicity and place of qualification.
• The benefits of objective assessment of equivalence of qualifications could be explored in more detail. Individuals experience training differently in different contexts; we may benefit from learning more about the difference in standards/content in order to determine equivalence of qualifications. It may be beneficial to seek further expert assistance in this area.
  • It is also recommended that the criteria outlined in the Acceptable Overseas Qualifications paper provided by the GMC is understood and regularly reviewed (GMC, 2010).
• A more systematic measurement of the effect of the pre-arrival information, induction on arrival, and ongoing support provided to overseas doctors entering training within the UK, may provide implications for possible interventions to support overseas doctors at the selection stage prior to training.

Actions and next steps

• Additional analysis of existing national selection data at a more detailed level including case level analysis by ethnicity and place of medical training and analysis of performance within ethnic sub-groups e.g. ‘Mixed’ or ‘Other’ ethnic groups. More in-depth analysis may provide greater understanding of the patterns of group differences currently observed and inform future diversity monitoring or further research.
• Continued equalities impact monitoring on an annual basis and regular reviews of the patterns in group differences in selection performance over time.
• Development of a central resource point which draws together all the relevant information sources from recruitment, deanery and general NHS websites for all applicants, including non-UK qualified doctors, looking to apply for GP speciality training and understand the culture of the wider NHS. The existing national recruitment website may serve as a useful foundation for providing a more holistic, single point of reference for GP-specific and general NHS familiarisation material for candidates, particularly international doctors, looking to work in the GP speciality.
• Facilitation of focus groups and consultation with doctors currently working in the NHS who qualified overseas (and ethnic minority groups if required), to understand their perceptions of the selection process, support received in preparation for selection and the quality and accessibility of information available. Greater insight into the challenges faced, support required and perceptions of GP/medical selection processes within the UK may be useful for informing future guidance provided.