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School of Emergency Medicine

EQUALITY, DIVERSITY AND UNCONSCIOUS BIAS

Presented by Josie Hastings

Produced by:

[pic]Josie Hastings Associates

New Mills House

18-28 Rosamond Street

Walsall, WS1 4LB

Telephone No: 01922 643330

Mobile No: 07957 870294

Email: josiehastings@

josiehastings.co.uk

EQUALITY, DIVERSITY AND UNCONSCIOUS BIAS WORKSHOP

OVERVIEW

This interactive workshop commissioned by the School of Emergency Medicine, East of England will focus on how equality and diversity impacts on the role of senior trainers, consultants and college tutors when working with medical trainees.

OBJECTIVES

By the end of the workshop, attendees will:

• Be familiar with the requirements of the Equality Act 2010 in relation to their role

• Have explored scenarios which could or have led to complaints of discrimination and how to deal with them

• Have considered the different forms of unconscious bias which could bias individuals when assessing trainees

• Have discussed ways in which the risk of bias and unfairness could be minimised

• Be familiar with the GMC and other relevant recommendations for ensuring equal opportunities in the training, curriculum development and assessment process.

PROGRAMME (2 pm – 4 pm)

Introductions and Expectations

The Equality Act 2010

• Protected Characteristics

• The Different Forms of Discrimination

Scenarios

Forms of Unconscious Bias

Minimising the Impact of Bias in Training, Curriculum Development and Assessment

The Public Sector Equality Duty

Judgement: BAPIO – v – RCGP and GMC

EQUALITY LEGISLATION

THE EQUALITY ACT 2010

PROTECTED CHARACTERISTICS

The Equality Act 2010 was implemented in the UK on October 1st 2010. It prohibits discrimination because of a protected characteristic. There are nine protected characteristics which are:

• Age or age group

• Disability

• Gender reassignment

• Marriage and civil partnership

• Pregnancy and maternity

• Race including colour, ethnic origin, nationality and caste (from 2015)

• Religion or belief

• Sex

• Sexual orientation

DIRECT DISCRIMINATION

It is direct discrimination to treat another person, or group of people, less favourably in a situation because of a protected characteristic.

Example: A core surgery trainee attends her ARCP and receives outcome 2 for poor engagement with ISCP and failure to pass the MRCS examination. She is very obviously pregnant and tells the panel that her trainer insists that she sits in clinic rather than stand in theatre and has excluded her from all theatre work for ‘health and safety’ reasons.

INDIRECT DISCRIMINATION

Occurs when an organisation applies a provision, criteria or practice (PCP) in the same way for all employees or trainees but this has the effect of:

• disadvantaging a person or group because of a protected characteristic, ie their age, disability, gender reassignment, marriage or civil partnership, pregnancy or maternity, race, religion or belief, sex or sexual orientation &

• cannot show the treatment to be a proportionate means of achieving a legitimate aim.

Example: BAPIO Action v RCGP and the GMC

• The Clinical Skills Assessment (CSA) does put South Asian UK and foreign graduates at a disadvantage

• The MRGCP is a licensing examination to enable doctors to practise medicine unsupervised. Patient safety is paramount.

• The CSA serves the legitimate purpose of protecting patient safety by means that are acceptable and at a human cost which is tolerable for those who ultimately succeed.

EQUALITY LEGISLATION

DISCRIMINATION ARISING FROM DISABILITY

Discrimination arising from disability occurs when:

• a person is treated unfavourably because of something connected with their disability, and

• the treatment cannot be justified as a proportionate means of achieving a legitimate aim.

It is not discrimination against a non-disabled person to treat a disabled person more favourably.

Example: A registrar attending his ARCP is recognised by a panel member. He tells the other members that when the registrar was a medical student there were concerns about his mental health and he took an overdose and received treatment for his condition. This is openly discussed at the ARCP.

DUTY TO MAKE REASONABLE ADJUSTMENTS

The Equality Act contains a duty to provide reasonable adjustments for disabled people. This means that organisations are required to take reasonable steps to:

▪ avoid substantial disadvantage where a provision, criterion or practice puts disabled people at a substantial disadvantage,

▪ avoid substantial disadvantage, where a physical feature puts disabled persons at a substantial disadvantage; this includes removing the physical feature in question, altering it or providing a reasonable means of avoiding it,

▪ provide an auxiliary aid where without one, a disabled person would be put at a substantial disadvantage.

Example: A trainee with a severe hearing impairment is referred to you as a doctor in difficulty. The other doctors say he cannot hear instructions when in theatre and this is putting patients at risk. His trainer is concerned that he will not be able to complete his training and suggests he is released from the training programme.

COMPETENCE STANDARD

A competence standard is defined as an academic, medical or other standard applied by, or on behalf of, an education provider for the purpose of determining whether or not a person has a particular level of competence or ability. It is not a PCP and therefore there is no duty to make reasonable adjustments in relation to the application of a competence standard. However, the duty does apply to the process of demonstrating that a person meets the competence standard.

RECOGNISING DISCRIMINATION

Working in small groups, please discuss the scenario given to you by the trainer from the examples below and decide:

• Whether the situation described could be discriminatory?

• How the situation could be resolved

Race/Religion

1. A Deanery has asked for your advice regarding a female trainee who is Muslim. A number of issues are identified as ‘causing problems’ ie

• during Ramadan she insists on bringing a prayer mat into theatre and stopping to pray once in the morning and once in the afternoon

• after attending hajj she states she has become more religious and wants to wear a niqab and jilbab (long black coat with a hood) when in clinic or on ward rounds.

2. You are visiting a training programme in your specialty. The TPD expects 70% attendance at the education programme. The sessions are always held on a Friday afternoon with additional sessions in the evening for those preparing for the examination. A Muslim trainee says he must visit the mosque on Fridays so he is either very late for the educational sessions, or if the traffic is bad, misses them altogether.

Age

3. A trainee who is an older, doubly qualified, overseas doctor challenges the outcome of his ARCP which states that he has made inadequate progress and additional training time is required. He tells the panel that his trainer has been against him from the outset and told him before the ARCP that remedial training would be pointless and he should withdraw from the training programme now. He says he does not believe a younger trainee would be treated in this way and claims he has been discriminated against because of his age. He says he has seen emails his trainer has sent to colleagues stating that he is ‘useless’ and others saying ‘training these older doctors is a waste of my time’ and ‘a drain on resources’.

RECOGNISING DISCRIMINATION

Gender

4. On a visit to a training programme, a female SpR tells you that her Educational Supervisor and the surgeons in her unit are men who are excluding her, which is affecting her training. When she works with the surgeons in theatre they speak Punjabi. They also speak in Punjabi to each other when she joins them at breaks, ignoring her. The rest of the time they speak to her as little as possible.

Sexuality

5. A trainee is referred to you as a doctor in difficulty as he is viewed as ‘not fitting in with the team’ and ‘finding it hard to engage with patients’. When you visit, his educational supervisor says that the trainee is technically competent but upsets people with his manner. He says the trainee is openly gay and has bleached hair and wears an earring which makes some patients uncomfortable as ‘this is a very traditional area’. In addition he irritates a number of the other doctors in the department who are quite religious and try to avoid mixing with him unless it is absolutely necessary. He goes on to say that he is sure that the trainee would do much better and be happier in a large city hospital.

Gender Reassignment

6. A trainee is referred to you as ‘causing problems’ with her colleagues and the Deanery is not sure how best to deal with the situation. The trainee has reassigned her gender, without any medical intervention, and has changed her name from Alan to Alicia and dresses as a woman at work. The Trust and Deanery have been fully supportive of her reassignment but have received a number of complaints from other staff who say she is using the female toilets and changing areas and ‘everyone knows she is still physically a man’. The staff say she should be excluded from using the female facilities.

Disability

7. A trainee who uses a wheelchair when in clinic and callipers when on ward rounds or moving around the hospital applies for a position in emergency medicine. His trainer and surgical colleagues believe it is unrealistic to accommodate him in this specialty and ask you for advice on how they should address the situation.

RECOGNISING DISCRIMINATION

Disability (cont’d)

8. A trainee is referred to you as a doctor in difficulty. She has developed an acute allergy to latex and has asked that her working environment is made ‘latex free’. After investigation the Trust and the Deanery say they cannot accommodate her request and she will have to be released from the training programme.

9. A trainee with autism is referred to you as a doctor in difficulty. He is a technically competent surgeon but due to his autism has poor social skills. The other staff he works with say he won’t speak to them and ignores them if they say ‘good morning’ to him or try to be friendly. He prefers to sit on his own most of the time.

However, when he does want to ask someone something about a work related matter, or on the rare occasion, chat about something, he just walks over to the person and interrupts even if they are talking to someone with no apology or respectful tone. He also stands very close to people when he speaks to them, which many staff, especially female staff find intimidating.

With patients he is straight to the point with no social ‘niceties’ and does not demonstrate any empathy when he has to give a patient bad news. When patients or relatives become upset he walks off. When the trainer speaks to him about his behaviour he says he understands but then carries on behaving in exactly the same way.

 

Racial harassment

10. A trainee is referred to you as a ‘doctor in difficulty’ His educational supervisor says his surgical skills are poor in a number of areas and there have been problems with the way he communicates with other medical staff, particularly nurses, which has led to complaints.

She shows you the records she has kept which relate to this trainee and what she has done to try and deal with the problems he is having.

When you speak to the trainee he gets very angry and says her concerns are exaggerated. He goes on to say that the educational supervisor has ‘always disliked him’, is overly critical and bullies him. He says she is not like this with the white trainees who she supervises.

UNCONSCIOUS BIAS WHEN SELECTING OR ASSESSING STUDENTS

Unconscious Bias: Refers to a bias that we are unaware of, and which happens outside of our control. It is a bias that happens automatically and is triggered by our brain making quick judgments and assessments of people and situations, influenced by our background, cultural environment and personal experiences.

(Source: Equality Challenge Unit 2013)

Working in small groups, please answer the following:

How do you think unconscious bias might affect you when selecting or assessing medical students?

UNCONSCIOUS BIAS

WHAT IS UNCONSCIOUS BIAS?

[1] ‘Because we are generally unaware that we are imposing a perceptual interpretation on the stimulus, we are generally unaware that our experience has an illusory aspect. The illusory aspect may only strike us after we are informed, for example, that the sizes or shapes of lines or areas that appear very unequal are, in fact identical in the picture.’

(Roger Shepard: 1990)

Unconscious bias refers to a bias of which we are not in conscious control.

It is a bias that happens automatically and is triggered by our brain making quick judgments and assessments of people and situations, influenced by our:

• background

• cultural environment

• personal experiences

(ECU: 2013 Unconscious bias in higher education)

IMPACT ON BEHAVIOUR AND DECISIONS

Unconscious biases can impact on our instinctive reactions, or the split second assumptions and decisions we make.

However, whilst our unconscious thoughts often happen instantly and quicker than our conscious thoughts, they can still prevail even after our conscious thoughts have had a chance to catch up.

The way we perceive people can continue to be based on those assumptions and stereotypes which we unconsciously associate with them.

UNCONSCIOUS BIAS

In a work or education situation, our unconscious biases can have a significant influence in a variety of situations, for example:

Staff

• Who we listen to most intently

• Who we disregard most easily

• How good we think someone is at their job and/or how good we think someone would be at a job for which they are applying

• How encouraging or discouraging our body language is towards different people

Trainee

• How suitable we think a trainee is for a particular programme

• How well we think a trainee will perform on a programme

• How much effort we perceive a trainee to be making

• The reasons we assign to trainees who are performing particularly well and/or who appear to be struggling.

PSYCHOLOGICAL STUDIES

There are numerous examples of psychological studies based on the impact of bias on behaviour and decisions and this is just one example.

Moss-Racusin et al (2012)[2] had staff in science faculties rate the application of a student for a position as a laboratory manager.

The application was used 127 times and randomly assigned either a female (64 times) or male (63 times) name.

Selectors rated the male applicant as significantly more hireable than the female applicant.

They also chose a higher starting salary and offered more career mentoring to the male applicant.

The gender of the selector did not affect responses.

UNCONSCIOUS BIAS

CATEGORISATION

One function of our brain is to rapidly categorise things and people in order to understand and interpret them quickly and efficiently. However that apparent efficiency can lead to mistakes. Our brain makes assumption based on the limited information we have about a person.

We process a person’s ethnicity, gender, age and disability before we even know we’ve done it. At the same time we also link that person to all the supposed ‘knowledge’ we have of the category with which have labelled them.

The stereotypes and societal assumptions and personal experiences that have framed the category become linked to the individual.

Unconscious bias exercise

To demonstrate how unconscious bias works the trainer will do an exercise with you. Work on your own and note your answer below.

In a work situation, our unconscious biases can have a significant influence in a variety of situations, for example:

Staff

• Who we listen to most intently

• Who we disregard most easily

• How good we think someone is at their job and/or how good we think someone would be at a job for which they are applying

• How encouraging or discouraging our body language is towards different people

Students

• How suitable we think a student is for a particular course

• How good we think a student will perform on a course

• How much effort we perceive a student to be making

• The reasons we assign to students who are performing particularly well and/or who appear to be struggling

UNCONSCIOUS BIAS

IN-GROUPS AND OUT-GROUPS

As well as categorising other people we also place ourselves within certain groups and categories.

‘The term in-group means a group to which someone belongs, and the term out-group means a group to which someone does not belong. This difference in affiliation has profound and robust effects on people’s evaluations of members of the different groups. In-groups appear to have an inherent, and automatic, positivity associated with them, whereas out-groups have an inherent negativity. In other words, people appear to think of their own group in positive terms and of the other group in negative terms, at even preconscious levels (ie without even realizing it).’

(Crisp and Nicel, 2004: p247)

We all have natural tendencies towards some people over others. They can be based on many things which may change over the course of our lives and vary depending on where we are, who we are with and what we are doing.

Factors of influence might be:

• shared interests and hobbies (for example, sport, music, gardening)

• similar lifestyle (for example, having children, caring responsibilities or pets)

• physical characteristics (for example, age, gender, race)

• similar background (for example, being from the same place, having a similar family background, having studied at the same institution)

Our in-groups are people who we feel safe with and towards whom we have unconsciously warm feelings. Our out-groups are people towards whom we feel less safe and who we can be distrustful and even dismissive or disdainful towards, without even realising.

(For more information see Social Categorisation Theory and Muzafer Sherif’s Robbers Cave experiment).

UNCONSCIOUS BIAS

IMPACT ON BEHAVIOUR AND DECISIONS

If we naturally feel warmer towards our in-group members and more cautious towards out out-groups it can impact on our behaviour in various situations.

For example:

• our body language towards different candidates in job/admissions interviews/assessments

• who we sit next to in meetings and at conferences

• which trainees we encourage and focus attention on

• who we listen to more readily and whose judgment we value most highly

• who we make time for and who we show an interest in

CONFIRMATION BIAS

People have a natural tendency to be selective in the evidence we listen to and the evidence we disregard. We do this through the way we:

• Search for information

• Interpret information

• Remembering/recalling information

We prefer information which confirms what we know and believe and are more likely to overlook information which challenges or contradicts[3].

CONFIRMATION BIAS IN THE WAY WE VIEW PEOPLE

1. You meet someone and unconsciously categorise them

2. The stereotypes and societal norms linked to those categories are linked to that individual

3. You are more likely to notice and remember their behaviour which is in keeping with the categories into which you have placed them – thereby reinforcing your opinion of them in that category. You are proving yourself to be correct.

4. You are less likely to notice and remember their behaviour which does not fit within the category

UNCONSCIOUS BIAS

IMPACT ON DECISION MAKING AND BEHAVIOUR

There is potential for unconscious biases to impact on how we perceive others’ ability and how we remember the work they have undertaken and what they have accomplished. For example:

Trainees

• How good/bad aspects of a trainee’s performance are noticed and remembered

• The ratings trainees are awarded depending on how forgivingly mistakes are looked upon or not

• Which trainees are encouraged to pursue further training.

REINTERPRETING INFORMATION DIFFERENTLY FOR DIFFERENT PEOPLE

Uhlmann and Cohen (2005)[4] conducted a study into hiring preferences for jobs. They found that participants re-defined the job criteria to fit the desired candidate.

In three studies, participants assigned male and female applicants to gender-stereotypical jobs. However, they did not view male and female applicants as having different strengths and weaknesses. Instead, they redefined the criteria for success at the job as requiring the specific credentials that a candidate of the desired gender happened to have.

For example, where they were hiring for the role of a police chief, they changed the important criteria the candidates needed to demonstrate to fit with their preferred candidate (a male).

When the male applicant is streetwise, being streetwise became the more important quality; when he is educated, education became more important.

This highlights the need to have specific job criteria set in advance with pre-determined priorities for what characteristics they were looking for in candidates.

MINIMISING THE IMPACT OF BIAS AND UNFAIRNESS IN WORKING WITH TRAINEES

What do you think the School of EM, or Clinical Tutors and Trainers could do to minimise the risk of bias, unfairness and discrimination affecting the assessment of, and advice given, to medical trainees?

THE PUBLIC SECTOR EQUALITY DUTY

The GMC is subject to the public sector equality duty (‘the duty’) which is outlined in section 149 of the Equality Act 2010 (‘the Act’). The duty also applies to a range of other organisations in the healthcare sector that exercise public functions, including the Care Quality Commission (CQC), the NHS and the Departments of Health for England, Scotland and Wales.[5] Doctors working in the NHS are also covered by the duty.

The purpose of the duty is to ensure that equality and good relations are given consideration and integrated into the day-to-day business of organisations.

THE PUBLIC SECTOR EQUALITY DUTY

This duty has 3 aims which are set out in statute: ‘A public authority must, in the exercise of its functions, have due regard to the need to:

▪ Eliminate discrimination, harassment, victimisation and any other conduct that is prohibited by or under this Act;

▪ Advance equality of opportunity between persons who share a relevant protected characteristic and those who do not share it;

▪ Foster good relations between persons who share a relevant protected characteristic and persons who do not share it.’

The Act further defines what ‘advancing’ equality of opportunity means:

▪ Removing or minimising disadvantages suffered by people due to their protected characteristics.

▪ Taking steps to meet the needs of people from protected groups where these are different from the needs of other people.

▪ Encouraging people from protected groups to participate in public life or in other activities where their participation is disproportionately low.

Fostering good relations between different groups is defined as tackling prejudice and promoting understanding between people who share a protected characteristic and those that do not.

PRINCIPLES FOR COMPLYING WITH THE DUTY

Case law has established that compliance with the duty requires an organisation to be conscious of its obligations and to take a deliberate approach to meeting them.

THE PUBLIC SECTOR EQUALITY DUTY

The GMC’s public functions include its four statutory functions under the Medical Act 1983. ’The functions of a public authority include all of their powers and duties. This means everything that they are required to do as well as everything they are allowed to do. Examples of this include: policy decisions, budgetary decisions, public appointments, service provision, statutory discretion, individual decisions, employing staff and the procurement of goods and services.’[6]

The courts have considered what a relevant body needs to do to fulfil their obligations to have due regard to the aims set out in the equality duty. The principles that are being applied include the following:

a. Individuals and groups responsible for making decisions in a public authority should be aware of the requirements of the duty and consciously consider the aims of the duty as an integral part of the decision-making process.

b. They should understand the effect of an organisation’s policies and practices on people with different protected characteristics.

c. Any third parties exercising public functions on its behalf are required to comply with the duty, and that they do so in practice. This is because the duty rests with the public authority, even if they have delegated any functions to a third party.

QUALIFICATION BODIES

Section 53 of the Act imposes a duty on qualifications bodies not to discriminate in the conferment of relevant qualifications and also imposes a duty on them to make reasonable adjustments for disabled people.

APPENDIX ONE: JUDGEMENT

KEY EXTRACTS FROM THE JUDGEMENT BY MR JUSTICE MITTING IN THE BAPIO ACTION LTD – V – ROYAL COLLEGE OF GENERAL PRACTITIONERS AND GENERAL MEDICAL COUNCIL

History

There have been numerous investigations (about 18 at the last count) into the clinical skills assessment by a medical academics and statisticians. In recent years notable reports include: 29 December 2010, a report by Katherine Woolf and others; May 2011, a review by Birmingham University; February 2012, one of several reports by Richard Wakeford of the University of Cambridge; 22 June 2013, a review by Denney, Freeman and Wakeford; 18 September 2013, a report commissioned by the GMC by Professors Esmail and Roberts and, later on in 2013, a report by Professor Norcini. It is not necessary to refer extensively to these reports. All that I need do for the present purposes is to summarise their conclusions:

1. There is a persisting difference in the outcomes of the clinical assessments between:

• doctors who are UK graduates and those who are foreign graduates;

• doctors who are UK graduates who are white and those who are South Asian or BME;

• doctors who are foreign graduates who are white and those who are South Asian or BME.

2. The difference reflects similar experience in other tests conducted by the Royal College, the Applied Knowledge Test, and by other examiners, for example the Professional and Linguistic Assessment and by examiners in other medical disciplines, for example, psychiatry.

3. There is an unavoidable risk of subconscious bias on the part of role players or, more significantly, examiners in a role play-based test. In one instance (in Denney et al), a small but significant bias was measured. BME examiners rated BME candidates 2.2 per cent higher than did their white colleagues.

4. A significant part of the difference between UK graduates and foreign graduates can be put down to different standards of education and cultural experience in the countries in which they graduated. In particular, foreign graduates may lack familiarity with the approach expected by patients of general practitioners in the United Kingdom because of the nature of their training and the nature of medical practice in the country in which they trained.

APPENDIX ONE: JUDGEMENT (CONT’D)

5. In addition, Professors Esmail and Roberts have concluded that the possibility of subconscious racial bias on the part of examiners may also play a part in the difference in outcome. So, too, may other factors identified by Dr Rendel: In the case of foreign graduates, a different age profile and the possible relative lack of rigour of the Professional and Linguistic Assessment; in the case of all graduates, differences in the quality of training under different Deaneries leading to different success rates. For example, the London Deanery has a first time pass rate of 82 per cent, the East Midlands Deanery a first time pass rate of 57 per cent. None of these factors are under the direct control of the Royal College.

In summary, the extensive research undertaken so far has identified the problem of differential outcomes which are only partly explicable by known factors and produced tentative suggestions for making alterations: within the competence of the Royal College, the encouragement of and cooperation with the Deaneries to educate candidates in the requirements of the Clinical Skills Assessment and an effort to secure a more representative profile of examiner. I would be surprised if the Royal College had not itself reached the conclusion that steps along those lines should now be taken and, if not, that the GMC, as its regulator, would not insist that they were taken.

Decision

It is rightly common ground that requiring would-be general practitioners to submit to a Clinical Skills Assessment is a provision, criterion or practice and that if it puts South Asian UK graduates at a disadvantage by comparison with their white UK graduate colleagues and South Asian foreign graduates at a disadvantage when compared with white foreign graduates, it is discriminatory and that it is for the Royal College to show that it is a proportionate means of achieving a legitimate aim to discriminate between them in the manner which has occurred.

• I am satisfied that the Clinical Skills Assessment does put South Asians of both categories at a disadvantage when compared with their white colleagues in the same category. Can the Royal College show that the assessments are a proportionate means of achieving a legitimate aim? Two pieces of evidence establish beyond argument what the legitimate aim is. I take the first from the witness statement of Dr Rendel and her citation from a paper produced by the Royal College in January 2011.

"The MRGCP [an acronym for the three assessments to which I have referred] is a licensing examination which is by definition 'high stakes' in that those who pass will be licensed to practise medicine in an unsupervised capacity.

APPENDIX ONE: JUDGEMENT (CONT’D)

Patient safety is therefore paramount and given that assessment is an imperfect science, the treatment of the measurable error must act in favour of patients rather than doctors.

Specifically, we must be more confident that doctors who pass are safe to practise than that doctors who fail are unsafe. This aim is achieved not by one examination component in isolation, but by all three components of the MRCGP acting in a mutually complementary and supportive capacity, much like the three legs of a stool."

• In their report Professors Esmail and Roberts describe the assessment as follows:

"The CSA is not a culturally neutral examination and nor it is intended to be. It is not and nor should it be just a clinical exam testing clinical knowledge in a very narrow sense. It is designed to ensure that doctors are safe to practise in UK general practice. The cultural norms of what is expected in a consultation will vary from country to country. So for example, a British graduate will have difficulty in practising in a general practice setting in France or India until they become acculturated to that system of care. British graduates have much greater exposure, both personally and through their training, to general practice when compared to the majority of IMG (foreign graduates) who graduate from health systems which are not as dominated by primary care as the NHS. Most medical schools in the UK now have well developed programmes for communication skills training, reflective practice and direct exposure of students to General Practice as a discipline."

• I am also satisfied that the Clinical Skills Assessment is a proportionate means of achieving that legitimate aim. It is necessary to test three of the skills required of a general practitioner: 1) gathering information; 2) arriving at a diagnosis; 3) communicating with the patient. No better means of testing those skills has yet been devised than the Clinical Skills Assessment. The method is in common use across the civilised world, unsettling and expensive though it may be for those who fail the first time at a cost of £1,600. The eventual failure rate is very small.

• The assessment serves the legitimate purpose of protecting patient safety by means that are, in principle, acceptable and do so at a human cost which is tolerable for those who ultimately succeed. There is no basis for contending that the small number who fail ultimately do so for any reason apart from their own shortcomings as prospective general practitioners.

APPENDIX TWO: EQUALITY ACT

ADDITIONAL INFORMATION

DISCRIMINATION BY PERCEPTION

It is direct discrimination to treat a person less favourably because others think they possess a particular protected characteristic. It applies even if the person does not actually possess that characteristic.

DISCRIMINATION BY ASSOCIATION

Discrimination by association occurs when a person is treated less favourably in a situation because they associate with another person who possesses a protected characteristic.

HUMAN RIGHTS ACT ARTICLE 9: FREEDOM OF CONSCIENCE

Everyone has the right to freedom of thought, conscience and religion.

Everyone has the right to manifest their religion or beliefs, which shall be subject only to such limitations as are prescribed by law, and are necessary in a democratic society in the interests of public safety, for the protection of public order, health or morals or the protection of the rights and freedoms of others.

PROTECTED CHARACTERISTICS: DEFINITIONS WITHIN THE ACT

RELIGION OR BELIEF

Religion or belief is defined as being any religion, religious belief or similar philosophical belief, but does not include political belief. A number of factors will be considered in deciding what is a religion, or similar belief, such as: collective worship, a clear belief system or a profound belief affecting the way of life or view of the world. The regulations also cover those without religious or similar beliefs eg an atheist.

SEXUAL ORIENTATION

Sexual orientation is defined as:

• Orientation towards people of the same sex (lesbians and gay men)

• Orientation towards persons of the opposite sex (heterosexual)

• Orientation towards persons of the same and opposite sex (bisexual).

GENDER REASSIGNMENT

Gender reassignment is a personal process (rather than a medical process) which involves a person expressing their gender in a way that, differs from or is inconsistent with, the physical sex they were born with. The personal process may include undergoing medical procedures or it may simply include choosing to dress in a different way, as part of the personal process of change.

APPENDIX TWO: EQUALITY ACT

ADDITIONAL INFORMATION (CONT’D)

DEFINITION OF AGE

This includes chronological age and apparent age. This means that if someone is discriminated against because they look “too old” or “too young” for a job, they will be able to complain successfully, even if the discriminator is wrong about their actual age.

PROPORTIONATE MEANS OF ACHIEVING A LEGITIMATE AIM

What is proportionate?

This means:

• what you are doing must actually contribute to a legitimate aim eg, if your aim is to encourage loyalty then you ought to have evidence that the provision is actually doing so

• the discriminatory effect should be significantly outweighed by the importance and benefits of the legitimate aim

• you should have no reasonable alternative to the action you are taking.

What is a legitimate aim? (Age examples)

A legitimate aim might include:

• the health, welfare and safety of the individual (including protection of young or older people)

• facilitation of employment planning

• particular training requirements

• encouraging and rewarding loyalty

• the need for a reasonable period of employment before retirement (default retirement age abolished on October 1st 2011).

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[1] Shepard, R. N. (1990). Mind sights: Original visual illusions, ambiguities, and other anomalies. With a commentary on the play of mind in perception and art. New York: WH Freeman & Co.

[2] Moss-Racusin, CA, Dovidio, JF, Brescoll, VL, Graham, M & Handnelsman, J (2012) ‘Science faculty’s subtle gender biases- favour male studens’. Proceedings of the National Academy of Sciences for the United Sates of America 109(41): 16474-16479

[3] There are various psychological studies on this, for example, Snyder, M., & Swann, W. B. (1978). Hypothesis-testing processes in social interaction. Journal of Personality and Social Psychology, 36 , 1202–1212

[4] Uhlmann, EL & Cohen, GL (2005) ‘Constructed criteria redefining merit to justify discrimination’. American Psychological Society 16(6): 474–480.

[5] The Equality Act 2010 does not apply to Northern Ireland. The legislation is very similar to the Great Britain legislation and there are plans to reform the legislation in Northern Ireland.

[6] Meeting the equality duty in policy and decision-making, Equality and Human Rights Commission, January 2012

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