What do you need to include?

EIAs must be supported with data or evidence. Examples of relevant data sources include:

• data relating to learners from minoritised groups, including those who completed their primary medical qualification outside the UK
• data on health inequalities experienced by specific patient groups
• feedback from consultations
• external research and statistics, for example our NTS reports and research into how training experiences and outcomes vary for different demographic groups.

Data and research continue to highlight that barriers to progression in training vary for different groups. Outcomes are notably poorer for doctors who qualified overseas, doctors from ethnic minority backgrounds, and doctors with a disability, for example. In your EIA, you should reflect on the data available to you regarding the demographics, learning experiences, and outcomes of the learners and/or exam candidates in your specialty. You should consider what opportunities there are to remove known barriers faced by marginalised groups and whether the changes you are planning could worsen those outcomes or training experiences.

You should also consider research evidence or data about certain patient groups, if a change would potentially discriminate against, or have a positive effect on them. You don’t have to submit these data, but it’s important for you to consider how what they show could affect the design of curricula or assessments.

Health inequalities are ‘avoidable, unfair and systematic differences in health outcomes between different groups of people’.* These disparities contribute to issues including lower life expectancy, the higher prevalence of some health conditions, and unequal access to care as a patient. Groups who are more likely to experience worse health outcomes (which are often a result of higher poverty levels), include those who are homeless, disabled, LGBTQ+, from a black, Asian, and minority ethnic background, or refugees and asylum seekers. All healthcare professionals have a role to play in achieving equity of health outcomes. Curricula and assessments should be designed so that doctors, PAs and AAs are equipped with the knowledge and skills to better meet the needs of different groups of people. As part of the EIA, royal colleges and faculties should consider data on health inequalities in their specialties when developing new curricula and assessments and look for opportunities to achieve equity of health outcomes.

Please see further resources and guidance for more information on differential attainment and health inequalities.

*What Are Health Inequalities | The Kings Fund

You should reflect on the quality of data and information gathered and make sure that you:

• consider any additional feedback which may not have formed part of the general consultation or engagement process
• assess if there’s sufficient data/feedback, and if significant gaps exist—consider whether further consultation or research is needed in the future
• engage with key stakeholders who have been previously consulted with if significant changes have been made because of their feedback. 

You’ll need to make sure that you:

• articulate clearly within the EIA the conclusions that you are drawing from the data you sourced
• highlight where inequalities already exist for learners or patients
• explain how you considered the impact of the proposed changes in the context of these findings.

In cases where there are very small numbers of learners, it may not be possible to draw meaningful conclusions from these data or present them publicly as it may mean individuals are easily identified. However, you should still carry out analysis as far as possible and highlight in the EIA the reasons why particular information/groups may not be covered.

Your primary aim is to use your data to identify if the changes might disadvantage certain groups of people more than others, or result in poorer outcomes. This could include differences in pass rates in examinations and assessments for learners who share protected characteristics, or poorer care for patients, which may then worsen inequity of health outcomes. You also have a duty under the PSED to look for opportunities to remove or minimise existing disadvantages where possible.

Where a proposed change has the potential to disadvantage a particular protected group, it may be justifiable in some circumstances.

The Equality Act 2010 sets out that differential treatment can be justified if it’s a proportionate means of achieving a legitimate aim. The aim is the reason for the action being taken, for example, making a change to curricula or assessments. To be legitimate, this reason must not be discriminatory and it must be genuine.

Legitimate aims in the context of postgraduate medical education and training often fit under the following categories:

• maintaining or protecting patient safety
• safeguarding the health, safety, and welfare of individuals or groups
• meeting the particular training requirements for a role.

An example of a legitimate aim would be allowing conscientious objection to fertility control. The obstetrics and gynaecology curriculum allows those with certain religious beliefs to demonstrate that they meet the knowledge criteria relating to contraception and termination of pregnancy by advising patients rather than performing associated procedures.

Financial constraints in isolation (for example, saving costs) may not be likely enough to justify a change where there’s an evidenced adverse impact on a protected group that could be mitigated or prevented. This may depend, however, on the scale of the costs in relation to the means of the organisation.

Being proportionate in this context means that:

• the aim is achieved by a proposed action or change
• the adverse impact or any discriminatory effect is significantly outweighed by the importance and benefits of the legitimate aim
• there’s no reasonable alternative to the action or change taken
• if the legitimate aim can be achieved by another or less discriminatory means, then this option should be chosen instead.

Once you’ve considered the potential or actual effect of any proposed changes on groups who share protected characteristics, you should be able to make an informed decision on how to proceed. There are three main actions you can take. You can:

• adjust the proposed change to the curriculum or assessment
• continue with the proposed change
• stop the proposed change.

In making a decision to adjust, proceed with or stop making the proposed change, you should give appropriate weight to the equality considerations, while balancing other factors such as patient safety or resource constraints.

You may decide to proceed with the change but take some actions to mitigate any potential negative impact on particular groups. These could include:

• making sure that all examiners undertake examination-specific diversity training, in relation to bias and awareness of differential attainment
• developing an examiner pool that is representative and inclusive
• making training guidance easily accessible to all and providing training and exam preparation materials for candidates
• reviewing and improving processes for responding to requests for reasonable adjustments from examination candidates with a disability. 

Assessing impact on equality, diversity and inclusion is an ongoing process that does not end once a decision has been made and a curriculum or assessment is implemented. It’s good practice to review any changes periodically and to include consideration of the Public Sector Equality Duty (PSED) as one of the criteria.

It’s important to monitor the potential impacts that an EIA highlighted and evaluate whether any mitigating actions have been effective. Where actions have not been effective, they should be revisited and revised accordingly. This may require changes to a proposed approach, for example, if it received negative feedback or if other relevant policies change.

When we approve a change, it’s likely that we’ll ask you to monitor its impact and report back to us after a period (usually 12 months after implementation). It’s common that we’ll also ask you to include some reflection on the impact of the changes on protected groups; those that were identified in the EIA and any that were unexpected. You should therefore think about how you will collect this information at an early stage, for example by asking a relevant question in a feedback survey, or reviewing the progression data (annual reviews of competency progression (ARCPs), exam outcomes etc) available to you.

We would also encourage you to share learning of any initiatives or actions that have worked well, for example in widening participation in training or reducing the attainment gap, with the GMC and with other royal colleges and faculties. 

If you have any questions about the curriculum and assessment approval process or EIAs please contact us at quality@gmc-uk.org.