Racism is established as a determinant of physical and mental health, with significant associations that persist after adjusting for other characteristics.¹ The pathways through which they act are increasingly understood,^2,3 with structural discrimination seeping into the functioning of institutions and systems, including health systems, subsequently impacting on health.⁴ Structurally embedded discrimination perpetuates disparities in power, constraining access to resources and opportunities, which, in turn, cause health inequalities. In the UK, adults from minoritised ethnicities who have faced racial discrimination are more likely to experience limiting longstanding illness, poorer physical and mental functioning, greater psychological distress, worse life satisfaction and poor self-rated health, after adjusting for age, sex, and socioeconomic factors including household income and education.⁵ The recent national review of child mortality shows one of the starkest examples of racial health inequalities. Reviewing data over the last five years, infants of Black Caribbean or Black African ethnicity are over three times more likely to die than infants of White ethnicity.⁶ A report revealed that the average age of death for people with a learning disability who are from an ethnic minority background is 34 years, just over half the life expectancy of their White counterparts at 62 years of age, with the report highlighting potential factors influencing this, including poorer healthcare access, experience and outcomes.⁷. Racial bias, however, is not always about measurable health outcomes; it can be as simple as the language used to describe patients. A study that reviewed health records found that Black patients are more than twice as likely to receive negative descriptors, such as ‘resistant’ or ‘non-compliant’ compared to White patients.⁸

Although these health inequalities have long been felt and known, they were catapulted to mass public consciousness by the COVID-19 pandemic in 2020, with its disproportionate impact on racially minoritised populations, coinciding with the increased awareness of the Black Lives Matter Movement following the murder of George Floyd in May of that year. This shone a light on structural racism in many UK institutions,⁹ with recognition that centuries of racial discrimination is hard-wired in the NHS. The Workforce Race Equality Standard (WRES)¹⁰ and, more recently, the Medical Workforce Race Equality Standard (MWRES)¹¹ revealed disparities in career progression, experience, and opportunities that exist for people from minoritised populations compared with White staff. The NHS Race and Health Observatory was also set up in 2021 to examine and tackle inequalities experienced by Black and ethnically minoritised patients, communities and staff.¹²

There has concurrently been a push toward improving equality, diversity and inclusion (EDI) in organisations. While EDI aims to bring about equality within the workforce and treatment of individuals, more intentional education and action is needed to understand the underlying causes of these inequalities and reduce patient and population inequities. There is an important distinction between anti-racism work, and the EDI agenda. Anti-racism can be defined as ‘the active process of identifying and eliminating racism by changing systems, organizational structures, policies and practices and attitudes, so that power is redistributed and shared equitably’.¹³ Anti-racism provides the foundational understanding that it is not race, ethnicity, religion, or migratory status that deems an individual to become unwell or fare differently. Rather it is the way the society in which they live and work, places value on them because of their characteristics, with the associated unequal power dynamics influencing their health outcomes and access to resources and opportunities. As healthcare professionals, we must acknowledge the racist and discriminatory ideologies and practices that underlie modern medicine and ensure that future practice views the structures that underpin health systems through a critical lens, to enable us to provide the best quality care for all patients.

This calls for the incorporation of specific learning outcomes within curricula that go beyond generic acknowledgement of the problem, to educate and equip doctors with the knowledge and skills for applying antiracist approaches in their practice.¹⁴ This must acknowledge that doctors, like anyone else, may already hold misconceptions about race and ethnicity^15–18 that are likely to perpetuate disparities.^19,20 In the context of widening health inequalities in the UK, there is a clear need for medical education to include knowledge of discrimination as a determinant of health²¹, conferring the sensitivity and skills to identify structural racism^22,23 and to address it.^24–26

This raises the question of the extent to which this is already happening. To answer it, we undertook two analyses. Firstly, we reviewed publicly available commitments from Royal Colleges, Faculties and examination bodies to address racism, xenophobia, religious discrimination (explicitly including Islamophobia and antisemitism given contemporary discourse)^27–29 and decolonisation, and whether the commitments included education-related actions. Decolonisation was added as a concept given the rise in its use as an approach to address inequalities resulting from colonial injustices, therefore including it in the analyses allowed us to investigate the type of actions outlined to address these structural harms. We also sought evidence of any stated measures of accountability.³⁰ Secondly, we reviewed postgraduate medical curricula to identify whether the impact of racism and discrimination on health was explicitly mentioned as one of the competencies expected of doctors in training.