Chasing equality in pharmacy training

Closing the awarding and attainment gap for Black trainees in pharmacy

This collaborative report describes how to close the differential degree awarding gap and registration attainment for Black trainees in initial pharmacy education and training.

Lead Author: Amandeep Kaur Doll
5 February 2024

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Executive Summary

This collaborative report describes how to close the differential degree awarding gap and registration assessment attainment for Black trainees in initial pharmacy education and training.

1. What is a differential degree awarding gap and a differential registration assessment attainment gap?

This report explores both the differential degree awarding gap (formerly known as the ’attainment gap’) and the differential registration attainment gap at the pharmacist foundation training registration assessment. In higher education, the degree differential awarding gap is the difference in the proportion of two student groups receiving a first or second-class degree.

There are significant gaps for student groups who share a protected characteristic in most higher education institutions¹.

The registration assessment differential attainment gap is the difference in the proportion of two student groups who pass the pharmacist registration assessment at their first sitting.

2. Sizing the gap

• Based on Higher Education Statistics Agency (HESA) data, an awarding gap in the Master of Pharmacy (MPharm) degree has been reported²
• In 2017/2018 and 2018/2019, 91% of White students were awarded first class or upper second-class honours, compared with 79% of Black, Asian and Minority Ethnic students
• In 2019/2020 and 2020/21, 94% of White graduates were awarded a first or upper second-class degree, compared with 86% of ethnic minority graduates. The degree awarding gap has narrowed to 8%
• In 2019/2020 and 2020/21, a 12% degree awarding gap has been recorded for those of Black ethnicity compared with White students
• A variation in the registration assessment pass rate for first time sitters between Black or Black British: African trainees compared to White: British trainees of 39% was first reported by the General Pharmaceutical Council (GPhC) in 2013
• The GPhC undertook a qualitative evaluation of the causes, which was published in 2016³
• Our research shows that an attainment gap persists a decade since it was first reported. Data suggests that the 2023 attainment gap Black or Black British: African and White: British trainees for first time sitters in the pharmacist foundation registration assessment is 23%
• While some notable progress has been made in some areas across the system, the degree awarding and registration assessment attainment gaps persist, and more action is needed today to make a change for the future.

3. Contributing factors

A system level approach is required to address the complex and multifaceted elements of the gap. These can be separated into:

1. Individual factors - helping students to challenge expectations about themselves and valuing the wealth of experience and cultural understanding they can bring due to their diversity
2. Institutional cultures and organisational structures – addressing negative institutional cultures, organisational structures, and leadership where present to provide a vision and strategy for inclusion within their organisations.

4. How can we close the gap?

Across the research literature in medical education⁴, and within the qualitative work undertaken by the GPhC⁵, a series of changes can be made from an organisational perspective to reduce the current degree awarding gap and registration assessment differential attainment gap including:

1. Monitoring data
2. Mentoring, role models and supportive networks
3. Improving cultural competence for tutors
4. Recognising and celebrating diversity
5. Regulation and quality assurance
6. Protected learning time.

5. Future actions and key areas of focus

The path to resolving the differential degree awarding and registration assessment attainment gaps relies on advocacy and support from across different parts of the system and organisation in the journey to registration.

Collective action is required as a profession, as it is now over a decade since differential attainment in pharmacy was first recognised⁶. The Royal Pharmaceutical Society has formed a working group with representatives from the British Pharmaceutical Students Association, General Pharmaceutical Council, NHS England’s CPhO Office, WT&E Team and IPP Advisory Board, Pharmacy Schools Council, Royal Pharmaceutical Society, and individuals representing Schools of Pharmacy.

The aim of the group is to address the challenges and to make positive strides in reducing the differential degree awarding and registration assessment attainment gaps. This working will feed into the NHS IPP Advisory Board.

This report brings together the knowledge and data of the current differential degree awarding and registration attainment gaps, analyses the progress that has been made to date, and recommends further steps to be taken.

The key areas of focus are:

• Improving data collection, analysis and data sharing
• Inspiring current and prospective students, supporting their aspirations with practical help and promoting the benefit of positive role models
• Removing bias from processes
• Providing support during the transition from pharmacy student to foundation training placements
• Additionally, we emphasise the importance of tutor training, the implementation of protected learning time in foundation trainee programmes, and an annual equality, diversity and inclusion forum to ensure good practice is being shared across Schools of Pharmacy and training placements.

6. Recommendations

Since 2013, there has been a recorded difference in degrees awarded and registration assessment pass rate attained by Black students and trainees.

These gaps must be addressed with positive action taken to ensure they are removed, to ensure that Black students and trainees can achieve the standards required for pharmacist registration, regardless of their backgrounds. This will also benefit patient care.

Ultimately, by creating a better experience for Black pharmacy students and foundation trainees, we can raise the quality for all students, and in turn all patients and the public. We also want to see a more open and inclusive culture for overseas pharmacy students.

As a working group we are dedicated and committed to work together to take forward the actions highlighted in this report, to ensure there is meaningful and sustainable change in reducing and removing the degree awarding gap and registration assessment attainment gap for Black students and trainees

The reasons for a differential degree awarding gap and registration assessment attainment gap for Black students and trainees are multifactorial, thus, an intersectional and a system-wide approach is required. The profession needs to ensure they are doing their part to address differential gaps and improve the Black student and trainee experience.

The actions highlighted in this report are not only for the working group to take forward; they require the whole profession to take action in their working environments to ensure Black students and trainees have a positive experience free from prejudice and discrimination and are offered opportunities to reach their full potential and thrive in pharmacy.

The following recommendations and outputs have been made for both the working group and for the wider profession:

1. Working group to primarily focus on addressing the differential degree awarding gap and registration assessment attainment gap for Black students and trainees, taking an intersectional approach to be taken. Targets and timelines will need to be set
2. Schools of Pharmacy, foundation training providers, and educational training providers to take forward the actions, as highlighted in this report, to make meaningful and positive changes in their own areas. Areas can form their own working groups to take meaningful steps to address the differential awarding and registration assessment attainment gaps for their students and trainees
3. Smaller task and finish groups led by members of the working group to focus on the key themes and areas highlighted and take forward the actions outlined. The task and finish groups will be formed by members of the profession with relevant experience to support in moving actions forward. Targets and timelines will be set to ensure actions are moving forward to reduce the differential gaps
4. Working group to meet every six months to review the progress of each organisation and task and finish group. This will help to ensure the differential awarding and attainment gap is reducing. Progress will be reported to the IPP advisory board to ensure accountability and to demonstrate progress in narrowing the degree awarding gap and registration differential attainment gap. Progress will also be reported annually at the EDI forum
5. Organisations continue to advocate and lobby to ensure all foundation trainees to receive regular protected learning time within their working day
6. Working group to review differential awarding gaps and registration assessment attainment gaps for other protected characteristics as part of their future remit to ensure pharmacy students and foundation trainees are not disadvantaged based on their protected characteristics.

In addition to the recommendations summarised here, there are a series of organisational actions for delivery to help bring these recommendations to reality.

7. Supported by:

• British Pharmaceutical Students Association (BPSA)
• Chief Pharmaceutical Officer for England
• Chair of the Inclusive Pharmacy Practice Advisory Board
• General Pharmaceutical Council (GPhC)
• Pharmacy Schools Council (PhSC)
• Royal Pharmaceutical Society (RPS)
• And additional Schools of Pharmacy.

Foreword

The truth about the registration assessment differential attainment and degree awarding gaps for Black students and trainees in pharmacy education and training has persisted for over a decade. Shockingly, despite being public knowledge, there has been a marked absence of concerted and persistent efforts to rectify this issue, resulting in a profound impact on the lives and careers of those affected.

At its core, closing the degree awarding gap and registration assessment differential attainment gap for Black individuals in pharmacy is a matter of moral imperative and strategic necessity. Beyond affecting individual career prospects and job opportunities, the profession is missing out on the wealth of incredible talent and diverse skills that could significantly elevate patient care, drive progress and deliver innovation.

The inertia to address these disparities reflects a deep-seated problem rooted in decades of structural and organisational racism and inequalities. From the initial entry into higher education to the intended careers, Black pharmacy students and trainees face systemic challenges that have been ignored for far too long. This neglect has led to a lack of visibility and representation in leadership structures, exacerbating the absence of diversity in academic faculties and teams.

Data from NHS England's Pharmacy Workforce Race Equality Standard (PWRES) emphasises the stark disparities faced by Black, Asian, and Minority Ethnic individuals in comparison to their White counterparts. Despite the proud diversity within the pharmacy profession, the report reveals an alarming truth: the playing field is far from level, hindering the equal chances of success for Black, Asian, and Minority Ethnic students at both undergraduate and registration stages.

The report serves as a resounding call to action, merging quantitative data with qualitative insights into the experiences of Black students and trainees. It sheds light on a vulnerable phase in their careers where many may lack the agency to speak up against discrimination or even be aware of their disadvantage based on their skin colour or ethnic background.

Acknowledging the valiant efforts of groups such as the Black Pharmacists Collective (BPC) and the Afro Caribbean Pharmacy Network (ACPN), the report highlights the inspirational case studies of those taking matters into their own hands. The case studies in the report are both humbling and inspirational. However, the report firmly asserts that the burden of addressing discrimination should not fall solely on those being discriminated against.

The Royal Pharmaceutical Society (RPS) plays a pivotal role in leading the profession, chairing a working group to tackle these disparities. Collaboration among stakeholders is recognised as essential to narrowing and ultimately eliminating the gaps. Through initiatives like RPS's work on Inclusion & Diversity and the Inclusive Pharmacy Practice Partnership with NHS England, there is a growing awareness of the intricate work needed to foster equity in outcomes, opportunities, and workplace inclusion.

The report aims to spark a profession-wide conversation on the Black degree awarding gap and registration assessment differential attainment gap, unveiling the profound impact of structural inequalities within universities and training placements on students' and trainees' ability to succeed.

As the green shoots of a new era for pharmacy in terms of racial equity emerge, the data presented in the report demands attention and action. The hope is that the recommendations outlined will not be mere rhetoric but will be implemented in a sustained and measurable manner. Moreover, the report calls for bold efforts from leaders and individuals to acknowledge disparities, enhance cultural competence, and create inclusive environments that offer everyone a fair chance at success. This commitment is crucial to delivering high-quality healthcare and attracting and retaining diverse talent within the pharmacy profession.

1. What is a differential degree awarding gap and registration assessment differential attainment gap?

This report explores both the differential degree awarding gap in pharmacy higher education (formerly known as the ’attainment gap’) and the registration assessment differential attainment gap at the pharmacist foundation training registration assessment.

Differential Degree Awarding Gap

The differential degree awarding gap in higher education is the proportional difference between two student groups receiving first and second-class degrees. Across higher education there are significant and enduring gaps for student groups who share a protected characteristic, for example ethnicity, gender and disability.

A national degree awarding gap remains significant in all subjects despite university efforts to address it⁷. A recent report by University UK and the NUS noted a national degree-awarding gap of 8.8% for Black, Asian and Minority Ethnic groups⁸; a 4.2% reduction from the 13% observed in 2017/2018⁹. However, the disparity indicates that further remedial measures are required.

Studies examining the causes of degree-awarding discrepancy demonstrate that social, societal, personal, institutional, cultural, and structural factors are considered to negatively impact the academic experiences of these students, contributing to the discrepancy in degree attainment between White and Black Asian and Minority Ethnic students^{10, 11}.

However, it is important to note that many studies researching the degree awarding gap consider Black, Asian, and Minority Ethnic students as a homogenous group that share similar experiences and inequalities, overlooking the specific experiences of Black students.

A degree awarding gap in the Master of Pharmacy degree (MPharm) was first reported in 2017/2018 and 2018/2019 based on Higher Education Statistics Agency (HESA) data, the data is reported in further detail below.

Registration Assessment Differential Attainment Gap

Differential attainment is the variation in attainment between groups who share a protected characteristic, for example, ethnicity, gender and disability. Differential attainment has been reported in medical education since the 1990s, with students from non-white backgrounds performing worse than those of White British heritage¹².

Awareness of a registration assessment differential attainment gap in pharmacy was first reported in 2013 when the General Pharmaceutical Council (GPhC), the regulator for pharmacy professions, began collecting data on candidate performance in the registration assessment according to self-declared ethnicity data.

The registration assessment¹³ is taken by trainee pharmacists at the end of their foundation training year. These trainees have completed an accredited MPharm degree programme in England, Scotland and Wales and undertaken a subsequent foundation training programme, which gives trainee pharmacists the opportunity to develop and demonstrate the skills, knowledge, and behaviours they need to practise to the standards expected of a pharmacist in real-life scenarios¹⁴.

In 2013, for the White: British cohort, the pass rate for first time sitters in the summer registration assessment was 93%, while for the Black or Black British: African cohort it was 54%. Subsequent years demonstrated that, overall, in comparison to other groups, self-declared Black or Black British: African candidates performed less well. This phenomenon is not unique to pharmacy and has been reported and explored across medical education¹⁵. In order to understand and interrogate the causes of the gap in pharmacy, we need to consider what leads Black or Black British: African trainees to experience these differences and seek to understand if any improvements have been made.

As a result, this report breaks down both the differential degree awarding gap and registration assessment attainment gap at all stages of the initial education and training of pharmacists, from entry into pharmacy undergraduate courses, through completion of pharmacy degree programmes, and finally to the registration assessment.

While the focus of this research is from the point of entry to university, societal barriers exist for Black students in their journey to university. It is worth noting that overall, there have been recent increases in the numbers of Black students applying to university, with entry rates rising from 21.6% in 2006 to 44.5% in 2019¹⁶. However, barriers to students throughout their formative education are likely to impact their higher education, and therefore it should be recognised that this challenge is not one for pharmacy alone.

It is now over a decade since this difference between these groups in pharmacy was first recognised. The Royal Pharmaceutical Society has formed a working group of interested providers, regulators and others to address these challenges.

Members of the working group, the governance structures, and how the working group will feed into the NHS Inclusive Professional Practice (IPP) Advisory Board is outlined in Appendix 1.

Against such a background, this report brings together the knowledge and data of the current differential degree awarding and registration assessment attainment gaps, analyses the progress that has been made to date, and recommends further steps to be taken.

The degree awarding gap and differential registration assessment attainment gap has been a high priority agenda item for Inclusive Pharmacy Practice (IPP). IPP is a joint initiative between NHS England, the Royal Pharmaceutical Society, the Association of Pharmacy Technicians UK, and 13 other national partner organisations.

IPP focuses on making the workplace more inclusive for pharmacy professionals, with a senior leadership that reflects our diverse communities and seeks to remove health inequalities in the population. It involves open conversations and meaningful actions to improve the experience of both patients and pharmacy professionals.

The IPP advisory board was established following a programme of work to develop principles and a framework that would encourage pharmacy organisations and professionals to embed inclusive pharmacy practice into their work. From July 2022 the IPP focus was on diversity in pharmacy leadership and representation, under which the degree awarding gap and registration assessment differential attainment gap was discussed and considered.

This report focusses on the differential degree awarding gap and registration assessment differential attainment for pharmacists and pharmacy students. Given the nature of the pharmacy technicians training programmes, there is little data to help us understand if a differential registration gap exists for the pharmacy technician profession. We would recommend further data to be captured for pharmacy technicians at the point of registration and in higher education programmes to understand if this is the case. It will help to better understand the differences and identify common themes.

The first section of this report provides an overview and introduction to the various stages to becoming registered as a pharmacist. The next section explores the current data that is known about these gaps, and the subsequent contributing factors to the differential degree awarding and registration assessment attainment gaps, before turning to some of the tangible changes that have been made by different organisations to close the gap. The final section describes the further opportunities that exist and the next steps and recommendations to be taken.

2. The stages of initial Pharmacy Education and Training

Figure 1. Stages of Education on path to registration as a pharmacist in Great Britain

The route to becoming a pharmacist often begins with early choices in secondary education about subjects to study, then in higher education with the choice to study pharmacy through a UCAS application.

The formative part of initial education and training of pharmacists happens during higher education at an accredited School of Pharmacy. Pharmacy students complete a four-year (or five-year integrated) MPharm course at a Higher Education Institute (HEI) accredited by the GPhC. All applications, including international applications, are handled by UCAS ¹⁷. The universities are accredited against the standards for Initial Education and Training of Pharmacists set out by the GPhC¹⁸. These standards were updated in 2021, setting out the education and training of pharmacists, so that graduates can play a much greater role in providing clinical care to patients and the public from their first day on the register, including prescribing medicines.

Generally, the reaccreditation process for existing MPharm degrees currently requires a full reaccreditation visit every six years, with an interim visit every three years. Students, upon being awarded a degree, then undertake a year as a trainee pharmacist. During this time, trainees must demonstrate the skills, knowledge and behaviours they need to practise to the standards expected of a pharmacist in real-life scenarios¹⁹. Towards the end of this period, students undertake a national registration assessment: the successful completion of this examination and the year allows students to be eligible to apply to join the GPhC pharmacist register. These stages of the typical path to registration are shown in more detail in Figure 1 below.

The pharmacist training model is still largely based on a standardised learning experience. This can put Black students and foundation trainees at a disadvantage at many points in their pathway to becoming a pharmacist, the reasons will be discussed below in more detail.

3. Sizing the current gap

The degree awarding gap at undergraduate level

At degree classification, pharmacy-specific data is limited. However, breaking down the data by individual ethnic groups reveals larger disparities, especially for Black students. Particularly concerning is the gap between White and Black Asian and Minority Ethnic students awarded a first-class degree classification, at 9.5%, rising to 19.3% for Black students in 2020-21 (data not specific to pharmacy)²⁰.

Based on Higher Education Statistics Agency (HESA) data, a degree awarding gap in the MPharm has been reported in 2017/2018 and 2018/2019.

Data from 4,690 graduates who had their ethnicity recorded showed, 91% of White students were awarded first-class or upper second-class honours, compared with 79% of Black, Asian and Minority Ethnic students over the same time period. Figure 2, taken from the Pharmaceutical Journal article ”The ethnicity awarding gap for the pharmacy degree during COVID-19" demonstrates the awarding gap in 2017/2018 and 2018/2019²¹.

Figure 2. 2017/2018 and 2018/2019 HESA data on the MPharm degree awarding gap

When this data is broken down further it shows there is a 15 percentage-point gap for those of Black and ‘other Asian’ ethnicity, compared with White students and a 14 percentage-point gap for those with ’other’ ethnicity. The awarding gap was smaller for those with South Asian ethnicity (11 percentage-points), Chinese students (10 percentage-points) and mixed ethnicity students (7 percentage-points).²²

There was considerable variation between pharmacy schools, with 18 showing degree awarding gaps of up to 37 percentage points in favour of White students. However, four schools showed gaps of up to 5% in favour of those from Black, Asian and Minority Ethnic groups. It is important to note that all four schools had a high proportion of Black, Asian and Minority ethnic students - at least 90% for each school. Only the University of Strathclyde showed no awarding gap based on ethnicity²³.

In 2019/2020 and 2020/21, of 5,210 MPharm degree graduates from 30 universities who recorded their ethnicity and degree classification, 69% were from an ethnic minority background. 94% of White graduates were awarded a first or upper second-class degree, compared with 86% of ethnic minority graduates.

However, the overall ethnicity awarding gap for Pharmacy degree graduates has narrowed to 8%, as demonstrated by Figure 3²⁴. Again, when this data is broken down further, it shows there is a 12% gap for those of Black ethnicity compared with White students. The gap for those of Black ethnicity remains the largest compared to other ethnic groups²⁵.

Figure 3. 2019/2020 and 2020/2021 HESA data on the MPharm Awarding Gap

^{Source and method: Higher Education Statistics Agency (HESA) Student Record. Our analysis of data excludes students of unknown ethnicity and does not account for other potential confounding factors (e.g. socio-economic background, degree choice reference, gender, qualification on entry or international student schemes). It does not consider students who did not complete the degree. The 2017/2018 and 2018/2019 analysis included 28 universities and the 2019/2020 and 2020/2021 analysis includes 30 universities.}

The differential attainment gap at GPhC registration assessment

The most authoritative information source is the GPhC, who have been collecting voluntarily reported ethnicity data on registration assessment candidates since 2013.

Data in Figure 4 and Table 1 was collected from GPhC Council papers and PJ articles for first time sitters in the first registration assessment of each year, the summer assessments. The GPhC has confirmed the data below is correct and accurate.

Figure 4. Registration Assessment Pass Rate for first time sitters in the first registration assessment each year by Ethnicity

Table 1 – Registration Assessment Pass Rate for first time sitters in the first registration assessment each year by Ethnicity²⁶

*_{Registration assessment online for the first time, including registrants that held provisional registration. There were three assessments held in 2021 and this is the pass rate for the first assessment only.}

The graph and table above show the pass rate for both White: British and Black and Black British: African trainee pharmacists, as well as the differential attainment gap for the registration assessment since 2013 for first time sitters for the first registration assessment each year. There is a clear differential attainment gap between Black or Black British: African trainees compared to their White: British counterparts, with Black and Black British: African trainees performing less well in the registration assessment.

The attainment gap between White British and Black or Black British African trainees narrowed in 2021 as it did for other ethnic groups. Additional experience under provisional registration during the COVID-19 pandemic may have contributed to higher pass rates for all groups.

4. Contributing factors to the current differential degree awarding gap and registration assessment differential attainment gap

There is extensive evidence of a differential degree awarding gap and registration assessment differential attainment gap between ethnic minority healthcare students and practitioners and their White counterparts, including those studying and/or working in pharmacy. Despite the consistent research highlighting this, the social barriers causing the differences in career and degree attainment are still prevalent^27.

It is clear a student’s race and ethnicity can significantly affect their degree outcomes. Of the disparities that exist within higher education, the gap between the likelihood of White students and students from Black, Asian or minority ethnic backgrounds getting a first- or upper-second-class degree is among the starkest. Differing attainment not only impacts retention and success, but progression into further study and employment as it can reduce the likelihood of having access to the same opportunities available to those who have been awarded a higher degree classification²⁸.

A survey by University UK revealed a lack of role models from various ethnic minority backgrounds, curriculum design and delivery, and a lack of ethnic diversity among senior staff were major contributing factors²⁹.

The survey also revealed other significant contributing factors such as lower socio-economic background and university culture and leadership. Other variables included, lack of a sense of belonging, inadequate information, advice and guidance, subject choice, and first-generation entry also affected Black Asian and Minority Ethnic students’ attainment at the university³⁰.

Qualitative analysis commissioned by the GPhC in 2016 points to several interrelated issues contributing to the current Pharmacy degree awarding gap and registration assessment differential attainment gap³¹. The report considered Black or Black British: African candidates’ experiences of their undergraduate education, pre-registration placement (now known as foundation training) and their performance in the registration assessment.

Bridging the gap requires a system level approach to address the complex and multifaceted elements of the degree awarding and registration assessment differential attainment gap. These can be broadly separated into:

1. Individual factors
2. Institutional cultures
3. Organisational structures.

Individual factors include helping students to challenge expectations about themselves and valuing the wealth of experience and cultural understanding they can bring due to their diversity. At an institutional level, this involves looking at institutional cultures and organisational structures and for leaders to provide a vision and strategy for inclusion within their organisations³².

The analysis³³ revealed the complexity of the issues that were contributing to this disparity. It described the characteristics of these students, the challenges of the experiences they faced at their school of pharmacy and through their foundation training year (formerly known as pre-registration). It was believed that approaches to teaching and learning employed in schools, such as IT proficiency and adapting to new styles of learning and assessment, were contributing factors. Those who were less confident, and/or those with accents or a poorer command of English, struggled to build the rapport required for access to personalised feedback from academic tutors. Some described their difficulty in forming networks with peers from other ethnic backgrounds. Mature students and overseas students in particular expressed feelings of isolation. In addition, financial pressures, undertaking employment and attending to family commitments were all highlighted as adversely impacting participants’ learning. These factors were particularly evident among mature students.

Further challenges existed in foundation trainee programmes, where candidates were subject to prejudices against their appearance or accent when applying for foundation training placements. The quality of foundation trainee experience is not uniform, with some community designated supervisors (previously known as tutors) seen to lack the appropriate knowledge, experience, and commitment to undertake the role effectively. When coupled with limited peer relationships, trainees struggled to access additional training and support required to prepare them for the registration assessment leading to further isolation.

Experiential factors at schools of pharmacy

Across the UK, there are 30 Higher Education Institutes that offer an MPharm programme, (see Appendix 2) with further intake expected into newly formed Schools of Pharmacy. There is a strong government imperative to further increase the number of students that study pharmacy and register as pharmacists³⁴.

These universities collectively form the Pharmacy Schools Council³⁵ (PhSC), which acts as the collective voice for the universities and provides a source of expert opinion and advice on matters concerning pharmacy education and careers from the perspective of pharmacy schools.

A series of observations and contributing factors to the differential attainment gap at the registration assessment were predicated on experiences at university. Which have been described in the GPhC ‘’Qualitative research into Registration Assessment performance among Black-African candidates’’³⁶, and further confirmed through discussions with the British Pharmaceutical Students Association (BPSA) and Black pharmacy student organisations (Black Pharmacists Collective (BPC) and Black Pharmacists Initiative (BPI). It is important to note that many Black-African trainee pharmacists, including overseas students and mature students, are highly motivated, do not experience the impact of the disadvantaging factors and are very successful in their education and training.

These observations include:

• Support and networks – Black students found it difficult to form networks with peers from other ethnic backgrounds, which contributed to mature students and overseas students in particular expressing feelings of isolation. The challenges with establishing supportive peer networks impacted on their study experiences
• Financial pressures – undertaking employment due to financial pressures adversely impacted participants’ learning experience, particularly among mature students. Support and access to financial aid was often not readily offered or clearly signposted during higher education, and financial pressures often meant undertaking free work experience wasn’t possible throughout their course
• Family commitments – attending to family commitments adversely impacted on participants’ learning, particularly among mature students taking the undergraduate programme. Family commitments often meant undertaking free work experience wasn’t always possible throughout their course
• Teaching styles – Black students reported difficulties in responding to the different teaching, learning and assessment styles, further exacerbated by challenges presented by language and IT proficiency
• Inclusive tutors – Black students reported facing challenges in their relationships with lecturers, academic tutors, and other senior figures. Black students reported feeling that they don’t ‘fit in’ and struggled to access support from seniors when under pressure. This was further exacerbated by a lack of Black role models within pharmacy education to guide, inspire and motivate students from similar backgrounds
• Access to personalised feedback– students reported that tutor feedback was not always personalised. They reported a need to be proactive in engaging with tutors to get feedback. Those less confident, including overseas educated students and those with accents or a poorer command of English, struggled to ask questions and obtain feedback. Reports in medical education suggest an unease in giving feedback to students who are from a different background, limiting students’ ability to respond to feedback³⁷
• Lack of inclusive curricula content and inclusive learning environment – promoting inclusion and representation when educating ethnically diverse student groups creates a sense of belonging which aids in combatting assessment disparities. Systemic and institutional biases within the curriculum, as demonstrated by the case study at Nottingham School of Pharmacy, found the curriculum lacked representation of ethnically diverse examples and topics, predominantly focusing on disease presentation in White groups³⁸.

Experiential factors during foundation trainee placements

The GPhC qualitative research reported a perception amongst UK and international graduates of bias in workplace-based assessments and recruitment. This is compounded by fear of living up to low expectations and stereotypical assumptions about performance placed on Black or Black British: African students. This was further exacerbated by:

• High quality placement access – students reported challenges in securing a foundation trainee programme of their choice, particularly those considered to be of higher quality. Indeed, students reported that hospital foundation training programmes, which typically have higher pass rates at the registration assessment, were felt to be out of reach for Black students
• Experience and knowledge – the reported quality of community training placements was overwhelmingly positive; however, some community tutors lacked appropriate knowledge, experience, and commitment. This inconsistent quality approach has been reported for all trainees³⁹, but was exacerbated for Black graduates due to the isolation faced by students in community pharmacy. They struggled to build the networks of support that other students could create during their university years
• Access to resources – access to study time, study materials, and mock exams were felt to be important, but access was variable. Where the network and support arrangements exist (including additional training), they were deemed to be extremely useful
• Prejudices in training placements - a small number of students thought that applying to community training programmes was open to prejudices against an applicant’s appearance or accent. This could also extend to systemic and institutional biases within the organisation, which may result in inequitable working environments
• Geographical location - Black students face a lack of autonomy about the geographical location of their training placements and work, combined with a poor work-life balance which can leave trainees unsupported, isolated and vulnerable to anxiety, depression and other mental health conditions
• Financial considerations – Black students had greater financial ties and burdens than other students - especially mature graduates. These included family commitments and caring responsibilities. This was often exacerbated by non-preferential placements that resulted in long commutes that made the training year more challenging.

Research unearthed examples of explicit prejudice towards and perceptions of implicit bias against Black students, particularly where they had undertaken their secondary education overseas. Related to this was a perceived lack of Black role models within the pharmacist education and training pathway, to guide, inspire, and motivate students of a similar background.

Experiential factors during the registration assessment

While previous sections have considered contributing factors to outcomes and performance in preparation for the registration assessment, some specific factors that were identified, focussed on two main areas:

• Content and format – the content and format of the assessment differed from the materials and resources students had used. As a result, students reported that the assessment structure was a surprise
• Past papers and revision guidance – informal networks and support created by other students allowed them access to past papers and revision guides. Black students reported further challenges in accessing relevant past papers and revision guidance, which may have further contributed to their performance in the assessment.

It is against a background of these contributing factors that a difference in attainment for Black students continues to be observed in the registration assessment pass rates.

5. How can we close the gaps?

Across the research literature in medical education⁴⁰, and within the qualitative work undertaken by the GPhC⁴¹, a series of changes can be made from an organisational perspective to reduce the current degree awarding gap and differential registration assessment attainment gap.

These include:

• Regulation and quality assurance - the qualitative difference in training placement opportunities contributed to outcomes, with Black students tending to seek the less competitive and therefore lower quality placements. Improving the overall standard of foundation training provision will help every student, and ultimately improve the quality of community pharmacy care
• Mentoring and role models - seeing ‘people who look like you’ in the training environment can provide encouragement, and role models contribute to challenging stereotypes. Schools of Pharmacy are encouraged to have a diverse range of academic staff and guest speakers to inspire and motivate students. Foundation training providers can also ensure their trainees are connected to local and regional multisector networks, or encourage engagement and seek mentorship from professional leadership bodies
• Supportive networks – building and providing students and trainees with supportive networks outside of the formal educational hierarchies can help enhance their training and development. Supporting existing students and trainees to understand the value of a diverse workforce and team can be undertaken at both undergraduate level and throughout foundation training
• Recognising and celebrating diversity - at all stages there is a need to avoid treating all students and trainees as a homogenous group or putting all Black students in the same ‘box’. Minority ethnic categories include numerous groups with differing cultural heritage and experiences. For example, this is recognised and celebrated by many universities which offer Islamic, Afro-Caribbean, and West African societies. Embracing and celebrating this diversity supports students to feel more integrated. Employers providing foundation training can encourage their trainees to join staff inclusion and diversity networks available in their organisations and within professional leadership bodies, to broaden their exposure. Organisations must ensure they have an inclusive culture, which celebrates diversity of their workforce, addresses systemic and institutional discrimination and bias, and creates a sense of belonging for all their teams
• Improving cultural competence for tutors - providing training and support for tutors in pharmacy schools and designated supervisors to interact with people from different cultures and respond to their needs. Creating a culture that recognises and respects difference requires self-awareness about your own culture and biases, too
• Protected learning time - juggling family commitments and work commitments in the time preceding the assessment was identified as a barrier. Provision of supported learning time ahead of the assessment, coupled with resources, revision materials and mock assessments, allowed trainees to prepare for the assessment without any “surprise”
• Monitoring data - under the mantra of ‘what gets measured, gets done’, we must continue to measure and understand relative gaps and where they occur. Assessment of performance is not in itself the root of the problem, but can be a useful barometer. Schools of Pharmacy and the GPhC already collect data on reported ethnicity throughout the student journey. However, greater transparency and analysis of this data against performance will help to understand where problems exist, so these can be quickly identified and addressed. The regulator could consider the extent to which this is recorded and reported as part of the reaccreditation of pharmacy undergraduate programmes. Foundation trainee feedback and satisfaction data collected by NHS England Workforce Education and Training could also be broken down by ethnicity to identify any potential problems within the foundation trainee year related to ethnicity
• Early intervention and support - schools of pharmacy tutors and foundation training designated supervisors need to ensure that they provide regular feedback and intervene early when they become aware of a problem affecting the students or trainees progress. Doing so in a timely manner enables corrective action to be taken before further problems arise
• Taking a holistic approach to trainee performance - understanding the range of factors that affect a trainee’s performance is vital. This could include mental health and wellbeing, practical issues around finances, housing, and visas and immigration. Solutions may include providing resilience and leadership training early to support students prior to challenges arising. There are a wide variety of support mechanisms available for students, but it is important to ensure that students are aware of these opportunities, especially when they are from a cultural background that may act as a barrier to them asking for support
• Learning and assessment styles - there is a wealth of educational research that demonstrates the different approaches to learning that students take, and this is further reflected in the outcomes that students achieve in different types of assessments. As a result, universities need to be cognisant of the biases and disadvantages that may be created for certain groups in their assessment approaches. This can also apply at foundation training stage and to be explored and understood by the foundation training designated supervisor.

While these points are not an exhaustive list, they provide a guide towards some areas that foundation training providers, educational training providers, schools of pharmacy and regulators may wish to consider. However, many organisations have, over the last decade, taken positive steps forward to close the gap and provide additional support and guidance to students. The next section of this report provides some further cases studies of the actions taken to address these gaps.

6. Organisations that contribute to initial education and training of pharmacists

Many different organisations contribute to the initial education and training of pharmacists, and this section describes the role of the organisations.

The organisation includes:

• General Pharmaceutical Council – the regulator for the pharmacy profession that set the registration assessments, conducts the accreditation of Schools of Pharmacy and sets the initial education and training standards for pharmacists
• NHS England’s CPhO Office - The CPhO office work collaboratively across the healthcare system and with national stakeholder organisations to influence, promote, and support the delivery of the highest possible standards of professional pharmacy practice to continue to drive up the quality of patient care. The team provides professional and clinical leadership and advice on NHS policies and programmes across a wide range of areas involving medicines, pharmacy, education and professional practice
• NHS England Workforce Training and Education (NHSE WT&E) (formerly Health Education England) – the organisation which funds and leads the National Foundation Trainee Pharmacist Recruitment Scheme in England through ORIEL. They also ensure quality assurance of training sites, including trainee feedback and designated supervisor training
• Pharmacy Schools Council – the collective body for Schools of Pharmacy in the UK, providing leadership for universities to help them navigate this area
• Royal Pharmaceutical Society – the professional leadership body for pharmacists in Great Britain has been instrumental in thought leadership and building momentum behind many of the actions being taken
• British Pharmaceutical Students Association – the official student body of the RPS and the voice of pharmacy students has sought to make changes on behalf of students over the last decade
• Foundation Training Programme Providers – individual foundation training programme providers and organisations have made improvements and changes to support trainee pharmacists
• Individual Schools of Pharmacy – individual Schools of Pharmacy have made local changes and developments to support their students. A list of all the schools of pharmacy in Great Britain can be found in Appendix 2
• Independent Foundation Training Providers – the independent educational providers for foundation trainees have made some improvements and changes to how they support Black foundation trainees.

These organisations have undertaken tangible actions over the last decade to bridge the degree awarding and registration assessment differential attainment gaps. Further information and detailed case studies about the initiatives taken by the General Pharmaceutical Council (GPhC), NHS England’s Workforce Training & Education Team, Pharmacy Schools Council, Royal Pharmaceutical Society (RPS), and British Pharmaceutical Students Association (BPSA) are provided in Appendix 3.

Individual members of the Schools of Pharmacy Council have taken forward initiatives to address the degree awarding gap in their universities. Appendix 4 details case studies from University of Sussex Pharmacy Department and Kingston University School of Pharmacy by way of illustration of the type of action taken.

University of Sussex Pharmacy Department (now closed) detail how they created an independently funded Race Equity Programme to combat the awarding gap by creating a learning environment in which Black, Asian and Minority Ethnic students can thrive. Kingston University have shared the initiatives they have taken across different parts of the course, from delivery through to training the academic faculty.

Some individuals and independent training providers have taken the initiative in addressing the registration assessment differential attainment gap. Case studies from the following organisations and initiatives are outlined in Appendix 3.

• African and Caribbean Pre-registration Pharmacist Network – Diane Ashiru-Oredope
• Pharmacy Foundations Bursary Award
• PreregShortcuts Sponsorship Program - Marvin Munzo and Umar Majid
• Focus Pre Reg Revision - Luso Kumwenda

Despite the initiatives taken by organisations to address the differential degree awarding gap and registration assessment gap, the differential gaps still persist a decade on from being reported. The evidence within this report highlights the need for a more system-wide and coordinated approach to reduce the differential awarding and attainment gaps in a sustainable and long-lasting way.

Representatives from the British Pharmaceutical Students Association (BPSA), General Pharmaceutical Council (GPhC), NHS England’s CPhO Office, Workforce Training & Education Team and IPP Advisory Board, Pharmacy Schools Council, Royal Pharmaceutical Society (RPS) and individuals representing Schools of Pharmacy have formed a working group (see Appendix 1). The aim of the group is to further build on the tangible action’s organisations have undertaken.

The working will be chaired by the Royal Pharmaceutical Society and supported by the evidence within this report to form a clear action plan moving forward. The working group will be reporting progress into the IPP advisory board (see Appendix 1) as well as providing regular updates to the profession.

The next section of the report will detail the discussions had at the first working group meeting, including future actions and recommendations for the working group and the profession to take forward.

7. Future Actions and Recommendations

The first working group meeting chaired by the Royal Pharmaceutical Society on 25 September 2023, with contributions from the following stakeholders:

• British Pharmaceutical Students Association 
• General Pharmaceutical Council
• Individual Schools of Pharmacy
• NHS England’s CPhO Office
• NHS England’s WT&E Team
• IPP advisory board representatives
• Pharmacy Schools Council
• Royal Pharmaceutical Society.

The group discussed the whole journey from being an A-level student, to becoming an undergraduate pharmacy student, through to becoming a foundation trainee, and finally qualifying as a pharmacist. Discrimination, institutional and systemic inequities and biases in education are experienced by Black and other ethnic minority students prior to applying for and entering into a pharmacy degree. The negative impact of this affects individuals throughout their undergraduate programme and professional career, affecting their learning styles, approach to learning, feedback received, and how they view themselves and their potential. This will need to be considered in any actions and recommendations to be taken forward.

A lack of visibility and representation; Black students not seeing themselves represented within the profession across all levels and particularly with the lack of diversity at a senior level, may deter individuals from applying to study pharmacy and may influence their foundation training choice.

The impact of all pharmacy students graduating as independent prescribers from 2026 needs to be considered in actions taken forward to address the degree awarding gap and registration assessment differential attainment gap. This additional requirement will impact student’s foundation training experience.

Changes to the pharmacy undergraduate programme will result in an increase in the number of practice placements students will need to undertake. Access to and the students experience during the placements needs to be considered in actions taken forward. They will also be allocated a Designated Prescribing Practitioner (DPP) in the foundation training programme. Potential biases and prejudices from the DPP will also determine their experience.

There was a discussion of the positive changes that have been undertaken by Schools of Pharmacy and independent foundation training providers, some of which have been showcased in Appendix 2 and Appendix 3. The learnings and successes of good practices and initiatives need to be shared with relevant organisations, to inspire change.

It is clear a system wide approach is required in addressing the differential degree awarding gap and registration assessment attainment gap, considering the student and foundation trainee as a whole and how different factors can influence their achievements, to ensure sustainable and meaningful changes are made moving forward.

Discussions building on the multiple individual, organisational and institutional factors⁴² highlighted above, below details of current practice on key themes and actions for the working group to take forward are highlighted:

Data

There are different data sets available highlighting the degree awarding gap at an undergraduate level collected by HESA who report this for all universities in the United Kingdom. However, this data is currently not collected in a central point for all Schools of Pharmacy.

Schools of Pharmacy are required to improve their Equality, Diversity and Inclusion data collection to ensure there is a fairness in their selection processes. They must give all applicants an opportunity to demonstrate their ability and suitability, taking into account their background such as protected characteristics, socioeconomic and education background. They also need to identify and reduce discrimination in selection and admission processes, including analysing MPharm degree admissions by protected characteristics and taking action if the process may be disadvantaging students. The Schools of Pharmacy also need to review student performance by characteristic and take action if problems are highlighted. As part of the GPhC accreditation process, action plans need to be reported to demonstrate improvements are being made.

The GPhC currently report the registration assessment data broken down by ethnicity after each summer sitting of the registration assessment at the October GPhC Council meeting.

NHS England WT&E have data from the national recruitment system (ORIEL), which they report on and review, to highlight any areas of potential discrimination. However, even though ORIEL has been successful at removing bias and improving the diversity in foundation training sites (see Appendix 3), problems still arise during the foundation training programme. NHS England WT&E also collect foundation trainee satisfaction data which could be better utilised to understand Black trainee experiences and to highlight areas of dissatisfaction and potential issues around discrimination and prejudices. There is also a need to ensure the data set collected is from across all areas of training including community pharmacy.

• Action: GPhC in conjunction with universities and statutory education bodies to consider how to bring together different data sets from UCAS admission, ORIEL and the registration assessment to produce a more complete dataset and provide a whole picture from applying to study Pharmacy to qualifying as a pharmacist. This data should be published to identify problem areas and to ensure accountability to reducing the differential awarding and attainment gaps.
• Action: NHS England to consider how to best utilise the ORIEL and foundation trainee experience data to understand the Black trainee experience further, ensuring data is collected from all training sectors. Including action plans being put in place to address variation and poor experiences.
• Action: Schools of Pharmacy to continue to demonstrate an improvement in collecting EDI data and improvement in reported action plans highlighted as part of the GPhC re-accreditation process.

Inspiration, aspiration and role models

As highlighted in the GPhC 2016 report⁴³ and feedback from Black students, a lack of role models to aspire to is a contributing factor to the differential degree awarding and registration assessment attainment gaps.

Visible and representative role models across all levels of pharmacy inspire and motivate Black students and trainees. Lecturers and faculty members in Schools of Pharmacy from diverse backgrounds will be able to relate to the students' experiences, sharing that through their teaching and feedback. Representation is also required throughout all levels in pharmacy, particularly in senior leadership roles, in order for Black foundation trainees to aspire to, thrive, and succeed.

A bigger consideration needs to be given to the negative impact on the students and trainees mental health and wellbeing. They are entering into an undergraduate programme, training placement and career cognisant they are more likely to fail or be treated differently because of their background, physical appearance, and/or accent. As a result, Black students and trainees may limit themselves, and not apply to study pharmacy or apply for their desired foundation training placement.

Students and trainees with family commitments may limit their aspirations due to obligations of family life. They may therefore limit themselves to only applying for training placements close to home or worry they will not be able to apply themselves fully in the training placement they really want.

• Action: Showcase role models throughout the workforce to demonstrate it is possible to have aspirations whilst having additional family commitments.
• Action: Explore options of how to increase the diversity and role models’ students are exposed to at an undergraduate level. The Royal Pharmaceutical Society is committed to creating a network of Black, Asian and Minority Ethnic guest speakers that Schools of Pharmacy and foundation training providers could access, to improve visibility, representation and role models.
• Action: Signpost foundation trainees to existing networks for support throughout the foundation training year. Utilising the Royal Pharmaceutical Society’s and UK Black Pharmacist Association’s mentoring platforms through promotion and encouraging trainees to sign up for additional support.

Tutor Training

Students and foundation trainees will be exposed to a range of individuals throughout their pharmacy course, undergraduate placements and foundation training, that will be responsible for education, training, and providing feedback to the students and trainees. The range of individuals includes:

• University faculty - all lecturer and academic staff
• Personal academic tutor
• Education and training lead pharmacists in their undergraduate practice placements and foundation training
• Foundation training designated supervisor
• Other members of the pharmacy team who will be involved in their training throughout their undergraduate practice placements and foundation training programme.

In this instance, we have used the term tutor to encompass all the roles outlined above.

Students and foundation trainees shared their experiences of explicit prejudice, discrimination, and perceptions of implicit bias against them, which has impacted their education and training experience in undergraduate and foundation training programmes. Therefore, tutors need to be aware of their own unconscious biases, and require cultural competence and cultural awareness training, to ensure they are culturally aware and sensitive to the diverse needs of students and trainees, including their learning styles and how to best provide feedback.

They may also need to be more proactive in providing feedback for students and trainees who may have less confidence in proactively seeking it themselves.

• Action: Engage with education and training leads to influence them on taking a more proactive approach on setting clear objectives for the foundation training year and proactively supporting their Black foundation trainees by having an awareness of the differential awarding and attainment gaps.
• Action: Recognising and managing unconscious bias, providing access to racial awareness training for all tutors, designated supervisors and other members of the team involved with training students and foundation trainees. This should be refreshed yearly for each new cohort of students.
• Action: All tutors, designated supervisors, and other members of the team involved with training students and foundation trainees should undergo cultural competence and cultural awareness training.
• Action: Equality and diversity training for all tutors, designated supervisor, and individuals involved in student and foundation training.

Removing bias throughout processes

A good example of removing bias in a process is the pharmacy national recruitment scheme, Oriel, which has removed the potential of introducing bias into the foundation training recruitment processes and improved the inclusivity and diversity of foundation training placements⁴⁴. This has improved access to training opportunities for Black foundation trainees (see Appendix 3). Even though the introduction of Oriel has removed the bias within the recruitment process, it does not address the discrimination and behaviour people may experience when they are in their foundation training programme.

Admission into university, access to undergraduate placements and the registration assessment processes, need to be reviewed to identify how bias can be removed. This should also include ensuring quality assurance of both the undergraduate practice placements and foundation training programmes to ensure all students and foundation trainees have a positive experience free from prejudice and discrimination.

• Action: Ensure the uptake of Oriel continues to provide improved opportunities for Black trainee pharmacists
• Action: Scope what processes need to have bias removed and how the principles in the No Tick Boxes report can be applied take that forward
• Action: GPhC have taken steps to assess bias in the registration assessment (see Appendix 3), to ensure these are embedded and any potential bias in the registration assessment is removed.

Supporting the transition of pharmacy students into foundation training

Moving from university as a student and entering the working world is a significant transition; further work is required to look at how this transition can be better supported to ensure individuals are prepared for training and the world of work. This should include how to balance study, work, and personal commitments.

• Action: A scoping exercise to consider how students can be better supported to transition into foundation training.

Embedding and sustaining change through sharing best practice

In 2021, the Pharmacy Schools Council in partnership with NHS England WT&E (formally known as Health Education England) held an EDI forum to share best practice, including how to embed inclusion and diversity into the undergraduate pharmacy programme which received positive feedback.

To ensure good practice is being shared across Schools of Pharmacy and foundation training sites, the EDI forum should be held annually. Future EDI forums will showcase case studies from Schools of Pharmacy sharing the actions they have taken to reduce their degree awarding gaps and how foundation training sites are ensuring fair and equitable experiences for Black foundation trainees.

• Action: To work with relevant organisations to agree a date and agenda for the next EDI forum
• Action: The EDI forum should ensure there is representation from across all areas of practice including primary care and community pharmacy.

Protected Learning Time in foundation trainee programmes

Access to protected learning time in foundation training programmes is inconsistent, this will impact the time foundation trainees have to access development opportunities and prepare for the registration assessment.

• Action: To continue to advocate and lobby to ensure all foundation trainees receive regular protected learning time within their working day.

There is an intersectional element that will run through each of the actions highlighted as certain groups may face additional barriers to those highlighted above for example mature students are more likely to be parents and carers. For each of the workstreams an Equality Impact Assessment should be conducted to ensure there are no groups disproportionately disadvantaged from the suggestions taken forward.

8. Conclusion and Recommendations

Since 2013, there has been a recorded difference in degrees awarded and registration assessment pass rate attained by Black students and trainees.

These gaps must be addressed with positive action taken to ensure they are removed, to ensure that Black students and trainees can achieve the standards required for pharmacist registration, regardless of their backgrounds. This will also benefit patient care.

Indeed, some progress has been made, and effort from national bodies, universities, regulators, professional bodies and the NHS have helped to create improvements in some areas. But clearly these improvements haven’t been enough to close the gap.

Ultimately, by creating a better experience for Black pharmacy students and foundation trainees, we can raise the quality for all students, and in turn all patients and the public. We also want to see a more open and inclusive culture for overseas pharmacy students.

As a working group, we are dedicated and committed to work together to take forward the actions highlighted in this report, to ensure there is meaningful and sustainable change in reducing and removing the degree awarding gap and registration assessment attainment gap for Black students and trainees. As highlighted above there is also an awarding gap for those with South Asian ethnicity, Chinese students and mixed ethnicity students⁴⁵ which we must not lose sight of. All the actions being taken forward will also ensure the awarding gap and attainment gaps experienced by other ethnic minority groups will be minimised.

As highlighted throughout the report, the reasons for a differential degree awarding gap and registration assessment attainment gap for Black students and trainees are multifactorial, thus, an intersectional and a system-wide approach is required. The profession needs to ensure they are doing their part to address differential gaps and improve the Black student and trainee experience.

The actions highlighted in this report are not only for the working group to take forward; they require the whole profession to take action in their working environments to ensure Black students and trainees have a positive experience free from prejudice and discrimination and are offered opportunities to reach their full potential and thrive in pharmacy.

This report has shared positive case studies from pharmacy student and trainee perspectives which should serve as inspiration to others, and provides examples of positive practice for others to emulate.

Based on the actions discussed, the following recommendations and outputs have been made for both the working group and for the wider profession:

1. Working group to primarily focus on addressing the differential degree awarding gap and registration assessment attainment gap for Black students and trainees, taking an intersectional approach to be taken. Targets and timelines will need to be set
2. Schools of Pharmacy, foundation training providers, and educational training providers to take forward the actions, as highlighted in this report, to make meaningful and positive changes in their own areas. Areas can form their own working groups to take meaningful steps to address the differential awarding and attainment gaps for their students and trainees
3. Smaller task and finish groups led by members of the working group to focus on the key themes and areas highlighted and take forward the actions outlined. The task and finish groups will be formed by members of the profession with relevant experience to support in moving actions forward. Targets and timelines will be set to ensure actions are moving forward to reduce the differential gaps
4. Working group to meet every six months to review the progress of each organisation and task and finish group. This will help to ensure the differential awarding and attainment gap is reducing. Progress will be reported to the IPP advisory board to ensure accountability and to demonstrate progress in narrowing the degree awarding gap and differential registration assessment attainment gap. Progress will also be reported annually at the EDI forum
5. Organisations to continue to advocate and lobby to ensure all foundation trainees to receive regular protected learning time within their working day
6. Working group to review differential attainment and awarding gaps for other protected characteristics as part of their future remit to ensure pharmacy students and foundation trainees are not disadvantaged based on their protected characteristics.

Appendix 1: Members and Governance of the Working Group

Appendix 3: Initiatives taken by pharmacy organisations to address the degree awarding and differential attainment gap

The following pharmacy organisation provided details of some of the initiatives they have taken.

1. The General Pharmaceutical Council (GPhC)
2. NHS England WT & E
3. Pharmacy Schools Council (PhSC)
4. The Royal Pharmaceutical Society (RPS)
5. British Pharmaceutical Students’ Association (BPSA)

1. General Pharmaceutical Council (GPhC)

The General Pharmaceutical Council (GPhC) is the regulator for the pharmacy profession and sets the registration assessments, conducts the accreditation of School of Pharmacy and sets the initial education and training standards for pharmacists.

In 2016, qualitative research revealed issues with the Registration Assessment, and their report in 2018, “Learning from the Registration Assessment 2010-2018’⁴⁶ highlighted students feeling ignored and experiencing racism. It recognised that unless there is a significant change in the profile of Foundation trainees, or in the delivery of a training scheme, future analyses would likely reveal the same trends.

Recognising disparities, the GPhC designed new Initial Education and Training standards⁴⁷ in 2021, emphasising equality, diversity, and inclusion. These standards cover treating people equally, meeting legal responsibilities under equality and human rights legislation, and respecting diversity and cultural differences⁴⁸. The standards aim to combat discrimination and deal with health inequalities. In June 2020 the GPhC Council highlighted the differential attainment of Registration Assessment performance among Black or Black-African candidates as a key issue for the GPhC. The GPhC subsequently launched a five-year EDI strategy in 2021⁴⁹.

The GPhC acknowledges ongoing attainment issues and emphasises EDI in accreditation visits. Action plans from underperforming schools will be examined through the accreditation process and a new quality assurance methodology aim to address concerns. It will emphasise the importance of regular data analysis to identify issues and attainment gaps.

The GPhC are also working on developing accreditation of pharmacist foundation training, which will be implemented in advance of the 2025/2026 training year, when independent prescribing will be introduced. Monitoring attainment will be a key part of the process which will be reported to the GPhC Council on an annual basis.

The GPhC developed and implemented a Diversity Action Plan⁵⁰   to support the recruitment process for its new Chair and continued to make internal changes through its Workforce Committee to address internal diversity gaps.

The GPhC have also taken the following broader measures to improve the registration assessment:

• Question writers, standard setters and the Board of Assessors are recruited in line with inclusive recruitment practices, and take part in EDI training once appointed
• An EDI screen is performed on all registration assessment and the GPhC monitors the ages and sex of patients represented to check they are representative of UK population
• The registration assessment includes questions that are focussed on health inequalities
• Photographs used in the assessment represent patients with a variety of skin tones
• The GPhC identify any questions in either part of the assessment that refer to a protected characteristic other than age and gender and review the wording in the questions alongside national guidance and reference sources if applicable.

Recent GPhC-commissioned research on registration assessment questions examined Differential Item Functioning (DIF) for different groups, including ethnicities. Preliminary results show a remarkably low level of DIF within demographic variables and protected characteristics which underscores the dedication to equal opportunity and fairness within the examination process, and highlights the GPhC's commitment to ensuring that personal characteristics do not unduly influence candidates' performance.

2. NHS England

NHS England set up the Inclusive Pharmacy Practice Board (IPP) which is a joint initiative with the RPS, APTUK and 13 other national partner organisations with an aim to bring about an increase in diversity in senior roles.

IPP focuses on making the workplace more inclusive for pharmacy professionals, with a senior leadership that reflects our diverse communities, to improve health inequalities in the population. It involves open conversations and meaningful actions to improve the experience of both patients and pharmacy professionals⁵¹.

Changes in foundation training have been precipitated because of the changes in the Initial Education and Training Standards. NHSE WT&E (formally HEE) fund foundation training sites. Students apply for foundation training programmes through the National Recruitment Scheme (NRS), also known as Oriel. From January 2024, this will be the only route for employers to obtain funding for the provision of Foundation Training across GB.

The NRS was established in 2017 to offset any bias at the point of entrance into the profession. NRS was recognised in the 2022 C&D awards for Inclusion and Diversity. Historically, the pharmacy recruitment model has always been fragmented, with huge variation in recruitment practices leading to recruitment bias. Personal accounts suggest that preferential appointments were made to the disadvantage of Black, Asian and Minority Ethnic applicants, aligning with systemic flaws revealed in research conducted by the GPhC. Oriel permits applicants to choose their employer rather than the reverse. Research conducted by NHS WT&E has found it is based on values and behaviours, and the process does not take into account academic achievement, school of pharmacy, ethnic background or gender, and so does not allow recruiter bias to affect candidate scoring⁵². The NHSE WT&E research included a focus group with Black African females; there was a unanimous view within this group that the process was fairer than traditional interviews, and that ranking of individuals based purely on their scoring allowed far less bias to creep into the selection process, and was ‘more of a level playing field’.⁵³

The thread of equality, diversity and inclusion that runs through the new GPhC Initial Education Training standards has encouraged a proactive approach being taken to implement, subject to Equality Impact Assessments. For example, one has been conducted on the Foundation Pharmacist Assessment Strategy to ensure inequalities are minimised.

NHS WT&E (when it was formally Health Education England) commissioned the cultural competence programme with CPPE as per one of the recommendations in the Inclusive Professional Practice to support health inequalities.

3. Pharmacy Schools Council (PhSC)

In 2020 the Pharmacy Schools Council (PhSC) publicly acknowledged that “more needs to be done in our institutions to actively promote equity, particularly for our Black students and staff but also for other minority ethnic groups” in their Position Statement on Enhanced support for BAME Students⁵⁴. This statement recognised that practical support is needed and overdue, in areas such as:

• Support in applying for foundation training programmes and subsequent support during the foundation training year
• Supporting academic achievement
• Reduction of the award gap
• Encouraging career progression particularly in leadership roles
• Greater provision of mentorship
• Facilitating availability and interaction with positive role models, encouragement and assistance with applications for promotions.

The PhSC, working in conjunction with NHE England WT&E have sought to implement the new IETs. As part of the GPhC IETs Schools of Pharmacy have embedded these into their course, reviewing and assessing part of the GPhC reaccreditation of the Pharmacy School. This includes collecting protected characteristic data particularly universities reporting in ethnicity data at a university level and reporting any degree awarding gaps.

4. Royal Pharmaceutical Society (RPS)

The RPS launched its Inclusion and Diversity strategy in June 2020⁵⁵ and committed to working with the GPhC, BPSA, UK Black Pharmacists Association, Pharmacy Schools Council, and other organisations to understand any disparity in Black students’ degree awarding and registration assessment pass rates and develop concrete plans to address them.

RPS has been working to raise awareness on the differential degree awarding and registration attainment gap throughout the profession in different forums to ensure it remains an important topic within the profession.

RPS worked with the GPhC to update the Initial Education Standards to ensure that inclusion and diversity was embedded throughout them.

Discussions have been had with the PhSC to see how RPS can collaborate in addressing the differential degree awarding and registration attainment gap, participating in an NHS Workforce Education and Training (formally Health Education England) and Pharmacy School Council EDI Forum with the BPSA representing the student RPS perspective.

As a lack of visibility and diverse roles were highlighted as a cause for the differential attainment gap, with passionate members of the profession and student groups including BPC, BPI and BPSA, RPS explored hosting a Guest Lecturer Network which Schools of Pharmacy and Foundation Training Providers can access to ensure students have diverse role models.

Through the IPP program differential degree awarding and registration attainment has been on the agenda and whilst the topic has been discussed at the IPP board meetings to continue to raise awareness there is still a need for sustainable and long-lasting change to reduce the gaps. A working group chaired by the RPS supported by the evidence within this report will enable a clear action plan and accountability moving forward.

To ensure the RPS educational frameworks are fair and equitable, Equality Impact Assessments have been undertaken to ensure we’re addressing any potential causes for a differential attainment in advanced practice and consultant level. Ethnicity data will be collected to monitor differential attainment for different ethnicities, differential attainment will be monitored as part of the educational governance quality assurance procedures and annual reports will be transparently published⁵⁶.

The Pharmaceutical Journal Mind the Gap initiative highlights social inequalities in pharmacy and pushes for change. They have also published articles highlighting the differential degree awarding gap at an undergraduate level, and hosted two podcasts to explore the impact on the student experience⁵⁷.

RPS has made changes to its membership arrangement for foundation trainees to give them access to guidance, practice questions, revision support and other tools at one inclusive price. This reduces the financial burden on all students. Employers are encouraged to support their trainees to become members of the RPS.

5. British Pharmaceutical Students’ Association (BPSA)

As the official student body of the Royal Pharmaceutical Society, the BPSA represents the voices of all pharmacy students from their first year until the completion of their foundation training year. A major focus of the Association’s Equality, Diversity and Inclusion (EDI) work is raising awareness of and the closure of the differential degree awarding gap throughout the MPharm degree and disparities in foundation trainee pharmacist registration assessment pass rates.

The BPSA has relaunched its EDI committee and is lobbying major stakeholders within pharmacy education and early career training to close the attainment gap and improve trainee pass rates.

Members unanimously voted that BPSA policy should do more to tackle the attainment gap, particularly that affecting Black trainees. Students are more aware of issues surrounding the awarding gap and eager to be a part of the change.

As an Association, the BPSA holds a unique position alongside other stakeholders and key leaders in the pharmacy world as it advocates predominantly for current pharmacy students and trainees. Many of the members it represents identify as Black Asian and Minority Ethnic, and their education, university, and training experiences continue to be directly impacted by numerous factors that contribute to the awarding and attainment gap.

The BPSA hosted numerous feed-in sessions, webinars and a workshop at its Black History Month conference in 2022. During the conference it gathered the views and experiences of students across different universities, and signposted them to various support resources they can access through their pharmacy journey. It also published its first anti-racism toolkit, focused on the unique perspective of anti-racism within academia and the foundation training year.

The BPSA hopes to work more closely with key organisations in pharmacy, eventually seeing a significant drop in the differential attainment gap.

Appendix 5: Acknowledgements

Alongside all the members of the working group listed in Appendix 1 we would also like to thank the following individuals who have supported and contributed to the preparation of this report:

Sejal Gohil - Training Programme Director for Early Careers/Foundation Pharmacists, NHS England Workforce Training & Education

Luso Kumwenda - Focus Pre Reg Revision

Marvin Munzu - Co-founder, Managing director, Clinical lead of Preregshortcuts Ltd

Umar Majid - Co-founder, Managing director, Clinical lead of Preregshortcuts Ltd

Jane Portlock - Professor Emerita in Pharmacy Postgraduate Education, University of Sussex

Atif Saddiq - Pharmacy Foundations Bursary Award