Making pharmacy foundation training genuinely inclusive requires system‑level change

Foundation training is a critical transition point in a pharmacist’s career. It shapes professional confidence, identity and future aspirations, which is designed to provide a supportive bridge between university education and autonomous practice.

However, for too many trainees, the foundation year is characterised not by belonging and growth but by exclusion, heightened scrutiny and unequal treatment. Evidence from an equality, diversity and inclusion (EDI) fellowship project in 2022 has suggested that pharmacy foundation training is not yet delivering an equitable experience for all, and incremental or symbolic approaches to inclusion are no longer sufficient.

Discrimination during training is widespread but often unseen

The EDI fellowship — conducted by Health Education England (now NHS England Workforce Training and Education) — explored the experiences of 28 pharmacy foundation trainees across the South West, Thames Valley and Wessex regions in England using an online survey.

Almost half (47%, n=28) of respondents reported experiencing discrimination during their foundation year. These experiences were rarely overt. Instead, trainees described frequent exposure to subtle but persistent microaggressions, which are behaviours or comments that, while often dismissed as innocuous, cumulatively undermine a sense of safety, confidence and belonging^​1​.

Common examples included repeated questioning about background or origin, mispronunciation of names, being ignored or excluded in the workplace and feeling subject to harsher judgement than peers. Such behaviours altered how trainees were treated compared with colleagues and often went unchallenged.

Importantly, a significant proportion of respondents initially reported that they had not experienced microaggressions; however, once provided with recognised definitions and examples, this figure fell markedly, highlighting how limited awareness can normalise problematic behaviours.

Why this matters for trainees — and for patients

Discrimination during foundation training has consequences that extend well beyond individual discomfort. Trainees described anxiety, reduced confidence and disengagement from learning opportunities, alongside the emotional labour of feeling constantly under scrutiny or needing to “prove” themselves. Some avoided the workplace when possible or took time away to protect their wellbeing.

These experiences occur during a high‑stakes, time‑limited programme, where assessments, sign‑off and progression depend heavily on workplace relationships. When trainees do not feel psychologically safe, learning is at risk of being compromised.

Concerns were also raised about the potential impact on patient care, with some trainees reporting witnessing discriminatory behaviours directed at patients. This reinforces that inclusion is not merely a workforce issue but a professional and ethical one.

National data echo these findings. Persistent differential attainment in pharmacy education and in the General Pharmaceutical Council (GPhC) registration assessment points to structural influences on outcomes. Data show differences in degree classifications — for example, 94% of white graduates achieve a first or upper-second-class degree compared with 86% of ethnic minority graduates^​2​. Meanwhile, there are disparities in GPhC registration assessment pass rates, with 96.6% of white British candidates passing compared with 80.5% of Black African candidates^​3​. Early insights from the Pharmacy Workforce Race Equality Standard further highlight disparities in staff experience, confidence in speaking up and perceptions of fairness across the profession^​4​.

The gap between policy intent and lived experience

The GPhC standards for initial education and training emphasise fairness, equality and learner support^​5​. However, findings from the fellowship reveal a gap between policy intent and operational reality. Some 40% of respondents (n=28) reported that they either did not know where to raise concerns or did not feel confident doing so, despite often feeling informally supported by colleagues.

This disconnect reflects wider systemic issues. Limited diversity in senior leadership, inconsistent cultural competence among supervisors, and unclear or opaque reporting pathways all contributed to reluctance to escalate concerns. Where trainees perceived leadership teams to lack visible diversity, confidence in being understood or taken seriously was particularly low.

Discrimination in this context is not the result of isolated incidents or “bad actors” — it is embedded within organisational cultures and reinforced by systems that fail to protect those with less power.

What needs to change

Addressing inequity in foundation training requires coordinated, system‑level action rather than reliance on goodwill or individual resilience. Fellowship findings point to several priority areas for change:

• Inclusion and belonging must be actively cultivated — allyship and active bystander training should be routine for all staff involved in training, not optional or one‑off;
• Everyday behaviours shape learning environments and staff must be supported to recognise and challenge microaggressions when they occur;
• Supervisers need stronger preparation for inclusive practice — cultural competence and inclusive supervision skills should be embedded within tutor and supervisor development programmes. Supporting trainees effectively requires more than technical expertise — it demands insight into how bias, identity and power operate in the workplace;
• Leadership and representation matter — increasing diversity in senior and educational leadership roles is essential to building trust and credibility in inclusion efforts. Trainees are more likely to raise concerns when they believe decision‑makers understand the weight of those experiences;
• Training quality assurance must include trainee experience — quality assurance processes should consistently treat trainee experience, including psychological safety and inclusion, as core metrics, not peripheral considerations;
• Raising concerns must be safer and clearer — reporting pathways need to be simple, transparent and clearly communicated during induction. Trainees must be confident that raising concerns will not lead to retaliation or detrimental outcomes, particularly in small organisations where supervisors may also be employers.

But isn’t inclusion already being addressed?

A common counter‑argument is that inclusion is already embedded through mandatory training, equality policies or broad organisational commitments. While these mechanisms are necessary, the fellowship’s findings suggest they are insufficient when not implemented meaningfully or consistently. Mandatory training was frequently described by trainees as disconnected from everyday practice, with persistent ignorance undermining its intent.

Others may argue that discrimination is subjective and difficult to measure. Yet the consistency of accounts — alongside almost half of respondents reporting direct experiences of discrimination — indicates systemic issues rather than isolated perceptions. The shift in understanding observed during the survey itself also demonstrates that education can empower recognition and action, rather than manufacture complaints.

One trainee also highlighted the need for “education on different cultures and impact on daily life”.

Why pharmacy teams must lead this change

Foundation training environments are shaped daily by pharmacy teams. Supervisors, tutors and leaders should influence whether trainees feel safe to ask questions, make mistakes and raise concerns. Inclusion is enacted — or undermined — through routine interactions, feedback, workload allocation and informal conversations.

Pharmacists therefore have a professional responsibility to ensure that learning environments align with the values the profession espouses. NHS England initiatives, such as the ‘Inclusive pharmacy practice’ work, the ‘Safe learning environment charter‘ and ‘Trainee support guide’ have been developed to provide important frameworks^​6–8​. However, their impact depends on consistent adoption, visible leadership commitment and integration into quality assurance processes.

Discrimination during pharmacy foundation training undermines learning, wellbeing and workforce sustainability. Fellowship findings show that while many trainees value informal support, too many experience exclusion and lack confidence in formal systems designed to protect them.

Creating genuinely inclusive foundation training requires embedding inclusion into leadership, supervision, education and quality assurance — not as an aspiration but as a measurable standard. If the profession fails to act, it risks normalising inequity at the very start of pharmacists’ careers. If it succeeds, it creates the conditions for all trainees to thrive, strengthening both the workforce and the care it delivers.

An inclusive profession is not defined by who enters it but by who is enabled to succeed.