Why is entry into medicine and surgery becoming more diverse, but less so at senior levels? A new study from the University of Surrey claims the answer lies in how careers are judged on a day-to-day basis.
Researchers have found that despite long-standing equality policies, who rises through the ranks in British surgeries still depends on who already controls the room. The study, published in the Journal of Management Studies, analyzed 10 years of NHS career data and found that surgeons from underrepresented groups were more likely to leave training and less likely to be promoted, especially in environments where senior roles were held by white men. This finding suggests that informal networks and professional culture continue to shape careers as much as formal rules.
Promotion decisions are not purely based on merit, but are influenced by who is considered to “fit” the traditional image of a surgeon.
Inequalities are even more entrenched in some areas of the NHS system, particularly in surgical specialties. The gap is closing at other hospitals, especially large teaching hospitals with stronger oversight and clearer procedures. This suggests that organizational context plays a crucial role in shaping outcomes such as promotion, retention, and experiences of inequality for staff from underrepresented groups. ”
Dr Carol Woodham, lead author of the study and Professor of Human Resource Management at the University of Surrey
Researchers analyzed the career paths of 3,402 trainee surgeons across 212 NHS trusts over a 10-year period, tracking promotion to consultant level and completion of training. They compared outcomes across gender and ethnicity, and investigated how outcomes vary depending on workforce composition and governance structure.
Dr. Carol Woodhams continued:
“People often think that inequality is a thing of the past because the rules have changed. But what we’re seeing here is that informal power relations still carry a lot of weight. Who gets recognized, supported, and ultimately promoted is shaped by who’s already in power.”
The study found that settings with a high concentration of senior white male surgeons tended to strengthen their in-group advantage, while other surgeons faced higher barriers. However, stronger governance and transparency can counteract this, especially in formal promotion decisions.
Dr. Woodhams added:
“This isn’t about blaming individuals; it’s about recognizing that systems and culture matter. The reassuring thing is that change is possible. When organizations take accountability seriously and make processes clearer, inequalities will start to narrow.”
Researchers argue that improving equity in elite professions requires more than just diversity efforts. We need to pay attention to how decisions are made, who makes them, and how accountability is enforced. Without this, formal commitments to equality risk being undermined by everyday practices.
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Reference magazines:
Woodhams, C. & Parnerkar, I. (2026). Institutional logics and relational inequalities in British surgery: Population advantage and the unequal governance of careers. Management Journal. DOI: doi.org/10.1111/joms.70107. https://onlinelibrary.wiley.com/doi/epdf/10.1111/joms.70107
