A group of ethnic minority doctors has failed to win a legal victory against the doctors' watchdog over alleged inequality in GP competency exams.
But the doctors achieved "a moral success" when a leading judge warned the bodies responsible for GP training that they must take action over acknowledged problems involving discrimination or face being found guilty in the future of infringing Equality Act duties.
The British Association of Physicians of Indian Origin (Bapio) pointed to a "significant difference in pass rates" between UK and international graduates, including those of Indian origin.
Their lawyers applied for judicial review at London's High Court against the regulator, the General Medical Council (GMC), and standards body, the Royal College of General Practitioners (RCGP).
They claimed the test, which confirms a doctor has satisfactorily completed speciality training for general practice and is competent to enter independent practice - known as the MRCGP exam - was flawed and unlawfully discriminated against international GP trainees.
In particular, they focused on the Clinical Skills Assessment (CSA) component of the MRCGP and argued there was a "significant difference in pass rates which cannot be explained by a lack of any knowledge, skill or competency on the part of the International Medical Graduates (IMGs)".
Dismissing the claim, Mr Justice Mitting ruled: "I am satisfied that the CSA is proportionate in achieving a legitimate aim."
But he warned that the medical authorities had in recent years received reports and reviews showing that the CSA was not "culturally neutral" and there was the possibility of subjective bias by examiners.
The judge said the Royal College now needed to act and identify means "to eliminate discrimination".
The judge said: "The time to act on the information... has either arrived or will do so very soon."
He warned that, although he was satisfied that the medical authorities were not currently in breach of their Equality Act duties, they might well be held by a court to infringe them if they failed to act.
The judge said he was satisfied that Bapio had brought its application "in good faith" and had sought "to rectify anomalies acknowledged by all to exist.
"This claim has served useful purpose and achieved not a legal victory, but a moral success".
RCGP chair Dr Maureen Baker welcomed the court ruling that the operation of the CSA is lawful and fair.
Dr Baker said: "Patients have a right to expect safe care and it is our responsibility to ensure that all doctors who qualify as GPs meet the highest standards to ensure this safe care.
"That is the purpose of this exam, and the other requirements to become a practising GP.
"We agree that further action is needed, and we are already working hard to find the best way of supporting the small number of trainees who fail to pass the CSA component of the MRCGP licensing exam to give them every chance of passing the exam.
"The RCGP has been at the forefront of identifying the differences in pass rates for some time, including that international medical graduates do not do as well in the exam as those from UK medical schools.
"Indeed, we were the first of the Medical Royal Colleges to publicly raise this issue and have commissioned and supported extensive research to understand what is happening and to try and identify what the causes may be.
"We are already developing further web-based learning resources and publications to help trainees and their trainers prepare for the exam and are reviewing how to improve the quality of feedback that candidates receive from the exam so that they can target any areas of underperformance with their trainer.
"We are also committed to acting on recommendations made in recent reviews to ensure the MRCGP minimises any possible risks of unfairness and we are very keen to work with the GP training community to develop effective training strategies for those who might struggle with the exam.
"Overall, around 95% of candidates will pass the CSA. Of the College's 30,271 Fellows and Members, who have declared their ethnicity, 30% are from a black and minority ethnic (BME) background."
GMC chief executive Niall Dickson described today's ruling as " an important decision for medical education and regulation".
Mr Dickson said of the judge's decision: "He has recognised that we take seriously our responsibility to operate procedures that are fair and free from discrimination.
"At the same time, stringent checks for doctors, and high standards of medical education, are vital for the safety and quality of medical care in the UK.
"As part of our ongoing programme to maintain these standards, we have commissioned a review of the Professional & Linguistics Assessment Board (PLAB) examination and of the language skills required by doctors coming to work in the UK.
"As a result of the language review we have increased the score required for the second time in the last four years.
'We do understand that there are serious and complex issues at play here.
"International medical graduates have made a huge contribution to healthcare in this country and we will continue to do whatever we can to support these doctors who provide so much frontline care in the UK.
"Last year, we commissioned Prof Aneez Esmail, of the University of Manchester, to carry out an independent review of the MRCGP examination and the Clinical Skills Assessment.
"His report raised some important issues and we are already working to take forward his recommendations.
"In addition, we are leading a review, working with the Academy of Medical Royal Colleges and others, on a project to understand and bring together the data in this area.
"The UK benefits from the diversity of the medical profession. We will work to make sure that diversity and high standards go hand in hand."
Bapio's "moral success" came at a high price. As they were denied a formal legal victory they were ordered to pay a portion of the defendant's legal costs, amounting to £50,000.
The combined total RCGP and GMC legal bill is believed to have been almost £400,000.
The group was given permission to appeal to the Court of Appeal against the judge's ruling with regard to the RCGP.