While entry into medicine and surgery has become more diverse, why does that diversity disappear at senior levels? A new study from the University of Surrey argues that the answer lies in how careers are judged day-to-day.

Researchers found that despite years of equality policies, who gets ahead in UK surgery still depends on who already dominates the room. The study, which has been published in the Journal of Management Studies, analysed a decade of NHS career data and found that surgeons from underrepresented groups are more likely to leave training and less likely to be promoted, especially in environments where senior roles are dominated by White men. The findings suggest that informal networks and professional culture continue to shape careers as much as formal rules.

Dr Carol Woodhams, lead author of the study and Professor of Human Resource Management at the University of Surrey, said:

“Decisions about progression are not purely based on merit but are influenced by who is seen to “fit” the traditional image of a surgeon.

“In some parts of the NHS system, particularly specialist surgical fields, inequality is more entrenched. In others, especially large teaching hospitals with stronger oversight and clearer procedures, the gap narrows. This suggests that organisational context plays a decisive role in shaping outcomes for staff from underrepresented groups, including their progression, retention, and experience of inequality.”

Researchers analysed the career paths of 3,402 trainee surgeons across 212 NHS trusts over ten years, tracking promotion to consultant level and exit from training. They compared outcomes across gender and ethnicity and examined how these varied depending on workforce composition and governance structures.

Dr Carol Woodhams continued:

"People often assume inequality is a thing of the past because the rules have changed. But what we see here is that informal dynamics still carry significant weight. Who is recognised, supported and ultimately promoted is shaped by who already holds power."

The study finds that environments with a higher concentration of senior White male surgeons tend to reinforce in-group advantages, while others face steeper barriers. However, stronger governance and transparency can counteract this, particularly in formal promotion decisions.

Dr Woodhams added:

"This is not about blaming individuals. It is about recognising that systems and cultures matter. The encouraging part is that change is possible. Where organisations take accountability seriously and make processes clearer, inequalities begin to shrink."

The researchers argue that improving fairness in elite professions requires more than diversity initiatives. It requires 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.