In September, HEPI, with support from the University of Sunderland, hosted a roundtable dinner on the future of medical education in the UK.
When the then health secretary, Thérèse Coffey, unveiled her winter plan, criticism focused on her failure to address shortages in the NHS workforce.
This is a longstanding issue and universities have been at the heart of attempts to tackle it.
In 2016, the then Health Secretary, Jeremy Hunt, promised that medical schools in England would be allowed to offer up to 1,500 extra training places a year with a view to making the NHS self-sufficient in doctors by 2025. In 2018, he announced that five new medical schools would be created, targeting regions where doctors were hard to recruit and where health inequalities were high.
These schools – at Kent and Medway (Canterbury Christ Church University in partnership with the University of Kent), the University of Lincoln (in partnership with the University of Nottingham), Edge Hill University, Anglia Ruskin University and the University of Sunderland are now up and running. At a recent HEPI roundtable event, academics, medical professionals, and representatives from NHS England and political think tanks met to discuss progress so far and future steps for medical education.
Introductory remarks were given by Sir David Bell, Vice-Chancellor and Chief Executive at the University of Sunderland, Professor Michael Young, Deputy Vice-Chancellor at the University of Sunderland, Professor Scott Wilkes, Head of the Medical School at the University of Sunderland, and Professor Elizabeth Hughes, Medical Director at Health Education. Discussion after the introductory remarks was under Chatham House rules, allowing the speakers anonymity to encourage frank debate.
Addressing the roundtable, Professor Michael Young said that Sunderland had decided to apply for a medical school as part of a commitment to improving social, economic and skills development in the north-east of England and a belief that the medical profession would benefit if it became more representative. It was felt that having a medical school would help with local NHS recruitment and strengthen the reputation of the University.
Professor Scott Wilkes said that from the outset, the school’s emphasis has been on promoting accessibility, generalism and meeting NHS priorities. He argued that it had been transformative for the university, the NHS and the wider region.
Professor Wilkes noted that the existence of the medical school brings in an annual £20 million to Sunderland and the wider north-east thanks to student spending, salaries and additional public funding. It has also helped the local NHS Trust in its recruitment of staff and in the planning of a new eye hospital for the city.
Some 47 per cent of students at Sunderland’s medical school are local and 27 per cent from widening participation backgrounds. The ethnic mix is 50/50 white/BAME, while assessments of the 250 students who have gone through the process so far have shown no attainment gap for gender or ethnic groups.
What has helped? Professor Wilkes noted that having students actively involved and sitting on governance committees had built a powerful sense of engagement. There had also been top-level backing from the University and investment in facilities, collaboration with regional NHS trusts and GP practices, rigorous external scrutiny, and support both nationally and locally from Health Education England.
Two fourth-year medical students at Sunderland, both local to the area, said applying to study medicine had been difficult but that the University’s approach to recruitment and selection had the made the process much more accessible. For example, unlike most medical schools, Sunderland does not select only from the top 20 per cent in the University Clinical Aptitude Test, although it maintains the triple A standard at A Level, with a contextual offer of AAB for local students.
The UK’s reliance on doctors trained overseas had long raised concerns about stripping other countries of talent. While Sunderland’s school – like the other four – was planned well before COVID, the pandemic underlined the need for more home-grown doctors. Despite the extra training places, this need continues and demand for medical school places remains high as competition this year was more intense than ever.
Yet strict caps remain on the number of medical students that can be recruited. One speaker at the roundtable said he felt this led to perverse outcomes. He could not understand why policy prevented capping the number of business studies students in an institution where only a quarter would go into a graduate job – and many would not pay back their student loans – while restrictions remained on medical places in areas that needed them, and when medical graduates would almost certainly repay their loans. If standards were met, and a university could persuade Health Education England that placements were available, it should be possible to run a medical degree, he argued.
It was noted that number caps are in place partly because of money. A medical degree costs around £200,000 per student and one speaker suggested that HM Treasury, with many more immediate calls on its resources, would be reluctant to make available that kind of sum in an unlimited way, with no ‘payback’ for at least five years.
There are also limits to the number of medical placements available, although another speaker insisted that while placement availability in London is indeed tight, there was more availability around the country than is often recognised. This was noted as another illustration of a London-centric approach to policymaking.
Others pointed out that there are also limits to the number of medical educators, with a large proportion of these now aged over 60. This would need to be addressed if quality and staff-student ratios in medical education were to be maintained.
Pace of change
Professor Liz Hughes, Medical Director at Health Education England, said healthcare was moving much faster than it had done in the past and medical education needed to match that rapid pace of change. Among other consequences, it would involve doctors working for longer and in more portfolio-type careers aligned to the changing healthcare needs of the population, advances in technology and the place of delivery of healthcare. The demographics of patients has changed, with patients living longer with complex co-morbidities that require more intervention.
Everyone agreed that a more diverse medical profession would have a better understanding of a more diverse population of patients, and this was not just in terms of ethnicity but locality. Both Sunderland medical students said that they wanted to stay in their community after graduating as they felt they understood it and wanted to contribute to its future wellbeing and success.
But does the evidence show that medical students tend to stay in the area they have been trained? Not for undergraduates but more for postgraduates, said Professor Hughes, which was why more flexible and part-time learning options were needed. She welcomed recent approval for a medical apprenticeship and said a blended learning degree would be starting at Queen Mary, University of London, in 2023.
Professor Young agreed with the point about flexibility but also noted that locally-focussed recruitment – such as was being seen in Sunderland – would make it more likely that those graduating would stay local.
NHS England is also considering more flexibility in admissions, with greater recognition for prior learning by, for example, pharmacists wanting to change careers. There was a potential opportunity after Brexit as previously UK medical courses were subject to an EU directive defining their length.
The pandemic, during which final-year students started working earlier in hospitals, also provided a model for change, as it enabled students to graduate earlier into junior doctor roles under stricter supervision before they enter their foundation year.
Some at the roundtable balked at the prospect of yet more change, suggesting that it should be phased, and that an eye should be kept on retention as well as on recruitment. Sir David Bell, in a concluding comment said that it all came down to more strategic thinking by government. ‘We need to take a long-term workforce planning view,’ he said. ‘Otherwise, we stumble from crisis to crisis, and it can’t go on.’
“Sunderland…maintains the triple A standard at A Level, with a contextual offer of AAB for local students”.
Sunderland, surely, is not alone in (generally) requiring AAA.
According to Ofqual, however, exam grades are only “reliable to one grade either way”. More specifically, the reliability of Chemistry grades is about 92%; Physics, 88%; Biology, 85% (https://www.hepi.ac.uk/2019/01/15/1-school-exam-grade-in-4-is-wrong-does-this-matter/).
So, for example, about 12 Physics students in every 100 are ‘awarded’ the wrong grade, a grade they did not merit (as determined by the grade that would have been awarded had a senior examiner marked the script).
That all implies that, for every 100 students taking Chemistry, Physics and Biology and receiving certificates showing AAA, about 15 should have had at least one B.
If AAA is used as a criterion for admission, those 15 places have been taken by students who are under-qualified – places that have been denied to students whose certificates show at least one grade B, but who truly merited AAA.
Admission to medical school is hugely competitive, and it is essential that the selection process is fair. But how can it be when grades are “reliable to one grade either way”?
Ofqual have known about this since at least 2016, but have failed to fix it. And the problem applies across all subjects, not just medicine.
Other than students themselves, HE is the largest, and most important, “user” of A level grades. That gives HE much power. But only if HE exerts it.
What needs to happen for HE to put pressure on Ofqual to fix this problem, and to deliver reliable and trustworthy grades – as indeed is required by Ofqual’s statutory obligation “to secure that regulated qualifications give a reliable indication of knowledge, skills and understanding”?
Are grades “reliable to one grade either way” reliable enough?
Great news and good to see and hear changes are on the way.
It is particularly important that monitoring of post graduates staying in the UK is known so that funding is not seen as wasted and for Apprenticeships, with perhaps aspiring doctors, spending more time on wards from their second year on so that they can develop communication skills and knowledge from experienced nurses, who do this for Junior doctors so successfully in most cases.
Perhaps those who go into private medicine could be asked to ‘pay back’ whole fee in order to sponsor another doctor in times of austerity and ‘levelling up’!
Other countries have a more relaxed entry requirement to Medicine that allows them to come here and upgrade where necessary – pharmacist qualifications already (in short supply) must be allowed to do Apprenticeships thus filling void and then be able to change to Medicine later too, as with other Medicine courses.
With the use of more robotics, technology and AI, it is also important that schools, colleges and universities are able to encourage more into a different kind of medical system and teach through STEAM aspects to encourage more girls that might be put off by the new technology, so that it becomes a natural, not add on to learning.
COVID showed us this can be done.
As someone who did their secondary education in Sunderland, I was delighted to read this report and learn about the new medical school at the local University and the benefit it has brought to the North East.
I hope the other 4, new, medical schools have also helped their communities in a similar way.
The statement “A medical degree costs around £200,000 per student ” came as a big surprise and made me wonder how the new medical apprenticeship degree, at £23,000 a year (for 5 years ?) was possible. Why is the University delivered one so expensive?
What do overseas self-funded students pay for a UK medical degree, I wonder?
Who will be the employers for medical degree apprentices and how will it affect the wages of their employees? I don’t see the employees accepting the minimum apprenticeship wage in their first year.
It is well known that a degree in medicine generally leads to a well-paid career, and it is no surprise that most graduates pay off their student loans in full. Commercially, becoming a taxpayer funded medical doctor must be one of the best deals going. (It also allows the University to get extra points for their students achieving higher than average incomes).
For those doctors who go on to leave the UK for the USA and Australia, (where medics are financially rewarded at an even higher level), it would seem fair to me for them to pay back some of the cost of their degree into a special fund to train more doctors in the UK.
Despite government promises to increase the number of doctors entering the NHS (given a current shortage of at least 10,000) there must be a way to help the Treasury come up with the £200k cost.
Could a possible solution be found by getting graduate doctors to pay higher taxes?