Memorandum submitted by The British Medical
Association (BMA)
The British Medical Association (BMA) is a voluntary,
professional association that represents doctors from all branches
of medicine all over the UK. It has a total membership of over
138,000, rising steadily, including more than 2,500 members overseas
and over 19,000 medical student members.
The BMA's Medical Students Committee and Medical
Academic Staff Committee have considered the terms of reference
for the inquiry and our comments, focussing on medical education,
are set out in this paper.
ROLE OF
UNIVERSITIES OVER
THE NEXT
5-10 YEARS
1. Medical students want adequately resourced,
good quality education and training that will result in a professional
degree and lead them to registration with the General Medical
Council.
2. Medical students wish to see the current
broad-based educational arrangements remain in place. A good doctor
is one with the creativity and initiative to recognise the issues
a patient has and who takes steps to address those issues. They
must also have sound clinical knowledge and skills. Currently
medical schools have autonomy to deliver teaching and training
in a way that ensures students are equipped to meet these requirements.
This variety of approach between medical schools allows a student
to choose a course type that best suits their learning style,
and we believe this is key to creating an environment where the
student can learn effectively. This is of benefit to the profession
and patients by enabling students to fulfil their greatest potential
as doctors. A variety of educational methods broadens the skill
mix within the profession with the ultimate goal of constant improvement
in patient care.
3. Medical education and training in the
UK is held in high regard outside the UK. In order to ensure that
it remains of a high standard, it is vital that adequate funding
is available. Universities have a key role to play in recognising
the value of medical teaching and in hosting an environment where
medical teaching careers can thrive. The quality of medical education
is under significant threat from the reduction in clinical academic
staff at a time when the medical student population has increased
markedly. The quality of education is further threatened by instability
in funding in the NHS of medical academic staff. Many Universities
have responded to changes in the curriculum by increasingly devolving
the delivery of medical student education to the NHS. This is
happening at a time when budget cuts in NHS funding and tightening
of supporting activities in NHS contracts are affecting the delivery
of undergraduate education.
4. Increasingly, Universities will have
a role to play in contributing to the UK economy through innovation
and excellence in health research.[27]
This will require better coordination between Universities, the
NHS, pharmaceutical companies and medical device companies and
an ongoing recognition of the synergy between education, research
and clinical practice in medicine.
5. The need for greater University collaboration
is especially vital given the dual funding of academic medicine.
Current NHS deficits and corresponding cuts in funding for medical
education will, we believe, directly affect teaching posts and
medical students, potentially in the longer term[28].
If the numbers of teaching posts are reduced the viability and
quality of teaching in the NHS and medical schools, as well as
schools themselves, will be endangered. This will have a consequent
adverse effect on the future medical workforce and impact on patient
care. This is compounded by the current problems with Modernising
Medical Careers (MMC) with the fear that up to 5000 doctors currently
in training could be sidelined into non-training posts.
6. Universities need to play a key role
in ensuring that the medical profession reflects the composition
of society and therefore schemes encouraging school students to
apply to medicine should target students from backgrounds that
are under-represented in the medical profession. We believe that
measures to widen participation in medicine must be targeted specifically
at medicine as well as the whole university to which the medical
school belongs. We are concerned that there are currently significant
barriers to entry to medical school from students from lower socioeconomic
backgrounds, particularly that the costs for students are prohibitive.
7. Figures from UCAS[29]
demonstrate that there has been no change in the socio-economic
number of applications to pre-clinical medicine for 2006 with
19% from the lower groups 4 to 7 submitting applications. This
is of concern both to the Department of Health and the BMA.
UNIVERSITY FUNDING
Lifting the cap on student fees
8. We strongly believe that the £3,000
cap on student fees should not be lifted after 2009. Student fees
are already affecting applications/admissions to universities
and to medical schools within universities with a 4% decline in
applications to universities and an almost 3% decline[30]
in applications to medical schools. This is at a time when student
debt is at an all-time high. Lifting the cap would we believe
aggravate this situation.
9. Results from the BMA's annual medical
student finance survey[31]
demonstrate that the average amount of debt for a medical student
was £12,657 and the highest figure was £53,350. Average
total debt increased markedly by year of study and ranged from
£6,920 for first year students to over £22,000 for students
in their sixth year. Thirteen per cent of respondents had total
debt exceeding £25,000, and amongst fifth and sixth year
students this proportion was considerably higher at 26% and 44%
respectively. Six percent of respondents had total debt exceeding
£30,000. The high debt levels are explained by the fact that
medical students study for two or three years longer than those
on most other courses, have fewer opportunities to work part-time,
and face additional expenses for travel to hospitals, and equipment.
10. Lifting the cap would severely exacerbate
medical student debt. We are concerned that this may deter able
individuals from studying medicine particularly those from lower
socio-economic backgrounds.
Medical degree funding
11. Funding for medical degree courses is
complex and lacks transparency. There are a broad and complex
range of finance streams and it is difficult to obtain information
about spend on medical education and training.
12. Given that block grant funding for medical
education comprises a significant proportion of the total central
funding for higher education institutions and all medical students
will pay £3,000 per year in tuition, there is a clear need
to improve transparency in funding within medical schools and
Universities.
Funding cuts
13. At some medical schools, and in some
specialties, the proportion of NHS funding for clinical academic
posts is much higher that Funding Council funding[32].
This year, NHS funding cuts have a detrimental effect on teaching
with Universities struggling to manage their finances for medical
degree courses. First quarter performance for the NHS[33]
indicates that Strategic Health Authorities have been required
to save £350m which is to be used to off-set overspending
elsewhere and will be held centrally by the NHS Bank as a "contingency
fund".
14. At the same time, Universities have
gradually reduced the numbers of clinical academics, (primarily
teaching academics), by moving the funding of teaching academic
salaries away from universities into the NHS funding streams.
Over the past five years the number of medical students has increased
by almost 10,000 to meet the future needs of the medical workforce,
and at the same time there has been a 25% reduction in academics
and an associated shift of undergraduate education to the NHS.
Further pressure on funding, from either funding source would
make the delivery of medical undergraduate education in many medical
schools unsustainable, given there are currently around 35,000
students in UK medical schools.
15. The pressure for job cuts, especially
teaching posts, appears fairly high. There is a real concern that
funding cuts will reinforce a continued high vacancy rate amongst
medical academics, especially if money is not available to recruit
to vacant positions. The current vacancy rate is 7% of the total
number of clinical academics and vacancies are especially prominent
in senior academic positions—in 2005 there were 91 professorial
vacancies.[34]
Flexible central funding
16. The University funding structure, especially
the Research Assessment Exercise (RAE), has the effect of discouraging
excellence and quality in teaching, in spite of the significant
and increasing amount that students are expected to personally
contribute to their tuition.
17. Despite the substantial in increase
medical students (10,000 over the past 5 years), discretionary
funding through the RAE has encouraged medical schools to expend
disproportionate amounts of energy on attracting money for research
at the expense of teaching and there is a real risk that medical
teaching and medical teachers are devalued. The result is that
medical teaching and its quality control has been shifted to the
NHS which is under threat from a number of quarters. For example:
— There is a tightening up of consultant
contracts and a corresponding loss of planned time for teaching
through supporting professional activities in job plans.
— NHS money for medical education through
the Service Increment For Teaching Money (SIFT) money has been
mis-spent on clinical work rather than teaching. In the current
climate of NHS deficits, the concern is that any cuts from this
budget line will preserve money spent on clinical work to the
detriment of money for education.
18. The present RAE actively discourages
a vigorous teaching culture in Universities, as it disengages
teaching from research by assessing them in different ways. Active
attempts should be made to integrate research and teaching through
funding mechanisms.
19. The measures of RAE assessment used
until now have been criticised for their narrow focus and a tendency
to reward laboratory based projects instead of human studies,
and hence an overall failure to adequately measure the contribution
of medical academics to clinical research.
20. University funding should give due consideration
to the differential requirements of professional groups in defining
quality. For medicine, funding must acknowledge innovation in
clinical research where innovation or change in practise is usually
the result of several (as many as four or five) complementary
studies and give appropriate credit for the contribution of each
piece of research made to the advancement of clinical practice.
Furthermore, research quality for medicine ought to value applied/translational
research, as well as basic science, to break down the divergence
of research outcomes that are expected of clinical academic staff
by Universities and the NHS.
CONCLUSION
21. The high quality and standard of medical
education and training in the UK should not be eroded by lack
of funding.
22. Medical students should have an expectancy
that the fees they pay will be hypothecated towards furthering
their education. As medical students pay £3,000 per year
of study and leave university with significant debts and a less
stable employment market, this expectancy should be met. Universities
should set up transparent funding mechanisms to ensure that students
are getting value for their money.
23. Lifting the £3,000 cap on student
fees is, we believe, unacceptable. This will adversely affect
applications to medical schools and for those who study medicine
would have a severe impact on student debt, particularly for those
from lower socio-economic backgrounds.
24. In addition, there is a clear need to
for medical teaching to be valued and better integrated into funding
arrangements than at present. These funding arrangements need
clarity and openness.
25. The quality of undergraduate medical
education should not be compromised by the significant increase
in medical students and massive decline in medical teachers. Adequate
funding to support teaching in medical schools is therefore essential.
There are potential tensions in the funding system which also
spans health sector (the latter budgets have been raided to fund
NHS deficits. Quality undergraduate medical education also relies
on synergy between teaching, research and clinical environment.
THE BOLOGNA
PROCESS
The Bologna Declaration has the potential to
change the face of medical education as it currently stands, and
consequently the experiences of the profession and those it serves.
The nature of the delivery of medical education proposes additional
challenges to the implementation of the Declaration and this needs
to be considered before wide reaching mechanisms are implemented
throughout higher education. Whilst aspects of the Declaration
have possibly detrimental affects through loss of diversity and
individual country autonomy through the bachelors/masters system,
increased quality assurance and collaboration throughout Europe
provide a valuable opportunity to enhance European achievement.
It is essential that UK stakeholders drive forward discussion
regarding the implementation of the Bologna Process in order to
have optimal results for the profession as a whole, in both the
UK and Europe.
December 2006
http://www.bma.org.uk/ap.nsf/Content/Studentfinance0506?OpenDocument&Login
27 Drive to boost Clinical Research 14 December 2006,
http://www.timesonline.co.uk/article/0,,5-2502546.html Back
28
House of Commons Health Committee, NHS Deficits, First
Report of Session 2006-07, Volume 1, 7 December 2006. Back
29
Applicants to Pre Clinical Medicine & Dentistry Received
by June 2006-UCAS. Back
30
UCAS figures for 2007 entry, News Release, 31 October 2006. Back
31
BMA,-Survey of medical student finances 2005-06. Back
32
Across the UK, clinical academic salaries are 38% NHS funded,
rising to 66% (Leicester), 71% (Bristol and over 90% (Swansea
and Keele). Source: Clinical Academic Staffing Levels in UK Medical
and Dental Schools, A data update by the Council of Heads of Medical
Schools June 2006. Back
33
NHS financial performance-Quarter 1 2006-07, Department of Health. Back
34
Clinical Academic Staffing Levels in UK Medical and Dental Schools,
A data update by the Council of Heads of Medical Schools June
2006. Back
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