Students and Universities - Innovation, Universities, Science and Skills Committee Contents

Memorandum 36

Submission from the British Medical Association


  1.  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 140,000, rising steadily, including more than 2,800 members overseas and over 22,000 medical student members.

2.  The BMA's comments draw on the work of the Association's Medical Students and Medical Academic Staff Committees.


  3.  Medical school application procedures should be open and transparent, and should include clear measures for medical student selection, in order for candidates to understand on what criteria they are being assessed.

4.  It is important to ensure that high calibre candidates gain entry to medical school. It is also important that any potential barriers to entering medicine are addressed, including the lack of encouragement or aspiration at an early stage in a students' education, the fear of debt, and any potential barriers to entry at application stage.

  5.  There should be flexibility on entry requirements to medical school, to encourage a wide diversity of capable applicants. Some medical schools currently have schemes in place to encourage those from lower socioeconomic groups to apply to medicine, whilst others have access courses for those whose background is not science based. These schemes should be assessed, developed and extended where possible.

  6.  The BMA would welcome the introduction of criteria other than solely academic achievement for entry to medical school. Such criteria or testing must be evidence-based, and open to audit and long-term evaluation, and should include a comprehensive equality impact assessment. There are currently significant barriers to entry to medical school for students from lower socioeconomic backgrounds and the cost of any additional criteria or testing in particular should not be a barrier to entry.

  7.  Despite admissions to higher education increasing over the last few years, those from lower socio economic groups have increased very little. The Government has made a commitment to widening participation in higher education, with various initiatives to encourage those from lower socio-economic groups to enter higher education. The BMA fully supports this aim. However, the evidence suggests that initiatives taken so far appear to have had limited impact.

  8.  The most recent figures from UCAS[112] 2008 demonstrate that the proportion of higher education applicants (age 18 and under) from lower social class backgrounds has moved very little, with the figures showing that applications were up by only 0.7%, from 29.4% in 2007 to 30.1% in 2008. This slight upward trend can be partly explained by the inclusion of Nursing and Midwifery students into the statistics for the first time.

  9.  The figures for participation in medicine from those from lower socio-economic groups are worryingly low. The BMA's survey of medical students' 2007[113] shows only 13% of respondents came from social classes IIIM (Skilled Manual), IV (Semi-Skilled), and V (Unskilled), with only 5% coming from the lowest groups IV and V. The BMA produced a report in 2004 on the Demography of Medical Schools, an update of which is expected to be published in 2009.[114]

  10.  Some of the key themes underpinning the Government's widening participation agenda include attainment and aspiration. Any initiatives addressing these issues are welcomed. However, only 19% of those from lower socio-economic backgrounds gain two or more A-levels and only 30% of children from lower socio-economic backgrounds achieve five or more GCSEs.[115] Of those who achieve up to eight good GCSE passes, only one in four working class young people end up not going into higher education. The Higher Education Funding Council for England (HEFCE)[116] found that people living in the most advantaged 20% of areas were five or six times more likely to enter higher education than those living in the least advantaged 20% of areas. We believe much more can be done improve on this, including looking at the fundamental causes of low participation by those from lower socio-economic groups in higher education.

  11.  The BMA believes that, although there are multi-factorial issues in relation to widening participation in higher education, affordability and the fear of debt have a disproportionate impact in medicine. Financial considerations play a larger role in medicine because of the higher levels of debt incurred than those on shorter courses. The length of the course and the inability to work part-time because of the demands of the course, play a key part in this. Additionally, it is often not possible for medical students to study locally and live with parents.

  12.  A study, commissioned by the Sutton Trust,[117] investigated the impact of financial considerations on 16 to 20 year old students' decisions about participation in Higher Education. The study reported that almost two thirds (59%) of students who decided not to pursue Higher Education cited avoiding debt as a major factor in the decision.

  13.  The study also found that bursaries only make a difference when they are large. Nearly two thirds of students reported that a £2,000 bursary would have a major influence on their decision making regarding choice of university. Crucially, among low income students, the figure was almost 85%.

  14.  The Government has said that it plans to begin a review process of the current £3,000 cap on tuition fees. A decision on this is expected in 2009, and any change is likely to be implemented in 2010. There is concern that the review will result in the cap being lifted. We believe this would severely exacerbate medical student debt. We are concerned that able individuals may be deterred from studying medicine because of the fear of the additional debt, which in turn could adversely affect equality of access to higher education.

  15.  Results from the BMA's annual medical student finance survey 2007 demonstrate that final year medical student debt is over £20,000. 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.


  16.  Academic medicine has two core functions: to train the next generation of doctors and to research into pioneering healthcare techniques for future generations of patients. It also has a key role in synthesising and delivering the knowledge all doctors need to keep up to date and in providing educational support for doctors in difficulty. It is a vital not only to the NHS and healthcare provision in the United Kingdom generally, but also to the economic and financial well-being of the UK.

17.  High quality training of medical students and the life-long learning of all doctors are crucial to the effective functioning of the NHS and must not be compromised. Traditionally, teaching (of medical students and of those undertaking masters degrees and doctorates) has formed a large part of the workload of full-time medical academic staff, but the reduction in the size of the academic workforce combined with an increase in student numbers means that increasingly those working in the NHS are having to play a greater role in the teaching and supervision of medical students than in the past. Despite the growth in student numbers, medical education has suffered from raids on its funds during times of financial difficulty and may do so again in the worsening financial climate. The proposed reform to the funding of medical education outlined in the Next Stage Review may also lead to further instability.

  18.  It is welcome that, through the Office of the Strategic Coordination for Health Research (OSCHR), there is a new focus on transparency of research funding and on the funding of translational research. OSCHR's role is to facilitate agreement between the Departments of Health and Innovation, Universities and Skills and the Medical Research Council on the allocation of the single, ring-fenced health research fund and on the overall strategy for UK health research.

  19.  Encouragingly, highly effective collaborations between the NHS and the Higher Education Sector are also starting to emerge drawing on international models. The combination of a sufficiently large patient population and a critical mass of researchers in certain parts of the country provide one basis for a new model of collaboration between the NHS and Universities. The Academic Health Science Centre (AHSC) bringing St Mary's NHS Trust, the Hammersmith Hospitals NHS Trust and Imperial College London under united governance arrangements offers unparalleled opportunities to improve patient care through collaboration and innovation to bring out new ideas, evidence and products.

  20.  However, the recent significant developments in research infrastructure and funding will be to little avail without continued support for the implementation of the recommendations in Medically and Dentally-Qualified Staff: Recommendations for training the researchers and educators of the future (UK Clinical Research Collaboration, 2006). For the first time a clear training pathway for medically qualified academic staff was outlined and with it an unsurpassed opportunity to harness the enthusiasm of young doctors emerged.

  21.  Such enthusiasm may be eroded, however, if attention is not paid to the working arrangements of the next generation of teachers and researchers. Both University and NHS employers must invest sufficiently in the next generation of clinical academics to make the career pathways attractive, or risk the chance to ensure a vibrant future for UK academic medicine. The landmark Follett Report showed the way forward, clarifying the dual obligations and joint working conditions of the two sectors. The BMA has published data about employment practice in higher education in the Good University Employment Guide in part to act as an incentive for improvement.

  22.  Despite recent improvements, there has been a dramatic fall in the academic workforce over the past decade. The number of senior academic trainees and fully qualified academics stands at only 2,937—a fall of 27% since 2000 (Medical Schools Council 2007). In addition, clinical academics are an aging group and one in which women remain under-represented at the highest levels, with only 11% of professors being women. The ageing workforce compounds the overall decline in numbers and gives the impression that academic careers are not worth pursuing by younger generations of doctors.

  23.  The relatively unattractive nature of academic posts is part of the reason for the decline in numbers. For example, academic trainees fall behind their wholly clinical colleagues in the salary scale because of the time they spend in the research component of an academic training post. There is also evidence that, despite the translation of the 2003 consultant contract into the higher education sector, clinical academics do not have pay parity with clinical colleagues. Of the stakeholders that are involved in academic training (universities, NHS employers and postgraduate deaneries), none appear willing to take responsibility for the academic and clinical training of Academic Clinical Fellows and Clinical Lecturers. The result is that academic trainees feel disillusioned about choosing an academic track.

  24.  The decline in the academic workforce has occurred at the same time as an unparalleled increase in the number of medical students and the establishment of new medical schools, especially in England. The intake in 2005 of over 5,000 students was 57% above the medical school intake in 1997 (Department of Health, 2004). With a current UK medical student population of around 30,000 students this equates to only one clinical academic per hundred medical students. This means that there is extra pressure on the remaining academics to deliver teaching to ever larger numbers of students on top of their clinical and research commitments. There has also been a new reliance on non-medically qualified staff to deliver medical education in universities and a shift of the responsibility to deliver medical teaching from medical schools to the NHS.

  25.  Medical education is carried out in many different situations. There are formal settings such as lectures in universities, hospitals and primary care settings. Very often smaller group environments, such as tutorials, ward rounds and clinics are used. The development of IT infrastructure also has seen the use of video conferencing and on-line learning, and there is a need to ensure these are fully and adequately supported. The range and depth of the learning experience is one of the strengths of UK medicine.

  26.  Changes to the way that the NHS is funded and structured could compromise that strength. The private finance initiative discourages the provision of minimum research or educational facilities, such as IT and teaching facilities, rooms for students and library facilities, because, by definition, such space and facilities do not generate a profit for the developer. In addition, new ways of delivering services in the NHS, such as the independent sector treatment programme, the care closer to home initiative and, more recently, the proposals for polyclinics, often fail to incorporate education and research adequately into both their planning and implementation. This may mean that the NHS will lose valuable opportunities for clinical research, innovation and improvement.

  27.  We would argue, therefore, that an acknowledgement by policymakers and managers of the immediate and long-term value of education to the NHS is required. Specifically, trusts need to discontinue pressurising those involved in teaching to reduce teaching activities in favour of carrying out clinical duties.

  28.  Incorporating the delivery of medical education and the ability to undertake NHS research into new systems for delivering care requires:

    — funding which acknowledges the additional costs of delivering education;

    — providing the physical space necessary for delivering teaching;

    — designing and supporting the teaching obligations of each new healthcare setting;

    — employing appropriately trained staff to deliver teaching ; and

    — ensuring access to and facilities for clinical researchers for research purposes

  29.  Discretionary funding available to the Higher Education Sector, available through the Research Assessment Exercise (RAE), rests on the narrowly defined research performance of individual academics. Those medical academics with clinical commitments are likely to have a reduced research output because they have less time in which to deliver their research compared with those academics with no clinical commitments. This often has a negative impact on the tenure of medical academics, particularly, it seems, during periods when institutions are submitting returns for research assessments. Universities often employ clinical academics on short term contracts and can easily make staff redundant at the end of the contractual period.

  30.  Existing measures of research assessment have a tendency to reward laboratory-based projects and thus fail to measure adequately the contribution of many medical academics to clinical research. Furthermore, the RAE has contributed to a fall in the numbers of teaching academics because successive RAEs assess research and teaching in different ways. There is a danger that the RAE replacement, the Research Excellence Framework, will perpetuate the historical bias against clinical research and continue to undervalue teaching.

  31.  We would argue that the future measures of research excellence should:

    — be based on peer review within the NHS as well as the higher education sector;

    — take into consideration the competing time pressures on medical academics to deliver research volume;

    — acknowledge the time it takes both to deliver tangible clinical outcomes and to measure the impact of clinical research;

    — develop innovative ways of incorporating education into measurement; and

    — seek to capture and recognise research that is undertaken for patient benefit more effectively.

  32.  It is important to recognise the unique nature of the medical academic at the interface between research, teaching and clinical practice. The medical education process will give a different slant to the research question; the clinical competencies that may be necessary for a medical academic could be different, more focussed, from those required of other physicians; and the medical academic will have insights into translational research which give added value to projects. Thus disaggregating the research and teaching roles into easily quantifiable packages may be useful administratively, but ignores the reality of the medical academic career.


  33.  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 BMA has a number of concerns over its potential impact on medicine. UK medical schools organise the structure of medical degrees in varying ways with different schools choosing an individual mix of theoretical and practical medical training throughout different years of study. This diversity could be jeopardised if a student cannot guarantee that they will be able to complete their entire five-year course in the same institution as universities will be forced to harmonise the content of their medical courses so that students who complete their bachelor degree at one university but their masters degree at another, are equipped with the same level of clinical experience. Universities will lose the flexibility and autonomy over the content of their medical qualification in order to conform to a perceived EU norm.

34.  The financial implications for students must also be examined. Breaking up the five or six year medical degree is highly likely to result in students no longer being able to ensure funding for the full period. Students will be forced to re-apply for funding at the end of their four year bachelor degree in order to complete their medical qualification.

  35.  The BMA does not want the Bologna Process to result in a potentially fragmented medical degree which may challenge the integrity of the final medical qualification and thus undermine Directive 2005/36.


  36.  Funding support is complicated for all students, and for medical students the system is especially so. Currently, it is almost impossible for a prospective medical student to calculate how much their education will cost and their entitlement to financial support.

37.  The current student support system (post September 2006) was designed to support students on 3 year degree programmes. As medicine is a significantly longer programme it does not meet the needs of medical students. The fact that medical students have to apply for support through three separate systems, each with differing rules, confuses matters.

  38.  The huge complexity now present in the system means that fundamental improvements require a more joined up approach between the NHS Student Grants Unit and the Student Loans Company. A more systematic approach is necessary and further work is urgently needed to streamline the systems to bring them into line. Students should need to apply to one source only. The BMA has been working on improvements to the NHS Bursary scheme, along with other stakeholders and the Department of Health with a view to improving the support for medical students.

December 2008

112 Back

113   BMA Survey of Medical Student Finances 2006/07. Back

114 Back

115   Widening participation in Higher Education, Department for Education and Skills, 2005. Back

116   HEFCE, young participation in higher education, 2005. Back

117   Sutton Trust, P Davies et al, knowing where to study: fees, bursaries, and fair access, 2008. Back

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