The Future of Higher Education

Written evidence from the British Medical Association (BMA)

Summary

· The BMA remains committed to state funding of higher education and to the ‘arms-length’ principle.

· We are concerned about the impact of funding cuts in higher education on medical education and research, and on the doctors that undertake this work.

· We are disappointed at the proposals regarding student financial support arising from the Browne Review Report and, in particular, its failure to address the concerns of medical students directly and to provide more detail on how courses with significant social benefit will be funded.

· We call for an early decision regarding the NHS Bursary scheme.

· We believe that the impact of the fear of debt of young people, particularly those from low income families, has been given insufficient consideration. This has a disproportionately adverse impact in medicine and needs to be analysed separately.

· We support the efforts being made to widen participation in higher education but argue that specific policies need to be established for medicine which, in turn, need to be analysed separately.

· We argue there has been insufficient transparency in the funding for teaching in higher education and that universities should be compelled to reveal internal cash flow for teaching delivery.

· We are concerned that the creation of a market in higher education will destabilise institutions to the detriment of education and research.

· The BMA believes that focussing research funding on a few institutions may well be fundamentally misguided and will reduce its diversity and likely effectiveness.

· We are concerned by proposals to allow private universities to open medical schools, or increase medical student numbers, especially if the decision is made without reference to NHS workforce planning.

Introduction

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 144,000, including medical academics, doctors who are employed by universities or work in higher education, and over 22,000 medical students.

Context

2. The immediate context for higher education policy overall is one of significant cuts in funding arising not only from the comprehensive spending review and but also from cuts announced by the previous government. Whilst science spending is to be held at the current rate, we note that, over the next four years, this effectively means a 10% cut in funding.

3. The BMA is concerned that cuts to other budgets will affect medical education and research. With the general reduction in higher education funding for teaching and a continued lack of clarity about the extent to which institutions will cross-subsidise between courses and between research and teaching, we are concerned that a number of staff that undertake medical research and teaching could be under threat of redundancy. The reduction in the Government’s commitment to teaching in higher education could, therefore, have a detrimental impact on the UK’s current and future research capacity.

Medical Student Finance and Lord Browne’s Report

4. The BMA contributed to Lord Browne’s Review into Higher Education Funding and Student Finance, and prepared submissions [1] . We explained the particular situation of medical degrees, which are longer and more intensive than the usual three year degree, and the specific issues this raises for medical student finance and debt. We also made clear our opposition to the timing of Lord Browne’s Review, which came before the first medical students under the current tuition fees system had graduated, preventing full analysis of the impact on students on longer courses of the current £3,000 fees.

5. The BMA was disappointed with the findings of Lord Browne’s Review regarding student financial support. Whilst some consideration was given to courses that delivered significant social returns, such as medicine, there was little detail in the proposals about how targeted investment by the state in these courses would affect the fees paid by students. We recognise that students will not have to pay up-front fees and that payments will be made through the tax system once graduates earn £21,000. However, as we outline below, evidence suggests that fear of debt is a factor in young people deciding whether to go to university and what course they would undertake and we believe that this has not been analysed sufficiently.

6. The BMA does not believe the case was made for an early decision to raise the cap on tuition fees. This made no sense before the full higher education funding and student finance package had been published by the Government, without which it is almost impossible to assess the overall impact of increased fees. The BMA was also concerned that the changes did not reflect the specific financial circumstances of medical students.

NHS Bursary Scheme and Review

7. In addition to the proposed increase in fees, the BMA remains concerned about the NHS Bursary Scheme.

8. The NHS bursary is a major part of the support package for medical students. The impact of higher education funding reforms cannot be fully understood without consideration of the future of the bursary. In common with other students, medical students on 5 and 6 year courses receive support from the Student Loans Company (SLC) for the first 4 years of study to cover their tuition fees (in the form of a loan) and maintenance (in the form of a means-tested grant and loan). From the fifth year, students enter the NHS Bursary scheme and the NHS pays their tuition fees. The bursary itself is means-tested and pays up to a maximum of £4,388 (the rate for students outside London). An NHS loan is also available in years 5 and 6 but is not means-tested and is granted at the reduced rate of £2,210 (outside London) for all NHS funded students, regardless of whether students are eligible for the bursary. Currently, the cut-off for the bursary is significantly lower than that for the means-tested loan available to all students.

9. The inadequate level of loan provided by the scheme leads medical students into higher levels of commercial debt, particularly in years 5 and 6, in part because the maintenance needs of the student do not decrease despite the reduction in student loan allowance.

10. In addition, the current bursary system and application process is incredibly complex to understand and navigate for students and differs hugely across the four nations of the UK. It also does little to address the need to widen participation in medicine. Indeed, this complexity is likely to have a disproportionate effect on students from low income backgrounds because they often have less access to information [2] .

11. The BMA was closely involved with the review of the scheme and made a detailed submission during the Department of Health consultation [3] . We supported fully the principles of the review and support ed the proposal that medical students from the lowest socio-economic classifications should be included within the NHS Bursary Scheme for the duration of their degree .

12. However, since the consultation closed in 2009 there has been little public progress. Our strong view is that a decision should be made as soon as possible on the future shape of the scheme and that the bursary must provide a sustainable amount of support for students.

Medical Student finance

13. We have calculated that under the current system [4] a medical student graduates with an estimated £37,000 worth of debt. This includes only those debts incurred from student loans and does not take into account overdrafts, credit cards and professional loans which many students depend on for additional support.

14. We would also point out that during the medical degree there are higher incidental costs than for most other courses. Medical students are expected to travel to clinical placements and to purchase expensive equipment. Medical students spend approximately 46 weeks per year at university, requiring more in maintenance support and limiting the opportunity for part-time working to supplement their income.

15. Following the vote to increase tuition fees, higher education institutions will be able to charge fees of between £6,000 and £9,000 a year. We would suggest that failure to widen access to medicine seriously weakens the case for higher fees for medical careers. The BMA estimates that if universities charge the maximum £9,000 rate, medical students could see their graduating debts increase to around £70,000 [5] . We are also concerned at the lack of analysis of the impact of the deferred payment of student fees on graduates with regard to other future borrowing such as mortgages.

16. A further concern is the Government’s plan of charging an interest rate of up to 3 per cent above inflation on loans taken out after 2012-13. Furthermore, the Education Bill does not specify any cap on the interest rate allowing future government to change the system further. These proposals will result in graduates repaying substantially more than the actual value of the original loan and add to their debt on graduation.

17. We believe that a separate analysis of the impact of any changes on longer and, therefore, more expensive courses, such as medicine, should be undertaken and that this analysis should include the extent to which price sensitivity is affected by access to part-time work. We also believe that an analysis should be made of the impact of the new system on courses students choose to undertake and the career choices they make on graduation. We would be concerned if perverse incentives were created that discouraged doctors from entering academic medicine and from practising in the UK.

Widening Participation

18. UCAS data [6] shows that in 2008 the proportion of applicants to Higher Education from lower socio-economic groups was 29.9%. Medicine is particularly under-represented with only 13% of medical students in 2008 coming from the lowest three socio-economic groups [7] .

19. A lthough there are multi-factorial causes for the failure to widen participation that need to be tackled, there is evidence that affordability and the fear of debt hav e a disproportionate impact in m edicine. Any plans to increase the contribution graduates make towards the education from which they eventually benefit must, therefore, be considered alongside our wider concerns that the fear of debt will deter students from lower socio-economic groups from undertaking medical degrees.

20. A 2008 study by the Sutton Trust [8] found that almost two thirds of students who decided not to pursue Higher Education cited avoiding debt as a major factor in their decision. The Government’s explanatory memorandum on the Higher Education (Higher Amount) (England) Regulations 2010 also acknowledged that ‘there is evidence of price sensitivity among students’ but that this could be off-set by comparable increases in student support. We recognise that the Government has stated that there will be increased support for poorer students. Nonetheless, the length of the medical degree course and the lack of time available to undertake part-time work mean that such support needs to be tailored to the needs of medical students.

21. We recognise the Government’s commitment to measure the proportion of students from disadvantaged background entering higher education as part of their success criteria and support the aims of this proposal. We also note that Universities can only charge fees above £6,000 if they have widening participation schemes acceptable to the Office for Fair Access, and that the OFFA has this week published guidance for HEIs on how to produce an access agreement for those charging fees of more than £6,000. To date, there have been numerous initiatives and schemes run by medical schools and others aimed at increasing applications and entrants from lower income families. Unfortunately, these schemes have had little national effect.

22. The percentage of students from lower income families is slowly improving across higher education but the rate remains stagnant in medicine. It is for that reason that we would strongly urge the Government and OFFA to measure medicine separately so that cross-institutional averages do not conceal the situation in medicine. Given the past failure to widen access, we would argue that the case made by each medical school for fees above £6,000 for medical students must be robust and measurable. Access agreements must specifically address access to medical degrees which are longer and more expensive than the standard three year course. In particular, they must tackle our concerns regarding the difficulties students from poorer families will have in undertaking the necessary work experience because they don’t have the financial support necessary to work unpaid for a period of time, or the personal or family connections to professionals who can facilitate internships, shadowing and work experience.

Higher Education Funding and Governance

23. The BMA remains committed to state funding of higher education and to the ‘arms-length’ principle. The Academy of Medical Sciences report Biomedical research - a platform for increasing health and wealth in the UK demonstrated that "medical research charity funding relies on a strong, publicly funded research base and infrastructure to achieve its aims." We also believe that there is an important role for an organisation in the sector between the individual institutions and Government. We would, nonetheless, welcome proposals that streamline bureaucracy, simplify regulation and improve transparency, but suggest that they must bear in mind the plan to establish a medical research regulator.

24. The BMA has argued there has been insufficient transparency in the funding for teaching in higher education [9] . We believe universities should be compelled to reveal internal cash flow from Higher Education Funding Councils’ funding towards actual teaching delivery. We acknowledge that funding teaching through the individual student rather than in the form of block funding gives the possibility of achieving the greater transparency we have sought. However, Science, Technology, Engineering and Mathematics (STEM) subjects will continue to receive some funding through block grants and we are concerned that there has been little clarity, as yet, regarding how much such funding will be available and how it will be allocated.

25. The BMA does, however, have concerns about the impact of funding teaching almost wholly through student fees and, by that, the creation of a ‘market’ in higher education. We fear that it could make institutions susceptible to quite rapid fluctuations in student demand, leading to the possible closure of some institutions. This could have a damaging effect on students on those courses affected, who will have committed time and resources to their studies. Degree courses (particularly medical degrees) take some time to plan and implement and are, therefore, not products that can be made available quickly in response to changes in the student market in the course of a year or even within years. The Government needs to have an active policy for managing mergers and acquisitions in the HE sector, thereby protecting teaching and research whilst at the same time saving money on management and administration.

26. We would also be concerned if funding for and from medical students was used to subsidise other courses to an unreasonable extent. We also note that, with much of the medical degree teaching taking place outside the university in NHS organisations, students may question whether their higher education institution is providing value for money for their tuition fees, and NHS organisations may query whether they should receive some of the fees from medical students. The possible destabilisation of the supplementary income for teaching (SIFT) system arising from the Department of Health’s review of the Multi-Professional Education and Training levy does not seem to have been taken into account in the current planning for student fees.

27. The BMA also believes that mechanisms other than the market can enable students to have an influence over the nature and quality of their experience at university and should not be ignored. These should include forums in which student views are aired to senior staff and formal procedures for taking student feedback into account.

28. The BMA is sceptical that the Government’s policy of offering shorter degree courses and of encouraging new modes of teaching would be appropriate for medicine. We note that the recently published report for HEFCE [10] on the subject does not consider medicine or other similar vocational degrees. With medical students already spending approximately 46 weeks per year at university, we would suggest that it would be very difficult to shorten the course.

Research

29. The BMA is concerned that, other than as a short-term device for solving the financial crisis, focussing research funding on a few institutions may well be fundamentally misguided. Pharmaceutical physician members of the BMA (clinical academics working in the pharmaceutical industry) have argued to us that the experience in the industry of focussing on large-scale centres of excellence had failed. The focus of the sector now was on a broad base which encouraged innovation and from which nuggets of research emerged. We believe that the centralisation of medical research would, therefore, reduce its diversity and likely effectiveness. We also have concerns that it would limit opportunities and access to role models for young academics and impede the development and training of the future generation of clinical academics. We have documented how dependent the growth of medical research is on medical academic role models seen early in a doctor’s career. Thus the notion of focussing research on a few centres may have long-term harmful effects on the clinical academic workforce and on research and innovation generally.

Non-Government Funding for Higher Education

30. The BMA supports the principle of academic medicine working more closely with non-governmental funders. Pharmaceutical and biotechnology companies appear to be supportive of this as the way forward for optimising translational research. We have called on the Association of the British Pharmaceutical Industry to promote and develop agreements to facilitate seamless transition of medical academic staff between employers within the NHS, higher education institutions and the industry without detriment to their employment benefits or conditions of service. We would also highlight the role of industry in assuring that there are adequate numbers of transparently funded PhD and MD posts.

31. The BMA also recognises that there is a role for voluntary giving in higher education, but only for additional non-core activity as mentioned in the Academy of Medical Science report noted in paragraph 23. Voluntary giving should not be seen as a substitute for state support but as a complement to it.

32. The BMA would be concerned by proposals to allow private universities to open medical schools, especially if the decision is made without reference to NHS workforce planning: the number of students currently admitted onto medical degrees reflects the workforce needs of the NHS. An oversupply of medical graduates would leave many students without a place on the Foundation Programme [11] and therefore unable to pursue a career in medicine . This is especially concerning given the significant cost to the Government of train ing medical students . The BMA would, therefore, be concerned at any proposal that institutions should face no restrictions from the Government on how many students they could admit . In addition, we would be concerned that " bidding wars" could arise for the necessary clinical placements for students.

33. We would be happy to provide further information to the Committee on any aspect of our submission.

10 March 2011