Why can’t we just have more medical student places?

That the UK is failing to train the number of doctors it needs is hardly news, though the weekend’s reports about the University of Worcester and shadow health secretary Wes Streeting’s recent policy interventions have thrust the issue back into the national eye.

Streeting has committed a Labour government to doubling the number of medical student places – a policy that is significantly more expensive than it looks.

How to build a doctor

Though other routes, including graduate entry, are available the default option puts a student directly into a four year undergraduate degree. Classically, the first two years are lecture and lab based, and could be compared to any other scientific undergraduate courses, the latter two are clinically based and see students primarily working on wards and in consulting rooms. This divide has blurred over time, with many medical schools now incorporating clinical experience earlier on in the course.

Following the successful completion of this degree, a medical student will usually enter two “foundation” years of postgraduate training – still learning and working in hospitals as a “junior doctor”. Though some students remain at the same provider for both undergraduate and postgraduate years, others take the opportunity to move.

After the foundation years, students then begin to train as a specialist – which takes anything between three and seven years to complete, via a range of potential delivery modes (including the need to apply for higher speciality training midway through the course). Tot all that up and you are looking at a minimum period of nine years between starting as an undergraduate and qualifying as a general practitioner.

Paying for it

For medical courses in England fee income is supplemented by “high-cost courses” funding from OfS and by Health Education England (HEE) funding for clinical placement costs (devolved nations have similar arrangements). HEE has a budget of £5bn, and supports clinical placement provision for the full range of healthcare programmes that include NHS placements. This includes the undergraduate, postgraduate, and specialism placements for trainee doctors described above – but also covers specialisms ranging from nursing to pharmacy to healthcare sciences.

With so much placement learning going on NHS settings need academic staff to deliver them – and for this experience to be most valuable to students these academics should also be clinical staff. For this reason, OfS provides direct support for the pay of clinical consultants (around £16m a year) and academic general practitioners (around £1m) plus NHS pension compensation (£5m).

HEE covers everything else – other staff time, administration and infrastructure, accommodation costs for medical undergraduates on placement, exam costs, staff training… This only relates to clinical places linked to the OfS annual intake numbers – the costs of this provision at providers not on that list have to be met elsewhere. To give you an idea, here’s some standard national tariff payments as of September las year:

• Medical undergraduate placements – £30, 750 plus a “market forces factor” (MFF)
• Medical postgraduate placement – £11,937 plus a contribution to salary (for the foundation years this is up to £20,435 per student)

There are then additional payments (covering placement fees and salary) linked to the higher levels of training. Our minimum example of 7 years of full time training to become a GP would include five clinical years at more than £30,000 each: north of £150,000 per doctor, not including fee loans, maintenance, or the OfS supplements.

Setting standards

The General Medical Council is responsible for setting required graduate outcomes, practical skills, and procedures for graduates, and regulates the quality and standards of medical education via a mixed system of inspections, self assessments, and data.

A notable source of data here are the annual national training surveys – where doctors in training feedback on the training they are getting, and trainers feedback on the support available to them. These cover pretty much every aspect of training – there’s a series of visualisations (including these of results from undergraduates by medical school) . Though it is all fascinating stuff, I can’t help but think this data should be openly available and better known among prospective doctors and those who advise them.

The challenge in growing provision

It’s pretty clear that simply having a medical school with a bit of capacity is only a very small component of what is needed to scale up medical provision. With the NHS at (and beyond) capacity, there simply isn’t the staff time or funding to push the number of medical students up to the numbers that many commentators say that we need.

The GMC also reports on “burnout” – the aggregate results of a series of questions asked of trainee doctors at each stage of their training. Burnout is a huge problem in the NHS – and is a contributing factor to the attrition of doctors to private practice, work overseas, or other careers.

Though more university places is often touted as a solution to NHS capacity issues, in reality the issue is complex and split across multiple systems. We do need more doctors, and we should be training more, but for this to be effective we also need the capacity for clinical placements and a livable experience as a trainee, junior doctor, and early career professional.

Government supported medical provision has expanded in recent years – in England both Lincoln and Anglia Ruskin established medical schools in 2018, both Edge Hill and Sunderland in 2019, and Kent and Medway Medical School was established in 2020. Outside of government support Brunel, Worcester, and Chester are in the process of establishing medical schools open to international and full fee students – these aim to follow UCLan’s lead in seeing an independent medical school eventually take on international students.

Further reading: In 2018 Jonathan Rees wrote a “beginner’s guide” to medical education for us and called for radical reform of medical education in 2021. I plotted some information on the pressures faced by medical schools during the bumper pandemic recruitment years on Wonk Corner.