David Harrison is a Research Fellow in the Research Department of Medical Education at UCL Medical School.
Recent announcements of five new medical schools in England, and the Government pledging to train 5,000 more doctors by 2020, comes in response to an NHS described as critically short of doctors, and recognition of the fact that the number of GPs has plummeted in recent years, particularly in many of the deprived areas of the country. These are drivers for new policies to deal with shortages in the NHS workforce.
The Secretary of State for Health, Jeremy Hunt, pledged that 1,500 new training places would help make the UK “self-sufficient in doctors” by 2025. Given that medical school is demanding, and it takes at least ten years to become a GP, this is no quick fix. But is creating more places enough to make to real change and a UK “self-sufficient in doctors”?
Certainly there is belief that it is:
‘…allocating these new places has also allowed the expert panel to prioritise new student places to those areas with a relative shortage of doctors overall, or in certain specialties, and also to widen the social profile of new medical students.’ (Professor Ian Cumming, Chief Executive Health Education England)
It was declared that the new schools will deliver a large chunk of the additional 1,500 medical school places on the understanding they would produce more GPs, and that they would select and train doctors from ‘non-traditional backgrounds’ (i.e. from social groups currently underrepresented in medicine), who - it is assumed - will be better able and more willing to care for under-served patient populations. A major problem with this solution is the poor evidence base for how medical schools should achieve it.
In the UK, medicine and being a doctor has traditionally been seen as a career for the elite or privileged in society. High status and exclusive. Although the medical profession has sought to combat this over recent decades, the Selecting for Excellence report released in 2014 found that 80% of all medical students in the UK come from just 20% of secondary schools. Despite the relatively high proportions of women and doctors from some black and minority ethnic backgrounds in medicine, the lack of doctors from lower socio-economic backgrounds entering the profession is still a reality.
With highly demanding entry criteria - including appropriate work experience, particular A-levels, aptitude tests and various forms of interviews - it is important that candidates to medical schools are selected in the fairest way possible. Medical selection is not standardised – each medical school selects differently, and concerns have been raised that some students, despite having the necessary aptitude to study medicine, are being excluded from this career pathway by the very complexity of the admission process – to the detriment of the profession.
There are now 40 medical schools in the UK. Together they will produce around 9,500 new doctors every year, the vast majority working for the NHS. We know some medical schools produce more GPs than others. We also know that medical schools vary in how they attract, select, accept and educate doctors, particularly in how they consider contextual factors when looking at applicants from non-medical families who went to state schools and other non-traditional backgrounds. Doctors from these backgrounds are more similar to the general population and may be more likely to work in under-doctored areas. Yet, despite a focus on medical applicant selection, we still don’t really know why medical schools differ in the sorts of applicants they attract and accept, or in the sorts of doctors they produce (Cleland JA, Nicholson S, Kelly N, Moffat M, 2015). More must be done than a strategy of ‘build it and they will come’.
Selecting the best future medical workforce: The UK Medical Applicant Cohort Study
To be able to predict the outcomes of selection we need to develop an understanding of applicant choices and the factors impacting on those choices. Long term follow-up of medical students is also needed to understand whether what we know about applicants at selection can predict what they are like as doctors.
The UK Medical Applicant Cohort Study (UKMACS) is a National Institution for Health Research (NIHR) funded research project that aims to develop an understanding of medical school application from the perspective of the applicant. NIHR funds research for patient benefit, and the study also aims to benefit patients by improving how medical schools attract and select future doctors from diverse backgrounds, and by providing the foundation for research on how medical selection shapes the medical workforce.
Fundamental to the study is the belief that widening participation is not just about ensuring those with the potential to become a doctor are given the opportunity, but also ensuring that the NHS itself has a workforce that understands and meets the needs of its patients.
UKMACS started in 2018 with a qualitative study, interviewing potential medical school applicants and current medical applicants around the UK from diverse backgrounds about how they choose which medical schools to apply to, including which information they used to help them make their choices. Findings from the initial analysis are being used to develop a questionnaire for all 2019 medical applicants to look at their strategies and application choices, which will be linked prospectively with data on their actual applications, offers, and acceptances.
The study will follow up those who enter medical school throughout their careers as doctors, by linking the results with the UK Medical Educational Database (UKMED), which collates routinely-collected administrative data on all UK-trained doctors. It comes at an interesting time, with 2019 being the first year that the new medical schools will receive applications. UKMACS also contains a retrospective analysis of administrative data on medical applicants from 2007 to 2017, which will enable us to establish whether applicants’ backgrounds influence their choices of medical schools, and whether those choices are partly responsible for the lower success rates of applicants from lower socio-economic backgrounds.
Brought together, the UKMACS findings will enable us to find out whether people from different backgrounds are using information differently, how this affects their choices, their chances of becoming a doctor, how successful they are and even what sort of doctor they become – it is already known that far fewer elite medical school graduates apply to become GPs, yet those that do are more successful. Final outcomes of the study will focus on improved advice and guidance and tools for all applicants to medical schools.
What has already come out from the interviews is a picture of medical school applicants as committed and thoughtful, intelligent individuals who differ in terms of their available social capital. Personal contacts through friends, family and school, as well as visits to medical schools are strong influences, and further UKMACS results will help reveal how these would-be doctors use information about the admissions process, about medical schools and about what life is like as a medical student or doctor to make their choices.
The Office for Students is currently working with students, universities and others to improve information, advice and guidance on higher education choices. While there is a wealth of information being made available to potential medical students by universities, charities and other stakeholders in medical education, awareness levels of the complexities of applying to medical school and of the available information and support vary by background and context, which affects how they use the information available to them and so influences which medical schools they apply to and even which specialisations they consider.
There are also strong indications of a divide over the priorities of each applicant and the criteria by which they select medical schools. For some – particularly those from more traditional backgrounds - the prestige of the medical school is vital as it impacts on their career prospects and status while for others, just getting to a medical school, any medical school is a considerable achievement. Applicants from non-traditional backgrounds seem more likely to have responsibilities or financial constraints which limit their options to nearby medical schools while other universities draw applicants from all over the country. Potential applicants often have little understanding of the course structure and teach style (would you choose early patient contact and problem based learning, or lectures and a focus on basic science?), admissions criteria (do you only take the UKCAT admissions test used by the majority of medical schools, or do you also take BMAT which is required by Oxford, Cambridge, and a few others?) and what it will be like to study medicine for five, six or more years, and beyond that, potentially to embark on a 30+ year career in the NHS?
The process of applying to study medicine is complex and highly competitive, with over 20,000 applicants for 8,000 places each year and only 50% of applicants receiving one or more offers. UKMACS aims to reveal some of the secrets of how background influences awareness of information, which information sources are privileged, and how the information is used to make choices that can impact their future prospects of getting into medical school and having a career in medicine. Universities market their courses to prospective applicants, teachers and parents may give advice, but exactly how these decisions are made is currently a mystery. In applying for medicine, we are asking 17-year-olds to make choices to achieve their dreams; we are saying that they impact on the future medical workforce and realising policies about changing the medical workforce they seldom know anything about. If we give them the tools to realise their dream of medicine, what will they build?
‘Taking context seriously: explaining widening access policy enactments in UK medical schools.’ Medical Education. 2015; 49(1):25-35.