What does the Journey to a Million mean for medical school expansion?

Medicine is an incredibly oversubscribed subject. There are currently three times as many applicants to medical school than there are places available, and each year many well-qualified candidates do not succeed in securing a place. This gap will only increase, as we could see up to a million students applying for higher education by 2030 resulting in more young people wishing to join the medical workforce and greater disappointment when they do not receive an offer. Despite this demand, the UK has never produced enough doctors to be self-sufficient. Even before the pandemic there were increasing concerns about the workforce’s ability to meet the nation’s growing health needs. Post-Covid, these issues are now exacerbated by a stretched health service – we now have backlogs of patients requiring elective care alongside exhausted health professionals who are burned out from working non-stop since the beginning of the pandemic. When this backlog of patients is seen in the context of an ageing population with increasing comorbidities, it becomes clear that a comprehensive and radical rethink of workforce planning and medical school expansion is now urgently required. The demand from all sides is undeniably there.

The argument for the global exchange of medical knowledge is self-evident – the training and employment of doctors and other healthcare workers from different nations is important for the UK’s growth and health research. However, it has also long been acknowledged that a dependency on international medical graduates, often from low- and middle-income countries, is neither sustainable nor appropriate.

The Journey to a Million therefore presents a once in a generation opportunity to tackle these issues. The exact needs of the UK population and the NHS are difficult to predict, but the Medical Schools Council’s (MSC) proposal is that the number of medical students should be increased by 5,000 making a total of 14,500 graduating per year. This total would address NHS staffing needs while also allowing space for a reasonable amount of overseas recruitment, as medicine is a global profession and input of doctors trained overseas is invaluable to the NHS. There are, however, major challenges to such an expansion. 

 

A medical student will require on average 10 to 12 years of education – undergraduate and postgraduate – to become a GP and longer to achieve a consultant position in secondary care. A government consultation prior to the last round of expansion in 2017 estimated that the cost of educating a UK medical student exceeds £200,000. Using data from the Royal College of Physiciansⁱ, it is estimated that the annual cost of increasing the number of medical students by 5,000 is approximately £1 billion.ⁱⁱ These figures represent a significant investment for both the medical student and the taxpayer. It is therefore essential that the Government, the NHS and universities work closely together to find a long-term, strategic and adequately funded plan, which ensures the supply of doctors closely matches demand.  

A second major challenge to facilitating medical school expansion is placement capacity. While there are a number of universities and associated hospitals that are pursuing the possibility of developing new medical schools, access to clinical placements, particularly in primary care settings, continues to be a limiting factor. Larger schools will notably find it more challenging to increase in size due to limitations on facilities and placements within the local area. Medical schools have already begun to develop new ways of enhancing clinical training to cater for an increase in numbers, including the use of virtual learning and trained educators within placements. However, it is still essential that universities are able to work with the government and the NHS to prepare sufficient clinical placements for all those attending medical school. 

A third challenge that needs considerable attention is around clinical academics. It may be obvious to state, but medical students need skilled educators and clinicians to support their learning. Medical schools employ clinically qualified academic staff who are responsible for course design, leadership and delivery, whilst at the same time delivering NHS services. Reinforcing this pipeline will be essential if the UK is to expand the number of medical graduates. The government must encourage more training and retention of clinical academics by creating more incentives, as well as promoting careers in clinical academia to students and junior doctors. Clinical academics also makes important contributions to scientific discovery and the UK’s health research, most recently seen with the rapid development of the Oxford/AstraZeneca vaccine.

The Medical Schools Council firmly believes that the medical profession should genuinely reflect the society that it seeks to serve – the argument for which is self-evident. In order to make the study of medicine more widely accessible and available, an expansion should include a broader range of entry routes and course delivery options to ensure the broadest possible criteria for selection. A more diverse recruitment of students will, obviously, in turn lead to a more diverse workforce. 

Medical schools have, for a while now, been paying closer attention to enrolling students from a wider range of backgrounds – there is, for instance, a course in Scotland that uses online learning and part time education to support healthcare professionals wishing to become doctors. Gateway, foundation and access courses can substantially diversify the pool of potential applicants, and an expansion will provide medical schools with the opportunity to further develop these unconventional entry routes. Other innovative ways into medicine such as apprenticeships, part-time education and conversion courses for healthcare professionals with relevant backgrounds are also in discussion. 

Similarly, medical schools have been making a concerted effort to attract and recruit students from disadvantaged backgrounds through initiatives such as ‘widening participation programmes.’ These initiatives look at criteria such as socio-economic background, school performance, time spent in care, free school meals etc. An expansion will give medical schools the opportunity to maintain and increase widening participation, and, if done properly, will have enormous benefits for ‘under-doctored’ areas, which tend to coincide with relative social deprivation. 

A UKMED study found that; ‘The majority of doctors prefer to train at postgraduate foundation schools that are reasonably close to the family home. Those who attended state-funded schools, from non-white ethnic groups and/or from lower socio-economic groups were significantly more likely to choose foundation schools nearer their parental home.’ⁱⁱⁱ

Placing medical schools in areas of deprivation and selecting students from that area could mean a majority of graduates remains in the region as well as improving the local health economy. UKMED’s findings also suggest that a significant number, particularly widening participation students, may also wish to return to train near their family homes. Where there are under-doctored areas where it is not possible to create a new medical school, this could be addressed by concerted efforts by medical schools to undertake outreach in these locations. 
These are just some of the challenges, considerations and possible means of fostering medical school expansion which the Journey to a Million can facilitate. The task is complex but if we focus on collaboration rather than competition and take a strategic approach to addressing barriers to growth, then we will be in a greater position to achieve a sustainable medical workforce. The potential benefits to the country are huge; the NHS is better supported with a larger workforce potentially leading to less burn out for its staff, patients with better access to care and improved health outcomes and bright applicants from across all sectors of our society have greater opportunities to begin a career in medicine.

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ⁱRoyal College of Physicians (2021), Double or quits – blueprint for expanding medical places.

ⁱⁱMedical Schools Council (2021), The expansion of medical student numbers in the United Kingdom.

ⁱⁱⁱKumwenda et al (2018), Geographical mobility of UK trainee doctors, from family home to first job: a national cohort study.