Report 99/42

Increasing medical student numbers in England

Executive summary

Purpose

1. This report announces the allocation of additional medical student numbers in England from 1999-2000, and explains the decision-making process underpinning these allocations.

Key points

2. The Medical Workforce Standing Advisory Committee’s Third Report in December 1997 concluded that a substantial increase of about 1,000 in medical school intakes was required. In agreeing the MWSAC’s recommendations, the Government charged the Higher Education Funding Council for England (HEFCE) and the Department of Health (DH) jointly to implement the introduction of additional medical student numbers for England (home and EC students only).

3. Arising from this:

• a Joint Implementation Group (JIG) was established, jointly chaired by Brian Fender (Chief Executive of the HEFCE) and Chris Kelly (Permanent Secretary of the DH)
• JIG decided that the majority of the additional places should be allocated through a competitive bidding process, in which universities would be invited to bid for numbers
• decisions on the allocation of places were taken according to published criteria which took into account regional priorities, innovation, quality, graduate entry, widening participation, and value for money.

4. There is a three-part allocation process: a small initial allocation of numbers among the established medical schools for 1999-2000; the main allocation of numbers from 2000-01; and a third tranche of numbers held for decision in 2000 to allow for the further development of particular innovative bids.

5. It is expected that the great majority of the additional student intake will be in place by 2005.

Action required

6. This report is for information.

Background

7. In 1991 the then Medical Manpower Standing Advisory Committee, later the Medical Workforce Standing Advisory Committee (MWSAC), chaired by Sir Colin Campbell, was asked by the Secretary of State for Health to make recommendations about the intake of students to medical schools. In doing so, MWSAC was asked to assess the likely future demand, consider the balance between home and overseas students, and take account of possible future changes in working patterns.

8. The main recommendations of MWSAC’s Third Report, published in December 1997, were:

• the annual intake of medical students should be increased by about 1,000 as soon as possible and in the most cost-effective manner
• clinical courses with graduate entry should be developed
• the number of undergraduate medical students from overseas should be held constant.

Joint Implementation Group

9. A Joint Implementation Group (JIG) was established to make recommendations on the allocation of additional medical school places in England. This was jointly chaired by the HEFCE and the DH. The funding bodies for Scotland, Wales and Northern Ireland considered their position separately.

10. The JIG membership is attached at Annex A.

Three-stage allocation process

11. Given the large additional numbers to be allocated, and the wish to implement the increase as quickly as was consistent with securing the necessary quality, JIG decided to adopt a three-stage process.

Stage one: pro-rata allocation of additional numbers in 1999-2000

12. The timetable made it unlikely that significant additional allocations would be feasible before the year 2000, but JIG recognised the need to make early progress towards the increased targets. As a first step, it decided to allocate some additional places in 1999-2000. JIG agreed that this allocation procedure should be simple, transparent and easy to implement, but that it should not detract from the main allocation of numbers for 2000 and beyond.

13. JIG decided that the fairest method for this initial allocation would be a pro-rata increase to current student target intakes at existing medical schools in England.

14. Not all medical schools accepted the pro-rata increase offered. The total additional number of places allocated in 1999-2000 was 276 over existing target intakes (which gave a net increase of 158 in actual recruitment, after allowing for those institutions already recruiting above their target). The first table in Annex D details the final allocation of numbers between institutions.

Stage two: competitive bidding round

15. JIG decided upon a competitive bidding process for the main allocation of additional numbers. After a wide-ranging consultation exercise with the higher education sector and other interested parties, JIG adopted the objectives and criteria set out in Annex B to underpin its decisions. In addition, it took into account the General Medical Council’s (GMC) main recommendations for the future of medical education, published in ‘Tomorrow’s Doctors’ (see Annex C).

16. A subsidiary recommendation of the MWSAC report, accepted by the Government, was that the number of undergraduate medical students from abroad should be held constant while the overall increase was being made. The great contribution made by overseas doctors to health services in the UK was well recognised. However, because many overseas doctors leave the UK after qualification, it was considered inappropriate to increase overseas student numbers as part of an initiative to secure the long-term supply of doctors for this country. Universities were asked to bear this in mind when preparing their bids.

Timetable

17. The group worked to the following timetable:

Working methods

18. JIG met four times between receiving the bids and making final decisions. An initial analysis of each bid was undertaken by the HEFCE and the DH, with informal advice from GMC members involved in delivering medical education. In most cases, where bids raised questions or issues which the group wished to explore further, and particularly where the bid was especially distinctive or innovative, universities were invited either to make a presentation to JIG or to submit further written evidence as clarification. In other cases this was judged unnecessary, because the written proposal gave sufficient information on which to base a decision.

19. The second table in Annex D details the provisional allocations agreed as a result of the competitive bidding exercise. These numbers will be allocated from 2000-01. They are conditional on receiving approval from the GMC in appropriate cases, and on satisfactory conclusion of negotiations with some universities regarding resource implications.

Stage three: further development of particular bids

20. There were several bids for new medical schools. Because the establishment of a new medical school represents a major challenge for any university, especially when undertaken on a stand-alone basis without partnership with an existing medical school, JIG considered these bids particularly carefully. The bid from the University of East Anglia (UEA), and the bid for a Peninsula Medical School from the Universities of Exeter and Plymouth, were felt to be innovative and of merit. But to ensure that the proposals were robust and fully specified, JIG decided to defer final decisions on these proposals until spring 2000. A proportion of the student numbers has been held back for this reason.

21. In the meantime, UEA and Exeter/Plymouth will be invited to develop their proposals more fully. JIG will establish a joint working group to work with the universities to produce business plans. The HEFCE will contribute to the costs of preparing these plans. There is no commitment to approve either proposal: approval will depend on the strength of their final business plans. On current assumptions, not more than one of the bids will be successful.

22. Any new course will have to secure GMC approval before graduates may register as doctors. This is likely to be a continuing process, involving monitoring of learning and assessment at intervals as the first cohort proceeds through the course.

23. In view of the importance attached to widening access to medical courses, a collaborative bid from King’s College London and the University of Kent was also considered worthy of further discussion. The bid concentrates on students from under-represented groups who would be targeted for admission to the last three years of the undergraduate medical degree, following successful completion of a clinically oriented BSc.

24. JIG will convene during the spring of 2000 to decide whether any of the UEA, Peninsula or King’s/Kent bids should be approved.

Outcomes

25. In drawing up its overall objectives for allocation, JIG looked in particular at widening participation, graduate entry and innovation within an overall regional framework. Allocations were based on judgements about the overall strength of each bid, taking into account all the factors involved. Successful bids included the following:

Widening participation

• University of Sheffield – an outreach scheme aims to widen access to medicine for pupils from the city’s most deprived schools
• Universities of Newcastle and Durham – a collaborative project with an access strategy based on Durham University’s Stockton campus.

Graduate entry

• St George’s Hospital Medical School
• Leicester University/Warwick University joint project
• Oxford University
• Cambridge University.

Innovation

• potential new stand-alone medical schools in the South-West (the Peninsula Medical School, a collaboration between the Universities of Plymouth and Exeter), and East Anglia (the University of East Anglia)
• collaborative ventures between existing medical schools and new university partners: the Universities of Leicester and Warwick; Manchester and Keele; and Newcastle and Durham.

Regional priorities/targeted areas of shortage

• potential new schools in the South-West and East Anglia
• Birmingham University
• Manchester/Keele and Leicester/Warwick collaborations.

26. In reaching its decisions JIG also took account of the available evidence about the quality of existing provision.

Annex A

Membership of the MWSAC Joint Implementation Group

Members

Brian Fender, Chief Executive, HEFCE (Joint chair)
Chris Kelly, Permanent Secretary, DH (Joint chair)
Professor Alasdair Breckenridge, Chairman of the Joint Medical Advisory Committee
Professor Liam Donaldson, Chief Medical Officer
Stephen Marston, Director for Institutions, HEFCE
Professor John Swales, NHS Director of Research and Development (until December 1998)

Secretariat

Jon Ashe, DH
David Noyce, HEFCE
Tracy Allan, HEFCE (joint project manager)
Bill Urry, DH (joint project manager)

Assessors

Andrew Smyth/Imogen Wilde/Steve Passmore, DfEE
Helen Burke, GMC

Annex B

Overall objectives adopted by the Joint Implementation Group for increasing medical school intake in England

(Not listed in any particular order of importance)

a. To develop new doctors who are equipped to meet the challenge of changing health and health care needs of patients and populations into the first half of the twenty-first century.

b. To develop new doctors who are able to practise to a very high standard, through being able to appraise and use evidence, to become lifelong learners, to maintain professional standards and to be effective team members and leaders.

c. To develop new doctors who are committed to and skilled in promoting health, preventing ill health, diagnosing and treating injury and disease and caring for people with long-term illness and disability.

d. To develop new doctors who understand the value of partnership and communication, with their patients, their colleagues, and with members of other professional groups.

e. To provide a high quality educational experience in an environment in which evaluation and research are fostered and which gives value for money.

f. To demonstrate an active commitment to the admission of students from a broad range of social and ethnic backgrounds, to reflect the patterns of populations which are served by the NHS.

g. To ensure that the distribution and patterns of training of students effectively increase the home supply of doctors, and meet the needs of the populations which are served by the NHS.

h. To enhance quality and value for money through collaboration between universities and partnership with the NHS.

Annex C

Main recommendations of the General Medical Council report, Tomorrow’s Doctors

1. The burden of factual information imposed on students in undergraduate medical curricula should be substantially reduced.

2. Learning through curiosity, the exploration of knowledge, and the critical evaluation of evidence should be promoted and should ensure a capacity for self-education; the undergraduate course should be seen as the first stage in the continuum of medical education that extends throughout professional life.

3. Attitudes of mind and of behaviour that befit a doctor should be inculcated, and should imbue the new graduate with attributes appropriate to his/her future responsibilities to patients, colleagues and society in general.

4. The essential skills required by the graduate at the beginning of the pre-registration year must be acquired under supervision, and proficiency in these skills must be rigorously assessed.

5. A ‘core curriculum’ encompassing the essential knowledge and skills and the appropriate attitudes to be acquired at the time of graduation should be defined.

6. The ‘core curriculum’ should be augmented by a series of ‘special study modules’ which allow students to study in depth areas of particular interest to them, that provide them with insights into scientific method and the discipline of research, and that engender an approach to medicine that is questioning and self-critical.

7. The ‘core curriculum’ should be system-based, its component parts being the combined responsibility of basic scientists and clinicians integrating their contributions to a common purpose, thus eliminating the rigid pre-clinical/clinical divide and the exclusive departmentally based course.

8. There should be emphasis throughout the course on communication skills and the other essentials of basic clinical method.

9. The theme of public health medicine should figure prominently in the curriculum, encompassing health promotion and illness prevention, assessment and targeting of population needs, and awareness of environmental and social factors in disease.

10. Clinical teaching should adapt to changing patterns in health care and should provide experience of primary care and of community medical services as well as of hospital-based services.

11. Learning systems should be informed by modern educational theory and should draw on the wide range of technological resources available; medical schools should be prepared to share these resources to their mutual advantage.

12. Systems of assessment should be adapted to the new style curriculum, should encourage appropriate learning skills and should reduce emphasis on the uncritical acquisition of facts.

13. The design, implementation and continuing review of curricula demand the establishment of effective supervisory structures with interdisciplinary membership and adequate representation of junior staff and students.

Annex D

Outcomes