medical education: The Bristol inquiry report has called for medical schools to broaden their selection criteria to produce doctors who are versatile and drawn from a wide social spectrum.Will the new medical schools deliver? Jeremy Davies investigates.

The word 'radical' is often overused in relation to changes in the health service, but in the context of current developments in medical education, it is apposite.

Until last year, there had been no new medical schools in the UK for nearly 30 years. By 2005, there will be two new, stand-alone schools, at East Anglia and Keele universities; three new joint schools, at Plymouth and Exeter, forming the new Peninsula Medical School; Hull and York; and Brighton and Sussex. Existing medical schools at Newcastle, Leicester and Leeds are also forming new collaborations, with Durham, Warwick and Bradford universities respectively.

All in all, English higher education institutions now have a total of nearly 2,300 extra medical student places to fill, with around half of these due to come on-stream by 2002 and the rest by 2005.

The Welsh Assembly has given approval in principle for the University of Wales College of Medicine to open a new clinical school in Swansea, which could raise the number of medical students in Wales by 65 a year from September 2002. A bid for a new school in north Wales is also on the cards.

The government first announced a step-change in medical student numbers in response to a report on the long-term demand for doctors in the UK - the third report of the Medical Workforce Standing Advisory Committee, published in December 1997.

This document showed that, assuming a similar level of annual growth in demand for doctors as had occurred over the previous 20 years (roughly 1.8 per cent a year), and a future 'wastage rate' - that is, a composite of death, retirement and career breaks among doctors - of around 3.3 per cent, an extra 1,000 or so places would need to be added to medical school intakes. This would, in theory, enable the NHS to maintain its existing 'home share' - that is, around 76 per cent of doctors being UK-qualified - in the year 2020.

As a result of the MWSAC report, a joint implementation group, chaired jointly by the Department of Health and the Higher Education Funding Council for England, allocated 1,129 new places in 1999. It announced, as part of the allocation, the establishment of the new UEA and Peninsula medical schools.

After publication of the NHS plan in July 2000, the Department of Health decided more new doctors would be needed in future years, and the joint implementation group was asked to establish a second bidding round. At this stage, a further 1,033 places were awarded. New medical schools were announced at Hull and York; Brighton and Sussex; and Keele, which had previously been awarded places as part of a bid with Manchester.

So according to what criteria were the places awarded? The HEFCE says that in drawing up its overall objectives for allocation, the joint implementation group looked in particular at 'widening participation in medicine, graduate entry, multiprofessionalism, and innovation within an overall regional framework'.

In some cases, especially where entirely new medical schools are being created, new and innovative networks between academia and the NHS are being developed in order to design institutions capable of producing 'fit-for-purpose' doctors of the future.

As Keele University vice-chancellor Professor Janet Finch points out, part of the reason the new schools offer such a welcome opportunity is that they are launching into areas where the local health economy should have scope for developing new partnerships.

'There are plenty of areas where the local hospitals and primary care trusts are reaching saturation point in terms of offering student placements, for example.We now have a great opportunity to develop some really high-quality clinical training, because the service can be more accommodating, ' she says.

The Peninsula medical school - the first in Devon and Cornwall for well over a century - is a case in point. The counties have not been entirely bereft of clinical training in recent years. In the past, Bristol University negotiated some student placements across the border in Devon.

But despite this background, Peninsula has its work cut out to develop placements across such a geographically wide area. Especially because of the community-based nature of much of the training it plans to offer - by year four, students will spend two days a week in community settings - the school will need strong links with a wide range of primary care and community trusts.

'It is a huge job, identifying those stakeholders who can become lead enthusiasts, but equally trying to make sure everything we do is representative of people's needs generally, ' says Dr Judy Searle, the school's associate dean for Exeter.

The school already has sub-deans in each of the three acute trusts in the region, and is in the process of appointing three community sub-deans in each of the current health authority areas. It is communicating with NHS bodies via regular newsletters, and attending local events to make sure its message gets across.

'There is no doubt that the quality of healthcare of whole regions lifts when you bring a medical school in, and this is a great opportunity to design an institution around regional needs, ' says Dr Searle.

'But you can't just parachute in and expect it all to happen. It is all about fostering genuine ownership.'

The new medical school places have not been awarded solely on the basis of geographical gaps in medical education. A number of bids are more focused on improving recruitment by widening participation in the medical profession - either through developing graduate-entry options or through attracting potential doctors from hitherto under-represented sections of society.

In a nation where doctors have for so long been treated like God's disciples on earth, it is perhaps not surprising that entry to the medical profession has tended to favour candidates from the higher echelons of British society.

Medical training is a long haul, with students spending five years at medical school followed by many more years undergoing specialist training.

A medical student entering university at the age of 18 is very unlikely to become a GP principal before the age of 30, or a consultant before 35.

The qualifications required to gain entry to medicine courses are extremely high, with the lowest average grade requirement of any UK medical school last year running at 27.2 points, which equates to just below two 'A's and a 'B' grade at A-level.

Training to be a doctor is also expensive because of the length of time involved. Table 1 (see page 28) shows the average debt of medical students in the UK as they progress through their training.

Despite the student loans scheme, which should in theory enable everyone to borrow enough money to see them through university, it is easy to see how an 18-year-old without a supportive, financially secure family behind them might decide against a medical career.

Official figures bear out the theory that medicine is still a profession for the chosen few. As recently as two years ago, more students from social class one were accepted into medicine than the combined total number from classes three, four and five. And even when relatively disadvantaged candidates do get as far as applying for medical school, government figures show they are much less likely to succeed. Fewer than a third of medical and dental school applicants from unskilled backgrounds are accepted onto courses, compared with half of applicants from skilled manual backgrounds and nearly two-thirds of those with professional parents.

The highest proportion of applicants accepted onto medical courses - more than a third - come from schools in the independent sector, with less than a third coming from state-maintained schools and only a fifth from comprehensives.

Since the publication of the General Medical Council's Tomorrow's Doctors in 1993, all medical schools have been modernising their curricula to move away from the fact-based learning of traditional courses.

Durham University centre for arts and humanities in health and medicine runs literature study classes as an option for medical students, focusing on works which deal with issues such as death, disease, disability and madness, for example.At Newcastle, a novelist runs a literature course with a creative writing element for doctors.

But changing the curriculum itself is just one part of the modernisation process, especially in the context of falling numbers of applicants and more places - and many medical schools are now signed up to proactively redressing the social imbalance of their intakes.

North of the border, for example, Edinburgh University medical school has linked up with the Sutton Trust, a charity run by philanthropist Peter Lampl, to run a pilot project called Pathways to the Professions.

Under the scheme, funded to the tune of£70,000 by the charity, students from the state sector will experience a range of inputs aimed at 'raising their aspirations and helping them see the route to medicine clearly'. Activities will include one-toone guidance on applications, work experience opportunities and extracurricular requirements;

opportunities to shadow current students; and advice for families and teachers.

'There are many able students out there with the potential to gain the skills and grades necessary, but who are not doing so because of the pervading belief that it is not for them, ' says Mr Lampl.

Almost 40 per cent of the new places awarded to schools since 1998 have been earmarked for graduate-entry courses which are now on offer at 10 medical schools, including Oxford, Cambridge, St George's Hospital and Queen Mary's medical schools in London, and the new joint school at Leicester and Warwick.

At least one of the new collaborations between institutions aims to widen access among ethnic groups. The joint bid between Bradford and Leeds universities focuses on raising recruitment from ethnic-minority students - especially those from black and Chinese communities, which are currently under-represented in terms of the overall population profile.

Forty places, out of the total of 258, have been allocated for students drawn from access courses aimed at such groups. If Bradford's previous success in raising the profile of nursing among the Asian communities is anything to go by, the places should soon fill - the proportion of Asian entrants to its nursing courses has risen from 6 to 24 per cent.

Other bids focus more generally on improving the chances of socially disadvantaged students. Preclinical courses taught at the Stockton campus of Durham University, for example, will build on an existing programme of health and social care-based access courses called 'Aspire'. It aims to deliver a medical curriculum rooted firmly in the health needs of the Tees Valley - an underprivileged, postindustrial community in the north-east.

Academic director Professor John Hamilton explains that the curriculum will produce doctors 'better qualified and more alert to the dilemmas of deprived communities' - for example, understanding the vital role of the health of the under-threes in laying down foundations for the future.

Students will be selected more in terms of their personal qualities, like motivation, communication skills, selfdetermination and ability to work through problems, rather than pure A-level grades. The course will also chime in with research at the campus, which focuses on pollution and other healthrelated issues relevant to the local community, such as breastfeeding and co-sleeping. A new research institute is to be established, with funding from the EU and the Wolfson Institute.

But despite such exciting initiatives, everything in the medical education garden is far from rosy, as the British Medical Association's annual conference for clinical academics heard in June.

Staffing is a particular problem. The conference was told that the proportion of NHS consultants working as clinical academics has dropped from 11 per cent to 8 per cent, with fewer than 1,000 clinical academic doctors working in the health service.

Seventy-nine professorial posts in medical schools remain vacant, along with 145 senior lecturer and 177 lecturer posts. Recruitment is particularly difficult in pathology, psychiatry and surgery.

Royal College of Physicians registrar Professor Ian Gilmore claimed that clinical academics routinely work 64-hour weeks - 32 for the NHS and 32 for their university - and wrestle with seemingly irreconcilable pressures to treat patients, conduct research and, often forced into third place, teach students.

The additional cost to the NHS of training medical and dental undergraduates is, on paper at least, met by the government through the service increment for teaching (SIFT), which paid out nearly£500m in 1999-2000.

But in practical terms, SIFT funds have simply become part of trusts' overall budgets. This has made educational resourcing 'ephemeral', says Bristol University medical school director of medical education Dr David Mumford.

Bristol is developing a model of medical education new to the UK - with five 'clinical academies' based in the NHS but functioning as part of an over-arching medical school network.

Under the system, lead teachers based in trusts will deliver a devolved, single curriculum, having contributed through a central organisational group to the design and strategy of the course. Staff will network with colleagues in the other academies but students will be attached to their own particular academy for stretches of six or 12 months at a time.

From a staffing point of view, the success of the concept - which places an emphasis on trust staff being seriously committed to teaching rather than just fitting in a few lectures here and there - will depend, says Dr Mumford, on funds remaining ringfenced.

'The lack of resource base for medical education over the years has meant we really do face potential meltdown, with academic staff being employed in such a way that they have to follow other agendas. As a result, teaching has been disastrously undervalued. It is going to be a real challenge to make this work.'

At the Peninsula medical school, Dr Searle is confident of being able to raise the profile of teaching posts through greater funding transparency. There is new money in the system to cover the extra places, she says, and more important, setting up a new school allows contracts to be negotiated from scratch.

'As we appoint new staff and negotiate service-level agreements with NHS bodies, We are now able to make sure the money is properly earmarked and spent on giving people the protected time they need.

'The next step, of course, will be for universities to start rewarding excellence in teaching rather than basing all the rewards on research, ' she adds.

Now that really would be radical. . .