The Medical Workforce Standing Advisory Committee has recommended that 1,000 extra medical students be trained each year. But where will the money come from and do we need them, asks Lyn Whitfield

Powerful voices are telling the government it needs to spend a lot of money training a lot of doctors.

The Medical Workforce Standing Advisory Committee, chaired by Nottingham University vice-chancellor Sir Colin Campbell, concluded last month that 'the annual intake of medical students should be increased by about 1,000 as soon as possible'.

It also argued the NHS should give 'further attention' to the improved recruitment and retention of doctors, investigate 'skill- mix, productivity and flexible working' and consider the effect of changing health policy on demand for doctors.

But its main recommendation could not be missed, nor its cost.

'Our broad-brush estimate for an increase of this magnitude is that additional, gross, recurrent costs might be around pounds200m a year,' the committee said in its third report on planning the medical workforce. 'In addition, there might be some capital costs.'

The report argues that an increase of this size is needed to meet increasing healthcare demands and to take account of changing working practices without increasing the proportion of foreign doctors in the workforce from its present 24 per cent.

It says the UK 'should not deprive overseas countries of doctors they have taken time and resources to educate', and that since an 'unequal trade' in medics cannot be sustained indefinitely the UK must aim for 'self reliance'.

The report has been received enthusiastically by the British Medical Association. A spokesperson says: 'There is a strong body of opinion in the medical profession that it is unethical to rely on doctors from abroad.

'At the same time, demand for healthcare is rising and there are recruitment problems in some areas. More people are trying to retire early. There are more women in the workforce, and women often want to take career breaks, while people in general want to work more flexibly.

'Add that together and you get a pretty strong case for training more people, which we endorse.'

Doctors are not the only ones pleased by the committee's report.

The Times Higher Educational Supplement says at least seven universities are scrambling to secure some of the new students and the money that will go with them.

The most ambitious are Brighton and Sussex universities, which are reportedly working on proposals for a new undergraduate medical school.

Durham, Plymouth and Keele universities are said to be interested in expanding their medical schools. And the universities of Leicester and Warwick are holding discussions about a joint medical school which would increase the number of medical students at Leicester and create a new graduate conversion course at Warwick.

Not everyone is impressed, however.

John Northrop, director of Pay and Workforce Research, suggests attempts should first be made to cut the 10 per cent drop-out rate from medical schools.

And, in a Nuffield Trust paper, Alan Maynard, professor of health economics at York University, and Arthur Walker, principal lecturer in economics at Northumbria University, question some of the advisory committee's basic assumptions.

Their paper, The Physician Workforce in the UK, is scathing about the policy of 'self-sufficiency'. Maynard and Walker see nothing wrong with 'employing people trained to excess by misguided foreign states' and deny it amounts to 'poaching doctors from South Africa'.

It argues EU doctors 'are an important source of potential recruits for trust hospitals' and 'further supplies of physicians are available from outside the EU' if scruples are dropped about 'reverse foreign aid'.

The paper also suggests that while the advisory committee discusses issues like a changing and more flexible workforce, it basically assumes more doctors will be needed to do the work now done by a predominantly male, full-time labour force.

Maynard and Walker conclude 'there is a clear need to consider more carefully the role of incentives, in particular, wages and conditions (including part-time contracts) as an alternative means of affecting the supply of physician services'.

They also say that although the advisory committee notes that health policy is changing, its calculations assume that the role of doctors is unlikely to change and that 'substitution possibilities (between physicians and other health service inputs) are limited'.

In fact, they argue that there is scope for nurses and other professionals to do some of the work currently done by more expensively trained doctors.

An Audit Commission report, published just before that of the advisory committee, put down a marker for how this could be done in hard-pressed services such as anaesthesia.

In Anaesthesia Under Examination, it argues: 'The most fundamental way to reduce demands for more doctors would be to adopt the anaesthesia system used in many other countries in the world - allowing non-medically qualified staff to maintain anaesthesia under the indirect supervision of doctors.'

This received a cool response from doctors' organisations. But Maynard and Walker are adamant that 'manipulating the supply of doctors in the manner of the recent past will waste scarce resources'.

Health minister Alan Milburn said the advisory committee's recommendations needed 'careful examination', and that the government would announce its response 'in the light of its comprehensive spending review'.

This was welcomed by NHS Confederation chief executive Stephen Thornton, who asked who would pay for 1,000 new medical students - and who would pay their salaries once they qualified.

'While we would welcome a modest increase in the number of medical students, we are concerned about the wider policy implications,' he says.

Mike Deegan, NHS deputy director of human resources, has written to health organisations stressing that no decisions will be made on the recommendations until they have been tested against emerging health policy and fully costed.

'I just hope the NHS Executive realises how radical some of the ideas could be,' muses Stephen Thornton. 'And what sort of headlines could be generated if we suggest changing the role of doctors.'

The Third Report of the Medical Workforce Standing Advisory Committee on the long-term demand for doctors. Available from the DoH web site at http://www.

The Physician Workforce in the United Kingdom, by Alan Maynard and Arthur Walker. The Nuffield Trust, 59 New Cavendish Street, London W1M 7DR. pounds12.50.