Over the weekend, the Sunday Times ran a story with the stark headline ‘British students locked out of new medical schools‘.
This referred to the fact that three universities – Worcester, Brunel, and Chester – are planning to launch medical degree courses which are only open to international students, leading to allegations that de facto private medical schools are operating inside public higher education institutions.
Anyone passingly familiar with what has happened to university places in Scotland will recognise the broad shape of the debate: institutions can charge international students £45,000, whilst domestic applicants pay a lot less.
But this is further complicated in this case by the presence of our precious state near-monopoly on healthcare provision. Universities are not just squeezing out British students because of lower fees; as the Dean of Brunel Medical School puts it:
“The demand for our new medicine degree programme has been high, and we welcomed more than 100 international students in September. They will be joined by home students at the earliest opportunity, subject to government-funded places being made available to us.”
This refers to the fact that whilst medical students do pay fees, many are eligible for NHS bursaries, an annual payment to help with tuition and living costs.
In theory, the logic behind this is sound, especially if – as many Conservatives profess – we want to be training up more medical staff domestically rather than endlessly importing them from overseas. But in practice, this system falls foul of the Treasury, because it is cheaper to recruit fully-trained personnel from overseas.
Even the fact that medical students are part of the fees system is relatively new, having been introduced under Jeremy Hunt (the above-linked page tracks the changes to eligibility for bursaries between 2017 and 2019) when he was Health Secretary. Before then, the number of places was even more tightly rationed.
This change has had some welcome effects: whilst the overall number of applicants fell after fees were introduced, the number of candidates actually accepted went up. As the chart below illustrates, the gap between the two figures fell from almost 40,000 in 2015 to around 25,000 in 2020, with the number of acceptances around 10,000 higher:
Source: The UK Nursing Labour Market Review 2020, p. 44
Unfortunately, schooling is not the only bottleneck choking the supply of domestic nurses to the NHS. Once you graduate, you then need to get a training placement – and as the cost of these comes directly out of the NHS budget, they are inevitably in short supply.
If your focus is on pounds and pence, as the Treasury’s is, this does make sense. Why invest scarce resources – and NHS resources are always scarce – in a British trainee, who will take many years to become a fully-trained part of the Service, when you can recruit a qualified nurse from the Philippines who can start at once?
Yet there are plenty of grounds on which one might reject that Treasury logic. Most obviously, a Government which is publicly committed to bringing down net migration levels should probably apply itself to tackling structural factors which have left a key public service dependent on immigrant labour. But one might equally object on the progressive grounds that this system strips developing countries of skilled professionals they badly need.
This hard partition between the NHS and medical schooling may also be costing the former money to boot. As Ann Bradshaw, a senior lecturer in adult nursing, argues in the Times Higher Education Supplement:
“But the national training was lost when nursing leaders persuaded the reluctant Thatcher government to move nurse education into higher education. They were motivated by a desire to increase the status of the profession – not to improve patient care. This was calculated by the National Audit Office in 1992 as £580 million for extra staff to do work previously done by students (now supernumerary) and £207 million to support colleges introducing the new system.”
In the previous system, medical students provided the NHS with labour whilst learning their vocation on the job. Now they must spend years in purely academic learning before even having the (limited) opportunity to enter the NHS; work they might have done must be done by full-time staff.
Meanwhile, the actual value of this degree-led approach is disputed. Bradshaw cites Geoffrey Rivet’s work to point out that “UK nurse practitioners are not prepared with skills of diagnosis, examination and treatment, like their US counterparts; instead, nurse practitioner courses are philosophical”; other academics argue that the actual value of the courses are extremely difficult to comparatively value.
This is further compounded by our insistence that nursing staff, for example, must (eventually) master multiple specialisms before they can work, rather than being deployed and then learning more as they work.
The modern, degree-led approach has its defenders, as such approaches always do, not least academics invested in an ever-larger role for universities and professional bodies and trades unions with a vested interest in restricting intake.
But were the Government to push back on this trend – as Suella Braverman has so recently done with policing – it would seem to have no shortage of allies within the medical profession, who don’t consider their rigorous practical training as of lesser value than years of general academic learning.
Wholesale structural change of the sort required to roll back Margaret Thatcher’s deeply misguided reforms to professional training are likely beyond the scope of a government which shows little sign that it expects to win another term.
But between T-Levels and apprenticeships, the tools are there for ministers to at least start laying the tarmac for non-academic, work-focused pathways into the NHS. This would allow recruits to start contributing much earlier and pay their own way, easing the need for artificial caps on places.
If they were really serious the Government could also match carrots with a bit of stick, for example making the non-repayability of any bursaries dependent on actually giving a certain number of years of service to the NHS. Medics would still be free to take jobs in better healthcare systems overseas, but their debts to the Government should follow them there.
(Ministers might also have classified training up British doctors and nurses as capital investment and allowed the NHS to pay them out of its capital budget – if the Health Service hadn’t previously allowed to divert capital budgets into day-to-day spending to mask stealth cuts.)
But whether or not such things are possible is downstream of whether there is any political will to do them. And on NHS recruitment, as so much else, the habit of British politicians is to shirk long-term investment, ignore structural reform entirely, and then plead the exigencies of the moment to claim to voters that the status quo really is the best we can do.