Opening doors to medicine

BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7455.1508 (Published 24 June 2004) Cite this as: BMJ 2004;328:1508
  1. Sean Hilton (shilton{at}sghms.ac.uk), professor of primary care,
  2. Kenton Lewis, widening participation officer
  1. St. George's Hospital Medical School, London SW17 0RE
  2. St. George's Hospital Medical School, London SW17 0RE

    Widening participation must sit alongside top up fees

    Today's universities must compete and thrive in an evolving and fast moving international market. The current funding gap in higher education in the United Kingdom must be bridged if institutions are to do so, and the government sees increased fees for students as part of the solution. Despite much controversy the proposed implementation of a system of top up fees for students in England and Wales is now established at the top of the higher education agenda.1

    In considering the impact on universities of top up fees the government's own commitment to increasing and widening participation is of major importance—namely, that 50% of those aged 18-30 are to have higher education experience by 2010. The relation between top up fees and widening participation is problematic. The people who are working to tackle commitments to widening participation are faced with apparently mutually exclusive policy positions—to raise participation by “debt averse” people in a system perceived to increase personal financial burden.

    Nevertheless widening participation is now a major policy strand in higher education and despite the apparent policy paradox, staff, students, and stakeholders are committed to it. Considerable strides have already been made by many institutions. However, to continue development and be able to answer increasingly sophisticated questions about the detail of widening participation, we need robust metrics and methods of evaluation. In an environment where transparency is essential, these should be easy to apply and interpret.

    A paper in this issue describes the application of one such metric—the standardised admissions ratio—to admissions to medical school (p 1545).2 The standardised admissions ratio is the proportion of university admissions from a particular subgroup of the population against the proportion of that subgroup in the general population. It may be applied by using publicly available statistics. The findings, in terms of ethnicity and social class differences, are stark. They indicate a 600-fold difference between the most over-represented (Asians from social class I) and under-represented (blacks from social class IV) groups. Although there are caveats and the authors rightly point out that equal representation across all subgroups is neither necessarily desirable nor possible, the paper indicates clearly that massive disparities exist.

    The paper's focus on admissions to medical school is timely. The need for widening participation in medicine is essential. Although medical schools may retain ingrained bias towards traditional backgrounds, recent trends suggest falling numbers of applications from such students.3 Education of future doctors now incorporates issues of health and social care that extend beyond the basic and clinical sciences. The under-represented sectors of society that widening participation aims to include are also those same sectors with high health and social care needs. If the NHS is to understand and serve the community the make up of its workforce should reflect that community. This is a challenge for provision of health care internationally. Initiatives in the United States for deprived communities, and in New Zealand, Australia, and Canada for rural practice are examples.48

    Notwithstanding the impact of top up fees, a wide range of initiatives to widen participation in medicine in the United Kingdom is being undertaken currently. Some of this is facilitation and progression work, such as the access to medicine programme that runs at King's College, London (www.kcl.ac.uk/depsta/medicine/access/index.html). This offers a six year extended medical degree programme to non-traditional entrants from local borough schools. Others (“Taste of medicine,” an interactive CD Rom, and the experimental roadshows run by St George's Hospital Medical School—www.sghms.ac.uk/Courses/wp/index.htm) are aimed at raising aspirations.

    All these projects recognise the importance of working with as young a cohort of potential applicants as possible. Outreach work is far more to do with challenging stereotypes and changing understanding than offering academic support. Additional time or support can have only a very limited impact on involvement of those disenfranchised with the educational system. Many of those targeted through work of this kind are identified as such by virtue of their not reaching their full potential. If the system they are involved with is failing them in this way then merely expanding the provision will not help.

    Another paper in this issue by Greenhalgh et al reports on focus groups conducted with high ability students from a wide range of backgrounds in six secondary schools in London (p 1541).9 Their findings underline the point that additional academic support or course duration is not the whole solution. We agree with the authors' conclusions that imaginative and unconventional approaches are required to promote understanding, attitudes, and aspirations in such students.

    Other factors, such as pressures to increase numbers of overseas students who pay high fees or the impact of expansion of the European Union, may also impinge on the traditional demography of medical schools in the United Kingdom in the next few years, but the widening participation agenda is one that we must embrace. We have much to gain from taking part and a wealth of wasted potential if we do not.


    • Conflict of interest None declared.


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