Changes in university funding for medical education in EnglandBMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c5781 (Published 18 October 2010) Cite this as: BMJ 2010;341:c5781
Opportunity costs money, and nobody likes paying. Amidst the alarm, considerable positivity greeted the report Securing a Sustainable Future for Higher Education.1 This is no mean achievement for the committee led by Lord Browne of Madingley. Principled and rationally argued, the report manages to avoid boxing politicians into corners on the sensitive issue of funding a competitive university industry, which is regarded as essential to future national prosperity. Few people would argue with the assertions that higher education is currently in crisis, and that current funding arrangements are not sustainable.
In the United Kingdom, students, their families, and the state all contribute to funding university education. This would continue under the Browne proposals, but the onus would change. With public finances under unprecedented pressure, the challenge is to match or exceed the investment of other countries in their university systems.
Browne cites global reports showing that the UK is at a competitive disadvantage because of its “inadequately trained workforce”2—in 2010 it was ranked 55th out of 139 countries on the quality of its maths and science education.3 Medicine is recognised as being important to the wellbeing of our society and to our economy, and the committee acknowledges the risk that if the charges to students for clinical courses reflected the high costs, students would opt for courses that cost less. The report, permeated by implicit faith in the market economy and explicit commitment to student choice, proposes that public investment should continue to support priority courses—including medicine, nursing, and other healthcare degrees—with oversight from the new Higher Education Council.
Browne proposes no limit on fees charged by universities. Instead, government would pay the fees and reclaim the money from students when they can afford to pay. This is a straightforward fee of up to £6000 (€6825; $9600) a year. Above that figure universities would pay a tapered uncapped levy on all fees. Thus, whereas a university that charged students £6000 would keep all that income, one that charged £9000 would keep only £7650, with £1350 going to government to help cover the cost of providing students with upfront finance.
The committee strives to support the principle that “everyone who has the potential should be able to benefit from higher education.” Public concern has been that long courses like medicine could seem prohibitively expensive as fees rise and thereby skew applications towards students from richer families. UK medical courses already struggle more than other university courses to admit a proportionate number of students from lower socioeconomic backgrounds.4 Browne proposes that students will not have to pay any tuition fees up front and will begin to repay the cost of their fees only when their earnings reach £21 000. Medical graduates, who will probably exceed this threshold as soon as they qualify, will then begin to pay their loans back with low interest. All students would be entitled to flat rate maintenance loans of £3750 a year, which would replace the current means tested system. Additional grants (that do not need to be paid back) of £3250 a year are proposed for students from households with incomes of less than £25 000, and partial maintenance grants for those from better off families with a household income of up to £60 000
Unpaid student debt would be written off after 30 years, but the Browne committee has not adopted the proposal that there should be an element of “forgiveness,” whereby those who work for a considerable time in the NHS have proportional amounts of their loan written off earlier.5 Very large debts would accrue on long courses. Careers advice would be essential at an early stage because potential medical students from all backgrounds would need to be able to balance debts against the compensation of relative job security and an adequate future income in medicine.
Graduate entry courses are not specifically mentioned, but the report encourages government to review the restrictions on access to funding for students who are studying for a second degree. Although postgraduate education was specifically part of their remit, the committee did little more than note that it is “a successful part of higher education system and there is no evidence that changes to funding or student finance are needed to support student demand or access.” There is welcome emphasis on the need for all new academics with teaching responsibilities to undertake teaching qualifications. The Academy of Medical Sciences also supports this but recommends flexibility to allow new academics to focus on research.6
For those who accept that the interests of students wishing to study medicine have been fairly and squarely tackled in the Browne report, the important focus for medical education is to predict the impact on the university system and on medical schools in particular. Competitiveness is explicitly encouraged by the committee placing confidence on informed student choice to drive up quality. Media focus has been on the potential for universities to fail, yet, somewhat confusingly, the report supports a power for the Higher Education Council to bail out struggling institutions. Medical schools, unlike some schools for the other healthcare subjects, are generally part of the stronger universities, so closure of the parent organisation seems unlikely.
What remains to be seen is how the allocation of medical student numbers will play out in future. If student choice is the most powerful driver, then no medical school can rest on its laurels because presumably the Higher Education Council will ensure that essential funding support for clinical education is directed towards the courses on which students wish to enrol, and fierce intraregional competition between schools can be anticipated. Recognition and reward for teachers are the key to developing world class medical teaching that delivers value to students and patients.
The principles of the Browne report need to be accepted, along with their philosophy that sees higher education as a precious resource supporting the country’s future wellbeing. Much work needs to be done collaboratively between the Higher Education Council, NHS workforce planners, and those responsible for postgraduate medical education, including Medical Education England and the General Medical Council. The objective must be to equip the most able students to practise medicine in the best interests of UK patients. Properly nurtured students must be trained in the best possible research based institutions and be confident that they can repay reasonable fees over a reasonable timescale.
Cite this as: BMJ 2010;341:c5781
Competing interests: The author has completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares: no support from any organisation for the submitted work; he was paid for academic and consultancy work by the University of Warwick, Queen’s University Belfast, and Karolinska Institutet Stockholm in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.
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