Widening access to the medical professionBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h1108 (Published 02 March 2015) Cite this as: BMJ 2015;350:h1108
- Caroline White, freelance journalist, The BMJ
Caroline White looks at the work of the Selecting for Excellence Executive Group and other efforts to improve access of people from disadvantaged backgrounds to the medical profession
Young people from disadvantaged backgrounds continue to be under-represented at higher education institutions.1 They make up just over 3% of those entering higher education in England, compared with more than 21% for those from the most advantaged backgrounds. The gap is even wider in medicine. Students from the most advantaged backgrounds make up 29% of those starting medical school, compared with 1% for those from the most disadvantaged backgrounds.2 General Medical Council data show that almost two thirds of doctors in training grew up in the most affluent areas of the United Kingdom and that one in three went to an independent or fee paying school, which educate just 7% of the population (General Medical Council, personal communication).
Tackling the issue
This situation persists despite efforts to redress the balance, says Tony Weetman, chair of the Selecting for Excellence Executive Group (SEEG), which was set up in 2013 under the aegis of the Medical Schools Council to widen participation in medicine.
“Medical schools haven’t just woken up to the problem,” he says. “They’ve invested huge amounts. But they haven’t always followed best practice or done detailed analysis to find out what does and doesn’t work.”
Jennifer Cleland, John Simpson chair of medical education at the University of Aberdeen, also points out that the impact of work to widen access is often not studied. “Many medical schools are spending a great deal of time and effort on widening access,” she says. “But very few are evaluating what they are doing.”
She adds, “To be fair, it’s hard to measure. A school with a widening access programme might get an applicant who would not otherwise have thought of applying for medicine, but equally it could be some other factor. There are lots of intangibles.”
St George’s, University of London, recently completed a 10 year analysis of its spring and summer schools, which are aimed at disadvantaged pupils. The analysis showed that residential courses that were at least three days’ long resulted in the highest number of applicants for healthcare studies.
“These courses are resource intensive, so we need to know if they are value for money,” says associate dean John Hammond. “A framework for evaluation would be very helpful so that universities could buy into certain evaluation tools rather than having to create their own.”
About 30% of those who participate in summer schools go on to apply for courses at St George’s. Helen White, who heads up work on widening participation at St George’s, says that as well as keeping tabs on how many summer school participants apply to courses at St George’s, staff try to track the destination of those who go elsewhere. “Monitoring and tracking to gauge the long term impact is our ultimate aim,” she says. “But it’s very costly and labour intensive, and we struggle to do all that we want to.”
Long term impact
The SEEG published its final report in December. Among its 68 recommendations, the report calls for information on the long term impact of activities to widen participation to be included in the proposed UK Medical Education Database.2 This database is intended to link performance and demographic data across the piece from application to medical school through to postgraduate education and training. But the project, spearheaded by the General Medical Council, is still at a very early stage and it’s a huge task.
“Because we are an independent healthcare institution, we can allocate a proportion of the fees to widening participation,” says White. “But other universities with medical schools attached will have to stretch their budgets over several faculties, of which medicine will just be one.”
Weetman sympathises with those facing the challenge of implementing the SEEG’s recommendations. “I can well understand people on the ground saying that it’s another thing to do when they have so much else to deliver on,” he says. “But there is money in the system, and if we can pool resources and share experiences, it will cost less and achieve more.”
Any university charging £6000 or more in fees has to commit a sizeable chunk to widening participation as part of its mandatory agreement with the Office for Fair Access. For 2015-16 the collective spend for universities on widening participation is projected to be £323m. This is a 33% rise on last year’s figure, and there will be a further £412m for student financial support.3
SEEG has set medical schools 10 year targets for boosting their intake of students from the two fifths of UK postcodes currently most under-represented in higher education. The targets are modest: a 3% increase for quintiles 1 and 2 according to Participation of Local Areas (POLAR) data to 8% and 12%, respectively, by 2023.
Weetman says that the targets set by SEEG are designed to be within reach of medical schools. “If we have 50% of schools and tech colleges not sending a single applicant to medical school in three years, there is clearly an enormous pool of talent we haven’t tapped into,” he says. “But we have to move at a pace that is doable. Targets are a compromise, but they are achievable.”
Brigitte Scammell, admissions subdean at Nottingham University, is less certain the targets can be met. “There are factors outside our control which work against us,” she says. “Nearly all our applicants are from social classes 1 and 2, no matter what we do. The others just don’t apply. Until that’s addressed, hitting a target is perhaps not going to be achievable. And we shouldn’t be selecting for the sake of it.”
SEEG recommends starting to interest children in medicine as early as primary school, and some medical schools run outreach schemes for this age group. But many secondary schools in deprived areas do not offer the same range of subjects as schools in other areas, which inevitably restricts career options.
Recent figures published by the Open Public Services Network suggest that in some parts of the United Kingdom up to half of state schools don’t offer triple science.4 The network attributes this to a desire to minimise potentially poor exam results and improve league table rankings.
“Triple science is not a requirement to get into medical school, but you need it if you are going to do well at A level because it provides the necessary scientific background,” says Harrison Carter, co-chair of the BMA Medical Students Committee.
Some medical schools seek to compensate by adjusting their entry criteria or running pre-access foundation courses with lower entry grades as part of a contextual offer that factors in social, personal, and educational circumstances in prior attainment. As yet, no uniform or evidence based standard exists for such an approach and there are fears that schemes such as these could lower academic standards and disadvantage those amply qualified to get in.
Hammond says, “Yes, some students from more privileged backgrounds might not get in, but I like to think of it more as levelling the playing field rather than discriminating against them. It’s about getting talented people through the door to show what they can do.”
Scammell says that the foundation year course at Nottingham is no easy option. It is “vastly oversubscribed,” with 25 applicants chasing every one of the 10 available places.
Carter says that it is important that high academic criteria are maintained. “But even with grade inflation, there’s a balance to be struck,” he says. “It’s just a case of identifying practical steps to unlock potential.”
Neil Croll, head of widening participation at Glasgow University, thinks that making adjustments will always raise hackles but the results of such efforts show the value of this work. “Our data show that students coming into medicine on adjusted offers through widening participation perform as well or better than those from more advantaged backgrounds,” he says. “They have had to do more and show a bigger commitment. But the process has to be transparent and robust, and apply across the board.”
Glasgow University is part of Reach Scotland, a national initiative to broaden the diversity of applicants to professional careers. In 2011, 13% of the students entering medical school came from schools that were at or below the national average for the number of students who went on to study at university. By 2013 this had risen to just under 30%.
Queen’s University Belfast has also tried to broaden the social profile of its medical students by encouraging graduates to apply for the five year course, and graduates now make up 20% of the intake. “These students have often not quite got the A level grades, but if they can get a 2:1, we let them in with an A and two Bs,” explains admissions dean Keith Steele. “Their quality is exceptional, and they have more experience of life, which helps the school leavers on the course.”
Steele says that the definition of widening participation and admissions criteria vary considerably among medical schools. “Medical schools should make very clear the criteria they use for admissions on their websites, and be able to defend them with evidence,” he says. “Applicants should get feedback and be told under what circumstances they can reapply.”
SEEG has concluded its work, but it has set up a selection alliance to look at the best methods of selection. It will also oversee progress on taking forward its recommendations, including dispelling the myth that work experience has to be in a healthcare facility, something which is often extremely difficult for those without family connections.
“This is permanent medical school business, and there’s no quick fix. We need to continue to maintain the momentum,” says Weetman. “The NHS needs the most talented people to enter medicine, and talent should be the only determinant. This is an opportunity, however flawed, to widen access for the benefit of patients.”
Competing interests: I have read and understood the BMJ policy on declaration of interests and have no relevant interests to declare.