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BMA criticises plan to make new doctors work in NHS for at least five years

BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j1370 (Published 16 March 2017) Cite this as: BMJ 2017;356:j1370

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Expanding undergraduate medical education in the UK - but at whose cost?

We read with alarm the UK Department for Health’s ‘Expansion of Undergraduate Medical Education’ consultation document (Department of Health. Expansion of Undergraduate Medical Education. Available from: https://consultations.dh.gov.uk/workforce/medical-education-expansion/ [Accessed 6 April 2017]) released recently (14th March 2017) in which the Government is looking at ways to maximise the benefits from increasing the number of medical students. As overseas students not from the European Economic Area (non-EEA), we were particularly distressed by point 3.11, which states that new overseas (non-EEA) medical students will have to pay for their own placement tariff, a fee paid to healthcare providers to cover costs of a medical student’s clinical placement. This tariff is, on average, £36,000 per year per student, and is currently subsidised by the Government for all medical students: home, EEA, and non-EEA.

The Department for Health intends to introduce this policy on international students starting their medical degree in the academic year 2018/19. This would mean that an overseas medical student at the University of Sheffield in their third year, for example, who would normally be expected to pay £35,500 per year** for the final 3 (clinical) years (University of Sheffield. Undergraduate Fees Look Up. Available from: http://ssd.dept.shef.ac.uk/fees/ug/ug-fees.php [Accessed 6 April 2017]), would see more than a 100% increase in fees for these years with the inclusion of the placement tariff, and around a 72% increase in total fees for their medical degree (from about £148,000 to more than £255,000).

As overseas medical students studying in UK medical schools, we feel that this dramatic hike in costs is bound to have an equally dramatic effect in the number and quality of applications to UK medical schools from overseas students, who bring not only diversity and an international reputation to the universities they choose to study in, but also provide a global outlook and fresh perspectives in solving challenges of globalisation that the UK is facing, including an increasingly diverse NHS patient population. Campaigns such as #WeAreInternational by the University of Sheffield, with the backing of over 100 universities, have highlighted the importance of overseas students in enriching the experiences of students and staff around them.

If overseas students become responsible for their placement tariffs, their expectations from placements will consequently change. Like a consumer in any other situation, they will expect to know exactly what they are paying for and would not be so ready to accept tagging on to the end of a ward round, sitting silently at the back of a clinic, or not getting formal teaching while on placement. This extra demand that might come with paying for hospital placements may lead to an undesirable consequence of creating an imbalance in training and education between overseas students and their home/EEA colleagues.

Also within point 3.11 is the removal of limits on numbers of international medical students a university can enrol, which, if taken with the previous consideration of introducing placement tariffs, reads like a desperate business opportunity rather than a welcome to overseas students to access some of the world’s best medical education here in the UK. This continues a trend of anti-immigration policies, such as the immigration health surcharge (£150 per year of university, paid upfront when applying for a student visa) which was introduced 2 years ago for all overseas students (The Lancet. UK immigrant health surcharge: unfair and short-sighted. The Lancet. 2015;385(9980): 1804. Available from doi:10.1016/S0140-6736(15)60912-6.).

We could not find any published studies investigating the proportion of overseas medical students graduating from UK medical schools that return to their home countries after graduation. In pages 14-15 of their 2012 Review of Medical and Dental School Intakes in England (The Health and Education National Strategic Exchange (HENSE). Review of Medical and Dental School Intakes in England. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil... [Accessed 6 April 2017]), the Department of Health and the Higher Education Funding Council for England (HEFCE) recognise that conclusions on this issue of international medical students leaving the UK after graduating cannot be made, and the Review suggested keeping the international student cap at 7.5% of total medical students enrolled at UK medical schools. Statistics of careers destination of medical graduates may be difficult to collate due to the fact that all students graduating from UK medical schools are on a level playing field when applying to the Foundation Programme and subsequent ST/GP programmes.

The Government’s return on investment from covering overseas students’ placements has been rewarding and will continue to be so. A considerable increase in tuition fees may change students’ priorities in deciding where to work and what specialty to train in, and the UK needs its international foundation and junior doctors who have graduated from UK medical schools to possess an outlook of serving long-term in the NHS instead of going overseas after graduation or choosing careers that ‘pay well-enough to make £255,000 worth it’ rather than going into undersubscribed specialties that the NHS desperately needs.

**2017/2018 clinical year tuition fee; overseas student fees elsewhere in the UK increase around 2% per annum in line with inflation, but the University of Sheffield is one of the few that has a fixed tuition fee policy

Competing interests: Both authors are overseas medical students at UK medical schools

06 April 2017
Ahmed Soualhi
Medical Student
Ayiesha Ahmad, Medical Student, University of Sheffield
GKT School of Medical Education, King's College London