Intended for healthcare professionals

  1. Caroline White, freelance journalist, London, UK
  1. cwhite{at}bmj.com

Medical schools are using various tactics to try to ensure the profession represents the people it serves and bring in more doctors from disadvantaged backgrounds, finds Caroline White, but change is slow coming,

In 2012 the UK government’s social mobility adviser lambasted the medical profession. Too few people from socially and educationally disadvantaged backgrounds were being encouraged to become doctors, Alan Milburn said.1

In response, five years ago the Medical Schools Council’s Selecting for Excellence project made recommendations to tackle the problem and shed the profession’s image as an enclave of privilege. But since 2014 progress has been slower than in higher education overall, despite efforts by medical schools to boost the intake of disadvantaged students. One challenge is that there is no one measure of disadvantage, with proxies including having been in care, attending a poorly performing school, or living in a deprived area.

Little significant improvement

UK universities currently spend £800m (€930m; $1bn) a year on various initiatives to widen participation to all under-represented students. Medical schools now provide 19 “gateway” courses that include an extra initial year for able students who have faced additional educational hurdles because of their circumstances. And some use contextual offers, which lower academic entry requirements for able students.

The Medical Schools Council’s annual report on widening participation from last December concluded that although “very good progress” had been made on approaching equality between men and women in the profession and on increasing ethnic diversity, “more progress is needed for other demographic variables associated with social and educational disadvantage. Despite modest changes in some . . . there is little significant improvement.”2

In 2016 two fifths (41%) of new medical students were of black or other minority ethnic backgrounds, compared with 25% in higher education overall, although Bangladeshi and black Caribbean students remained under-represented, the report said. And the proportion of entrants declaring a disability matched that in higher education overall (10%). But the proportion of new medical students from the two fifths of UK postcodes currently most under-represented in higher education stood at just 16% in 2016. The figure for students across all subjects was 25%. And the proportion of medical students coming from lower socioeconomic backgrounds was half that among university students overall.23

Gap in educational attainment

“If we are measuring success by the number of ‘widening participation’ students making it on to courses and graduating as doctors, then the statistics are not changing as fast as we would like,” acknowledges Gail Nicholls, a member of Selecting for Excellence’s implementation board and associate professor of primary care at the University of Leeds. But she adds, “We are investing not only in the immediate future. I don’t think there are quick wins: it’s got to be a long term strategy.”

Widening participation in medicine “is a very difficult task,” agrees Clare Owen, assistant director at the Medical Schools Council. “Educational inequality in the UK means that academic attainment is linked to socioeconomic background,” which can’t be fully corrected for in selection processes, she says. “There’s also the issue of aspiration and people seeing that medicine is a career option open to them. Lots of effort goes into [tackling] this, but it takes time to change the perceptions of young people, teachers, and parents.”

Owen thinks that medical schools’ efforts are being undermined by gaps in the wider educational system. She cites the example of careers advice, provision of which “has taken a big dip” since the loss of ringfenced funding, meaning that medical schools are having to do more outreach and help would-be students with applications.

The gap in educational attainment at the end of secondary school between the most and least disadvantaged pupils has barely shifted since 2014, reports the Social Mobility Commission, an advisory non-departmental public body.4 Disadvantaged 16 year olds are much more likely to go into “overlooked” and underfunded further education colleges than to school sixth forms, it says, and so may not get the qualifications they need for medicine.

Half of all secondary schools and technical colleges didn’t send a single pupil to medical school in 2009-11,5 and schools’ engagement with medical school outreach is persistently absent in some parts of the UK.2

What’s being done?

Starting last year the government is funding 1500 extra medical school places in England, 500 at institutions with a track record in widening participation and the rest at five new schools. The new schools, located away from existing ones, had to commit to having at least 20% of their intake from under-represented groups (personal communication, Office for Students, July 2019).

Having more medical schools “in itself increases choice, because students from under-represented groups are potentially less likely to travel and more likely to study closer to home,” says Ed Hughes, head of medicine and health at the Office for Students (OfS), the regulator of higher education in England. “And if they are mature students, that’s another reason why local study options might be preferable.”

Boosting numbers of mature students could also help widen participation, thinks Chris Milward, OfS’s director for fair access and participation. “The number of older students has been declining. There are a lot of late developers out there who are not ready [to study medicine] at 18.” But graduate students are eligible for only limited funding, so it’s unclear how many of those from disadvantaged backgrounds would be able to do this.

In Scotland, universities have statutory targets to admit 16% of all students from the 20% most deprived backgrounds by 2021, rising to 20% by 2030.

In England, OfS has set a target to eliminate the gap in admissions between the most and least represented groups at universities with the toughest entry criteria by 2038-39. James Turner, who runs the social mobility charity the Sutton Trust, thinks this is the right approach but cautions, “Straightforward quotas would be a blunt tool and could result in perverse incentives.”

Contextual offers

“There’s probably more activity than ever before around widening participation in medicine,” Turner concedes. “But there’s been marginal progress on intake, and senior positions are still dominated by those from well-off backgrounds . . . and they are the people shaping medicine.”

It isn’t poverty of aspiration that is holding up progress, he suggests, but rather that “bright kids from low income families lack the support and infrastructure.” He adds, “We need to be bolder. If we wait for the [educational] attainment gap to close, we will be here for a long time.”

The OfS believes that contextual offers are the key to recruiting more students from disadvantaged backgrounds.6 But these, with lower entry requirements to allow for factors such as attending a poorly performing school or being in care, are “still the exception rather than the rule” at medical schools, Turner says, as are extra preparatory years.

In the higher education sector as a whole, medical schools have been ahead of the curve on contextual admissions (boxes 1 and 2), because they have had to think hard about how to widen access to particularly competitive courses with restricted numbers of places, says Milward. It’s not known how many contextual offers medical schools make, as this information isn’t collated nationally (personal communication, Medical Schools Council, September 2019).

Box 1

Widening participation at King’s College London

King’s has been offering lower grades for entry to medicine to able but disadvantaged medical students since 2001. It was one of the first medical schools to use these “contextual offers.” This year, 500 people applied for its 77 ‘widening participation’ places, while 5000 applied for the 313 places on its standard course.

“We started by offering three grade Cs at A level, but students on these grades were less likely to succeed, so now we offer an A and two Bs,” explains Jane Valentine, lecturer in medical education and co-director of King’s widening participation programme. Its standard offer for medicine is A*AA.

The first year of the standard entry course is split over two years for widening participation students. “They require a longer transition period and a slower pace of learning to enable them to develop the self confidence and study skills they need,” Valentine says. “They have the same sorts of issues as any other student, just more pronounced. One of the main ones is finance, because their household income is generally lower, and many have additional financial or caring responsibilities or both,” she adds.

Attrition is similar to that in the standard entry courses, with most dropping out in the first year. Widening participation students rarely leave the course for academic reasons, says Valentine: those students who do drop out usually do so because of personal commitments.

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Box 2

Case study: Michelle Sebele, third year medical student, King’s College London

Sebele arrived in the UK aged 5 with English her second language and went straight into care. She entered the extended medical degree programme at King’s with an ABB offer.

“I was driven from a young age, and my foster carers encouraged that. I liked human biology and had a fantastic teacher at secondary school, which is when my interest in medicine started.

“I was the first person from my school to study medicine. A lot of the teachers didn’t know about the application process or how to guide me, even simple things like knowing about the earlier deadline. I had to research all that myself.

“My AS level grades weren’t fantastic, but I got two As and an A* at A level.

“The first year was spread over two, and we were given additional financial, pastoral, and academic support, including with essays, presentations, and academic posters for research. These are skills you don’t necessarily have if you come from a state school.

“Being in a smaller group of 60 students meant I built strong relationships with my peers. It’s daunting studying medicine, especially coming from a different background. I was worried about whether I would integrate, so it was nice to be with people similar to myself to begin with.

“Some people experienced snide comments from other students. I didn’t. But I had achieved the grades necessary for a standard course, and was accepted for one [but opted for the longer course because of what it offered], so never felt I wasn’t good enough.

“I have been an ‘outreach for medicine’ ambassador [a King’s programme] for four years. We go into state schools and run workshops for years 7 to 12 to prove that they can go into higher education too. It’s really important that they see students from similar backgrounds to themselves.”

“Only 7% of looked-after children go into higher education, and only 1% of them go to prestigious institutions. A lot of care leavers move from placement to placement. You can’t possibly thrive in those circumstances.

“People like me get into medicine through hard work. But you have got to believe in yourself, and you need others to believe in you too.”

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But, explains Owen, “There’s no magic way of identifying an [eligible] student.” Data from different sources are required, which need validating. “That’s time consuming and expensive, especially when dealing with large numbers of students.”

Institutional reluctance

Relaxing entry criteria to medicine may not affect undergraduate performance. One recent study that tracked 2107 students at 18 medical schools found that students given contextual offers generally outperformed their more privileged peers in medical school exams.7

In terms of undergraduate achievement, A level results up to two grades lower than the standard offer (ABB, for example) achieved at a poorly performing school are “worth” the same as triple As achieved at a top performing school, the researchers concluded.

“There’s clearly scope for looking at other ways of recruiting students from less advantaged backgrounds when entry requirements are high,” says OfS’s Hughes. Some medical schools are considering dropping the requirement for A level chemistry.8 Much of A level chemistry is unrelated to the content of a medical degree, thinks Jenny Koenig, who teaches pharmacology to medical students.9 But students who don’t have this qualification are likely to need extra support, she cautions.

The evidence for contextual offers is still evolving, and there’s no consensus on the best way to use them. Some universities may be cautious about the potential effect of contextual offers on their league table rankings, which they use to market themselves in a competitive higher education marketplace.

The OfS is due to review the whole university admissions process next year. “We need to tackle not only how [universities] think about recruitment, and what factors they take into consideration, but also how that is presented by others outside the higher education system,” says Hughes, referring to rankings in the media.

The UK could follow US universities by reporting equality and diversity as a measure of excellence, says Milward. The OfS now requires English universities to have plans to narrow inequalities. If universities fail to increase diversity, it will apply “conditions and sanctions, including financial penalties,” he warns.

Footnotes

  • Competing interests: I have read and understood the BMJ policy on declaration of interests and declare that I am a lay member for public and patient engagement, Waltham Forest Clinical Commissioning Group, and part time senior media relations executive, BMJ.

References

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