It is a pleasure to have this debate under your chairmanship, Ms Dorries. I am very pleased to have the opportunity to raise some key issues about the funding of medical students. Aspects of the upheaval in higher education funding are, of course, important both for the recruitment of doctors and the availability of opportunities to study for the medical profession. They are of particular concern in my constituency, which is home to 1,000 undergraduates and 1,300 postgraduates in medical sciences. I am grateful for the briefing that I have received on the matter from the British Medical Association and the Oxford university medical sciences division, as well as for the concerns that constituents have raised with me on these issues.
At a time when higher education as a whole faces the challenges and dangers of the 80% cut in university teaching support and the trebling of fees, concerns about the costs of and access to medical education are all the greater. The length and intensity of medical courses both add to the cost to students and limit their opportunity to supplement their income through paid work.
The BMA estimates that, under the present system, medical students graduate with some £37,000 of student debt. With all universities charging or set to charge £9,000 for medical studies under the new regime, the BMA estimates that that figure will go up to around £70,000. That does not count overdrafts, credit cards, professional loans or family borrowing. We do not need to exaggerate the impact of prospective debt on students’ choices to be concerned that debts of £70,000 or more might be a barrier to able people from poor—or, indeed, middling—backgrounds who are considering entering the medical profession.
My concern is about the funding position facing all medical students. However, on the challenge facing us on widening participation, there is likely to be a triple impact on entry to medical studies. The A-level admission grades are understandably particularly demanding and poorer students from schools serving poorer areas are less likely to achieve them, which clearly demands further action within the school system. The requirement of medical work experience is also likely to be harder to fulfil for school students from financially hard-pressed families or, indeed, from families with no connections to the medical profession. At the same time, the prospective length and costs of study are considerably higher and it seems plausible that those are also having an impact on the relatively low rates of admission to medical studies from poorer socio-economic groups.
Statistics on admissions show that the wider challenge of opening up access to higher education is certainly compounded in the case of medical studies. The BMA equal opportunities committee report published in October 2009 includes a review of UCAS data. It states:
“The proportion of acceptances to medical school coming from socio-economic class I (31%) was almost twice that of acceptances to all other degrees from class I (16 %). Just 15% of students accepted into medical school came from the four poorer socio-economic classes (grades IV to VII) compared with 24% of students accepted to all degrees.”
The BMA has also said:
“The percentage of students from lower income families is slowly improving across the higher education sector but the rate remains stagnant in medicine.”
In the light of all that and the Government’s stated commitment to widen access to higher education, I would like to ask the Minister what the Government’s specific proposals are to widen the pool of talent entering medicine and whether the Government, in bringing forward the higher education White Paper, will look at the likely special factors at work in relation to medicine? I have listed some of those.
Will the Government also consider the advice and support given to able students in school, the necessity and operation of the work experience requirement and the £75 cost of the UK clinical aptitude test used as part of the selection process? That test gives an early signal to students from poor backgrounds that studying medicine is an expensive undertaking.
An important part of overall support for medical students is the provision of bursaries. As the Minister will be aware, the future shape of those has been uncertain for some time. The previous Government consulted on options for change in 2009, and last month the present Government set out new options for reforming the system.
As I represent the other half of the Oxford university seat, the right hon. Gentleman will know that I share many of his concerns. In the light of his valid concerns about equal representation among medical students, does he agree that now is the crucial time to decide about the NHS bursary scheme, given that many students are deciding which courses to apply for?
I am grateful to have the support of my colleague. I might describe her constituency as covering the other third of Oxford university. Her support on that point is very welcome. I was about to say that people are already asking what the situation will be, and obviously the sooner they can have certainty, the better.
The BMA has joined other bodies in consulting on the issue, and I understand there is some expectation that agreement will be reached. However, one big outstanding question is whether the new proposed bursary arrangements will cover tuition fees in the same way as they are covered now, with the Department of Health paying the fees for years 5 and 6 of an undergraduate course. If the bursary does not cover fees—it seems extraordinary that Ministers have not yet made the Government’s position on that clear—medical students would obviously face still higher costs and debt.
As my colleague and friend the hon. Member for Oxford West and Abingdon (Nicola Blackwood), whose constituency represents the other third of Oxford university, says, mounting urgency on that matter arises because would-be applicants worry about how the arrangements will work for 2012-13. I press the Minister to give an undertaking that tuition fees for medical students will be covered at least as well as they are now.
The other point that needs to be made is that many of these courses are for six years, not just five. We need to take into account the cost of living expenses and the fact that many medical students have to take out commercial loans in addition to student loans, which makes the matter especially significant. I declare an interest as the mother of a medical student on a six-year course.
The hon. Lady will know all about the matter. That was a very well made point. I will come to the subject of commercial loans later.
I also want to press the Minister on the position of graduate-entry medical students. That is an even more important route of entry than the 10% of total numbers that they represent suggests. The BMA has pointed out to me that its 2009-10 medical student finance survey shows that a higher proportion of students from poorer socio-economic groups enter medicine through graduate-entry courses than do so through undergraduate courses. Oxford university medical sciences division has pointed out to me that the best graduate-entry students are extremely strong and do exceptionally well. That route into medicine is important both for excellence and widening access.
The pharmaceutical and medical sectors of industry have clearly made many financial commitments to a number of universities across the whole of the United Kingdom, including at Queen’s university, Belfast. Does the right hon. Gentleman think that the pharmaceutical and medical industry could do more to help poorer students with tuition fees?
A number already do, and of course we are grateful to those who give support directly, or through foundations and trusts. If more could be given, that would be very welcome. As the hon. Gentleman says, whether in Northern Ireland or elsewhere in the UK, the contribution that spin-offs make to our economy, as well as the direct benefits of investment in medicine, is enormous. Those who benefit from that in profit should put extra back.
The point that I was making about graduate-entry medical students is that they are not eligible for loans to cover tuition fees and have to find first year fee costs out of their own pocket or from other sources of help, some from specific university bursaries. If graduate-entry students had to raise £9,000 for their first, and maybe subsequent, year fees, on top of the debts that they would have already accumulated as undergraduate students, that might be prohibitively expensive and inflict real damage on the quality and social range of graduate-entry medical students. What assurances can the Minister give on graduate-entry student funding? Will there be additional help for first year fees in light of the increase? Will tuition fees for subsequent years be supported by the Department of Health at the new, higher rate?
Another concern, which relates to the point made by the hon. Member for Oxford West and Abingdon, regards graduate-entry students who may no longer have access to some of the loans for professional development that have been made available by commercial lenders. The BMA has cited the recent decision by banks such as NatWest to withdraw those loans, which were obviously hugely important for graduate students who were ineligible for tuition fee support. Will the Minister make representations directly to the banks and to the Chancellor of the Exchequer, who might usefully underline that this is an especially important area for us all to be in it together in doing what we can for graduate medical entry?
All in all, there are big challenges facing prospective medical students. Yes, demand for the courses is high, and it is good for patients, science and the economy that so many of the brightest want to study medicine, but we cannot be complacent. It is vital that people from all backgrounds are encouraged and helped to fulfil their potential in medicine when they have something good to offer.
I would like to thank and praise the work of access officers, at Oxford university and elsewhere, who are working hard to reach out to schools and students who have not in the past thought of Oxford, and to raise aspirations and challenge prejudice. A very good example is the university of Oxford’s UNIQ summer school—it is unique, I think, but it is called UNIQ too—which is a programme of free residential courses in July and August for year 12 students from UK state schools and colleges.
The summer schools are targeted at academically talented students whose school or college has little or no history of making successful applications to Oxford. Participants follow a week-long academic course designed and taught by Oxford lecturers and tutors, as well as taking part in social activities and meeting up with alumni of the university and current students.
In its first year, 69% of UNIQ summer school students went on to apply to Oxford and 27% were given conditional offers by the university. I understand that the medical strand of that initiative has attracted a lot of state school applicants, and that the conversion rate to application and the offer of an undergraduate place in medicine is very good. That shows what can be done. Let us, through the funding arrangements for medical students, make the job of those promoting access arrangements easier, not harder.
This country can be very proud of the quality of education, training and research in medicine, and the scale of achievement in my constituency is awesome. We all want to see the most able people, regardless of background, working in the profession. Criteria for admission and the judgment of would-be students’ potential must, as with the assessment of their progress and qualifications, be matters for the medical schools and universities, not the Government. The Government have a clear responsibility to act and open up opportunities to ensure that there is the right advice and support, to raise school standards and aspirations, to remove barriers and to fund medical students fairly. I look forward to hearing from the Minister on whether and how the Government intend to set about that.
I congratulate the right hon. Member for Oxford East (Mr Smith) on securing this debate on what I know is an area of great importance. He is right to say that it is about recruitment, skills and the development of the profession. I would also like to thank him for his praise of access officers at Oxford, and for highlighting the summer school. It is important to see universities doing what they can to ensure that participation is widened, and that people who might not have felt able to apply to such universities as Oxford, or who might not have felt that they had the necessary skills, are given the greatest opportunity to do so. It is good to hear the right hon. Gentleman raise the point that this is something that schools have to take on board. We often discuss the issue of universities widening participation, but we also want to ensure that our schools prepare young people, and have the skills to prepare young people, to apply to all universities. Young people should not feel as though they are excluded from any opportunity.
There is no doubt that training for medical students in this country is some of the best in the world, and we want to keep it that way. That means that funding must be at a level that allows for the best training. The consultation paper “Liberating the NHS: developing the healthcare workforce” sets out our proposals for a new framework for education and training, and the right hon. Gentleman raised particular issues that I will come back to in more detail. The proposals would see health care providers take the lead. They would plan and develop their own work force, and take on many of the responsibilities that were previously held by the strategic health authorities. A new statutory body, health education England, would provide national leadership for education and training, with a strong clinical focus from top to bottom. The proposals for health education England have been widely applauded—it is very important to have that leadership in education and in that strong clinical focus. We now have an opportunity to review and reshape our work force and what it is designed to do, so that it can respond to the challenges of the future while still providing excellent care. We sometimes lag behind, trying to solve the problems of tomorrow with the solutions of yesterday.
For patients, of course, but also for staff and students, there must be a secure, diverse work force that has full access to education, training and opportunities to progress. That must be transparent, so that we can see how it is working and help ensure that we all get value for money, students included. The Government have consulted to see how that can happen. We have involved a wide range of people, because the new framework is about giving some of the power to those people. The central pillar is the transfer of greater responsibility to health care providers, escaping the one-size-fits-all approach that has been too prevalent in the past. Those providers will need to work together to co-ordinate the development of their local work force, so that it is tailor-made for the individual pressures of individual areas, which vary widely. That means building strong partnerships with universities and colleges to put the skills of educators to the best possible use and strengthening those relationships, which I do not think have been strong enough. There has been a general recognition among health care providers that those relationships have not been strong enough in the past.
I know that those involved with both the medical profession, including the BMA, and the education sector, want to ensure that medical education is protected and improved. They also want to know that the role of the postgraduate medical and dental deaneries, which currently form part of the strategic health authorities, will continue, so that medical students and trainees continue to be well-supported. Medicine, like many other professions, does not end at the end of training—continuing professional development is an important part of it.
I am happy to—so that the right hon. Gentleman does not feel I am ducking his questions, I will deal with them once I have finished with the deaneries.
We want to retain and build on the important functions of deaneries as we build the new framework for education and training. We know how important that is, because any transition not only makes the participants feel nervous but is a significant operation for any Government. The transition is when we can let the baby slip out with the bath water.
The right hon. Gentleman raised the issue of bursaries in particular, but I have to disappoint him, in that I cannot make an announcement today. We are acutely aware how long awaited it is. No one could be more frustrated than me with the slowness of government at times, but it is important that we get it right. I thank my hon. Friends the Members for Oxford West and Abingdon (Nicola Blackwood) and for Totnes (Dr Wollaston) for their contributions. My hon. Friend the Member for Totnes also raised the issue of some of the indirect costs of training, to do with the length of the course. We will be making announcements soon but, as I said, it is important that we get it right and that we involve other Departments.
The right hon. Gentleman also asked if I would make representations via the Treasury to other organisations about supporting training schemes. It is important that we continue to do that—perhaps we do not see enough of that in this country. At this point, I should mention that Julie Moore, the chief executive of University Hospitals Birmingham NHS Foundation Trust, is leading some of the work we are doing with the NHS Future Forum, as part of the ongoing listening exercise on the health reforms. Julie will continue the debate started in the consultation, so there will be further opportunity for input. I urge him and the other Members present to get involved, to ensure that their views and the particular issues faced by medical students are taken on board.
Our responsibility is held jointly with the Department for Business, Innovation and Skills, so the right hon. Gentleman should ensure that any comments made today also go as directly to it. The two Departments are working closely together, so that the specifics of medical education can be recognised.
I wanted the assurance that, as part of the Department of Health’s collaborative work with the Department for Business, Innovation and Skills, the long-awaited higher education White Paper, which it would have been better to have had before the fees increase rather than after, will address the specific position, challenges and opportunities of medical students.
Very much so. To some extent, the health of the nation rests on the skills of the professions that deal with the consequences of poor health. Medical students and doctors are part of that, so it is important that we get the system right. We need to maintain a competitive edge if we are to continue to produce medical graduates of the highest calibre. We shall not fail in our duty to make representations to other Departments, although working together is not always as easy for government as it sounds. However, we have made significant progress, and I think our words are being heard loud and clear.
As the right hon. Gentleman knows, universities will be able to charge a basic threshold of £6,000 a year for courses, and up to £9,000 a year for some, but subject to much tougher conditions on widening participation and fair access, which he mentioned in particular. There are still many such challenges, not only for universities but for our education system and at a wider societal level, if we are truly to get participation as wide as it can be. We need to look at all sorts of other drivers in the system directing young people to their choices.
We are shifting the balance of contributions from taxpayers to graduates, who benefit most from higher earnings over the course of their working lives. It is important to recognise that, after medical students have gone through the system and become consultants, they are probably among the top few percent of wage earners in this country. Contribution from them, therefore, is important. For poorer students, who might feel that the burden is too high, there is a balance or tipping point at which active participation in a fees scheme becomes a barrier. We have done a lot of work to ensure that that is not the case, and we continue to do so.
Many of the subjects associated with medicine cost more to teach, and we want a system in which anyone with the ability can access university and study such courses without being put off by the cost. That is why we will continue to provide additional funding for science, technology, engineering and medical courses.
The NHS bursary, which is in recognition of the length of time it takes to study medicine, will continue, helping students with their tuition fees and supporting those from low to middle-income families—sometimes, the middle-income families get squeezed in the middle. We have undertaken a review of the bursary, and will make some announcements shortly. In the review, we considered the views of the British Medical Association, which played an active part, ensuring that the perspective of medical students was considered.
In addition to the NHS bursary, last year an additional £890 million were invested by the NHS to provide clinical placements to medical students, ensuring that NHS providers continue to deliver high-quality clinical placements, which are an important part of such training.
The central investment in 2011-12 is £4.9 billion, a 2% increase on 2012-13. It is important that the funding mechanisms provide the right incentives and allow funding to be transparent, to drive quality and to be value for money, supporting a level playing field between providers. Any bursary schemes included should be easy to use and to access—sometimes, the mechanisms by which one can get support are only available to those at the top end of the IQ scale, because they are so complicated. Such complexity can be another significant barrier.
Current funding for clinical education and training is based on local agreements between strategic health authorities and providers. It can result in inequities in the funding of similar placements in different parts of the country. To resolve that, we have been working with others to develop proposals for a tariff-based approach to clinical education and training funding. Such tariffs would enable a national approach to funding all undergraduate clinical placements, including placements for medical students, as well as postgraduate medical training programmes. That will support a much more level playing field between providers. The variation in current funding arrangements means that the introduction of tariffs would have a bigger impact on some providers than others.
We are looking at that issue at the moment. We have received about 500 consultation responses, so I am sure that it will be highlighted—it is something we need to look at. The other important thing we are looking at is proposed levies on private health care providers. Certainly, when I trained as a nurse—many years ago—that was an issue, and it remains so today.
The tariff ought to mean a more even and equitable system throughout the country. We will continue to work with SHAs and providers, and we will consider all the views expressed, to build understanding of what the tariffs will do and of how to manage the transition.
I assure the right hon. Gentleman that the Government recognise the importance of medical education and of continuing medical education. The new arrangements will take on board many of the issues he has raised, to ensure that we have a health care work force fit for the future.
Question put and agreed to.