Medical schools: are we paying for education or for technical training?

Not the least of the challenges facing medical schools in the UK is an increasing pressure on funding. The first major challenge came from the Research Assessment Exercise in 2001. Research units within higher education in the UK were categorized on a 5-point scale according to the national or international profile of the research that they conducted. The grade awarded determines the research support funding that the institution receives until the next assessment exercise. There was widespread expectation within the sector that units with grades of 3a (research of national significance) through to 5 (research of international importance) would receive funding; the level of funding being adjusted according to the grade obtained. In the event, funding went only to units with grade 5 or 5*. Many medical schools’ research units received grade 4 (research of national importance with some of international importance). These units lost the research support funding and in some cases this led to redundancies among academic staff.

The medical schools have been further hit by the Government’s Widening Participation programme. The medical schools, many of which have already established programmes to facilitate the entry of educationally disadvantaged students, support the concept of widening participation in higher education. However, the way the programme is funded has resulted in loss of income of some 5.5% to the medical schools since it is focused on students at the lower end of the ability range rather than targeting students of all abilities who have been prevented from reaching their full potential.

It has been suggested that the financial difficulties could be ameliorated if the responsibility for funding of medical education was transferred from the Department for Education and Skills (DfES) to the Department of Health (DoH).

The funding of healthcare education

The funding of healthcare education in the UK is bewildering. The funding of the education of health professionals other than doctors and dentists is the responsibility of the DoH and is administered through the Workforce Development Confederations who contract with the higher education institutes for the delivery of educational programmes following a tendering process. Contracts were typically for 5 years and much time and effort went into regular renegotiations, with the constant risk that the programme would be lost to a rival educational establishment.

In contrast, medical education has for 150 years been based in universities. Ostensibly DfES provides the funding, which is given at two different levels with lower fees for the preclinical years and higher fees for the clinical years. Given that medical schools have been encouraged by the General Medical Council to move towards integrated curricula, this is in itself anomalous. Moreover, the DoH actually provides more funding in the form of Service Increment for Teaching (SIFT), which is paid for the clinical years. SIFT was introduced when it was realized that teaching hospitals cost more to run than non-teaching hospitals, and enabled the teaching hospitals to continue providing a service to patients. It was not supposed to pay directly for teaching and in many cases could not be identified as a separate spending stream within the hospital budget.

The recent increase in student numbers resulted in the injection of new money into the system, which has allowed more transparent administration of the SIFT resources. As the teaching of medical students has moved away from the teaching hospitals into the district hospitals and increasingly into primary care it has been possible to transfer some of the funding to the new educational providers. Although SIFT is still being used for its official purpose of supporting service delivery, it can now be linked very directly to the teaching that is taking place.

If the DoH is already providing the bulk of the funding, why are the medical schools so anxious that the remaining funding should not be transferred from the DfES? At one level there is concern that a transfer of funding would mean the introduction of a contracting process similar to that of the other health professions. There is a perception that short-term contracts would inhibit the development of the medical schools because the planning horizon would be so short. When competitive bidding takes place the costs are likely to be driven down, resulting in a reduction in the medical schools’ income. In reality, it is unlikely that a higher education institute without a medical school would be able to bid against an established school. In any case, the DoH is moving towards granting rolling contracts with a much longer time frame for the other health professions.

The fear has also been expressed that, if all of the funding were to be in the hands of the DoH, service needs would take precedence over teaching. This fear is fuelled by the way that SIFT has been managed in the past. However, given that the funding from the DfES has fallen recently, the alternative of remaining with the DfES cannot be a guarantee of continued stability.

The purpose of medical education

Is the purpose of medical education merely to provide a workforce for the NHS? The tone of some of the recent discussion implies that this is now the accepted purpose. There is a danger that the undergraduate medical course will deteriorate into a technical training rather than an education. A technical training prepares individuals to use current technology; an education prepares individuals to develop new approaches and technologies.

Medical students must learn the core skills and knowledge needed to practise medicine safely; they must develop their understanding of the scientific principles underlying the practice of medicine; and they must develop appropriate professional attitudes and behaviour.^1,2 In a period of rapid development in biomedical and behavioural science, cross-fertilization from disciplines outside of medicine is essential. This is more likely to occur when the medical school is an organic part of a wider multidisciplinary university. These benefits may extend beyond insights into science. There is an as yet unproven, but very attractive, hypothesis that exposure to the humanities is of value to medical teachers and students alike.³

The role of research in teaching

High-quality research is clearly essential if medicine is to continue to advance, and unless students are exposed to research they are unlikely to be attracted to research in the future. More fundamentally, for many people, it is the link of learning with research that defines higher education. At the time of the founding of the University of Berlin in 1810, Humboldt wrote

‘It is furthermore a peculiarity of institutions of higher learning that they treat higher learning always in terms of not yet completely solved problems, remaining at all times in a research mode (i.e. being engaged in an unceasing process of enquiry). Schools, in contrast, treat only closed and settled bodies of knowledge.’

While some medical teachers have been guilty in their teaching and assessment of students of behaving as if medicine were dealing with a ‘settled body of knowledge’, there is an increasing emphasis on educating the students in the acquisition, evaluation and synthesis of new information. It is therefore argued that medical students must be taught in a research-rich environment. Only in this environment will the teachers keep up to date and the students absorb the ethos of research-led and evidence-based practice.

The evidence to support this contention is difficult to find. Hattie and Marsh⁵ conducted a meta-analysis of studies of the research/teaching link and were unable to demonstrate any relationship. From this and similar findings, it is now being argued that teaching in higher education can be separated from research. This may be a false conclusion. There are no agreed measures of what constitutes good research and, especially, good teaching. Measurements of research excellence include number of publications in high quality journals and the amount of grant income obtained; however, the comparators for both these measures vary from subject area to subject area and, in any case, reflect past achievement rather than current performance. Assessing teaching excellence is even more difficult. Most often, reliance is placed on feedback from students, which may reflect the style of the teacher rather than the substance of the learning. Attempts to find correlations between measures of teaching and measures of research are therefore futile. More importantly, the stress on teaching is misplaced. The relationship suggested by Humboldt is between research and learning. His emphasis is on the shared experience of the instructor and the student in exploring new material, not the transfer of a body of knowledge from one to the other. Elton⁶ has suggested that student-centred approaches to learning, such as problem-based learning, are the most likely to show a close link between learning and research, but this has still to be shown empirically.

The shift to curiosity-led learning is encouraged by the General Medical Council in Tomorrow’s Doctors and is a major feature of the new undergraduate medical curricula that have been introduced in many UK medical schools. If Elton is correct, it is particularly important for these schools that those involved in student learning are also involved in research.

There are many unanswered questions. For example, is it necessary to display excellence in research in order to achieve excellence in learning, or is there a threshold level of competence in research that is effective? If the latter is the case then the decision to withdraw funding from Research Assessment Exercise grade 3a and 4 units is both perverse and counterproductive. Once again, no empirical data are available.

The role of clinical service for the medical schools

It is taken for granted in the UK and elsewhere (but not everywhere) that medical education will be delivered by individuals who continue to practise medicine. NHS staff are a major teaching resource but, just as importantly, clinical academics continue to deliver NHS service alongside their other duties. This involvement of academics with routine professional activity is unusual among the professions and is one of the strengths of medicine, not only in teaching but also in research.

The effect of funding transfer

Do any of these considerations have any bearing on the suggestion that the funding for teaching should be transferred to the DoH while the funding for research continues to come from the DfES? So long as those involved in student learning are also involved in research does it matter where the funding comes from? Clinical academics already have a difficult division of responsibilities between clinical service and academic duties. Despite recent moves towards joint job planning and joint appraisal in accordance with the Follett report, there are still tensions between these components of the job. If the accountability for teaching is divorced from the accountability for research by a division of the funding, the tensions will increase. The danger of one area being neglected at the expense of another will increase, and eventually it will appear logical to divorce teaching and research completely.

Conclusions

The funding of medical schools will always be problematic. Different solutions are possible but whatever is done certain key principles must be preserved for the good of the medical profession and society as a whole.

• Medical schools must be encouraged to continue to conduct high-quality research

• Students must be exposed to that research and learn from it

• Clinical academics must continue to be involved in service delivery, teaching and research

• Lines of accountability must be such that they support all of the activities appropriately.