COUNCIL OF HEADS OF MEDICAL SCHOOLS
AND DEANSOF UK FACULTIES OF MEDICINE
CHMS Response to the White Paper on The Future of Higher Education
1. Introduction
1.1. The Council of Heads of Medical Schools(CHMS) is pleased to respond to the White Paper on The Future of HigherEducation. CHMS represents all themedical schools in the United Kingdom, including the new medical schools, whichcomprise a significant part of the major expansion, and innovation, of medicaleducation. We have confined our commentsto elements of the White Paper relevant to medical education and to research inmedical schools.
1.2. However, the rle of medical schoolsin particular, and academic medicine in general, is much wider than teachingand research. Academic medicine worksin close partnership with other university disciplines, other healthprofessions and with the NHS. It iscrucial to the quality of the NHS workforce, and its leadership. It leads in the development of NHS quality,and of innovations in service. Itcontributes substantially to the national effort in research, particularly inrelation to the pharmaceutical, biotechnology and medical devicesindustries. Academic medicine is aregional leader in innovation, and in the development of the local economy. It is through their close partnerships withthe NHS and the related industries that the medical schools contributesubstantially to knowledge transfer, innovation, economic and socialdevelopment, and to their local communities.
1.3. A large part of the NHS workforce is madeup of university employees with honorary (i.e. unpaid) NHS clinicalcontracts. This includes about 3,000academic staff with NHS consultant contracts who not only make a substantialcontribution to the routine clinical service, but provide leadership inteaching hospitals, the Medical Royal Colleges, and in association with theDepartment of Health.
1.4. In addition to support of the clinicalservice, and of research, medical schools have led in high-quality innovativeteaching. Medical education in the UKis successful, flexible, responsive to needs of the healthcare system, and isinternationally recognised for its high quality.
1.5. It is therefore essential that theincreasing support offered by the Government for higher education is applied insuch a way as to enhance existing success, and not to destabilise key elementsof academic medicine.
1.6. In responding to the White Paper, we notethe interdependency of the White Paper, this years letter from the Secretaryof State for Education and Skills to the Chairman of HEFCE, and the recurrentgrant allocations for 2003-4 to HEIs in England. Similar considerations apply in the other countries of theUnited Kingdom. This response alludesto the interdependency of the White Paper with the rapid application of some ofits principles.
2. Areas where universities have toimprove
2.1. In his foreword, the Secretary of Stateidentifies two areas where universities have to improve. The first is to ensure that the expansion ofhigher education extends appropriately to the talented and best from allbackgrounds. Members of CHMS have, formany years, worked hard to ensure that entry to medical school is equitable,based on potential and ability, rather than solely on previous achievement, andreflects the nature of our society. Webelieve that our efforts in widening participation have not always been fullyrecognised.
2.2. The second area highlighted by theSecretary of State is the need to harness knowledge to wealth creation. In the context of academic medicine, wecontribute to wealth creation in two ways.The first is the close interaction with the pharmaceutical,biotechnology and devices industries.The quality of British academic medicine is one of the reasons for thesuccess of the British pharmaceutical and biotechnology industries. The second area in which we contribute toindustry is by our contribution to the development of health-care practices,both in the NHS and more widely. Therecan be few more important measures of the wealth of a nation, than the healthof its people.
3. Research excellence
3.1. CHMS welcomes the increase in researchfunding agreed by the Government. Wenote that the overall allocations from HEFCE to the three clinical medical unitsof assessment, for 2003-04 have increased compared to 2002-03 by some 20million, and this increase is applauded.However, the allocations include substantial reductions in researchsupport for some medical schools, which will cause considerable difficulty forthem and their NHS partners.
3.2. Furthermore, new medical schools arefaced with extreme difficulty in attempting to build up their researchcapacity, in the current funding system, and opportunities for them to work inconsortia, and collaboration with other institutions, are very limited.
3.3. Therefore, we welcome the increasedcapital and recurrent funding, but are concerned about progressiveselectivity. It is regrettable that themethodology for allocating funding has changed so much after the 2001 ResearchAssessment Exercise. Medical schools would have adopted different submissionstrategies if there had been prior knowledge of the allocation methodology tobe used. As a consequence there has beena substantial arbitrariness in the recent research funding allocations.
3.4. The effect of these changes must be seenagainst a number of other major issues in funding, which collectively maydamage the complex synergy between the teaching, research and clinical rles ofmedical schools, and their interaction with NHS and regional partners:
Reduced teaching funds for medicine to allow wideningparticipation in other disciplines.
The increased research selectivity in the 2002/03funding round, resulting in an overall reduction of approximately 7% inresearch funding for medical schools.
6% cut in the weighting for clinical research (amultiplier of 1.7 being reduced to 1.6) for 2002/03.
The transfer of generic research (GR) funding tomainstream QR funds for 2002/03. Thereis evidence that GR funding was an important element of the overall funding forbiomedicine.
Reduction in the weighting for charity funded researchfor 2003/04.
Loss of funding for 3A-rated research, and substantialreduction in funding for 4-rated research, in 2003/04.
3.5. In addition to these financial factors,stability and recruitment and retention of staff are further threatened by:
Pressure within the NHS for short-term clinicalservice-led goals, and for immediate delivery of NHS Plan targets.
Unresolved uncertainties in the new contracts forclinical academics, whether linked to the NHS consultant contract, or to thenew GP contract.
The introduction of reforms in the modernising medicalcareers process.
3.6. We support the view of Universities UK,who have stated that the net effect of the research proposals in the WhitePaper could be a more rigid hierarchy of institutions with only a relativelysmall number having access to significant research funds. It would be deleterious to medical educationand research, to the quality of the NHS workforce, and to the delivery ofpatient care, if universities with medical schools were excluded from thoseinstitutions having access to significant research funds.
4. Research excellence additional points
4.1. The White Paper proposes additionalsupport for research in larger units, with the development of critical mass,and of collaboration. The evidence thatcritical mass is an important factor in high-quality biomedical research ispoor. Furthermore, for research onclinical problems, whether in individual patients or in populations,researchers must be based in reasonable proximity to the subjects that theystudy and have access to high quality, research sensitive, clinical servicesfor involved patients.
4.2. We welcome the support for emergingresearch proposed by the White Paper.However, this will be damaged by concentration of substantial researchfunding in fewer centres. This will beparticularly harmful to research in community-based subjects, notably primarycare and public health, given the high number of 4-rated returns inCommunity-based Clinical Subjects (Unit of Assessment 2) in the 2001 RAE.
4.3. We welcome proposals to develop and rewardtalented researchers. However, inbiomedical research, the lead time for development of the research workforce ismany years, and rather than sudden increases in the number of researchpositions available, a better approach would be a gradual increase, with betterfunded researchers, and better career pathways (see 3.5 above).
5. Higher education and business exchanging and developing knowledge and skills
5.1. As noted above, as well as the interactionof academic medicine with industry, our primary interaction is with thedelivery of healthcare. We know that medicalgraduates tend to work near where they qualify: this emphasises the importanceof appropriate regional distribution of medical schools. Medical schools have great potential tostimulate not only the quality and volume of healthcare, but also to promotethe regional economy. They can only dothis if they are all funded appropriately for their missions in teaching,research, patient care and clinical leadership.
6. Teaching and learning
6.1. The quality of teaching and learning inmedical education is ensured not only by the mechanisms applicable to alluniversity subjects, but also by the General Medical Council, which has astatutory responsibility for medical education. Similar considerations apply in our partner subjects inhealthcare, such as nursing, dentistry, pharmacy and the other professionsallied to medicine.
6.2. The rigour with which these professionalregulatory bodies ensure that teaching and learning is of the highest qualitycould be an exemplar for other parts of the higher education system.
6.3. The quality of teaching is threatened bythe reduction of teaching funds for medical education in the current fundinground, for the support of widening participation in other disciplines. This is a wholly retrograde step.
6.4. Although the White Paper (atparagraph 2.7) casts doubt on the degree to which high quality teaching need belinked to research, the General Medical Council states explicitly that everymedical student should during their undergraduate training use research skillsto develop greater understanding to influence their practice. This implies that medical students shouldlearn in a research-rich environment.We submit that this remains essential: students who do not learn of thecontributions of research to medical practice, who do not fully understand howto evaluate new research findings, and to apply them, and who are not fullyequipped to learn how to learn, will be inferior doctors. CHMS therefore rejects any notion that therecould be any kind of teaching-only medical school. This does not mean that all schools should attempt to conductresearch in all, or even most, areas of biomedical science. Nevertheless, all areas must be taught: wedo not have the option to limit the range of the medical curriculum. Furthermore, we believe strongly that thequality of clinical practice, which itself is influenced by research findings,is a key factor in sustaining and improving the quality of teaching.
7. Fairaccess
7.1. Medical schools have been committed tofairness and transparency of admissions policies for many years, and haveadopted appropriate strategies to widen participation. Such activities deserve recognition, andfinancial support.
7.2. CHMS welcomes the proposals to improvebenchmark data on widening access, rather than relying on the existing crudeindicators. For those medical schoolsinvolved in education for other health professions it is important.
7.3. CHMS notes the Governments proposals fora new Office for Fair Access. It isessential that this new body takes into account the work that medical schoolshave been doing for a number of years.With this proviso, and also providing that bureaucracy is minimised, andnew benchmarks are agreed, the Office for Fair Access is cautiously welcomed.
8. Freedoms and funding
8.1. Many of our comments on this subject havebeen made above, in relation to research, and to teaching. These two activities are so closelyintegrated in medical schools that their funding is inevitably closely interdependent.
8.2. The additional funding set out in theWhite Paper is welcome. However, muchof it is earmarked for specific Government-led initiatives and will nottranslate into core funding for institutions.We concur with Universities UK in its concern that there is a real termsreduction in funding for baseline teaching and learning. We agree that this is difficult toreconcile with the White Papers emphasis on teaching excellence. The linkage of most additional funding tospecific initiatives is inhibitory to the necessary freedom to develop thebest.
8.3. CHMS does not believe the freedom to sethigher tuition fees will solve the funding shortfall. It is essential that the level of recurrent public funding bemaintained, because the additional student fee income is needed to enhance, notreplace, public funding.
8.4. The question of the way in which medicalstudent fees will be funded must be kept under observation, to ensure thatthere is no negative impact on our agenda to widen access. There is also a risk that post-qualificationrecruitment into those clinical specialties that do not provide access tosubstantial private practice opportunities, including recruitment into theclinical academic workforce, will be inhibited by the accumulation ofsubstantial debt at graduation.
8.5. Medicine is an internationaldiscipline, and CHMS would regret any funding decisions that reduce mobility ofstudents across national borders within the UK.
9. The public sector workforce
9.1. CHMS takes particular note of the pointsmade in paragraphs 7.46 to 7.48 of the White Paper.
9.2. We have noted above that higher fees formedical students must not damage the widening access agenda, and look forwardto working with the Department for Education and Skills, and the Department ofHealth, to ensure that this does not happen.At present, the Department of Health meets the cost of fees for medicalstudents in the fifth and later years of the normal 5 or 6 year medical courseand in years 2 to 4 of the new accelerated four-year graduate entrycourses.
9.3. It is important that none of the policydecisions following the White Paper, particularly those on funding, damage thecomplex interaction of academic medicine and medical schools with the rest ofthe university sector, and with the healthcare system.
9.4. This implies that there must be closeco-ordination between the Education and Health Departments, the Office ofScience and Technology, and the funding councils. The strategic alliance between HEFCE and the Department of Healthin England is a good example.
9.5. CHMS particularly welcomes the excellentinterdepartmental interactions that exist between the Department of Health andthe Department for Education and Skills, and values the continued and positiveinteraction we have with officials from these Departments in working throughthe problems that confront us.
9.6. The co-ordination of planning and fundingfor medical and other healthcare education and research is essential. The new Strategic Learning and ResearchAdvisory Group for Health and Social Care, which is to meet for only the secondtime in June, will have an important rle to play at the national level inthese interactions.
9.7. CHMS supports the retention of the generalpattern of existing funding for medical education and research, with the corefunding for teaching and research coming from DfES, and elements relating toclinical facilities, and some parts of student support, coming from theDepartment of Health. We concur withthe view of Universities UK: although two different funding streams means twodifferent accountability arrangements, there are clear benefits in retainingthe current funding arrangements for medicine and dentistry, since they areknown and recognised, and reasonably transparent. The interdependence of medicine and basic science means thatmaintaining funding coherence with these subjects is important not only for theeducation process, but also for Health Service research, and the wider UKeconomy, particularly the pharmaceutical and biotechnology industries. Any changes should be fully assessed beforea decision is taken, since these relationships are complex, and the effects ofany change would not be confined to the higher education sector alone.