The Scottish Government

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Future Practice: A Review of the Scottish Medical Workforce

3.2 Supply from the education sector

Student numbers and selection

105. Output from basic medical education. Increasing the output from basic medical education is one way of increasing the supply of doctors for Scotland. It takes effect in the medium to long term and must support any overall expansion in doctor numbers which is driven by increasing service demand and the factors already identified which will reduce the service contribution of all doctors.

106. For Scotland the supply of trained doctors depends on the interplay of a number of factors including:

• the numbers applying to and entering medical schools;

• how students are selected, which can affect whether the doctor, once qualified, stays in Scotland; and

• the retention of potential and registered doctors in Scotland as they continue through the postgraduate education and training continuum.

107. These factors should be addressed in a UK context. A simple increase in student numbers in Scotland might merely increase the numbers selected from outwith Scotland as well as the southward cross-border flow of new graduates. From the point of entry to medical education, if not before, steps should be taken to encourage those trained in Scotland to remain here or to return to Scotland later in their careers.

108. A unique arrangement provides for students studying medicine at St. Andrew's University to move out of the Scottish system to Manchester to complete their clinical undergraduate years. If this arrangement were to be modified additional numbers of potential doctors could be retained in Scotland. Equally St Andrews could provide a "bridging course" for potential mature or graduate entrants by preparing them for later entry to a clinical course.

109. Currently almost 60% of those accepted to Scottish medical schools are female. In coming years as the female ratio rises in the NHSScotland workforce, this will have implications for working practices and indirectly on service provision. Further work is necessary to understand how service may be affected.

110. Student domicile varies across the medical schools but currently about half of those accepted to Scottish medical schools are domiciled in Scotland.

Chart L: Scottish Medical Schools (November 2001)

111. The social diversity of medical students should change to better reflect the social mix in society - particularly entrants from less well advantaged backgrounds. Indeed the Kennedy Report ¹⁸ has called for a broadening of the social and academic base from which health care professionals are drawn. However, standards should be maintained. This approach should also increase the proportion of locally-based students who may be more likely to stay in Scotland as doctors. The key to improving social diversity is the way in which students are selected at entry. Criteria should cover the range of personal qualities and experience that the doctor of the future will require, rather than just academic excellence. A recent report of the National Audit Office in England ¹⁹ found that poorer social classes had significantly lower participation rates than others in higher education occupying the same low share of places in courses in 1999-00 as they did six years previously. Although there is widespread activity by institutions to raise the aspirations in groups with low representation, there is much less done to ensure that their applications have a fair chance of succeeding. They and applicants with disabilities have particularly low success rates in applications to study medicine, dentistry and veterinary science.

112. Specific mature-entry medical courses in Scotland leading to a primary medical qualification would enrich the medical profession with the individuals' prior experience and would stimulate culture change. Mature entrants could come from:

• general educational backgrounds;

• relevant first degrees in the life sciences; or

• other health professions with appropriate recognition for prior learning.

113. It is easier to select mature entrants than 17-year-olds against the non-academic qualities referred to in paragraph 111. If the gender imbalance among students in part reflects the greater maturity of females than males at 17 years; mature entry might help redress that imbalance.

114. Providing the future workforce. More information is needed to understand the characteristics of the workforce entering medicine in Scotland and what happens to graduates. Further work is required to identify and review the options for modifying the present arrangements for entry to Scotland's medical schools. We believe the need to do this is urgent.

Student funding

115. High potential debt levels are a disincentive for students entering medicine from less affluent backgrounds, despite the relatively high income expectations for doctors. The current rules in Scotland for student support for mature entry students are likely to discourage:

• entry by those under 25, who would be assessed on their parental income; and

• those who have already graduated in another discipline.

An innovative and constructive review of medical student support should help to broaden recruitment and thus make a specific contribution to medical workforce planning.

Delivering the undergraduate and postgraduate curriculum

116. Team-based and problem-based multi-professional learning methods, combined with assuring core knowledge and skills, will make graduates more 'fit for purpose' in the service delivery teams of a modern NHSScotland.

117. Role models. The influence of role models during training can be positive or negative (reflecting a bad work experience) or outdated (reflecting the role model's own past rather than the trainee's future). Doctors responsible for training should be more aware of the differences between the basic training they received and that of new doctors. It is vital that doctors graduating now should be 'fit for change'. The medical apprentice model is justifiably a mainstay of training (particularly postgraduate training) but may not in itself be sufficient to deliver this. Inherent in fitness for change is a sound knowledge of career paths and opportunities.

118. Multi-professional learning. We recognise that there are advantages if multi-professional teams can learn, train and develop together. There should be opportunities for common and shared learning across the continuum of education. Again this has been highlighted in the Kennedy Report. Given the importance we have placed on teamwork there is scope within undergraduate curricula to provide opportunities, when relevant, for students to learn with other health professionals.

119. Training capacity is a potential limiting factor on the ability to train doctors. There currently appears to be sufficient capacity provided resources are managed effectively. It should be recognised that all hospitals are teaching hospitals and the potential contribution of primary care should be realised in full. The importance of teaching in the clinical environment needs to be better recognised and it should be given sufficient priority to ensure that it happens and is high quality. We welcome the review of ACT ( Additional Cost of Teaching) which supports undergraduate medical education in the service and encourage the group undertaking the review to take account of the issues identified in this Report and particularly those applying to the remote and rural environment.

120. Innovative curricular development. The Group learned of early proposals to develop an International Virtual Medical School in Scotland. They are encouraged by this development.

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