Hotel California, and who pays for the education of doctors?

I wrote a post on this topic awhile back trying to map out the territory of funds going in and out of undergraduate medical education. It was a bit too rambling but more thought out I feel than Jeremy Hunt’s latest slant on statistics that the Guardian (and others) reported. So here are some bullet like points on this issue, together with some questions. The backdrop is the article I wrote before, and the issue of ‘we paid for their training so we can seize their passports’ (Phil Hammond’s, ‘Hotel California clause’: ‘you can check in but you can never leave’.) And because, somebody asked me to spell things out a little more.

In England medical students pay 9K fees. HEFCE (Higher education funding) add another 10K. Lets round up and call it 20K. HEFCE also adds money beyond fees for other expensive degrees (engineering, for example) although I do not know if it is 10K or less. This 20K goes through the universities

Medical students do not pay their final year fees in England, but must meet all their living costs, and 9K fees for the other 4 or 5 years. Government loans attract interest and, as others have commented, the government alters the conditions in a way that would be illegal for any bank (Gee! The government makes even the bankers look like saints). So say 40-45K fees, plus living costs. I doubt much change from a 100-120K. The money attracts interest and will be much larger by the time it is paid back, and will also feed into the debt of students who do not earn enough to pay back their fees.

The other funding stream is via the NHS. In England this is called SIFT, in Scotland it is called ACT. This is probably in the region of 20K per student per clinical year, and is designed to meet the costs of the ‘students on the wards’ and pay for all the NHS staff time for those involved in teaching. This money stays within the NHS, and the universities have essentially no access to it.

If you add there two streams together you are talking about close to 30K of ‘state funding’ plus 10K from the students. Living expenses are on top, and I will ignore opportunity costs of what students defer from earning.

The problem with the 30K state funding figure is it fails the reality test. These sums add up to a figure (40K) close to what Stanford charges its small medical student cohort, and yet it is clear that our UK medical students get a much worse deal. Or just compare what this sort of money buys you at an expensive private school. There is a (fat) rabbit off somewhere. Nobody with any knowledge of medical education, and who isn’t playing politics, believes that is what we spend on each of our students.

Above, I said 20K goes through the universities, but I did not say that universities spend that 20K on delivering undergraduate teaching. The obvious issue is that medical research is big business, and most research in general loses an institution money — this is especially true of charity funded research, the main funder of medical research in the UK (although there is an attempt to make up this deficit from QR funds but it is grossly inadequate). Peacocks tail, and all that. So, teaching fees are used to subsidise this loss. There are good costings for this in some US schools, but they use endowments to meet the costs; in the UK we get students to pay for this. To what extent? I do not know. Do not ask, is the mantra. This will run and run. And then unwind.

What about the NHS money. Well, nothing is transparent in the NHS, but we know most of the this money is not used to support teaching, but siphoned off to pay for clinical care. What proportion? I would start at saying 70% (i.e. only 30% goes for what it is intended for). So I think 18K over the whole course. But I know of no convincing data in this area, just the sort of bumph Hansard repeats, which is not reality based. Do not ask, is again the mantra.

My previous post added in come complexities. And there are more, that I have not mentioned.

The key points are:

1. We do not know how much undergraduate medical education costs, just that the available figures are not credible.
2. Much of the money said to support medical education is used for other purposes (this is a generally accepted argument across many research universities throughout the world).
3. Costing is opaque and multiple parties have little interest in transparency.
4. Money (as in staff) is a key determinant of teaching and learning. Until you follow the money, you cannot seriously think about improving medical education. Some of us even think it is possible to reduce costs and improve learning at the same time. This is why all this  matters — and not just to students.
5. Institutional and student interests are not completely aligned.
6. Certification is a monopoly business. To paraphrase Derek Bok, a distinguished former President of Harvard, if institutional survival (money)and morality conflict, morality goes out the window.
7. Current models of medical education are based on what made sense in the immediate post-war world. It really should be done so much better.
8. People often ridicule arts students, saying how little contact time they have. Meaningful contact time in medicine not what it was, nor what it should be — talk to medical students across the UK.
9. Hospitals perform worse than GPs in delivering teaching. There is a moral here.

Anyway you can still listen….