Teaching medical students: follow the money.

by reestheskin on 22/10/2015

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[This is a draft, so apologies for the  typos. Part 1 of a two part story]

I can’t stop thinking about money. Not my money (although, I do think about that) but the funding of higher education in general and how we pay for undergraduate medical education in particular. It’s complicated, as they say, but money flows underpin what we can, and what we cannot do. If we are going to improve student learning and cut costs (as in, we need to be better at what we do), we have to know how much things cost. Cross subsidies are necessary and useful, but long term may cause havoc (just as a foolish and narrow obsession with ROI can). What has happened to undergraduate teaching is an example.

Once upon a time it didn’t see quite so critical: I am not certain this is entirely true but that is how it seems to me. Now, things are different. In the past, there was more consensus about funding, there were agreed common goals, student numbers were smaller, and the idea of spending on elites for the public good, part of ‘common sense’. Expenditure still was predicated on education — even that of doctors — as an investment and as a (largely) public good. Professional judgment and opinion, were less challenged (or if you prefer, not subject to scrutiny). And in one sense both universities and NHS were ‘public sector’, with a history of ‘shared expenditure’. Not any more. My take on all of this is that you cannot think about improving undergraduate medical education (and it is in sorry need of improvement) without following the money. 

Students throughout most of the UK pay fees to universities. Many, if not the majority will have substantial debts when they qualify. Up until now, the medics have been guarantied well paid employment, but that situation is changing. Some aspects of postgraduate (as in junior doctor) life have improved, but others are much worse than when I qualified. Financial rewards are substantially down, and working conditions worse. The status of medicine and its practitioners, is changing, and a minority of us believe that most of our students will not end up being employed by the NHS for most of their careers. The nascent backlash seen in recent weeks from junior doctors, is possibly only the start of a longer shift in attitudes by doctors to what is, in effect, a monopoly employer — and an employer that seeks to control all aspects of practice at the postgraduate level, and increasingly what goes on in university classrooms, with an unhealthy focus on process rather then outcomes. There is little institutional independence of judgment or opinion in UK healthcare. But back to the money.

There are two funding streams supporting undergraduate teaching in medicine. Students pay fees (in most of the UK), and the government puts in roughly the same amount again, making in total around ~18-20K per student directly available to universities. Students must also borrow money to live on. So far, the story is similar to some other STEM disciplines. Where it gets complicated is that money also flows to the NHS hospitals or regions where students are taught. The reason for this is obvious: students spend much of their time in these hospitals, and NHS staff — those without university contracts — deliver a lot, if not the bulk of clinical teaching. 

The sums of money that flow to the NHS from the government to support this ‘clinical teaching’ are large, say £15-20 million for a large medical school. Back of the envelope calculations, suggest per clinical student per year, we are again talking about ~20K. So, if you add the two funding streams together each clinical student is attracting ~ 40K. This is not too far away from what an elite and very small medical school like Stanford charges. And at Stanford this figure buys you a ‘medics only’ gym, and proper food on site, both available 24/24 (or so I am told). As for the UK, if you spend time on the shop floor, it is hard to believe these cash figures: so my figures are either wrong, or the money is going somewhere else. I cannot be 100% of the figures, but I have yet to find anybody ‘in the know’ who disputes them, or thinks they are seriously in error. My working hypothesis therefore favours the latter explanation: the money is not going where it is said to be going. I will deal with NHS support first (this NHS funding stream is labelled ACT in Scotland, and SIFT in England).

This money was never ‘real’ money, in so far as that when this stream was identified, across the whole of the UK, it was money the teaching hospitals were already receiving. True, it is real, if say a new medical school within a region opens up, or if a particular hospital stops teaching students, because the pot is fixed, and funds are allocated roughly based on the head count of students attending any centre. In reality the money is mostly embedded and — wait for it — a significant proportion is not used for its supposed purpose. In fact NHS hospitals are currently creating yet another layer of admin to pretend the majority of this money is used for undergraduate teaching: this is a familiar tactic to anybody with experience of the UK public sector, and the NHS in particular. And of course, this whole admin structure largely mirrors what already exists in the medical schools. Some/ much of this money is indeed used for its intended purpose, largely to pay for non-university medical staff who teach medical students. Hard estimates are hard to come by, but my guess is only ~20-30% of the funding for teaching medical students actually finds it way to frontline teaching, if we were to strip out the ‘mirroring’ of medical school structures in NHS hospitals. (BTW, none of this discussion is about postgraduate training of medical staff in NHS hospitals).

If this seems obtuse, I warn you it gets worse. Universities employ clinical academics as well as non-clinical academics. With occasional exceptions, clinical academics provide clinical care for around half their time, leaving the other half available for research or teaching. This is a point to remember, as it is a key reason for why teaching is frequently neglected by medical schools. If we think student fees are supporting teaching (with or without research) a significant flow of cash is going from universities to the NHS (the amount of clinical care provided by academics is small in comparison with overall care, but large as a proportion of university academic resource). As a student from overseas remarked to me, it seems hard to justify why a large part of his 30+K university fees were going to supplement NHS care.There are more complications however. A proportion (used to be quoted as 30-40%) of clinical academic staff were funded by the NHS (the money for their salaries was paid to the university, who then employed them directly). On the other hand, some of the money that flows to support NHS staff time for undergraduate teaching (via ACT or SIFT) is for work that is actually performed by university staff who are ‘core’ university funded (as in those who do not receive their salary by way of the NHS paying the university).

Much of this complexity mattered less when both NHS and universities were both viewed as part of a larger public sector. After all, it was all the exchequer’s money, and both parties were once shielded somewhat from the vagaries of political electioneering. So, what has changed? Lots, is the answer. And in reality a lot more needs to change.

The pressures on the NHS are well known. The increase in cost of health care, like the change in demographics, was predicted over 40 years ago. People just pretend there is a ‘recent’ crisis, because they chose to behave like King Canute. The NHS has a subsistence culture, and subsistence societies do not develop complex cultures or survive sudden environmental change. Given the widespread culture of organisational dishonesty in the NHS, arguments about educating tomorrow’s doctors cut little ice. Most hospital CEOs are more concerned about CQC inspections, or as one of my colleagues put it, ‘Jonathan, a dead baby in an ambulance because Special Care is full, can bring a government down. Do you really think the quality of student teaching can compete in this environment?’ He was, and is right. If we look at NIHR research funding England, we know this giant increase in funding was only achieved by pulling this money out from local hospital control. Just like SIFT or ACT, hospitals will always divert money from education into what seem more pressing problems, like trying to ensure patients are seen promptly or trying to staff wards at a safe level. The lesson is very clear, this money will only be real when it is pulled out, and competed for — but competed for out with NHS control or influence. Until hospitals know they can lose large amounts of money, they will be full of empty and warm words about student experience. Furthermore, until the money is pulled, there is no real incentive to do anything cheaper or better, so innovation does not occur. No Chief Executive is interested in cutting teaching funding by doing it better, because he or she knows most of this money doesn’t go to teaching anyway. You will see little innovation, or disruption to traditional modes of teaching until the money is out with the hospitals budget, or the NHS budget. Of course, if you believe this NHS support is warranted, beware that serious revision of how we teach may not be based in the traditional ‘teaching hospital ward’. The result is what we have seen over the last 30 years or more: lots of talk and good intentions, but any hospital Chief Executive will resist any attempt to account for this money except by claiming large amount of admin overhead is require to ‘support’ teaching. This argument doesn’t wash: we already have medical schools.

University leaders are aware of this, but tend to look in a different direction, partly because they have their own problems that they would prefer to keep to themselves. For many academics, their job can be divided into research or teaching. At the advanced level these two activities go together. It is hard to think of any institution, apart from say Max Planck units or MRC units that provides the environment for high level research education, such as that provided at PhD or post-doc level, by universities. In this respect, good  universities really are precious. However, contrary to what many pretend, a large chunk of university education is concerned with large scale teaching at a far more basic level. You do not need to have drunk all the MOOC kool aid to know that this activity is quite capable of being taken on by people who make their primary focus teaching and scholarship. Most of undergraduate medicine is ‘basic’ and requires an approach to scale not found in the traditional four ‘bright things’ reading their essays to their tutors. In any case, many universities have already voted for ‘bums on seats’ / stack them high, in an attempt to balance their books. The question is to what extent the large amounts of money going to support undergraduate teaching are being diverted elsewhere. There are several issues here.

I have mentioned already, the problem that clinical academics spend up to half their time on clinical duties. As my old professor told me, ‘the old reason academics should see patients is either because you need that knowledge to do research or because you need it in order to teach the medical students. Instead, the NHS has increasingly sought to claim ownership of half of what these university employees do with their time. But in the UK, universities are not funded to deliver clinical care; students do not pay fees in order to entitle them to NHS care, either. What of the remaining half the week? Well, this is either to be spent on research or teaching, but again we have to watch the money flows. 

First, there is and has been great pressure on spending and consuming more and more research (I choose my words with care — I am not talking about solutions nor genuine clinically relevant discovery). But most universities lose money on research, but research buys prestige. The peacock’s tail if you will. Even with overheads, research sucks money from elsewhere, and in medicine the problem is particularly acute because most medical research is funded by charities. The lessons from the US (see some of Rich Demillo’s books) are very clear: this deficit is either made up from endowments or you have to raid the teaching funds. If you are a rich elite institution such as Stanford or MIT, endowments are there — and not just to support research, but also to support teaching. There are of course sources of funding to obviate this problem but they fail, hence the failed attempts of some universities to discourage applications to Wellcome, BHF or CRUK. Anybody concerned about medical teaching knows that teaching is at best tolerated, occasionally even praised, but frequently impoverished: the real business is the next REF. (If you doubt any of this, ask yourself why simple no-shows by staff timetabled to teach run at 10-20% in many medical schools). These issues are of course shared with much of the rest of the university, but medicine really is different simply because many staff have already lost half their time to clinical service. What is left is not enough to keep the lights burning in many of our student’s minds.

Are there solutions to this problem? I think there are, and many other countries provide lessons (but not a template) for how we can move things forward. The focus has to be not on teaching per se, but on reforming clinical academic contracts, as there is going to be lots of pressure from out with the universities to sort out exactly what value they provide to their undergraduate students. That will be the subject of another post.