John M Eagles Consultant Psychiatrist, Royal Cornhill Hospital, Cornhill Road, Aberdeen, AB25 2ZH
Email: john.eagles@gpct.grampian.scot.nhs.uk
SMJ 2005 50(4): 144-147
Introduction
The welcome recognition that more doctors are required in the UK has led to an increase in medical student numbers. Concomitantly, medical schools have been struggling progressively to recruit sufficient doctors into academic medicine. Within the NHS, some recent changes have given rise to a reduction in the time doctors may have to devote to undergraduate education. Responsibility for providing that education remains blurred between the universities and the NHS, and this combination of circumstances is likely to impact adversely on medical students. This paper will seek to briefly describe these and related issues and to explore how the NHS might help to enhance the quality of undergraduate education and training.
Difficulties within academic medicine
While descriptions of the scale of the difficulties have varied from “faltering"1 to “in crisis",2 there is no doubt that academic medicine has been struggling over recent years. An international working group has been convened and a campaign to revitalise academic medicine is underway.2-4 I shall outline some of the current problems in academic medicine and how these may impinge on medical student teaching.
Up to 20% of academic posts in the UK are currently vacant.5 Stewart1 has suggested that this is due in part to the uncertain career structure for young academics and gender inequalities among senior academics6 may constitute a disincentive to the growing numbers of female medical graduates. Loss of earning potential through private practice may be a discouragement to an academic career,1 although distinction awards are more commonly acquired by academics than by NHS consultants.7 Recruitment to academia is likely to be diminished by the unrealistic expectation that one might excel in all three areas of research, teaching and clinical practice.8 The Research Assessment Exercise (RAE) has also been blamed for erosion of morale among academics and for distortion of incentives away from teaching and towards research.
Around two thirds of the income of most medical schools arises on the basis of medical student numbers and only one third on average depends upon the RAE.1 While teaching income is received regardless of teaching quality, the RAE seeks to assess and reward university departments on the basis of the quality of their research. Although the RAE has its strengths, significant concerns exist about its objectivity and its fairness,9,10 and there is unanimity that it gives rise to a focus on research before teaching within university departments. The career success of an academic relates to his or her prowess in research, not to proficiency as a teacher; research raises the profile and income of a department, but teaching does not.
Unfortunately, while the campaign to revitalise academic medicine does mention teaching, research appears also to be a much more major focus therein; one BMJ editorial11 entitled “Reviewing academic medicine in Britain" started with the sentence: “Without high quality research there can be no high quality evidence on which to base effective health care". This paper went on to mention “research" on a further 16 occasions and the word “teaching" did not appear. Also, when academics talk about “training in academic medicine” this can seem fairly synonymous with training in research.12
In the light of these factors, it seems unlikely that the campaign to revitalise academic medicine, which is in any case envisaged to develop over several years, will give rise to improvements in undergraduate medical education in the near future. It seems more likely, in the words of Pritchard,13 that teaching may continue to be “relegated to a poor third when the need to educate tomorrow’s doctors and dentists has never been greater". Meanwhile, as Rahman14 has graphically described, both academics and NHS consultants may feel justified in shouldering a minimal teaching load and deciding that other aspects of our work should take precedence.
It will be argued below that the NHS might contemplate taking the initiative, adopting one of the possible options described by Lewkonia15 in his analysis of the relationship between medical schools and health services, and should assume lead responsibility for the education of doctors beyond the stage of the basic sciences.
Medical students in a changing NHS
Recently replaced by an updated document,16 the publication of Tomorrow’s Doctors in 199317 heralded significant changes in the training of medical students. Important alterations of emphases included keeping factual information to an essential minimum, bringing forward patient contact to earlier years of training and ensuring the acquisition of practical and communication skills. To many of us, these appropriate changes moved the balance further away from an academic learning model to one of a guided apprenticeship, and placed more responsibility on NHS doctors (both in hospital and primary care) to ensure that these changes took root. It seems probable that this has occurred; in 2000 Professor Sir Graeme Catto wrote that at least 70% of teaching was undertaken by NHS staff.8
Meanwhile, doctors working in the NHS may complain of progressively attempting to cram quarts into pint pots, with decreasing time in which to fulfil our increasing responsibilities. Decreasing time derives from European working time directives, consultant contracts and partial shifts. While clinical workloads certainly do not decrease, we are asked to give attention to audit, clinical governance, continuing professional development and appraisal. Modernising Medical Careers18 will give rise to reduced service provision by junior doctors and, presumably, to consultants who will be both busier clinically and attempting to provide the same amount of clinical training over a shorter period of time.
Our growing numbers of medical students might legitimately expect that NHS doctors have both the time and the expertise to teach, which may progressively entail the need for updating our skills in tandem with new methods and technologies.19,20 That is to say, we should anticipate devoting rather more of our time to teaching, within the above pressures and demands. Without something changing significantly, this may seem to resemble a mission impossible.
Medical Act monies
History
Additional Cost of Teaching (ACT) monies in Scotland are the equivalent of Service Increment For Teaching (SIFT) monies in England and Wales. This funding comes directly to the NHS to support the teaching of undergraduate medical students.
A full review of the origins and evolution of SIFT / ACT monies has been provided by Clack et al.21 I shall review these areas briefly, focussing on Scottish ACT monies.
ACT and SIFT monies came into being during the 1970s, in response to the fact that teaching hospitals were significantly more expensive to run than were non-teaching hospitals. It was assumed that this excess expense derived mainly from the presence of medical students, although ACT allocations also took account of the need to consider the increased complexity of case mix and the higher staffing levels of medical and paramedical staff in teaching hospitals. Certainly, hospitals in the four teaching health boards in Scotland experience higher levels of consultant staffing; Scottish Executive figures in 2003 indicated that the four teaching boards cared for 50.5% of the Scottish population and employed 63.0% of the consultant workforce.
At the outset, ACT funding was calculated on the basis of average differentials in cost between teaching and nonteaching hospitals. It became part of the core funding upon which teaching hospitals relied. The monies were not ring-fenced for teaching medical students and tended to be absorbed into generic budgets without any clear tracking system with regard to how the monies were being deployed. A small proportion was top-sliced by the teaching boards and used to administer, often through university infrastructures, some aspects of student teaching. Some monies followed the students to “non-teaching” health boards when medical students undertook clinical attachments outwith teaching board areas. A significant proportion has been directed more recently to fund teaching in primary care (see below).
However, the lion’s share (probably around 90%) of ACT monies has gone to support “clinical teaching” amorphously in teaching health boards. As above, much of this money presumably supports higher consultant staffing levels. This may well be regarded as entirely appropriate, since surely experienced doctors are the principal NHS resource required in the education of medical students.
General practice
With ACT monies arising as described above, primary care services found themselves excluded from this avenue of funding to support the training of medical undergraduates. From around 1980 some committed general practitioners mounted a campaign to right this inequity and to develop an appropriate academic teaching base in primary care.22 These protracted negotiations, described eloquently by Howie,23 gave rise to the first allocation of ACT monies to primary care in 1992.
Funding for teaching in primary care thus started with ring-fenced monies and a relatively blank sheet of paper. The funding also coincided with the logical movement of student teaching out of hospitals and into the community, where the majority of medical care is provided,24 and Bain et al25 have described the imaginative developments which occurred in Tayside, including the integration of undergraduate and postgraduate teaching. With clearly identified money following students, motivated teachers have been recruited in practices and in university departments, where academic general practitioners place much greater emphasis on teaching than do their counterparts in hospital medicine.26,27
Probably few hospital doctors would dispute the contention of Rees and Wass24 that “general practitioners have much to teach medical schools about effective ways of learning". Over the twelve years since this statement was published, and undergraduate education has moved further into community settings, the need for hospital doctors to look and learn has perhaps been accentuated. This possibility is certainly borne out by the comparison between the feedback from Aberdeen undergraduates upon their primary care and their hospital attachments.
ACT allocation proposals from NES
In 2004, NHS Education for Scotland (NES) assumed responsibility for managing medical ACT monies and, following a consultation process, produced new allocation proposals for ACT monies.28 Given the considerable ACT budget - £86.6M in 2004/5 – the effects of the proposed changes are likely to be wide ranging.
There is to be no major change in the overall amount of ACT monies and two large teaching health boards will essentially lose income in order to fund increases elsewhere. Changes are to be phased in relatively gently over several years, and those most cogent to the issues raised above are likely to be the following:
(a) ACT monies will follow students in a much more transparent manner, with uniform funding per student and with more monies going to primary care and directly to “non-teaching” health boards.
(b) In conjunction with regional planning teams, NES will introduce performance management arrangements, part of which will require health boards to submit satisfactory proposals for the use of ACT monies before additional funding will be disbursed.
In essence, the quality of teaching within the NHS may be meaningfully scrutinised for the first time and the more readily identifiable funding will, at least to some degree, become contingent upon the quality of teaching.
Summary of the main problems and issues
There appear to be four main difficulties:
1. Teaching is not a priority in either the Universities or the NHS.
2. Teaching by doctors is insufficiently recognised and rewarded.
3. Responsibility for specific aspects of student teaching is not clearly defined.
4. Teaching budgets do not clearly follow students.
How might the NHS respond?
For the reasons described above, it is illogical to envisage university departments contributing more than they currently do to undergraduate education. Especially if we agree that the need to educate the doctors of the future has never been greater,13 then this is surely a challenge to which the NHS should rise proactively. If altruistic motives do not lead to this conclusion, then the new arrangements for allocation of ACT monies may provide an alternative spur. I shall outline below some possible responses the NHS might adopt.
While universities continued to take responsibility for teaching the basic sciences and for student assessment, the NHS would take core responsibility for the administration and delivery of student teaching. As noted above, more than 70% of clinical teaching is provided by NHS staff8 and it is illogical to leave the administration in the hands of a minority provider. University departments are, of course, funded to teach students, and some resource transfer would be appropriate but it would be disingenuous of the NHS to claim that we are under-resourced to administer teaching; just 10% of the ACT allocation in 2004/5 is £8,600,000, which is probably sufficient in itself to administer clinical teaching across Scotland. With regard to the core responsibility to deliver teaching, ACT funding of the additional consultant posts in teaching health boards can be viewed in a similar vein, and there is no reason to think that university colleagues would contribute less than currently, particularly if measures described below were invoked with regard to the recognition of teaching expertise and commitments.
Very much as occurs already in general practice, specific NHS consultants in each specialty and in each geographical area should be allocated time and responsibility for clinical teaching. Within consultant contracts, at least half of these sessions should be construed as clinical care so that there is less competition for space within the few hours available for supporting professional activities. Managers wishing to preserve ACT monies may see this as a good investment. The role of these teaching consultants would include overseeing and supervising the administration of clinical teaching in their specialty. This would include logging and circulating within the specialty the teaching contributions of all consultant colleagues. It would be crucial for this teaching consultant to stay, or to become, abreast of advances in teaching techniques and technologies,19 and to have time to contemplate and to introduce innovations and refinements into the students’ courses. He or she would take a lead role in training junior staff with regard to “teaching the teachers to teach”. These measures, and the existence of the post in itself, should serve to raise the profile and importance of teaching within the NHS. This consultant would require administrative secretarial support and, perhaps with the assistance of a committee within the specialty, would have control of a teaching budget identified from within ACT allocations.
Additional cultural changes are required to elevate the status of teaching within the NHS. Allegedly, in some clinical departments it is almost laudable to be “too busy to teach the students”. Within the decision making process on distinction awards and discretionary points, and whatever may replace these, the importance of teaching contributions should be significantly upgraded both for NHS consultants and for academic colleagues. Concomitantly, logging of consultants’ teaching activities should inform the jobs planning process, with careful annual review of the appropriate amount of teaching hours in each consultant’s contract. As already mentioned, at least half of a consultant’s teaching commitments would helpfully fall under direct clinical care for contract purposes. If clinical departments remain genuinely unable to prioritise teaching among overwhelming clinical pressures then, in the context of national norms of workload, managers in receipt of ACT monies would be expected to address this understaffing situation. If this can not be achieved, student teachers and ACT funding could be moved elsewhere.
The advent of Modernising Medical Careers has given rise to the planning of runthrough training and provides an opportunity for all specialties to introduce new elements into training programmes. The acquisition of teaching skills, for both future general practitioners and hospital senior doctors, should become part of training requirements. While we see it as necessary to teach communication skills, practical procedures and research methodology, it is entirely illogical to anticipate that doctors will acquire skills in teaching by osmosis or by absorbing skills from senior doctors who have not themselves been taught how to teach. For these uneducated seniors, continuing professional development sessions may have to suffice.
As the new ACT allocation proposals take root, it is greatly to be hoped that, as in primary care, ring-fenced teaching budgets will progressively follow students into hospital specialties. As part of the ACT performance management process, it is to be presumed that student feedback will attain a position of increasing importance. Ahead of that time, the NHS may wish to contemplate whether we can listen and respond proactively to the views of our consumers of undergraduate education.
ACKNOWLEDGEMENTS: I am grateful to Drs. Sheila Calder and Sam Wilson for their comments on the first draft of this paper. Lana Hadden did the secretarial work. DECLARATIONS / DISCLAIMER: JME chairs the Royal College of Psychiatrists’ Scottish Division Undergraduate Student Teaching And Recruitment Group (S-DUSTARG) but the views expressed in this paper are explicitly his own and do not seek to represent those of the Royal College of Psychiatrists.
REFERENCES
1 Stewart P M. Academic Medicine: a faltering engine. Br Med J 2002; 324: 437-8.
2 Clark J, Smith R. BMJ Publishing Group to launch an international campaign to promote academic medicine. Br Med J 2003; 327: 1001-2.
3 Tugwell P. Campaign to revitalise academic medicine kicks off. Br Med J, 2004; 328: 597.
4 Wilkinson D. ICRAM (The International Campaign to Revitalise Academic Medicine): agenda setting. Br Med J 2004; 329: 787-9.
5 MacDonald R. Survey shows serious shortage of medical academics in the UK. Br Med J 2002; 324: 446.
6 Ioannidis J P A. Academic medicine: the evidence base. Br Med J 2004; 329:789-92.
7 Lambert T W, Goldacre M J, Vallence E, Mallick N. Characteristics of consultants who hold distinction awards in England and Wales: database analysis with particular reference to sex and ethnicity. Br Med J 2004; 328:1347-52.
8 Catto G R D. Interface between university and medical school: the way ahead? Br Med J 2000; 320: 633-6.
9 Tomlinson S. The research assessment exercise and medical research. Br Med J 2000; 320: 636-9.
10 Williams G. Misleading, unscientific and unjust: the United Kingdom’s research assessment exercise. Br Med J 1998; 316: 1079-82.
11 Goldbeck-Wood S. Reviving academic medicine in Britain. Br Med J 2000; 320: 591-2.
12 Savill J. More in expectation than in hope: a new attitude to training in clinical academic medicine. Br Med J 2000; 320: 630-3.
13 Pritchard L. From the wards to awards. Med Educ 2004; 38: 236-8.
14 Rahman A. Teaching students – whose job is it anyway? Br Med J 2005; 330: 153.
15 Lewkonia R. The functional relationships of medical schools and health services. Med Educ 2002; 36: 289-95.
16 General Medical Council. Tomorrow’s doctors: recommendations on undergraduate medical education. London: GMC, 2003.
17 General Medical Council. Tomorrow’s doctors. London: GMC, 1993.
18 Department of Health. Modernising Medical Careers. The response of the four UK health ministers to the consultation on Unfinished Business: proposals for the reform of the senior house officer grade. Department of Health: London, 2003.
19 Benor D E. Faculty development, teacher training and teacher accreditation in medical education: twenty years from now. Med Teacher 2000; 22: 503- 12.
20 Anonymous. More medical students, more stress in the medical education system. Med Educ 2004; 38: 460-2.
21 Clack G B, Bevan G, Eddleston A L W F. Service Increment for Teaching (SIFT): a review of its origins, development and current role in supporting undergraduate medical education in England and Wales. Med Educ 1999; 33: 350-8.
22 Howie J G R, Stevenson J S K, Hannay D R. The Mackenzie Report: general practice in the medical schools of the United Kingdom. Br Med J 1986; 292:1567-71.
23 Howie J G R. Patient-centredness and the politics of change. London: Nuffield Trust, 1999. 24 Rees L, Wass J. London after Tomlinson: undergraduate medical education. Br Med J 1993; 306: 258-61.
25 Bain J, Scott R, Snedden D. Integrating undergraduate and postgraduate education in general practice: experience in Tayside. Br Med J 1995; 310: 1577-9.
26 Lee P, Goldacre M. Views of general practitioners in academic posts about careers in academic general practice: a national survey. Educ Prim Care 2002; 13: 465-71.
27 Hilton S, Carter Y. Academic careers in general practice and primary care. Med Educ 2000; 34: 910-5.
28 NHS Education for Scotland. Medical ACT direct costs: allocation proposals from 1 April 2005. NES: Edinburgh, 2005.