Supplementary Response to Welsh Government Consultation on Medical recruitment

Swansea University

Respondent: Professor Keith Lloyd, Dean, Swansea University Medical School

Prepared for: Health Social Care and Sport Committee, National Assembly for Wales

Date: 28 February, 2017

Dear Sir / Madam,

Swansea University Medical School has already submitted evidence in response to the committee’s consultation, and to address core questions relating to the capacity of the medical workforce to meet future needs, the implications of Brexit, factors influencing recruitment and retention of doctors, the delivery of medical recruitment campaigns to date, and the extent to which recruitment processes are joined up.  

The committee have subsequently asked for my views on the evidence received to date from the range of organisations responding to the consultation, some of which relate to admissions to Welsh medical schools.

I understand that of particular interest and concern is evidence the committee has heard about apparent difficulties for Welsh students getting into Welsh medical schools, but being subsequently accepted to study medicine in England and low numbers of Welsh domiciled students being accepted to medical school in Wales.  The supplementary evidence given here seeks to address these points and also to provide further related information where this is thought to be useful to the committee’s considerations.

Context

Swansea University Medical School’s quality profile, student satisfaction and outputs are consistently good. At the point of qualification Swansea medical graduates top the UK survey for F1 preparedness.  After qualification, Swansea medical graduates are significantly more likely than their Cardiff counterparts to remain in Wales, to go into higher training in the UK, and to enter general practice. These findings come from the last three years’ data provided by the UK Foundation Programme Office. Elsewhere, the 2017 Complete University Guide and the Times & Sunday Times University Guide both rank Swansea among the top 10 medical schools in the UK. Last year the medical school was recognised at a UK level for its work towards gender equality by the award of Athena SWAN silver status.

Admissions to Welsh Medical Schools

The medical School focuses on Graduate Entry Medicine (GEM) which provides the quickest route for training doctors in Wales, with students graduating in 4 years, rather than 5 or, in some cases, 6 years.  GEM is a very popular course and each year almost 1000 applications are made to undertake study. Of these around 288 are interviewed by the University with between 175 and 200 being deemed appointable.  At present 72 new places are funded each year by the Welsh Government. 

As part of its strategy - and in support of the on-going needs of the medical workforce in NHS Wales reflected in evidence to the committee from almost all respondents - the medical school is keen to increase its GEM provision as well as other undergraduate and postgraduate places in subjects which are allied to medicine and life sciences.

We are taking a range of actions to support this ambition and to positively affect access to study medicine:

· We have recently introduced a pathway from our undergraduate degree programmes into the Graduate Entry Medicine programme. This is a significant attraction for applicants to our undergraduate degrees whilst also increasing the likelihood that our medicine graduates will stay and practise in Wales (having been here 7-8 years). Over 50% of UK applicants to our “feeder” B.Sc. degrees are Welsh-domiciled

· From this year onwards we are introducing a foundation year for the Applied Medical Sciences B.Sc. programme.   This will provide an alternative entry route for students who have the right level of qualifications but are without the required results at A-Level for direct entry onto the 3 year Applied Medical Sciences course (which then has a pathway through to the medicine degree) and will therefore contribute to the widening access agenda.

· We are creating a number of general modules that underpin or provide some component part of a variety of different undergraduate courses so that new, federalised programmes of study can be used to support a wider range of courses in subjects allied to medicine, and needed by the Welsh NHS.

These actions are part of the schools aim to work with health board partners to develop an end-to-end approach to education and training which can deliver against the workforce requirements of NHS Wales by educating tomorrow’s doctors and life scientists in a way that makes sure supply is matched with demand and graduates enter the workforce with a rounded understanding of how the NHS operates. Creating a better university offer, with a wider range of courses, more ways to access and move between them is a core part of this.

However, the process begins much earlier than university entry and I agree with the view of many others who have given evidence that more needs to be done to encourage and facilitate school age children in Wales to gain access to medical school.  To this end, the medical school already plays an active role in engaging with secondary schools and further education colleges and we are keen to build on this through working in partnership with health boards. This includes though the development of the Talent Bank approach being taken forward under the ARCH Programme. At the other end of the educational journey it is important to offer graduates and qualified clinicians the opportunity to continue their development through specialisation and/or academic opportunities.   The depth and breadth of the medical school’s offering in these areas are also being reviewed.

Welsh Domiciled Students

Each medical school sets its own entry criteria.  There is of course a balance to be struck between the level at which the ‘entry score’ is set and the potential of the applicant to go on to successful study and practice.  The setting of the score is therefore subject to regular and stringent review.  In this context it is worth noting that 49 students (of varying domiciled status) who were accepted on to the GEM course in 2016/17 only received an offer from Swansea.  At the same time we have a very low attrition rate for the course (c.1%) and have again come top of the NHS F1 Trainee Survey for overall preparedness to practice - as determined by students themselves.

Admissions data also shows that 80% of the Welsh domiciled students who were offered a place to study at Swansea in last year’s intake took up that place, with 100% doing so the year before.  The data also shows that in 2016/17, 4 students had 3 offers and chose Swansea and 1 student had 4 offers and chose Swansea. 

Whilst we do not hold direct information about where an applicant may go on to study if they are unsuccessful in securing a place at Swansea, the information above would suggest that we do well developing future doctors and that if there is an issue of Welsh domiciled students studying in England as a result of not securing a place in Wales, it is not as a result of Swansea Medical School’s admission policy.

I do however recognise the value of encouraging more Welsh domiciled students to study in Wales.  Students who study close to where they live are more likely to stay to practice after qualifying.  In Wales there are also other attendant benefits such as an understanding of the distinct health issues of an area and the likelihood that the individual will speak Welsh or at least have a sound educational basis from which to take up the language again.  By its very nature, GEM attracts older students who are even more likely to have responsibilities and ties to the area in which they live than 18-year old undergraduates.

Admissions data show that 32% of all students enrolled in GEM across all years of study in 2013/14 were Welsh domiciled which is in keeping with figures suggested by the Higher Education Funding Council for Wales and the Welsh NHS Confederation in their evidence to the committee (MR21 and MR 30 respectively).  It should be noted however that there are fluctuations in the number of Welsh domiciled students enrolling on the GEM course each year (the figure was 42% in 2010 for example).   Nevertheless, these fluctuations do not result in the current picture being as bad as Welsh NHS Confederation evidence goes on to suggest with 19% of the current GEM student cohort being Welsh domiciled (the confederation’s evidence suggest the current figure may be as low as 8-10%).  Meanwhile, written evidence to the committee from Dr Heidi Phillips (Director of Admissions for GEM Programme in the medical school) shows that of the 822 students accepted onto the course since it began in 2010, 28% have been Welsh domiciled. Dr Phillips’ evidence (MR28) provides further information on the origins and destinations of GEM students and I need not repeat it here.

More can be done however and the school is working to increase the number of Welsh domiciled students including through the introduction of contextual admission arrangements.  ‘Contextual admission' is a term used to describe the use of additional information, including school performance data and socio-economic markers, to provide context for individual applicants’ university applications and achievement. It is a process used by many UK medical schools and like many other institutions, Swansea University is working to increase participation and widen access in higher education by students with no previous family experience of university education and from disadvantaged groups. Each application is still considered on its merits to ensure fairness and consistency.  Such arrangements operate within current policies but allow discretion in the sifting of applicants once a minimum level of entry criteria (in part established through GAMSAT scores) has been met.

As set out in our previous evidence the school would also be supportive of ring-fenced places for Wales-domiciled students studying medicine or allied medical professions. Meanwhile a further relatively easy-to-introduce initiative would be a national programme of additional support for Welsh applicants who are considering medicine and which explains and demonstrates the interview process.  This would help prospective Welsh students who,in the experience of the school’s admissions team, are often not as well prepared as some of their counterparts from elsewhere even when their GAMSAT scores are similar.  

Retention

It is also worth noting the Wales Deanery’s view in their evidence (MR06) that Wales has generally retained two thirds of its medical school ‘output’ in part as a result of the quality of the training students receive.  This is a of course a subtly different point to Welsh domiciled students as here graduates may have originated from elsewhere in the UK or further afield.  Both quality of training and increasing Welsh domicile are however seeking to deliver the same end – the retention of qualified medical professionals in the Welsh NHS.  The picture on retention put forward by the Wales Deanery is supported by the Foundation Programme’s analysis of foundation places which shows that Swansea GEM students are more likely to remain in Wales than Cardiff graduates (62% to 54% in 2016).  Evidence submitted by Dr Phillips, and drawn from a questionnaire of all GEM students indicates that 67% of GEM students who studied at Swansea are still in Wales, further substantiating this picture.

However, graduates who train in Wales but then leave to work elsewhere are both a service and financial loss to NHS Wales.  This is why the school is introducing near-peer support for GEM students from F1 and F2 doctors as part of our student offering as an initial step in improving retention by ensuring that students are supported by people who have begun to work in the region.  The review of the school’s continuing professional development offering is also intended to be a component in an improved retention offering.

More widely, through involvement in the ARCH programme with ABMU and Hywel Dda University Health Boards we will also using our expertise to build on existing mentoring and development schemes to establish a more ambitious range of retention initiatives.  Furthermore, if the City Deal is supported, for example, there will be a substantial investment in health and well-being and life science centres across South West Wales, attracting students to train and stay within the region for the opportunity to experience new and cutting edge healthcare delivery environments and partnerships with the life science sector. 

Over and above these actions the school also proposed in its previous evidence that the repayment of student loans over a period of years post qualification for those students who remain in Wales should be explored as a retention incentive.  Packages which offer financial benefit in return for service have recently been introduced by the Welsh Government for those who take up GP specialty training in areas which have been hard to recruit to. Nursing bursaries have also been maintained on the understanding of agreeing to a two-year service tie-in.  Whilst there is of course on-going pressure on the NHS finances - including the funding of training and continuation of SIFT - the fact that the total system cost of training a GEM student amounts to approximately 114k over the 4-year course, means that there is potential for return on investment through targeted use of such any such package.

Finally, given the committee’s recent inquiries into the GP Workforce in Wales and into Primary Care, members may also wish to note that recent analysis of recruitment to general practice undertaken by the GMC shows that 29% of students who spent all 4 years studying GEM at Swansea entered General Practice.  This is in keeping with findings from the Foundation Programme whose analysis shows that Swansea graduates are more likely to enter general practice than Cardiff graduates in successive years at 31% versus 17% in 2014 and 43% versus 21% in 2015.

In conclusion, Swansea University Medical School welcomes the Health, Social Care and Sport Committee’s ongoing work on the subject of medical recruitment and feel we are well placed to assist in developing innovative solutions to respond to the challenges facing the NHS Wales though the continued redesign, education and training of the workforce.