1. Introduction of Participants

Name - Role - Initials

Colin Elton - Chair - CE

Daren Francis - Colorectal Surgeon - DF

Professor Anthony Warren - Dean Bart’s Medical School - AW

Professor Derek Alderson - Previous President of Royal College of Surgeons - AD

Phil Martin - Assistant Director, Education Policy, GMC - PM

Sanjeev Ahluwalia - Postgraduate Dean (London) , Health Education England - SA

Megan Annetts - Past President Bart’s and The London Students' Association - MA

Shonnelly Novintan - President UH MedGroup London - SN

Gurdas Singh - Co-Chair, BMA Medical Student Committee - GS

Professor Bijen Patel - Director, Bart’s Cancer Institute - BP

2. Background

CE: Following a Webinar in July this year, it became apparent that there is a need to shake up the curriculum for medical students throughout the UK.  Financial problems and mental health problems abound in high percentages: 60% of medical students experience financial pressures with 70% experiencing mental health pressures.  We suggested, and there was general agreement from the Webinar, that we could form a Focus Group, exploring either an apprenticeship or a paid internship in the final year of medical school as a possible way forward to meet the future challenges of doctors, to create a more practical year where the deficiencies in practical ability could be met, and to help solve the problems with finances.  I had sent out documents to all of you, summarizing the differences between apprenticeships and internships.  Shonnelly and Megan have put together a diagram to illustrate their views on this final year paid internship.  So, over to Shonnelly. 

SN:  The priorities for the final year were summarized by sharing the attachment: Priorities of the Final Year.   The GMC sets out the number of clinical hours that students must cover. It is also important that students use their final year to consolidate their knowledge.  Apprenticeships have a 5 year duration whilst internships comprise 4 years of medical school plus an employment internship for one year to prepare student for medical life, with an emphasis on learning and clinical skills.  

3. Apprenticeships Vs Internships

CE: Is it a matter of one or the other? Isn’t it true that you cannot realistically have both.

PM: A blended model cannot exist.  Apprenticeships or internships must be offered, not both, as different people are involved in each and different finances are required for each. Internships may not even be paid – and this is one of the main incentives of an apprenticeship over an internship.

SA:  Discussions are underway on this subject and HEE are developing an apprenticeship route for undergraduate medicine, in partnership with employers.  The aim is to make an application to the Department of Education for approval and to include the GMC in these discussions. If granted, work will be required with employers to develop ‘earn and learn’ opportunities.  The benefits of apprenticeships are to improve diversity and inclusion of medical students.  

GS: There are negotiations between the UK and the EU over the hours students work.  International students are just as likely to be offered employment as UK ones.  There is no longer a priority for UK students, as was the case previously.  A four year course may not satisfy the required amount of hours a medical student needs to cover.

SN:  Medical students in Cardiff in their final year of medical school are offered shadowing opportunities in local Trusts in a role that they will eventually take over as junior doctors.  Once in post, only a small number leave. This is deemed a successful system.  Final year exams take place at the end of year 4 and are within the placement.

AW:  Apprenticeships have strict rules and we are hoping these may be varied for Medicine.  For four-year graduate-entry courses, hours accrued as undergraduates are counted towards final exams – although this model was not universally accepted in Dentistry.  There is still a lot of medical information to learn in the final year and students might lose much of the opportunity to acquire this if they were employed.  This might not be the ideal way forward.  Support preparing for practice is definitely needed but not at the expense of adequate academic training in Final Year 5.

CE:  Internships can be multi-faceted, not just offering practical experience but also including the basic education that will form the scaffolding for understanding medicine.  I agree that a lot of background learning must still take place, but this year can be structured well to meet the education and practical challenges. 

BP:  The internship model being discussed will be challenging and we do not want to lose the basic science.  Is there room for a hybrid model?

SA: Any apprenticeship programme will be for the whole undergraduate programme. Assistantships or internships are geared towards preparedness for work.  UK students are leaders in terms of gaining practice but they also need to gain knowledge of how to work within the NHS.  It is sometimes hard to make that transition.  The GMC have data from F1 doctors which demonstrates the proportion who feel adequately prepared for the spread of variety at work. As an example, Imperial Medical School is looking at its final year curriculum and reshaping it to introduce greater elements of preparedness for work.  The question of a paid assistantship is an interesting one. 

DA:  There used to be a system whereby a student could receive ‘acting up’ pay and this preparedness is key in the final year.  As far as the internships idea, a healthy mix of education and sufficient clinical experience with patients is needed.  I struggle with the notion of apprenticeships as students cannot chop and change as the course progresses. The internship model could be used and with some remuneration offered – a hybrid solution. 

MA: Using my own experience as a final year student, if some students are able to ‘act up’ and others not, are there noticeable differences? Informal feedback shows little difference.  But the Cardiff model is so successful because students continue to work in the local, familiar area and those who found it most useful stayed working within the same Trust.  This all helps with confidence building.  Priorities for the final year are indeed to gain clinical skills, but also to gain the ability to bring together management plans etc. For the first time, some final year students are doing this in a shadowing format.  Being on call as a student means being confident doing that same role as a doctor and students were allowed to use their medical school knowledge.  One Trust opted for some medical students to take over as Healthcare assistants, as this proved more economical than using bank staff.

CE: To summarise then, the final year needs restructuring and must include preparedness for work and consolidation of theoretical knowledge.  However, how is this year going to be funded?  Universities are already under financial pressure.

AW: University income is decreasing as (due to COVID) there are fewer International students.  There is a fear that some universities may not even survive.

CE: Funding cannot come from Universities then.  Any ideas as to where this revenue can be sourced?

SA: It is the HEE that funds placements, not Universities.  Plus, let us remember that the end of medical school exams are very important.

CE: This means paying for the final year.  Who would pay for this?

SA: HEE currently pays a placement tariff for undergraduate placements to providers. What matters most is the content of the final year.

CE: The content is extremely important but there is a major issue of financial pressure in medical school.  Paid internships would relieve this pressure.

SA:  COVID has created the opportunity to think differently about everything we do. It would be useful to hear about ideas that people have to innovate. 

CE:  HEE funds are government resources.  Do we have government support?

AW:  There may not be any funds from the government, especially after COVID-19.  More creative approaches have been sought over the last couple of years and this will need to continue.  Government buy-in is needed to expand numbers and participation through HEE and the GMC.

SN: What is the financial source and what are the expectations when this idea is pitched?  Important priorities would be to serve the NHS, help with workload and make clinical decisions.  It is a fine balance.

CE:  Is there the possibility for medical students to help shape this final year.  They are the ones going through the system and the ones who have the current practical knowledge of what works well for them.

AW:  The student voice must be included.

SA: Proper engagement and a pilot model are needed to do this properly.  Also remember that learning does continue after medical school.  But, as this is public money, we must also carefully consider how the funds will be spent.

CE: Will the funds be used to attract more medical students?  At a recent webinar a Conservative MP on the Health Select Committee was very supportive of the concept of an internship year.  However, he explained that, as so many industries have suffered during Covid, there are so many other priorities.  I did explain that during Covid, everything was locked down, except for Healthcare, showing that health is still the most important issue and above everything else.

SA:  There will be no new funds.  We must re-prioritise and conversations are already taking place.

DF:  On listening to the debate, it is apparent how much thought and effort is being invested.  The work being done sounds wonderful.  Nothing controversial!

BP:  We must learn from engineering colleges, who are currently debating this same topic.  They did the fundraising first, then set up engineering colleges to deliver the graduates.  We should also look to liaise with new and existing Universities.

CE: We will need to be creative with the funds! It is exciting if this could be created and piloted.  By being a pilot, changes can and will be made.  We also need to source the required funding.  

SN: Will the money be used to offer medical students flexibility to, for example, pay 10% less and work in part?

SA: For your information, the tariff for a medical student placement is around £35,000.  There are opportunities to review this and work out if funds raised could be used to offer flexibility.  Placements for multiprofessional learners, are by contrast, around £3,500. This is a significant discrepancy. 

DA:  Please note that the London template may not work across the rest of the country, where there are many variations.  Information from other medical schools in the country needs to be reviewed to see what progress has already been made.

SA:  And to see what has already been done.

CE:  Thank you to everyone.  The minutes from today’s meeting will be circulated to everyone in the Focus Group before it is published.  To wrap up and in summary: 

• The next steps are to formulate the idea of a final (medical student) year paid internship which incorporates education, clinical skills and service.  Such an internship needs to be piloted. 

• Resources need to be provided.

• The progress will be fed back to those involved in the Focus Group.