Medical Students

Andrew Smith Excerpts

Tuesday 3rd May 2011 Westminster Hall

[Mr Andrew Smith (Oxford East) (Lab)]

It is a pleasure to have this debate under your chairmanship, Ms Dorries. I am very pleased to have the opportunity to raise some key issues about the funding of medical students. Aspects of the upheaval in higher education funding are, of course, important both for the recruitment of doctors and the availability of opportunities to study for the medical profession. They are of particular concern in my constituency, which is home to 1,000 undergraduates and 1,300 postgraduates in medical sciences. I am grateful for the briefing that I have received on the matter from the British Medical Association and the Oxford university medical sciences division, as well as for the concerns that constituents have raised with me on these issues.

At a time when higher education as a whole faces the challenges and dangers of the 80% cut in university teaching support and the trebling of fees, concerns about the costs of and access to medical education are all the greater. The length and intensity of medical courses both add to the cost to students and limit their opportunity to supplement their income through paid work.

The BMA estimates that, under the present system, medical students graduate with some £37,000 of student debt. With all universities charging or set to charge £9,000 for medical studies under the new regime, the BMA estimates that that figure will go up to around £70,000. That does not count overdrafts, credit cards, professional loans or family borrowing. We do not need to exaggerate the impact of prospective debt on students’ choices to be concerned that debts of £70,000 or more might be a barrier to able people from poor—or, indeed, middling—backgrounds who are considering entering the medical profession.

My concern is about the funding position facing all medical students. However, on the challenge facing us on widening participation, there is likely to be a triple impact on entry to medical studies. The A-level admission grades are understandably particularly demanding and poorer students from schools serving poorer areas are less likely to achieve them, which clearly demands further action within the school system. The requirement of medical work experience is also likely to be harder to fulfil for school students from financially hard-pressed families or, indeed, from families with no connections to the medical profession. At the same time, the prospective length and costs of study are considerably higher and it seems plausible that those are also having an impact on the relatively low rates of admission to medical studies from poorer socio-economic groups.

Statistics on admissions show that the wider challenge of opening up access to higher education is certainly compounded in the case of medical studies. The BMA equal opportunities committee report published in October 2009 includes a review of UCAS data. It states:

“The proportion of acceptances to medical school coming from socio-economic class I (31%) was almost twice that of acceptances to all other degrees from class I (16 %). Just 15% of students accepted into medical school came from the four poorer socio-economic classes (grades IV to VII) compared with 24% of students accepted to all degrees.”

The BMA has also said:

“The percentage of students from lower income families is slowly improving across the higher education sector but the rate remains stagnant in medicine.”



In the light of all that and the Government’s stated commitment to widen access to higher education, I would like to ask the Minister what the Government’s specific proposals are to widen the pool of talent entering medicine and whether the Government, in bringing forward the higher education White Paper, will look at the likely special factors at work in relation to medicine? I have listed some of those.

Will the Government also consider the advice and support given to able students in school, the necessity and operation of the work experience requirement and the £75 cost of the UK clinical aptitude test used as part of the selection process? That test gives an early signal to students from poor backgrounds that studying medicine is an expensive undertaking.

An important part of overall support for medical students is the provision of bursaries. As the Minister will be aware, the future shape of those has been uncertain for some time. The previous Government consulted on options for change in 2009, and last month the present Government set out new options for reforming the system.

[Nicola Blackwood (Oxford West and Abingdon) (Con)]

As I represent the other half of the Oxford university seat, the right hon. Gentleman will know that I share many of his concerns. In the light of his valid concerns about equal representation among medical students, does he agree that now is the crucial time to decide about the NHS bursary scheme, given that many students are deciding which courses to apply for?

[Mr Smith]

I am grateful to have the support of my colleague. I might describe her constituency as covering the other third of Oxford university. Her support on that point is very welcome. I was about to say that people are already asking what the situation will be, and obviously the sooner they can have certainty, the better.

The BMA has joined other bodies in consulting on the issue, and I understand there is some expectation that agreement will be reached. However, one big outstanding question is whether the new proposed bursary arrangements will cover tuition fees in the same way as they are covered now, with the Department of Health paying the fees for years 5 and 6 of an undergraduate course. If the bursary does not cover fees—it seems extraordinary that Ministers have not yet made the Government’s position on that clear—medical students would obviously face still higher costs and debt.

As my colleague and friend the hon. Member for Oxford West and Abingdon (Nicola Blackwood), whose constituency represents the other third of Oxford university, says, mounting urgency on that matter arises because would-be applicants worry about how the arrangements will work for 2012-13. I press the Minister to give an undertaking that tuition fees for medical students will be covered at least as well as they are now.

[Dr Sarah Wollaston (Totnes) (Con)]

The other point that needs to be made is that many of these courses are for six years, not just five. We need to take into account the cost of living expenses and the fact that many medical students have to take out commercial loans in addition to student loans, which makes the matter especially significant. I declare an interest as the mother of a medical student on a six-year course.

[Mr Smith]

The hon. Lady will know all about the matter. That was a very well made point. I will come to the subject of commercial loans later.

I also want to press the Minister on the position of graduate-entry medical students. That is an even more important route of entry than the 10% of total numbers that they represent suggests. The BMA has pointed out to me that its 2009-10 medical student finance survey shows that a higher proportion of students from poorer socio-economic groups enter medicine through graduate-entry courses than do so through undergraduate courses. Oxford university medical sciences division has pointed out to me that the best graduate-entry students are extremely strong and do exceptionally well. That route into medicine is important both for excellence and widening access.

[Jim Shannon (Strangford) (DUP)]

The pharmaceutical and medical sectors of industry have clearly made many financial commitments to a number of universities across the whole of the United Kingdom, including at Queen’s university, Belfast. Does the right hon. Gentleman think that the pharmaceutical and medical industry could do more to help poorer students with tuition fees?

[Mr Smith]

A number already do, and of course we are grateful to those who give support directly, or through foundations and trusts. If more could be given, that would be very welcome. As the hon. Gentleman says, whether in Northern Ireland or elsewhere in the UK, the contribution that spin-offs make to our economy, as well as the direct benefits of investment in medicine, is enormous. Those who benefit from that in profit should put extra back.

The point that I was making about graduate-entry medical students is that they are not eligible for loans to cover tuition fees and have to find first year fee costs out of their own pocket or from other sources of help, some from specific university bursaries. If graduate-entry students had to raise £9,000 for their first, and maybe subsequent, year fees, on top of the debts that they would have already accumulated as undergraduate students, that might be prohibitively expensive and inflict real damage on the quality and social range of graduate-entry medical students. What assurances can the Minister give on graduate-entry student funding? Will there be additional help for first year fees in light of the increase? Will tuition fees for subsequent years be supported by the Department of Health at the new, higher rate?

Another concern, which relates to the point made by the hon. Member for Oxford West and Abingdon, regards graduate-entry students who may no longer have access to some of the loans for professional development that have been made available by commercial lenders. The BMA has cited the recent decision by banks such as NatWest to withdraw those loans, which were obviously hugely important for graduate students who were ineligible for tuition fee support. Will the Minister make representations directly to the banks and to the Chancellor of the Exchequer, who might usefully underline that this is an especially important area for us all to be in it together in doing what we can for graduate medical entry?

All in all, there are big challenges facing prospective medical students. Yes, demand for the courses is high, and it is good for patients, science and the economy that so many of the brightest want to study medicine, but we cannot be complacent. It is vital that people from all backgrounds are encouraged and helped to fulfil their potential in medicine when they have something good to offer.

I would like to thank and praise the work of access officers, at Oxford university and elsewhere, who are working hard to reach out to schools and students who have not in the past thought of Oxford, and to raise aspirations and challenge prejudice. A very good example is the university of Oxford’s UNIQ summer school—it is unique, I think, but it is called UNIQ too—which is a programme of free residential courses in July and August for year 12 students from UK state schools and colleges.

The summer schools are targeted at academically talented students whose school or college has little or no history of making successful applications to Oxford. Participants follow a week-long academic course designed and taught by Oxford lecturers and tutors, as well as taking part in social activities and meeting up with alumni of the university and current students.

In its first year, 69% of UNIQ summer school students went on to apply to Oxford and 27% were given conditional offers by the university. I understand that the medical strand of that initiative has attracted a lot of state school applicants, and that the conversion rate to application and the offer of an undergraduate place in medicine is very good. That shows what can be done. Let us, through the funding arrangements for medical students, make the job of those promoting access arrangements easier, not harder.

This country can be very proud of the quality of education, training and research in medicine, and the scale of achievement in my constituency is awesome. We all want to see the most able people, regardless of background, working in the profession. Criteria for admission and the judgment of would-be students’ potential must, as with the assessment of their progress and qualifications, be matters for the medical schools and universities, not the Government. The Government have a clear responsibility to act and open up opportunities to ensure that there is the right advice and support, to raise school standards and aspirations, to remove barriers and to fund medical students fairly. I look forward to hearing from the Minister on whether and how the Government intend to set about that.

--- Later in debate ---

[Mr Smith]

Will the Minister come on to the specific questions that I asked about bursaries, both for undergraduates and those on postgraduate entry?

[Anne Milton]

I am happy to—so that the right hon. Gentleman does not feel I am ducking his questions, I will deal with them once I have finished with the deaneries.

We want to retain and build on the important functions of deaneries as we build the new framework for education and training. We know how important that is, because any transition not only makes the participants feel nervous but is a significant operation for any Government. The transition is when we can let the baby slip out with the bath water.

The right hon. Gentleman raised the issue of bursaries in particular, but I have to disappoint him, in that I cannot make an announcement today. We are acutely aware how long awaited it is. No one could be more frustrated than me with the slowness of government at times, but it is important that we get it right. I thank my hon. Friends the Members for Oxford West and Abingdon (Nicola Blackwood) and for Totnes (Dr Wollaston) for their contributions. My hon. Friend the Member for Totnes also raised the issue of some of the indirect costs of training, to do with the length of the course. We will be making announcements soon but, as I said, it is important that we get it right and that we involve other Departments.

The right hon. Gentleman also asked if I would make representations via the Treasury to other organisations about supporting training schemes. It is important that we continue to do that—perhaps we do not see enough of that in this country. At this point, I should mention that Julie Moore, the chief executive of University Hospitals Birmingham NHS Foundation Trust, is leading some of the work we are doing with the NHS Future Forum, as part of the ongoing listening exercise on the health reforms. Julie will continue the debate started in the consultation, so there will be further opportunity for input. I urge him and the other Members present to get involved, to ensure that their views and the particular issues faced by medical students are taken on board.

Our responsibility is held jointly with the Department for Business, Innovation and Skills, so the right hon. Gentleman should ensure that any comments made today also go as directly to it. The two Departments are working closely together, so that the specifics of medical education can be recognised.

[Mr Smith]

I wanted the assurance that, as part of the Department of Health’s collaborative work with the Department for Business, Innovation and Skills, the long-awaited higher education White Paper, which it would have been better to have had before the fees increase rather than after, will address the specific position, challenges and opportunities of medical students.

[Anne Milton]

Very much so. To some extent, the health of the nation rests on the skills of the professions that deal with the consequences of poor health. Medical students and doctors are part of that, so it is important that we get the system right. We need to maintain a competitive edge if we are to continue to produce medical graduates of the highest calibre. We shall not fail in our duty to make representations to other Departments, although working together is not always as easy for government as it sounds. However, we have made significant progress, and I think our words are being heard loud and clear.

As the right hon. Gentleman knows, universities will be able to charge a basic threshold of £6,000 a year for courses, and up to £9,000 a year for some, but subject to much tougher conditions on widening participation and fair access, which he mentioned in particular. There are still many such challenges, not only for universities but for our education system and at a wider societal level, if we are truly to get participation as wide as it can be. We need to look at all sorts of other drivers in the system directing young people to their choices.

We are shifting the balance of contributions from taxpayers to graduates, who benefit most from higher earnings over the course of their working lives. It is important to recognise that, after medical students have gone through the system and become consultants, they are probably among the top few percent of wage earners in this country. Contribution from them, therefore, is important. For poorer students, who might feel that the burden is too high, there is a balance or tipping point at which active participation in a fees scheme becomes a barrier. We have done a lot of work to ensure that that is not the case, and we continue to do so.

Many of the subjects associated with medicine cost more to teach, and we want a system in which anyone with the ability can access university and study such courses without being put off by the cost. That is why we will continue to provide additional funding for science, technology, engineering and medical courses.

The NHS bursary, which is in recognition of the length of time it takes to study medicine, will continue, helping students with their tuition fees and supporting those from low to middle-income families—sometimes, the middle-income families get squeezed in the middle. We have undertaken a review of the bursary, and will make some announcements shortly. In the review, we considered the views of the British Medical Association, which played an active part, ensuring that the perspective of medical students was considered.

In addition to the NHS bursary, last year an additional £890 million were invested by the NHS to provide clinical placements to medical students, ensuring that NHS providers continue to deliver high-quality clinical placements, which are an important part of such training.

The central investment in 2011-12 is £4.9 billion, a 2% increase on 2012-13. It is important that the funding mechanisms provide the right incentives and allow funding to be transparent, to drive quality and to be value for money, supporting a level playing field between providers. Any bursary schemes included should be easy to use and to access—sometimes, the mechanisms by which one can get support are only available to those at the top end of the IQ scale, because they are so complicated. Such complexity can be another significant barrier.

Current funding for clinical education and training is based on local agreements between strategic health authorities and providers. It can result in inequities in the funding of similar placements in different parts of the country. To resolve that, we have been working with others to develop proposals for a tariff-based approach to clinical education and training funding. Such tariffs would enable a national approach to funding all undergraduate clinical placements, including placements for medical students, as well as postgraduate medical training programmes. That will support a much more level playing field between providers. The variation in current funding arrangements means that the introduction of tariffs would have a bigger impact on some providers than others.

Paediatric Cardiac Surgery

Andrew Smith Excerpts

Wednesday 7th July 2010 Westminster Hall

[Liz Kendall (Leicester West) (Lab)]

It is a pleasure to serve under your chairmanship, Mr Benton, and to have secured this debate on the Government’s review of children’s heart surgery.

I am sure that Members in all parts of the House agree that children who need heart surgery should have the best-quality care. Outstanding treatment is provided in many parts of the country, including at the congenital heart centre at Glenfield hospital in my constituency. My first visit as the new Member of Parliament for Leicester West was to the centre. I met staff in the paediatric intensive care unit, which is the seventh busiest such unit in the country, and staff on the children’s ward and from the cardiac nurse liaison team, seeing for myself the excellent professional and high-quality care that they provide.

I also talked to parents about their experiences, and they spoke about their shock at discovering that their child had a congenital heart problem, their fears about the operation and other procedures, and whether their child would survive. They talked about how they were coping with having a very sick child at the same time as holding down a job and looking after other children, particularly if they lived a long way from the hospital, as many of the parents do. Above all, however, they talked about the excellent care that they receive at Glenfield and about how the help and support from the doctors, nurses and other staff is second to none. I am proud to have Glenfield’s congenital heart centre in my constituency, and I express my gratitude to all the staff for their excellent work.

Although excellent care is already available in many parts of the country, experts in children’s heart surgery have for some while argued that change is necessary, to ensure that all children get the highest-quality care. Those experts include the Royal College of Surgeons, the Society for Cardiothoracic Surgery, the national clinical director for children, young people and maternity services, and the NHS medical director.

Children’s heart surgery is complex, and is becoming ever more sophisticated. Technological advances mean that care is becoming increasingly specialised, capable of saving more lives and improving outcomes for very sick children. Many clinicians, however, argue that services have grown up in an ad hoc manner and now need to be better planned to ensure that all care is safe and sustainable, and that surgeons need to treat sufficient children and have sufficient variety in their case load to be skilled and experienced enough to deliver care of the highest quality. They further argue that that is likely to require fewer and larger specialist centres. I have always believed that when changes in hospital services are necessary to improve patient care, we should have the courage to make them happen. I therefore welcome the review, which was initiated by the previous Government.

However, we need to ensure that the right principles and criteria drive the review, the right balance is struck, the right weight is given to the different criteria and principles, and the views of parents and families are properly heard. The Government document “Children’s Heart Surgery: The Need for Change” sets out four key principles to guide the review:

“High standards. All children in England who need heart surgery must receive the very highest standards of NHS care, regardless of where they live… Personal service. The care that every centre provides must be based around the needs of each child and family… Local where possible. Other than surgery and interventional procedures all relevant treatment should be provided as close as possible to where each family lives… Quality. Standards are being developed and must be met to ensure that services deliver the best care.”

I want to say more about those principles. My first point is about the number of surgeons and of patients required in each centre to ensure that all children receive the best possible care. “The Need for Change” stresses that each unit needs enough surgeons to provide care 24/7 and to avoid surgeon burn-out in this complex and demanding field. It questions whether units with two or fewer surgeons can achieve that goal, and states that four surgeons is “the magic number.”

The document also emphasises that surgeons need to treat enough patients and have a sufficient variety of cases to get the skills and experience they need, and to ensure that junior doctors have the best training. I fully accept the review’s concerns about units with two or fewer surgeons, but from talking to clinicians I understand that the clinical evidence on the optimum number of surgeons and the precise number of patients a centre should treat a year is the subject of some discussion, both in this country and internationally.

The centre at Glenfield hospital provides care 24 hours a day, seven days a week. It has three surgeons, treating about 300 cases a year. The staff in the centre are determined to continue to improve the quality of care that they provide, and are planning to appoint a fourth surgeon in the next few months and increase the number of operations to more than 400 a year. Nevertheless, Glenfield hospital and my local primary care trust are very clear about the fact that the centre already delivers high-quality, safe and sustainable care.

Wider clinical issues also need to be considered by the review. Many children who need heart surgery often have other complex conditions, so the review needs to consider the range of surgical and other specialties available in hospitals with children’s heart surgery units, and look at how they all link together. Glenfield deals with congenital heart defects in babies, and follows them through childhood and into adult life. Staff and patients say that that continuity of care is a crucial factor in delivering high-quality, personalised services, and it will become increasingly important as survival rates improve.

Glenfield is also the busiest of four ECMO centres in the UK. ECMO—extra corporeal membrane oxygenation—allows blood that has been drained out of a patient’s body to have the carbon dioxide removed and oxygen added before being returned to the body, thereby allowing the heart and lungs to rest and recover. Because of its ECMO facility, Glenfield can provide complex thoracic, or chest, surgery in children, especially for those who also have cardiac problems, as well as cardiac surgery for children who have reduced heart or lung function and who otherwise might not be able to have heart surgery, or recover.

Glenfield is the only centre in the country that provides ECMO for patients of all ages, from newborns to adults. It treated 180 patients last year, including 50 swine flu patients. ECMO is provided by the same staff who work in the congenital heart centre, so if the centre closed, Glenfield would lose its ECMO service too—a service used by patients across the country.

Another issue that the review must fully consider is access to care. “The Need for Change” says that most parents would travel long distances to ensure that their children got the best possible care. That is true. Parents would travel to the ends of the earth if they had to. Many parents whose children need heart surgery are, however, already travelling very long distances. Glenfield’s centre serves the entire east midlands, with outreach clinics in Nottingham, Derby, Mansfield, Peterborough, Boston, Grantham, Lincoln and Kettering.

[Mr Andrew Smith (Oxford East) (Lab)]

I congratulate my hon. Friend on securing the debate. I know that the time available is limited, but I wish to underline the importance of the point that she has just made in relation to our own heart centre in Oxford. It is critically important that there is close liaison and consultation with the parents whose babies are affected and who are campaigning to save the centres.

[Liz Kendall]

I agree absolutely with my right hon. Friend. Many parents and staff are rightly concerned about the implications of travelling longer distances, particularly in emergencies.

I am a former director of the Ambulance Service Network, and I know that paramedics are highly trained professionals—increasingly to degree level—who can provide lifesaving treatment for patients while taking them to specialist centres further away, but that is not always possible, and the review must thoroughly consider the implications of further travel for the lives that could and will be saved.

High-quality care is not just about standards of surgery, the links with other specialisms or the ability to access planned and emergency care. A recent event organised to discuss children’s heart surgery in Leicester was attended by more than 800 parents and former patients, and those present felt that many more people would have attended if the event had not been held mid-week and during working hours.

The families said that the help and support that they get from the nurses, doctors and other staff at Glenfield are outstanding, and the key point that came up time and again was the excellent communication and support provided by the centre. Parents spoke about how staff go the extra mile to explain diagnoses and procedures simply and clearly, often at a frightening and worrying time. Every child gets a diary that explains in a way the whole family can understand what care they have received. It provides something for the children to look back at when they are older.

Parents said that the staff were like members of their own family; they could ring them day or night if they had any concerns. That familiarity with individual patients and families is crucial. All the studies by groups such as the Picker Institute of patients’ experience of care prove that individual, personalised care and communication are vital. One young man said that the staff knew him as a person, not as just another case, and that he was worried that that would be lost in a larger unit or if his care were split between outreach clinics and other centres.

Families also spoke about the fantastic help they get from the Heartlink charity at Glenfield, which has raised money to provide accommodation so that parents can stay overnight with their children, a play area so that brothers and sisters can play while families are visiting the child, and day trips for the patients as they get older. Those wider aspects of care are vital to parents and patients, but are barely mentioned in “The Need for Change”. I urge the Minister to ensure that the review has fully considered those issues when it makes its recommendations.

The final factor that the review of children’s heart surgery needs to take into account is affordability. It must be driven by the need to improve quality, not to cut costs, and, in these financially constrained times, it must acknowledge that there will be costs associated with changing children’s heart surgery in England.

Child and Adolescent Mental Health Services

Andrew Smith Excerpts

Wednesday 7th July 2010 Westminster Hall

[Mr Andrew Smith (Oxford East) (Lab)]

I, too, congratulate my hon. Friend the Member for Stalybridge and Hyde (Jonathan Reynolds) on securing this important debate and on his well informed and persuasive speech. It is encouraging that the debate is so well attended and that it is informed by the personal experience of parents of children with autism.

Like other hon. Members I have received a number of representations from constituents in support of the National Autistic Society “You Need to Know” campaign. I applaud the work of the society and its supporters in raising the profile of the needs of children and young people with autism and of the importance of ensuring that there is proper diagnosis and support from CAMHS, GPs and other health professionals for the 70% of children with autism who also have mental health issues.

My hon. Friend set out both the range of difficulties that young people face as they go through life and the opportunities that are opened up by the right skilled help. I want to raise a couple of points that I think are important. The first is the interaction between autism and mental health and the number of young people who are not in education, employment or training. An interesting Audit Commission report on re-engaging young people—published today, coincidentally—includes an analysis of the characteristics of young people in the NEET category, and shows for example that whereas young people with either learning difficulties and disabilities or one or more special educational needs statements comprise 10% of all young people, they comprise 23% of young people who are not in education, employment or training for six months or more. It does not give figures specifically on those with autism, but the proportion will be significant—not counting, of course, those who have not been properly diagnosed. That is an important issue.

One of the key recommendations of the Audit Commission report is that local councils, especially with the transfer of 16-19 funding, and all the existing and coming pressures on local budgets, need to understand the nature of their local NEET population and to target their support appropriately. I urge that understanding the extent of autism and mental health difficulties among those young people should be a key part of the analysis and of the supportive action that needs to be provided by health, education and training professionals.

Another point that I would like to stress follows from the comments of the hon. Members for Mid Dorset and North Poole (Annette Brooke) and for South Swindon (Mr Buckland): it is the importance of improving and joining up support for young people with autism as they move into adulthood, which is understandably a particularly stressful time for the individuals concerned and their parents. Certainly in my area in Oxford, although there is still some way to go, there have been welcome improvements in support for children and young people in education. Parents have praised to me the work done by Oxford and Cherwell Valley further education college. However, as youngsters become adults it can be an especially uncertain time, when the prospects for work, other meaningful activity, further training, social relationships and housing become problematic, and their parents are getting older. There needs to be a better joined-up approach between health, social services and housing providers so that there is a coherent system of support. As the Audit Commission report recommends, there is a need for better co-ordination between Connexions and Jobcentre Plus, and better handover arrangements as people move forward and look to the possibilities of work.

At a time when local council budgets face huge cuts, it is all the more important that we should speak up for the needs of those young people, which have so often been misunderstood and neglected in the past. They must not be marginalised in the battles for funding ahead. One crucial point from the Audit Commission report is that early intervention and the right early support not only make a huge difference to people’s quality of life, but, as the hon. Member for South Swindon said, can save big sums of public money in the long run. The report illustrates that fact by contrasting the example of a young man with Asperger’s who gets the right support and ends up with a life in work, and one who does not, and ends up with a life on benefits.

I would be grateful if the Minister let us know what guidance and support will be given to local councils, health authorities and others on relevant matters so that young people with autism and their families can face the future with more confidence, and in particular what action the Government will take to ensure that CAMHS and adult mental health teams work together so that there is the right continuing support.