Affordability,inclusivity and justice – threats to the sustainability of the medical workforce in an economic crisis

There has been significant investment in widening participation to medicine over the last decade or so in many countries, including the United Kingdom. ¹ However, these efforts to increase diversity and equity within the medical profession are threatened by the current economic and political climate. Previously, Smith and Cleland ² highlighted that the changed ways of working in response to coronavirus disease 2019 (COVID-19) would likely exacerbate existing educational attainment gaps between different societal groups and thus impact significantly on young people from less privileged backgrounds who aspired to study medicine. These predictions held true: recent research demonstrated that the impact of the pandemic on loss of learning amongst those from less privileged backgrounds is greater than peers from more privileged backgrounds. ³

Certainly, there has been significant effort by universities to promote widening participation since the pandemic. These efforts include expanding the use of contextualised admissions (i.e., considering, and adjusting for, the context of the circumstances in which applicants achieved their education) ² along with the development of online outreach activities. ⁴ However, we argue that these efforts are not sufficient given that the gap between students who have experienced disadvantage and those from more privileged backgrounds has widened. ³

Moreover, getting more diverse students into medicine is only one part of the picture: students need to be supported to stay in medicine until they successfully graduate, enter the medical workforce and complete training.

Recent data from the British Medical Association ⁵ student finance survey suggest that of their sample of UK medical school students, nearly half (44.3%) expect to run out of money before the end of the academic year, over a tenth are unable to travel for their studies and/or training because of financial circumstances, around 1 in 25 were using a food bank, and 1 in 7 had applied for hardship funding. The latter was linked with markers of disadvantage at the point of entry to medical school. Medical students from underprivileged backgrounds may also need to juggle working multiple jobs while on clinical placement. ⁶ In short, medical students, particularly those from less affluent backgrounds, are facing notable financial challenges which are adversely impacting on their experience of, and possibly also their attainment at, medical school. Graduates are also facing significant debt because of taking out loans to support learning and living costs while at medical school. This last point is increasing pertinent given junior doctors’ salaries have not kept up with inflation (estimates suggest pay has been cut by over 25% since 2008) and one of the reasons why there are plans for strike action amongst junior doctors across the UK. ⁷

We ask how, in the face of such hardships, are students from less privileged backgrounds expected to progress through medical school and working in the National Health Service (NHS)? It is going to be increasingly difficult to attract, recruit and retain students from less affluent backgrounds into medicine if they cannot afford medical school and struggle to pay off debts incurred during medical school once in the workforce. If we do nothing to intervene, we risk setting back any advances which have been made in respect to widening participation in medicine, and in promoting inclusivity, diversity and equity within the profession.

This challenge is not simple to address and needs to be addressed at government level. However, we propose several suggestions which can be implemented by medical schools and universities to help support students from less privileged backgrounds into and through medical school.

Firstly, students should be able to access adequate information on student finance and loans which are available to them. ⁸ This may be achieved by relevant signposting by schools and universities both prior to entry and over the course of a student’s studies. We also suggest that medical students are characterised as ‘employees’ in the NHS, and are supported to undertake basic duties, while on clinical placement, which are within their competencies for example, to clerk patients, request already determined investigations, be a pair of hands in various settings, etc. Doing so would effectively kill two birds with one stone: it would relieve more senior doctors of some of these duties and provide students with an income over the course of their studies.

Secondly, many medical educators are from more ‘traditional’ backgrounds and may not be aware of some of the hardships facing students who have, or who are experiencing, disadvantage. As such, universities could offer staff development in relation to the potential difficulties facing students from less privileged backgrounds via information sessions, workshops or similar. For example, reverse mentoring may prove fruitful in ensuring mentors are aware of hardships facing some students. ⁹

Thirdly, we suggest that systems to support students and professionals from less privileged backgrounds are developed in partnership (co-designed) with those that they affect to ensure that new systems are fit for purpose. Systems put in place during the pandemic were reactive and it is timely to fully consider proactive and sustainable systems which support medics over the course of their education and training.

The question is this: who do we want our doctors to be? Talented, educated, committed for sure. We wish to see doctors who look and sound like us across our diverse communities in the United Kingdom. To exclude such people who have these characteristics but are disadvantaged by being financially challenged in the sixth most affluent country in the world could be seen, at best, as an indictment of the system. Where then, the just culture, the fair society? The design and implementation of useful strategies to support efforts to strengthen and maintain widening participation in medicine is a clear priority, particularly in the face of the current cost-of-living crisis in the post-COVID era.