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Broadening access to undergraduate medical education Carole Angel and Allan Johnson discuss their recent presentation at the Millennium Festival of Medicine
In their statement of principles, the Council of Heads of Medical Schools indicate that the purpose of a medical education is to graduate individuals well fitted to meet the present and future needs of society for medical care.1 They go on to state that this can be achieved, at least in part, if the social, cultural, and ethnic backgrounds of graduates reflect broadly the diversity of the patient population. It seems that this principle is not currently met by medical schools in the United Kingdom. In a study commissioned by the Council of Heads of Medical Schools in 1998, McManus found that certain groups (students from ethnic minorities, sixth form colleges or further education institutions, and lower socioeconomic groups) were disadvantaged when seeking admission to medical school.2 As a result, the council devised an action plan in which medical schools were required to draw up policies relating to equal opportunities as a matter of urgency. An untapped pool In general, the groups of people that are underrepresented in the medical profession tend to be overrepresented in the patient population as a result of many factors, including poverty, poor diet and housing, poor educational standards, and occupational factors. Pupils from lower socioeconomic groups are disadvantaged in many ways when applying for entry to medical education. Their secondary schools are not usually those with a record of high academic achievement, and progression to further or higher education is not a tradition. Similarly, the pupils come from backgrounds where participation in higher education is rare. They often do not have the opportunity to undertake suitable work experience and thus have difficulty demonstrating through their application that they are suitable for a career in a caring profession. As a result, their application forms do not often contain the type of features usually looked for by admissions tutors and may therefore not be considered further. Schemes aimed at widening access should be designed to attract this previously untapped pool of potential doctors into medicine, thus providing the NHS with a clinical workforce which more accurately reflects the socioeconomic base of society. Such schemes need to raise awareness of higher education in general and to show pupils that a career in medicine, which might at first seem outside their wildest aspirations, is in fact possible. The schemes should attempt to provide some sort of compensation for pupils' relatively poor academic base and in particular should provide the type of generic, transferable skills to which such pupils may have had limited exposure. Communication skills are particularly important in this regard. Finally, the schemes should make appropriate work experience and exposure to the profession in general available to the pupils. A new recruitment programme The University of Sheffield as a whole has shown a longstanding commitment to widening access to higher education, particularly in the local area, and already attracts high numbers of students from lower socioeconomic groups, as evidenced by the substantial Widening Participation premium additional funding allocated by the Higher Education Funding Council for England to the university for 1999-2000. The medical school already participates in some of these activities and will shortly begin a new recruitment programme aimed specifically at students from non-traditional and underrepresented backgrounds. This early outreach programme is described in detail below, but the medical school has already shown its commitment to widening access by welcoming applications from applicants with non-traditional backgrounds. We already have a relatively high proportion of mature students (25% of entrants to the six year foundation course and 14% of entrants to the five year course). Students with a background in nursing are particularly welcome, and we have a relatively high proportion of students with non-traditional educational backgrounds, including BTEC and GNVQ courses. The Compact Scheme The Compact Scheme began in medicine in 1994. It provides individual support by trained admissions staff, and the formal academic entry requirements are relaxed where appropriate. Year 12 pupils whose personal, domestic, or financial circumstances may prevent them from displaying their full academic potential are helped in the application and admission process. Pupils are first identified in their schools and, if thought to be suitable, are referred by the school to the university and then to the scheme's liaison officer for the school of medicine. In an informal interview, students are assessed in general terms and are given advice and support about their application. The majority then proceed to the formal interview stage, along with the standard applicants. We feel it is important that such students should not be made to feel "different" from their fellow applicants and thus, although the interviewers are made aware of the pupil's special circumstances, the other applicants being interviewed at the same time are not. Similarly, once admitted, these students are not identifiable in any way to their fellow students or to teaching staff, unless the students themselves decide to inform them. They receive no special treatment and in particular are not identifiable during assessment episodes. They are, however, followed closely during their studies and are made aware that they may seek advice and guidance from the liaison officer at any time. Individual circumstances Not all applicants to the scheme come from schools with relatively low academic achievement. For some candidates, most of whom tend to be more mature, personal circumstances have prevented them from achieving high academic results. Some may be supporting dependent family members; others have political or economic refugee status; and still others, predominantly female, come from ethnic backgrounds in which women are not encouraged to leave homeand study. Each case needs tobe assessed on an individual basis. Many applicants have battled against incredible difficulties to reach this stage in their lives, and some students' stories are awe-inspiring. It is important to realise that such schemes are not intended to reduce the academic ability of medical students and that they will in no way produce a "dumbing down" of the profession. In general, the schools and colleges involved are not identifying students whose academic performance has already been lower than that normally expected for an applicant for medicine. Rather, the schools believe that the pupil's circumstances may be impairing their performance. In practice, we do not often find that their academic performance is seriously affected. In the university in general, students on the Compact Scheme may be admitted with examination results that are below the usual standard, but in medicine the pupils who are conditionally accepted at interview are expected to achieve the usual standard of examination results. Flexibility is then operated when examination results are known, but in practice the majority of candidates achieve the required grades. It is early days, but we have no evidence that the academic progress of these students differs from that of standard entrants. Of the Compact Scheme students currently studying in Sheffield, all but one are progressing satisfactorily and most are above average academically. Overcoming difficult circumstances to reach medical school may equip such students well to get through the rigours of medical education. It is vital, however, to ensure that the personal, academic, or financial circumstances that prevented students from displaying their full academic potential in school of college cease when they begin their medical studies. Reaching pupils in secondary schools The second scheme being operated at the University of Sheffield is the Early Outreach Scheme, and the medical school will be participating in this scheme in the near future. In a 1996 report, the Higher Education Funding Council for England acknowledged that the problem of increasing participation from social groups III and IV may not be one that the higher education sector could readily address, since it required action at an earlier stage of the educational process.3 The Early Outreach Scheme shows how universities can work alongside schools and colleges to increase aspirations and hopefully increase access in underrepresented groups. It targets 14 year olds (year 9 pupils) and provides focused guidance and support throughout their education.
The school of medicine has recently been awarded an additional 20 places reserved for pupils undergoing a special scheme for medicine. Specially selected year 9 pupils will be encouraged to pursue science based GSCE courses, and year 10 and 11 pupils will be exposed to the world of medicine, participating in hands-on science based activities related to medicine and encouraged to do work experience placements associated with community service. Comprehensive advice on suitable choices of subjects and qualifications for medicine will be an essential feature. In year 11, pupils will be identified for consideration for formal entry into the scheme. We intend to invite existing medical students to become involved and to act as role models. In fact, Sheffield medical students are already involved voluntarily in such school based activities through the Committee of Medical Education of MedSIN (Medical Students International). In the first six months of guidance during pupils' studies for A levels, the year 10 and 11 activities will be consolidated, including a formal selection procedure for admission to the pre-entry programme. The preentry programme will include structured community service and work experience related to medicine, personal skills development, a summer school with an academic basis, financial advice and planning, and a pre-application interview. The programme will be sufficiently flexible to be adapted to each participant's circumstances, and successful completion will guarantee a place in the medical school. The formal academic requirements may be at a reduced level compared with the standard academic requirements, but this will be carefully monitored to maintain standards. Post-admission support will be available should successful candidates require it, including ready access to suitably trained and experienced staff. Around 80 schools and further education colleges in the local region will be targeted. Commitment to widening access The University of Sheffield Medical School is showing its commitment to widening access to medical education by participating in the schemes described in this paper. Students and graduates should reap enormous benefits from such schemes: their aspirations will be raised; they will be able to fulfil their academic potential; and their earning power will be raised. At present, there is little substantive evidence that the medical profession as a whole will benefit as a result of this increased diversity in its workforce. Widening access to higher education in general has produced private returns through higher earnings and public returns to the state from the tax revenues generated,4 and the benefits to the NHS in possessing a workforce whose diversity more closely matches that of the patient population must be considerable. This is an edited version of a presentation at the Millennium Festival of Medicine in London, 6-10 November 2000. Competing interests: None declared.
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