How much? The price of medical education

Marc Gutenstein explains why medical students are big business See also p36

Choose a house. A car. A camper van for the summer. Choose lots of fancy furniture, designer clothes, a powerful new computer, a widescreen TV, lava lamp, and electrical tin openers. Choose holidaying in the Pacific, eating in expensive restaurants, drinking fine wines, eating cheese. . . With £200 000 you could do a lot. You could even become a medical student.

It is often reported that £200 000 or more is the price of educating a medical student from leaving school to entering the NHS.¹ Indeed, the cost of the government's initia- tive to train 1000 more doctors each year is estimated at £200 million.²

Two funding bodies

So where exactly does all this money come from? Where does it go to? How is it spent? As with many things bureaucratic, the answers are shrouded in secrecy, and encased in obscure jargon. Difficult perhaps for the layman, but not for us medics - we live and work by mnemonics and euphemisms. And the two of relevance here are HEFCE and SIFT.

The Higher Education Funding Council for England

The Higher Education Funding Council for England (HEFCE) is the organisation responsible for distributing public money to teaching and research institutions in higher education. Similar organisations operate in Scotland, Wales, and Northern Ireland. These are the bodies responsible for funding the universities' contribution to medical education. Aside from their contribution, universities also get substantial sums of money from the many research councils that exist, from fee paying students, and also from sponsorship, conferences, and so on.

In essence, the universities receive public funds from HEFCE to provide core facilities for education and research. The council also grants extra money for each student taught. This varies depending on the subject, but rest assured that clinical medicine is the most expensive, with preclinical only a step behind.

So since 1998, in addition to a general grant, the universities have received about £5000 for each preclinical student and about £12 000 for each clinical student each year from HEFCE.³ Things are done a little differently in Oxbridge because the universities and their colleges are all separate financial entities, but the end result is the same: we medics are already worth a significant sum of money.

The service increment for teaching

The other half of the equation is the NHS side of medical education. The service increment for teaching (SIFT) is a special NHS levy that is given out as extra funds to NHS institutions that take part in training undergraduate students. As such it rubs shoulders with other special funds like the medical and dental education levy (MADEL), which takes care of part of the salary and all the training costs of junior doctors.

SIFT has the explicit aims of "ensuring that the NHS supports undergraduate medical and dental education" and "ensuring that service providers do not have higher treatment costs simply because they support medical and dental education."⁴ In other words, it takes care of the extra costs to the NHS of teaching medical and dental students but, we are told, "is not a payment for teaching, as such."⁵

SIFT's aims

SIFT has an illustrious past. Started in 1977, it was renamed SIFTR in 1990 to highlight the important role that "R," or research and development, played in incurring extra costs in the NHS. Since 1995 the research and development has been taken care of separately and so we're back with SIFT again.

At the beginning of a year the NHS Exec- utive determines the amount of money to be put into SIFT and hands it out in portions to the NHS Executive regional offices. These offices work with the university medical schools in their region to determine how the money will be allocated. Most of the money goes on medical students and is split into two streams. Twenty per cent goes on "clin- ical placements" or the costs depending directly on the presence of students. The remaining 80% goes on "facilities," or the more tangible and fixed assets, that teaching requires.

Where does the money go?

So far so good. But SIFT gets a little stickier when trying to work out exactly what is bought for all that cash. SIFT money need not be "ringfenced" for teaching, but rather inserted into the big NHS melting pot. And in practice it is hard to know where NHS clinical services finish and university teaching begins. For example, many NHS consultants regularly teach medical students, whereas many university employed lecturers have regular clinical duties. In the past, the potential confusion has been managed by "avoiding elaborate and expensive accounting exercises" and employing a "knock for knock" principle that acknowledges the "mutual uncosted assistance" between universities and their hospitals.⁶ This seems to be jargon for "you scratch my back and I'll scratch yours" and "let's have a cup of tea." It is perhaps unsurprising that in recent years there has been pressure to quantify the costs involved more precisely.

Conclusion

In the 1997-8 season about £450 million went into SIFT. Of this over £410 million went on medical students (the rest on dental students). At the time there were about 10 000 clinical students in the NHS. So that translates into approximately £40 000 per student per year, or £120 000 to the NHS for a student to do a clinical course - little wonder our teaching hospitals love us so much. Add the HEFCE payment - about £45 000 per student for five years of medicine. Add the money given to the universities for facilities - and there's the final answer: we medics are indeed worth an absolute fortune!

So training medics is big business. It has been that way since before the inception of the NHS, when Sir William Goodenough proposed that, "The spirit of medical education must permeate the whole of the health service ... medical education cannot be regarded as merely incidental to the hospital service."⁷ Judging by the costs involved, med- ical education is far from incidental. Let's hope that it is good enough.

Marc Gutenstein, final year medical student, Queens College, Oxford
Email: email


studentBMJ 2000;08:1-44 February ISSN 0966-6494

1. BMA News Review. September 1998:4
2. Medical Workforce Standing Advisory Committee. Plan- ning the medical workforce. Third report. London: DoH, 1997.
3. http://www.hefce.ac.uk (accessed 15 November 1999)
4. Department of Health. Service increment for teaching: accountability report 1996/97. London: DoH, 1998.
5. Service Increment For Teaching: Operational Guidance. Health Service Guidelines. 1995.
6. Department of Health. SIFT into the Future: future arrangements for allocating funds and contracting for NHS service support and facilities for teaching undergraduate medical students. London: DoH, 1995.
7. The Goodenough Report and medical education in 50 years of the National Health Service. London: The Stationery Office, 1998.