Issues surrounding the NHS and health provision are a regular feature in the UK media. With fresh challenges on the horizon, how will medical schools need to adapt over the coming years? Here, Professor Colin Macdougall, Head of the MB ChB at Warwick, shares his thoughts.

---

Predicting the future is somewhere between an inexact science and a mug's game. Mere seconds of Googling produces a myriad of quotes reinforcing this or highlighting extreme examples of individuals and organisations failing to predict major aspects of the world we live in today. That would be a Google search, via Google.com, a domain registered almost exactly 10 years ago, not much more than 10 years after domain names came into existence at all. Perhaps before thinking about the next 20 years we should pause briefly to think about what has changed in the last 20.

Change is relentless

Clearly, change is relentless. I graduated into an NHS that ran mostly without IT. Now, all functions grind to a halt every Thursday morning at 9am at University Hospitals Coventry & Warwickshire when the generator restarts all the computers that allow outpatient services to function. Yet the tasks I do (talking, exploring, thinking, proposing, planning) are largely unchanged.

As we welcome our new 2017 cohort of medical students, it is worth considering - if not what the world may be like when they may get to retire in 2059 or beyond - then what the world is likely to be like as they graduate, in a mere four years. Although as a clinician, my expertise is in medical education (and therefore I will limit myself to this area and leave other experts from the school and University to mull over where community care, diagnostics, cell biology or a range of other issues will take medicine, and humanity, over the next few years) I will also play it safe and highlight things that are already in play, although where the outcomes may still be uncertain.

2017 to 2021: A major period of upheaval

2017 to 2021 is clearly a major period of upheaval certainly for our nation, and probably the world. By 2021, we will be post-Brexit, but perhaps in a transition period. We will likely be facing a general election. There is also no question that the nature of healthcare overall will change. The NHS Five Year Forward View period (2014-2019) will have finished and the first NHS sustainability and transformation partnerships plans will be coming to an end. We may or may not be clearer as to the service we are training people for, the roles they will undertake and the names we will call them.

Graduate-entry medicine programmes

What will Warwick offer? The good news for Warwick is that graduate entry programmes no longer seem under threat. Previous concerns related to two things; the requirement for a course to be a specific length (under EU regulation) and whether a four-year course would still be compliant if the point of full registration for doctors moved to the point of graduation (rather than after working for one year, an idea proposed in the Shape of Training Review in 2013.)

Clearly, the role of EU regulation will change with Brexit. However, in the recent Department of Health consultation on expanding student places there was an acknowledgement of support for GEM courses;

“There was support for graduate entry medicine as an example of attracting a different group of students who may be attracted to roles like that of a GP”

“While outside of the scope of this consultation, there was support for graduate entry medicine”.

Additionally, although not formally announced, we are aware of proposals from the General Medical Council (GMC) to ensure GEM courses can continue if the point of registration changes even in the face of current legislation.

Notably, however, this is about structures. Despite much talk about such a move, there is little of substance on what this would mean for doctors and the public. Would a doctor straight from graduation be the same as one who has worked for a year? How would we ensure that they were, and is this desirable? It is also worth noting that this discussion is still only about the first year of a doctor’s working life, not the next 40.

Doctor numbers

Next, how many doctors do we need to train? The Government is clear that the answer for now is 1,500 more than the UK currently does, although this is from a starting point of having always under trained (notably, the last time numbers were reviewed in 2012, spaces were reduced by 2%). Is 1,500 more the right number? Can the UK increase training places in such a big step and ensure quality? What is clear is that this will bring larger courses and new schools, bringing the opportunity for new organisations training doctors and perhaps new ways of doing so, although the Government is in a hurry and with a start date of 2018, there is little time to plan innovation, particularly as the process to bid for these places is not yet open. Certainly, there is laudable talk about ensuring we train doctors who are from across the socio-economic spectrum.

Will this be enough doctors? Well, in part it depends on what they are there to do. There are new roles such as Physicians Associates, but no clear commitment to expand this type of work, and new ways of working, not least the ambition for seven day services.

Meeting future health needs

Even if we fully understood what we need NHS doctors to do in the future, there is a more philosophical question: to what degree is it the responsibility of UK medical schools to specifically staff the future NHS? Partly this is a question of whether higher education is an end in itself or is primarily about future work, although it needs to be recognised that the NHS is both a monopoly employer of many types of doctor but is also but a substantive resource into pre-registration and post-registration training of health care professionals.

Also, is the understanding of future health care needs good enough to change courses now? History is full of types of doctors who were suddenly not needed as perhaps diseases, treatment or technology changed, although few would currently challenge the increased complexity of care (and the associated need for generalist care) and the burden of mental health issues aligned to the previous status of mental health funding.

Assessing future doctors

Finally, how will we assess that they are good enough? (and be seen to do so?) The General Medical Council is clear that they see a problem and there is need for a single assessment for every doctor to practice in the UK (a UK Medical Licensing Exam or UKMLA). This has been consulted on, but the consultation not yet released. Most notably, it needs to be clear on what problem the UKMLA is being designed to solve, i.e. who is currently passing finals and graduating that shouldn’t. The UKMLA then needs to demonstrably and reliably pick up this group without letting through another group (that currently, rightly, don’t pass), whilst at worst maintaining or, better still, improving standards overall. This is a tall order for an assessment and the outcome of the consultation will be of great interest when released.

Change is everywhere

So where does that leave me as I welcome the new intake? Maybe I should just reassure them that a lot of these changes, such as UKMLA, shouldn’t affect them. Maybe remind them that change is everywhere and, as a previous boss said to me when I was worried about a proposed move of a children’s department across a city, there will still be patients, we will still need to care for them, and we just need to focus on making sure everyone remembers that. As a post script, the move did happen and was a great success – evenough though it happened 10 years later than it was supposed to.