Gettyimages 1176987489 V3

Two tribes?

Life at Work
Ben Ireland

Become a doctor with no tuition fees and get paid while you train – that’s the promise of a new medical degree apprenticeship scheme being piloted. But will it lead to a two-tier training system?

Applications for the first medical degree apprenticeships are likely to open next year. NHS England says the new five-year undergraduate pathway for aspiring doctors involves ‘the same training, at the same high standard’ as medical school.

Medical apprentices will attend universities, must pass medical degree exams and the UK MLA (medical licensing assessment), and ‘meet all requirements’ of the GMC before their foundation years.

The GMC is yet to approve any medical degree apprenticeship programme, but told The Doctor it is ‘supportive of the principles behind apprenticeships’. It says it ‘would need to be content that any proposed programmes met our standards’.

Degree apprenticeships are an established training route for professions such as nursing and physician associates, as well as engineers and solicitors. Whether they would be appropriate for medicine is still up for debate.

Advocates say apprenticeships can widen participation in medicine and help plug hospital workforce gaps in areas struggling to recruit, but critics fear the model could create a two-tier system, cause rifts and exploit those who sign up. With partial funding confirmed for the first 200 places, questions remain.

Different paths

Guidance from February says apprentices will receive ‘all the same training as a medical student following the established route’ with ‘no element, academic or practical’ omitted.

The statutory requirement is for apprentices to spend 20 per cent of their time ‘off-the-job’, but this would be ‘considerably higher’ for medical apprentices.

What is asked of apprentices day-to-day, and how they’re supervised, will be down to participating trusts, which will work with medical schools to design courses. Apprentices will work as ‘trainee medical practitioners’ at a level ‘suitable to their stage of training’. As employees, they will be entitled to annual leave and a pension as well as pay. They will be ‘supernumerary’, so not counted as part of the staff.

Penny Sucharitkul
Sucharitkul: Questions when apprentices would find time to study

Penny Sucharitkul, a final-year medical student and Doctors Association UK representative, questions what apprentices’ work will entail, and at what point it begins.

She says: ‘There are only a few things you can do as a first-year student on the wards. You can’t just be a HCA [healthcare assistant] – that involves clinical experience, which you have to develop. When you do a degree, it’s a gradual approach to placement. You’re not just left to walk the wards. You’re supervised the whole time.

‘The reason we do a five-, six-year degree is to understand things like why we’re stopping certain medications. If the work side of the apprenticeship is a role where you're taking instructions, you’ll never understand why you're doing something, which is what you learn on placement.’

Raymond Effah, co-chair of the BMA medical students committee, is urging participating trusts to publish course structures as soon as possible.

He asks: ‘If you’re working every day, when are you on placement? Is work your placement? If so, how is it different from a university course? ‘Realistically, it’s not possible to have an apprentice – or student on placement – working in a capacity that benefits the trust from day one.

'In my first year, I shadowed people. It was only by year four or five I really benefited the team, by taking bloods and things like that.

‘If they employ apprentices in HCA roles, it’s not going to teach them much of use to a doctor in the long run. I’ve done HCA work while at medical school. I enjoyed it but it wasn’t applicable to my medical degree. I learn more in lectures.’

There are only a few things you can do as a first-year student on the wards. You can’t just be a HCA

Penny Sucharitkul

Sir Sam Everington, an east London GP who was co-chair of the medical apprenticeship steering committee at Health Education England before it merged with NHSE, argues: ‘This is not just about getting brilliant students through an academic course. This is about producing confident and capable doctors. You’re training them for the NHS.

‘If you think about it, current teaching of postgraduate specialties is apprentice training. So why do people have a problem with undergraduate apprenticeship training?

‘It's not good enough to be a perfect scientific biomedical doctor who knows all the NICE guidance. When I trained 40 years ago, it was about making doctors the font of all knowledge. Now, it’s much more about helping people make choices.’

Jahangir Alom, a specialty trainee 1 in emergency medicine who studied on a widening participation programme, says the BMA must engage with the apprenticeship process to iron out unknowns. ‘It is happening,’ he says, noting the course structure ‘has to be approved by the GMC’ so ‘standards can’t be lower’.

Learning opportunities

NHSE says it is important to ‘ensure apprenticeship students are adequately supported and have time for private study’ which is ‘expected to be completed in contracted hours’.

Ms Sucharitkul says: ‘The reality is, doctors’ teaching happens sporadically. Basically, it’s when they’re free. We study in between, but if you’re paid to be there and have responsibility for patients, emptying catheters, taking bloods or whatever, you might miss teaching. When are you going to have time to study?’

Dr Alom says doctors’ teaching time is ‘a wider issue that’s not specific to the apprenticeship programme’ that would ‘still exist if you increased traditional medical school places’.

He adds: ‘If the apprenticeship looks like an inappropriate amount of work, we can revise curriculums if we engage.’

Sir Sam Everington
Everington: ‘Let’s move everything to apprenticeship training’

Sir Sam believes apprenticeships can be ‘part of a wider change’ to medical education – including who is teaching. ‘People will say we haven’t got resources to teach these extra people,’ he says.

‘But teaching comes in all shapes and sizes. People will say you can’t have HCAs teaching phlebotomy. But they’re highly skilled; they’re exactly who should be teaching medical students to take blood.

‘Everyone in a teaching hospital should be a teacher. Many young doctors I’ve talked to don’t see the point in lectures, they’re quite capable of learning via the internet or in the library.

‘About 95 per cent of my work is pattern-recognised. You learn pattern recognition through apprenticeship training. Let’s go back to basics and ask what we need to teach and how we teach.’

Paying or paid

Apprentices will not pay tuition fees, which are currently up to £9,250 a year and often leave graduates in multiple tens of thousands of pounds of debt when they qualify.

Ms Sucharitkul, a young carer from a family in the lowest income threshold, accepts the lack of debt is ‘a huge carrot’ but warns: ‘These places are going to be very, very competitive and I’m worried the widening access students who really need it aren’t going to get on this scheme.’

She fears animosity between students and apprentices. ‘What if two of us are training on the same ward, one is a student paying £9,250 a year and the other is being paid to be in the same teaching sessions. Does that create a sour feeling?’

Raymond Effah
Effah: Students may want to swap to the apprenticeship course

Mr Effah adds: ‘A lot of medical students are going to be saying, “Why can’t I swap onto the medical degree apprenticeship course?”.’

Dr Alom disagrees. ‘I did an additional year; at no point did my peers feel I was taking learning opportunities away from them,’ he says.

Medical apprentices will be paid. How much is down to trusts. The national minimum wage for apprentices is £5.28 an hour but those aged 19+ are entitled to the national minimum wage for their age once they have completed their first apprenticeship year. This is £9.50 for those aged 23+.

‘The idea of being paid while studying is going to be attractive,’ says Mr Effah. ‘But if you’re a [physician associate] on a decent wage, are you going to step that down to £5.28 an hour? That’s a huge drop, especially if you have kids.’

Ms Sucharitkul questions if this is enough to live on without another job, which she says ‘would be more unrealistic than it already is as a medical student’.

Dr Alom says it is not uncommon for students to balance their study with other jobs.

‘When I was at med school I worked as a HCA every Sunday because the NHS bursary wasn’t enough,’ he says, though he accepts ‘it’s incredibly tough’.

This is about producing confident and capable doctors. You’re training them for the NHS

Sir Sam

One of NHSE’s aims is to offer a route into medicine for people from deprived backgrounds for whom tuition costs are a barrier, including those who already work in the NHS in other roles.

It notes a ‘majority of medical students come from a small section of society’ and has not set an upper age limit on the apprenticeship. It cites the Government’s 2020 Social Mobility Commission’s report which concludes ‘apprenticeships are one of the few indisputably effective tools of social mobility’ currently available.

Dr Alom thinks widening participation is admirable. He says: ‘Let’s say a 35-year-old band-six physiotherapist with two children wants to move to medicine. The only option is to stop their career and apply to postgraduate medicine without any income. With the apprenticeship, you get a salary and don't pay tuition. It offers an alternative.

‘We assume widening participation means getting young people who are school leavers from atypical backgrounds into medicine. But it includes mature students who've had other careers, maybe have had children or faced adversity in their teens and early 20s that prevented them from applying to, or even considering, medical school. This could help diversify our workforce.'

Dr Everington adds: ‘One fact that has not changed in all my years: You are six times more likely to get into medical school if you've gone to private school. There's a very strong bias, also, if your parents are doctors. Imagine if men were six times more likely to get into medical school than women. People would be up in arms. This is about providing equal opportunities.’

Jahangir Alom
Alom: Ringfenced money available

Entry requirements will be set by participating trusts. NHSE says they should be ‘comparable’ to medical degree entry requirements but ‘flexible’ and include ‘contextual factors’ to ‘minimise barriers and optimise opportunity for applicants from a diverse range of backgrounds’.

NHSE says this approach also means employers can ‘invest in future talent that can be encouraged to remain in their area’. Sir Sam says this gives trusts an opportunity to ‘grow your own’.

He believes ‘every medical school should have a geographical responsibility to recruit’, noting research he was involved in which found that ‘if you recruit people to medical school locally, they’re much more likely to stay local and be there permanently’. He says this continuity would benefit the apprentice and the employer.

NHSE says apprentices should have no ‘special arrangements’ when entering speciality training. While it says it ‘may consider’ working with the UK Foundation Programme Office on pre-allocation criteria for apprentices so employers can ‘benefit from their support and investment’, it stresses ‘a balance [must] be struck’ so there is ‘no compulsion for the apprentice to accept the offer’. In return, it says there must be ‘no obligation’ on trusts to continue employing an apprentice after they graduate.  

Funding concern

Ms Sucharitkul believes the Government should instead fund more medical school places, reduce tuition fees, improve bursaries and restore junior doctor pay. ‘The [current] system works, it just needs to be funded properly,’ she says.

‘There’s very strong evidence that by supporting current students better they’re less likely to leave. Retention is the problem. It’s like there’s a bucket with holes in it and we’re just filling the bucket with more water, hoping it doesn’t spill.’

The apprenticeship levy – which employers with wage bills of £3m or more pay into – provides part of the funding. For the pilot scheme, NHSE is also contributing. Employers hosting apprenticeships must still provide some funding, which is expected to come out of their existing budgets.

Dr Alom says the NHSE contribution is ‘ringfenced money that will train more doctors’, adding: ‘We either use it or we don’t.’ But Mr Effah says apprenticeships would neither fix the retention crisis or be a principal way to get more doctors into the NHS.

Sir Sam says there is ‘a general acceptance that we’re not training enough medical students’ and sees the pilot as a means to boost places. He believes apprenticeships are the future of medical training: ‘There are massive challenges and issues with traditional medical school. My view would be: Let’s move everything to apprenticeship training.’

Forthcoming debate

The 200 pilot places will be in addition to the current government cap of 7,500 medical school places a year in England.

The BMA has been lobbying for a huge expansion of traditional medical school places, replacing the current ‘restrictive’ cap. Its current policy is that the association is ‘concerned by proposals to establish a medical apprenticeship scheme that will lead to a two-tier system’.

The issue is set to be debated again at this year’s BMA annual representative meeting in Liverpool next month. The draft motion asks the representative body to consider apprentices as ‘a vital experiment in addressing the shortage of doctors in deprived and under-doctored areas’ with trusts to ‘actively recruit from those areas’.

It insists assessment standards should be ‘the same as via traditional medical schools’ and calls for lobbying for ‘golden handshakes’ to encourage qualified doctors to work in relevant areas ‘to ensure adequate supervision and mentorship’.

There are massive challenges and issues with traditional medical school

Sir Sam

Ultimately, the BMA wants to see more doctors trained and retained, with England’s medical workforce short of 46,300 doctors compared with the OECD average.

It backs the campaign for a liveable NHS bursary for medical students and wants ‘a greater concerted effort’ to widen participation.

Dr Latifa Patel, chair of the BMA representative body, says: ‘It remains to be seen whether future apprentices, medical schools and employing organisations can navigate the complexity of implementing medical degree programmes to meet individual apprenticeship needs, while adhering to the exact same high standards of training experienced by traditional medical students.

‘As it stands, we don’t have the basic bread and butter of how it will work. Given the substantial unknowns, we continue to have concerns about the proposed model.’