Aligning the education of medical students to healthcare in the UK

Introduction

China’s higher education is entering a stage of popularization, and the development of medical education is entering a new era. Medical education accounts for 8.6 % of students in 13 subject categories. More than 500 colleges or universities in China provide clinical medical education, including 184 undergraduate level universities, constructing the world’s largest medical education system [1]. The Ministry of Education in China is in the process of implementing the ‘Six Excellent and One Top-Notch’ Plan 2.0 with the aim of substantially revising the teaching of engineering, medicine, humanities and agriculture. With respect to medical education, the primary goal is to develop a new medical talent training system that meets future needs, with an emphasis on integration, innovation and interdisciplinary approaches.

Unsurprisingly, given we live in a global world, this is very much the way that medical education in the United Kingdom (UK) and elsewhere is evolving. In the UK, approximately 45 medical schools provide pre-clinical and clinical medical student education. Medical education and healthcare in the UK have their own characteristics. This article will outline the current relationship of the education of medical students to the healthcare systems in the UK. Of comparable importance is the education and training of, for example, nurses, midwives, dentists, pharmacists and numerous allied health professionals but this article will focus on doctors.

Healthcare in the UK

Medical education in the UK needs to be considered against a background in which, like in many other countries throughout the world, healthcare is struggling to keep pace with demand [2]. Patients worry about being able to see a doctor or dentist, and to receive treatment in a timely manner. There is a general feeling that the health service is underfunded and understaffed. Increased funding of healthcare could lead to more beds, shorter waiting times, more clinics, more doctors, more nurses and more ancillary staff. In 2023, both junior doctors (equivalent to interns, residents and fellows in the US) and consultants (senior physicians) in the UK went on strike, an action that in itself raises ethical and moral questions [3] and has the potential to affect patient outcomes [4]. Hospital managers had to put in place strategies to ensure that urgent, emergency and time-critical hospital-based healthcare could continue. The strikes have had a major impact on healthcare delivery and the backlog created has caused considerable concern among many people in the UK.

Healthcare in the UK is delivered by two parallel systems, the National Health Service (NHS) and private healthcare.

The National Health Service Act of 1946 [5] led to the formation of the NHS in 1948. Historically, most of the UK population have been very proud of the NHS with a general feeling that the treatment received is usually of high quality. The NHS Constitution for England states that ‘The NHS belongs to the people’, that it provides ‘a comprehensive service available to all’, and that ‘access to NHS services is based on clinical need, not an individual’s ability to pay’ [6]. NHS treatment is free at the point of care to all who are ‘ordinarily resident’ (living lawfully and on a settled basis) in the UK and is funded by a combination of general taxation plus a ‘National Insurance’ (NI) contribution. NI is an additional tax paid by working people with a contribution from both the employer and the employee. Government income from a portion of general taxation, together with income from NI, is distributed to the NHS.

An indicator of the public’s affection for the NHS is that every week during the COVID-19 pandemic people would lean out of their window, go out onto their balcony or stand outside their front door and clap their hands to show appreciation for the doctors, nurses and all other staff who were having to look after patients affected by SARS-CoV-2 infection.

Whilst access to NHS services is based on clinical need, not an individual’s ability to pay, there are some aspects of NHS healthcare that do require payment; for example, a contribution towards the cost of drug prescriptions, eye care and dental care. However, there are a number of exemptions with reduced or no cost, for example people aged 60 or over, those on a low income, those with certain long-term medical conditions, and so forth. An important organization in the UK healthcare landscape is the National Institute for Health and Care Excellence (NICE) which assesses what the NHS can and cannot afford, for example in terms of new therapeutics.

About 11 % of the UK population have some form of medical insurance [7]. This is often included as part of an employment package in which the employer provides health care insurance. Alternatively, individuals can themselves pay to have private health care insurance. Every working UK citizen over 16 years of age, except those on a low income or of state pension age (currently 66), must pay NI even if they choose to only have private healthcare and not use the NHS at all.

People that do not have private healthcare insurance can, of course, also pay as and when they choose to have private rather than NHS healthcare. The NHS is often unable to keep up with demand, leading to longer waiting times for non-urgent appointments and for operations. For example, if a patient needs a knee replacement due to pain and/or difficulty in walking, this is clearly not an urgent operation compared to somebody that needs the removal of a malignant tumor mass. A knee replacement carried out by the NHS will be free and in theory the operation should be scheduled within 18 weeks of the referral from a primary care physician (general practitioner, GP) to a hospital [8]. However, this target is often not met and the average waiting times for knee replacement in one area of the UK (Swansea) in 2023 was over two years, with nearly half of the patients having to wait longer than this [9]. Furthermore, operations can be cancelled at the last minute. The aim in such cases is to reschedule within a further 28 days [10], but again this is a target which often is not achieved. It is not only the elderly whose quality of life may be greatly impaired. In any age group, extended waiting times can lead to increased physical strain on previously unaffected areas, for example the other knee or the hip, causing further trauma. These waits can therefore be stressful and affect both the patient’s physical and mental well-being. In contrast, if the patient decides to pay to have the operation done privately, they can have a knee replacement within one or two weeks, compared to potentially over two years using the NHS. Therefore, people without private health care insurance are increasingly using a mixture of the NHS for situations that are not urgent and paying for private healthcare if they want something treated quickly. However, private healthcare is expensive and most of the UK population cannot afford this luxury.

Employment and regulation of doctors in the UK

Fully qualified doctors in the UK can work either in the NHS or in private healthcare, or in both [11]. If working in private healthcare, doctors can potentially earn significantly more than if they only work in the NHS. Because the NHS does not collect data on the work that doctors undertake outside of the NHS, hard data is difficult to obtain. It is estimated that approximately 35%–50% of senior doctors do at least some private work. However, most of these spend the majority of their time working within the NHS and less than 10 % working exclusively in private healthcare [12].

Regulation of all doctors, both in the NHS and private sector, is by annual appraisal by their employer. In addition, the General Medical Council (GMC, a government-appointed body) validates doctors and then revalidates them every five years, certifying them to continue to practice [13]. The GMC decides which doctors are qualified to work in the UK and will take action to prevent a doctor from putting the safety of patients, or the public’s confidence in doctors, at risk.

UK medical schools

As of 2024, there are 45 medical schools in the UK. However, the number of medical graduates is insufficient for the needs of the NHS. Currently, there’s a UK government cap at approximately 9,500 students per year. Although this is an increase of 2,000 from 10 years ago, it’s still not sufficient to supply the UK’s need for doctors [14]. The head of every medical school is a member of an organization called the Medical Schools Council [15] which wants to expand the number of medical students in the UK to 14,000 per year. Even then, due to the aging population, more complex treatments, etc., the NHS would still need to recruit doctors from abroad [16]. The number of doctors per population actually varies quite a bit throughout the world. For example, in Sweden, there are 7.0 doctors per thousand people; in Germany, 4.5; in the USA, 3.6; in the UK, 3.1; in China, 2.4; and in India, 0.7 [17]. Although the effectiveness of healthcare is not solely related to such ratios (depending also on factors such as access to healthcare, quality of the healthcare and so on) there is a general consensus that the UK urgently needs more doctors.

So why doesn’t the UK train more doctors? There are a number of obstacles. Firstly, it’s very expensive to train a doctor [14]. Furthermore, qualified doctors are needed to train junior doctors and this in itself presents a potential barrier to expanding the number of medical students. Also, because there’s not enough doctors now, they don’t necessarily have the time to train junior doctors. Therefore, it’s a bit of a vicious circle.

The standard medical degree in the UK is five years, although in some medical schools it is six years. There are also some four-year accelerated programmes (in some medical schools five years) for graduate entry. Unlike in the USA for example, most UK students do not already possess an undergraduate degree when they start medical school. These students will need to obtain the required grades in their high school examinations, pass an entry examination and, for nearly all medical schools, an interview.

Some UK medical schools offer a preliminary one-year course, so that the medical degree takes six years instead of the standard five years, for students that obtained high grades at the end of school exams (A levels or equivalent) but did not take the required science subjects. This is different to the one-year gateway course mentioned in the next paragraph.

There is a major effort in the UK and elsewhere to widen participation by providing opportunities for students that traditionally would not have gone to medical school, for example, due to socioeconomic or educational barriers. The Medical Schools Council has stated that ‘an applicant’s chance of entering a medical degree programme should be dictated by factors such as academic ability, motivation and conscientiousness. Factors like wealth or cultural background should not present any barrier to studying medicine [15]. Not only does widening participation provide opportunities for students but it results in a medical profession that more accurately reflects the diversity of the population it serves. Some medical schools in the UK offer a medical degree with an additional one-year gateway for students that exhibit excellent potential but are from backgrounds where there have been barriers to their learning. There are also access courses available, which are not run by the medical schools, for mature learners that do not possess the qualifications required for standard entry to medicine. Thus, there are now a number of non-traditional routes into UK medical schools.

Four of the world’s top 10 medical schools are in the UK; University of Cambridge, University of Oxford, Imperial College London and University College London (UCL) [18]. Thus, the UK is clearly well-placed to provide high quality medical education. Of the 45 medical schools, five have a compulsory integrated/intercalated BSc (Cambridge, Edinburgh, Imperial, Oxford, and UCL), 30 have an optional, integrated/intercalated BSc and 10 do not offer the option of doing a BSc in addition to the medical degree. Upon graduation, newly qualified doctors undergo two years of foundation training. This is followed by three years of specialty training for junior doctors that are going to become GPs or between five and eight years for other specialties [19]. Junior doctors all work in the NHS initially but can take on private work after completing their specialty training.

Medical education in the UK

Regulating UK medical education

As already discussed, the GMC sets the standards that must be met when teaching, assessing and providing learning opportunities for UK medical students [20]. Graduates ‘must demonstrate professional values and behaviors, professional skills, and professional knowledge’. These encompass ‘professional ethical and legal responsibilities, patient safety and quality improvement, dealing with complexity and uncertainty, safeguarding vulnerable patients, leadership and team working, communication and interpersonal skills, diagnosis and medical management, prescribing medications safely, and using information effectively and safely’. Students also need to be aware of the similarities and differences between the healthcare systems in the four administrative regions of England, Scotland, Wales and Northern Ireland which collectively constitute the UK because although they are all part of the NHS, the way that healthcare is delivered does vary slightly [27]. If doctors have been trained in England and then, for example, go to work in Scotland, they need to be aware of any differences in healthcare management and delivery.

Other components of the GMC standards relate to applying biomedical scientific principles, psychological principles, social science principles, health promotion and illness prevention, and clinical research and scholarship. Newly qualified doctors must be able to apply biomedical scientific principles to their practice and integrate these principles into patient care. The GMC states that this includes principles and knowledge relating to anatomy, biochemistry, cell biology, genetics, genomics, and personalized medicine, immunology, microbiology, molecular biology, nutrition, pathology, pharmacology, and clinical pharmacology, and physiology. Newly qualified doctors must be able to:

1. Explain human structure, function, physiological processes in health and disease, including in infants, children, pregnancy, childbirth and the elderly

2. Explain relevant scientific processes underlying common and important disease processes

3. Justify the selection of appropriate investigations for common clinical conditions and diseases

4. Select appropriate forms of management for common diseases

5. Select ways of preventing common diseases

6. Explain modes of action of common disease, and their risks from first principles

7. Describe therapeutics, pharmacokinetics, side effects and interactions

8. Describe pharmacogenomics

9. Describe antimicrobial stewardship

10. Analyze clinical phenomena

11. Conduct appropriate critical appraisal and analysis of clinical data

12. Explain clinical reasoning in action and how to formulate a differential diagnosis and management plan

Whilst the GMC standards listed above provide clear guidance on what should be taught to medical students, and certainly these are attributes that one would want in one’s own doctor, it does leave open the question as to what level of detail each of these areas needs to be taught? Above all, the duties of a doctor registered with the GMC once they are qualified is to make the care of their patients their first concern, provide a good standard of practice and care, keep their professional knowledge and skills up to date, and work within the limits of their competence. It is really important that we instill in our medical students the fact that they’ll never know everything and that, on occasion, they will need to consult with colleagues. Safety and quality, communication, partnership, teamwork and maintaining trust are all important aspects of working within competence limits.

It is also important to consider how to measure the ‘success’ of a medical school. Whilst various rankings exist which place one medical school above another, it is fundamentally important that every single medical school produces doctors that are safe and effective. How do medical schools ensure that they are actually doing what they intend to be doing? There are of course a variety of ways in which relevant data can be gathered. These include student feedback, student outcomes, internal review and external review. In the UK, there is a GMC annual self-assessment questionnaire which is checked against data and intelligence, and medical school management has to meet every year with the GMC quality assurance team to ensure that, despite their diverse curricula, teaching styles and assessments, all UK medical schools can demonstrate that they comply with the GMC standards and learning outcomes for medical education.

Employer feedback can also be extremely helpful. When healthcare systems are employing doctors from a particular medical school, how do senior doctors and managers feel those doctors compare to other doctors who trained in other medical schools? Are there any gaps in knowledge or in attitudes and professional behaviors that might need addressing when updating the curriculum?

Summarizing and looking ahead

Medical education bears the important mission of cultivating high-quality health talent, and its fundamental task is to address the demand for individuals with professional qualities, practical abilities and innovative spirit. By providing healthcare staff that are aligned to technological achievement and social service, medical schools contribute to comprehensive societal progress and development of the health industry.

Chinese medical education follows the direction of modern medical integration development, emphasizing the integration of clinical treatment and disease prevention, basic and clinical integration, clinical and pharmaceutical integration, and the integration of medicine and humanities in the process of talent cultivation. Chinese medical education has gradually formed its own characteristics, and its international competitiveness has also significantly improved [1].

Medical education in the UK is considered amongst the best in the world. Both domestic and international students are able to gain a comprehensive knowledge of all aspects of medicine. In addition, students’ practical abilities are cultivated by provision of practical medical experience through clinical internships and internship arrangements. The medical curriculum and quality in the UK must comply with GMC standards. There are certain differences between medical education in the UK and China in terms of educational objectives, teaching models, and evaluation methods. This article summarized the characteristics of medical education in the UK, which has certain reference significance for improving the quality of medical education in China and generating high-quality medical talent.

The new era of medical education has arrived. Artificial intelligence (AI) is changing both medical education and the work of doctors [28]. Currently, medical school curricula and assessments are designed by humans but in the future, they may well be designed by AI. Nevertheless, academics and clinicians will need to ensure that AI-developed curricula and assessments are appropriate. We also need to teach our students how to optimally utilize AI, both during their time in medical school and in their future work. One of many current approaches is to ask students to use AI to write an essay on a particular topic and then have the students critique the essay produced by the AI. Could they have produced a better essay themselves, either without using AI at all or by using AI as one of several sources? Clearly, there are ways to capitalize upon the fact that students use AI rather than seeing it as a threat to academic rigor. It is imperative that teachers in medical schools collaborate with colleagues in their own universities, or in other universities, who are computer scientists with expertise in AI. For example, the membership of teaching committees should include someone who is an expert in AI. There is a brave new world out there that medical schools and curriculum committees need to fully embrace.