Higher education in the United Kingdom: who should pay?

Graeme Catto looks at the newly proposed funding arrangements and how they might affect medical students

It is one of the ironies of life that those who once benefited from free university education and student grants are now recommending student fees for others. During the 1960s and 1970s the expansion of higher education, including additional numbers of medical students, was accompanied by a grant scheme for UK students that was sufficiently generous to prevent sizeable student debt. Today, when we are all more aware of the importance of widening participation in higher education to include those with ability from deprived backgrounds, a recent white paper, The Future of Higher Education, recommends that universities should be allowed to charge higher fees than at present.¹ These fees may be up to a suggested maximum of £3000 ($4881; 4546) per year—provided that the universities meet certain conditions. The principal requirement for any university proposing to charge the increased fee will be to meet its target for recruiting students from groups with low participation. Currently these groups are assessed by social class, postcode, and whether they attended state or private schools. The government, however, wishes to move towards more sensitive indicators including family income, parents level of education, and the average results of the school or college attended. To oversee this complex and controversial system the white paper proposes that an “access regulator” be appointed; this Kafkaesque post has been dubbed “OffToff” by the British press.

The scale of the problem?
JOHN GILES/PA

Policy shift by the Labour government

The white paper signals a major shift in higher education policy for university funding—a change made all the more significant coming, as it does, from a Labour government with a commitment to “education, education, education.” What has brought about this change of heart? First and foremost there is an appreciation that the universities are underfunded—not abundant with an over educated and under employed staff as might well have recently been suggested, but manifestly underfunded and no longer sufficiently internationally competitive. As this analysis has not been seriously challenged, the issue is now how best to raise the necessary resources—and for what purpose. The white paper proposes that those who benefit from higher education should pay—not all of us through taxation for the benefits that an educated population confers on society but, rather, the individual student.

The individual pays

There are two principal arguments. Firstly, that graduates earn more than non-graduates and should thus pay more for the economic advantage that a degree confers; secondly, that paying fees has not deterred students in other countries from seeking higher education. At present, it seems likely that student fees will be introduced inEngland, coupled with a scheme that ensures that graduates pay back loans when their annual income exceeds a certain amount; £15 000 is the current suggestion. Students with parents on the lowest incomes (less than £10 000 per year) will be eligible for the full higher education grant of £1000 annually; smaller grants will be available for those with parents earning up to £20 000 per year. This means a student coming from a family earning less than £10 000 per year will be entitled to £1100 in fee support and a £1000 grant as well as the full student loan for living costs. The loan is currently £3905 for students studying away from home (more in London); in total they will have almost £5000 a year and help with their graduate contribution. According to speculation in the press, only few students will benefit from these arrangements, and more generous proposals may shortly be announced by the government.

Serious considerations for medical students

The concerns are that the complexity of these arrangements may mean that many potential students will reconsider their decision to enter university and that the total amount of student debt is bound to increase. For medical students on long courses that is a serious consideration, particularly as current average debt on graduation is in excess of £15 000. It is not yet clear whether or not the Department of Health will offer additional financial support for students on courses such as medicine and dentistry. In the section dealing with the public sector workforce, the white paper proposes carefully costed and planned programmes to modernise and develop the public sector workforce, and to recruit and retain staff in a targeted way. Any such measures will need to be funded from within the departmental spending plans then in force. Among the examples given for current arrangements is the funding from the Department of Health for medical and dental students in the fifth or later years of their courses. The implication is that any such funding from the Department of Health to meet the proposed student fee will have to be met from savings made elsewhere.

Down to balance between government departments?

Viewed more broadly, the relations between the Department for Education and Skills (DfES) and the Department of Health for medical education is not entirely clear. While the DfES through the Higher Education Funding Council for England (HEFCE) officially has responsibility for higher education, medical school, and universities, the Department of Health not only contributes substantially to the funding of clinical teaching through the service increment for teaching (SIFT) allocated to NHS trusts but has views on the desired outcomes from the undergraduate medical education. Across the world medical education is balanced somewhat precariously between those government departments responsible for education and those responsible for health. As there is no perfect solution, the balance between the two departments alters from time to time. With the current commitment to delivering the NHS Plan for England, the Department of Health is taking a particular interest in recruitment issues and dropout rates. Instead of remaining trapped between these two large departments of state, both of which have other matters of more immediate concern, it would seem sensible to create an interdepartmental board with overall responsibility for medical education—and preferably for health related education more generally. For the moment any such development seems only a distant dream.

Prime Minister Tony Blair as a student in 1975 did he have to pay fees?
SOUTH WEST NEWS/REX

Widening participation?

Important as these funding issues are, the government is indicating even more fundamental changes to higher education. Widening participation remains a key priority. Although several successful initiatives are directed to widening access to medical education, participation is still dominated largely by students from relatively privileged backgrounds. It is now generally accepted that this imbalance must be addressed. One way may be to reassess the entry requirements for medicine.

At present, entry is largely determined by the educational qualifications of the applicant. These qualifications are generally A levels and reflect a candidates ability to learn known facts, a process that is influenced by both social and educational background. Once admitted to medical school the student is assessed by different criteria—the ability to solve problems rather than acquire facts. To help resolve some of these issues a number of medical schools in this and other countries have been exploring the value of aptitude testing. Preliminary data from Australia indicate that such tests help both to identify applicants who have problem solving skills and to resolve the educational disadvantage experienced by those from deprived backgrounds.

Keeping an eye on the ball

The white paper emphasises the importance of high quality learning and teaching programmes. While few would disagree with that proposition, the proposal that such programmes might be delivered by universities in the absence of a research commitment is likely to prove more controversial. The need for greater selectivity and research funding is clear. In medicine, however, the evidence base is so weak that all medical students should acquire both an understanding of research and scientific methods. Only by keeping the emphasis on high quality teaching will tomorrows doctors be able to ensure that health care for patients continues to improve.

And, of course, it remains unclear how Scotland will react to the proposals in the white paper.

Graeme Catto, dean, Guy's, King's and St Thomas's medical school, and president of the General Medical Council


studentBMJ 2003;11:43-86 March ISSN 0966-6494

1. Department for Education and Skills. The future of higher education. London: Stationery Office, 2003. www.dfes.gov.uk/highereducation/hestrategy/ (accessed 10 Feb 2003).