- Matthew David Morgan, deputy dean1,
- Jahangir Alom, emergency medicine doctor2,
- Elisha De-Alker, final year medical student1,
- Sally Curtis, deputy head of school education3
1Hull York Medical School, University of Hull, Hull, UK
2Barts Health NHS Trust, London, UK
3Primary Care, Population Science and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
- Correspondence to: M D Morgan Matthew.Morgan{at}hyms.ac.uk
The NHS has been under severe pressure for many years, exacerbated by substantial gaps in the healthcare workforce and complicated by inequities in healthcare access and outcomes.1 In response, NHS England’s long term workforce plan proposes to increase medical student numbers by 30% by 2028-29, including 850 medical doctor apprenticeships, and to double numbers by 2031.2
The past two decades have seen the introduction of four year graduate entry programmes, and six year widening participation (Gateway) programmes for underrepresented students from low socioeconomic backgrounds. Despite these initiatives, 72% of entrants to four and and five year programmes in 2017 came from “managerial and professional” households.3 Further, the rising cost of living has highlighted unequal access to financial support for medical students, including the inadequate NHS bursary and accrual of substantial debt from tuition fee and maintenance loans.4 Students in England entering a five year programme in 2023, and dependent on student loans to cover tuition fees and living costs, can expect to owe at least £70 000-£90 000 (€80 000-€100 000; $90 000-$115 000) by the time they graduate.5
The proposed doctor apprenticeships6 will be a fundamentally different route into medicine. Apprentices will be employed by NHS organisations such as hospital trusts or primary care practices and contribute to delivery of care but will not be “working as doctors” until their undergraduate training is complete. Over five years, apprentices will work towards a GMC approved medical degree, meeting all required professional standards78 before gaining provisional GMC registration and entering the foundation programme.
Apprentices will receive a salary, set by their employer, and will not be liable for university tuition fees. This may help school leavers from less affluent backgrounds become doctors. In addition to overcoming financial barriers, Health Education England promotes doctor apprenticeships as a way to increase diversity, boost training and recruitment of doctors in underserved areas, and provide a route for other health professionals to retrain in medicine.910
Missing details
NHS England has stated that doctor apprenticeships will be piloted in 2024-25, but so far the participating medical schools and employers, curriculum and placement plans, and the length of and proposed evaluation of the pilots are not in the public domain. This lack of detail has led to much speculation and misinformation.111213 The NHS long term workforce plan proposes that doctor apprentices will account for 13% of UK medical students (2000 apprentices) by 2031.2 The delivery and evaluation of this will require careful planning and transparent reporting of outcomes.
The language used to publicise doctor apprenticeships aligns with widening participation goals set out by the UK’s Medical Schools Council in 2014.14 But there is no indication that contextual data15 such as first generation in higher education or being from an area of lower participation in higher education will be used during selection. Entry requirements and selection procedures will be agreed between NHS employers and partner medical schools but are not yet published, even for the pilot programmes. For apprenticeships to widen participation, entry requirements and support for students—including opportunities to engage in research, leadership, and education—must be comparable with those in existing programmes.
An apprentice working in multidisciplinary clinical teams during five years of training should benefit from a more authentic learning experience and greater patient contact than students on conventional programmes. But information is lacking on curriculum design and delivery for doctor apprenticeships, including details of their clinical role and what “on the job” training comprises in practice.
Limited capacity in clinical placements is already a challenge for all health professions. Different healthcare students compete for the same resources, and it is difficult to see how doctor apprenticeships will fit into existing training models. Careful exploration of alternative ways of delivering clinical workplace learning will be required to accommodate the proposed doubling of medical student numbers, including apprenticeships.
The state funding available to support doctor apprenticeships is substantially less than the nearly £200 000 currently available to train a medical student in England.1617 Up to £27 000 is available for training and assessment of an apprentice,6 with NHS England agreeing to contribute an additional £50 000 each for up to 200 apprentices in the pilot schemes.18 Any additional costs, including salary costs, must be met by the employer. It is not clear whether apprenticeship schemes will be a financially viable option for medical schools, or whether NHS employers will be willing to gamble on the costs of employing and training doctor apprentices without any guarantee that they will stay and work in the organisation once qualified.
Will apprenticeship programmes achieve their aims? It is too early to tell, but the pilots due to launch in 2024 will be critical to our understanding of how this new route into medicine will work in practice.
Footnotes
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Competing interests: We have read and understood BMJ policy on declaration of interests and declare that SC, MDM, and JA advised Health Education England on aspects of the medical doctor apprenticeships relating to widening participation.
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Provenance and peer review: Commissioned; not externally peer reviewed.