Kieran Walsh: Can we make savings in medical education?

The age of austerity in the NHS has only just begun. The next few years will likely bring closed Casualty departments, downgraded district hospitals, longer waiting times, and rationed treatments. As Whitehall casts around for more targets for efficiency savings, will it look at the £5 billion spent each year on healthcare professionals’ education? Will this spend be frozen or cut back? Would Whitehall know what to cut back on?  

The answer is not that straightforward. When any number cruncher looks at a figure like £5 billion, the first question they ask is how does it break down. And the answer? Nobody knows but the following is a reasonable guess. Just over £1 billion is spent on undergraduate medical education; over £1 billion is spent on postgraduate medical education; and it is difficult to know how much is spent on continuing professional development or allied healthcare professionals’ education. And how does the £1 billion spent on undergraduate medical education breakdown? That is even more difficult to tell—indeed it is difficult to tell how much of it is actually spent on education. Tertiary care teaching hospitals have three core functions—to care for patients, to teach students, and to carry out research. But there is no doubt where the kudos is—in research. The majority of a senior lecturer’s salary may be allocated to teaching but they may in fact spend most of their time doing research or covering clinics. To look at the £1 billion from another perspective, you might ask how much is spent on curriculum design or assessment or small group learning—but then you will really be met with blank stares.

Could healthcare professionals be educated at a lower cost, or could we squeeze more educational delivery out of our £5 billion spend? The Department of Health may talk about cost effective educational delivery, but nobody really knows what that means and the concept of cost effective education may be an oversimplification in any case. Education is not like a drug that can be consumed and digested and expected to result in easily measurable outcomes. It is more complex than that.

The concept of spend on postgraduate education is a particularly tricky one. The health service is paying for the education of postgraduate trainees—but the trainees in turn are responsible for much frontline healthcare delivery. If the trainees were told—okay you’re only here to learn and not to deliver care—then who would deliver the care? And where would we find the money to pay them? As medicine is best learnt by practice under supervision, the idea of trainees that don’t deliver any care is unlikely to be a good one. Perhaps this is all a stone best left unturned, it may turn out that we are in actual fact getting quite a good deal out of £5 billion.

£5 billion may in any case be too low. The recent Lancet commission on healthcare professionals’ education bemoaned the lack of investment in education—especially in such a talent driven industry. It said that investment in education—as a proportion of total healthcare spend—was too low. That would be an interesting outcome—an efficiency drive that results in a higher spend.

Competing interests: Kieran Walsh works for BMJ Learning—the medical education division of the BMJ Group. He has written a book on cost and value in medical education published by Radcliffe.

Kieran Walsh is clinical director of BMJ Learning—the education service of the BMJ Group. He is responsible for the editorial direction of BMJ Online Learning, BMJ Masterclasses, and BMJ onExamination. He has written two books—the first on cost and value in medical education and the second a dictionary of medical education quotations. He has worked in the past as a hospital doctor – specialising in care of the elderly medicine and neurology.