Melanie Etti: The A levels fiasco is part of a wider picture of inequality in medical school recruitment

This year’s A levels debacle is fresh proof that more needs to be done to widen access to medicine, says Melanie Etti

The initial release of A level grades this year resulted in widespread uproar as almost 40% of students across England saw their predicted results downgraded, causing many to miss out on their places at university. Their final grades had been calculated from their predicted grades using a new algorithm—its flaws soon became glaringly apparent. The algorithm favoured students who studied in smaller cohorts and who were from historically high performing schools, meaning the downgrading was inordinately skewed towards students who attended larger, state funded schools.

Among the reports of students who were adversely affected by this downgrading, there was a disappointingly high number of students who had lost out on their places at medical school. Many of the students I saw telling their story were from lower performing schools, less advantaged socioeconomic backgrounds, and of Black or minority ethnic heritage—a sad yet unsurprising outcome to say the least. 

The government has since backtracked on their decision to use this algorithm in the allocation of A level grades. Nevertheless, the fallout from this initial act has been profound and, in many ways, this year’s debacle has only forced into clearer view the inequalities that many students from disadvantaged backgrounds face every year in trying to gain a place at medical school.

The lack of diversity in medical school recruitment has long been recognised and documented, with last year’s annual report by the Medical Schools Council Selection Alliance revealing the extent of the persisting inequalities in the UK. In 2017, just 120 medical school entrants were from households with at least one parent in a lower supervisory and technical occupation, a figure that remained largely static over the preceding decade. While the number of entrants from Black and minority ethnic groups has increased overall, students of Black heritage continue to be under-represented among both standard and graduate entry medical school recruits. 

As the child of African migrants, I understand and have experienced firsthand the challenges that many Black students face when applying to medicine, and how feelings of impostor syndrome can develop from being underestimated by those around you. The opportunity to take my A level exams in many ways felt redemptive, and allowed me to prove myself, independently of my circumstances. Sadly, this opportunity was not afforded to A level students this year, meaning their futures hinged almost entirely on estimations of their capability made by others. 

Organisations such as IntoUniversity, Generation Medics, and the National Medical Schools Widening Participation Forum have been instrumental in responding to these disparities, providing much needed assistance to students from various social circumstances in their pursuit of a place at medical school. The BMA has also launched a number of initiatives to widen participation in medicine, including the BMA aspiring doctors programme. Many medical schools have also committed to increasing access to medicine by providing foundation years and widening their entry criteria to include the successful completion of an access course. The use of the algorithm in the initial allocation of this year’s A level grades undermined the efforts of these organisations, essentially building back up the barriers that they strive to overcome and reversing vital work done throughout the year.

While there is often pushback against the notion of introducing quotas to medical school recruitment, I would argue that the outcome of this year’s A level grade allocation demonstrates exactly why quotas are not only justified, but necessary. One of the main arguments against them is that they would allow disadvantaged students who are not deserving of a place at medical school access to one. Yet the government was complicit in implementing a system that produced the exact opposite outcome. 

It therefore seems illogical to view the introduction of quotas as discriminatory when they are merely compensating for an imbalance that already exists. Formalising medical schools’ recruitment targets for students from underprivileged backgrounds would go some way to mitigating the limitations that their circumstances can impose on their ability to reach their full potential.

The events that unfolded this summer also signify the need for the government to increase their involvement in widening participation schemes. The government cannot hope to improve access to medicine if they are not at least partially invested in the ongoing efforts towards this goal. It is important that we begin to hold them accountable for ensuring that the tools for upwards social mobility are available to those who need them most. The initiatives required to enable these students a real chance at successfully entering medical school must be implemented during their school years, and only the government, through the Department for Education, have sufficient oversight over the state funded education system to be able to realise such a vision.

For many students this year, the glass ceiling was held very firmly in place by a system that purported to be rooted in meritocracy, but instead favoured those in positions of privilege. This may have a lasting effect on their self-esteem, reaffirming any budding feelings of impostor syndrome that might have already started to develop. While the government has announced that they are lifting the national cap on medical school places, many of those who have now fulfilled their grade requirements will still likely see their entry to medical school deferred until next year. This could mean that the effects of this flawed judgment last for years to come. 

A vast chasm already separates many disadvantaged school students from a chance of attending medical school. It is imperative that the government begin to put corrective systems in place in order to prevent it from widening any further. 

Melanie Etti is a clinical research fellow at the Institute for Infection and Immunity, St George’s, University of London. She is also a mentor with the Black Medical Society, a peer led organisation that provides support for Black medical students, junior doctors, and school students who are considering a career in medicine.

Competing interests: None declared.