The growth of the UK’s population together with an aging society with increasingly complex health and social care needs has placed a greater demand on statutory care services.(1, 2) The UK’s National Health Service (NHS) has grown and expanded to support these demographic and epidemiological trends offering a seven-day service evolving a model of delivering care that is more person-centric and integrated across organisational and sectoral boundaries.(3) In view of this emerging landscape, the UK Government has sought to increase its medically trained workforce in order to better respond to the demands placed on the health service. Despite removing the limits on the numbers entering some healthcare professions namely nurses, midwives and allied healthcare professionals in 2017, the restrictions on the numbers of students entering medical schools have remained unaltered.(4) The issue is further compounded by the system of medical education being remarkably competitive, even though medical schools in the UK receive a significant number of applicants, each year medical schools refuse applications from individuals who have the potential to contribute to a career in medicine. In 2017 (prior to the announcement of the extension of medical school places to students in 2018) there were 20,000 applications to medical schools, with only 8,000 places being available in the whole of the UK.(3, 5) Areas of medicine struggling to recruit graduates are in general practice and in many other specialities (such as psychiatry) in a number of regions not exclusively but including rural, coastal and urban areas.(4)
The expansion of medical school places was put forward by the UK Government in 2016 as a potential solution to expanding the medical workforce with a proposed increase of 1,500 places, which would be comprised of 500 additional places for allocation across existing medical schools and a further 1,000 places in new medical schools.(5) A competitive selection process was undertaken and in March 2018 five universities were announced as homes to new medical schools offering undergraduate places to boost the numbers of doctors training in England.(6) Areas for new medical schools were selected in Sunderland, Chelmsford, Canterbury, Lincoln and Lancashire, with Anglia Ruskin Medical School kick-starting enrolment of undergraduates for a 2018/19 intake.(7) By 2021, there were 9,000 medical school places following the Government’s adjustment to the cap on numbers. The new medical schools were chosen in areas with systemic staff shortages in medicine and difficult to fill vacancies.(8) It has been shown in research by Goldacre et al. 2013 in their cohort survey of 31,353 UK trained doctors in 11 cohorts from 1974 to 2008, doctors were more likely to work in the region they trained in, with 48% undertaking specialty training in the same region as their medical school. In addition, 34% of respondents who had reached GP or consultant status has settled in the same region as their home.(9) Doctors therefore invariably were more likely to work in areas in which they trained, therefore the aim of the five new medical schools is to retain and recruit doctors in areas which have traditionally been underserved by a medical workforce.(7, 10)
The impact of a new medical school to a region goes far beyond an increase in medical school places with the ensuing increase of the medical workforce,(11) but has the potential for bringing widespread change to aspects of a region’s resources, commercial interests, economy, health and research activity. The social and economic impacts considered in this paper concentrate around four related benefits which have the potential to transform a region: (1) economic sustainability; (2) improvements in the social determinants of health and health equity; (3) addressing social accountability of the medical school in the region; and lastly, (4) increasing research activity.(12, 13) With respect to economic sustainability, new medical schools encourage people to live, work and learn in communities that are economically challenged.(10) In Hogenbirk et al. 2021’s recent research on the Northern Ontario School of Medicine (NOSM) in Canada, it was found that for every dollar spent by NOSM in support of the medical education programme and associated activities including spending by staff, clinical teachers and learners, an estimated $0.66 cents (CAD) was generated in additional economic activity in 2019 in NOSM’s service region of Northern Ontario. The economic impact in Northern Ontario increased by 60% over 11 years from $67M CAD in 2008 to $107M CAD in 2019. However, often the wider community impacts are still unknown. Hogenbirk et al. 2021 suggest in addition to an increase in expenditure on associated economic activity, there is the potential to improve the social determinants of health and the health of the population, which is the focus of our next impact for consideration.(10)
Moreover, when the new medical schools were announced in England, a driving force behind the expansion was not only to address national recruitment, but provide clinical placements in specialties to regions where the shortage of doctors is the most acute. A key aspiration is that the new medical schools would be placed in areas based on the availability of clinical placements and ultimately around the needs of the local populations within geographical areas.(4, 5) Regionality is a critical factor – not only providing clinical placements in large urban teaching hospitals, but instead distribution of placements would focus on building capacity in rural and coastal settings and smaller hospitals serving local populations. This shift in placements and learning opportunities, it is hoped, will help to re-focus expansion efforts of medical schools on under-doctored regions and specialties.(4)
Medical schools have a responsibility to operate under a social accountability framework in their region. The notion of the social accountability of medical schools was first introduced by the World Health Organisation in 1995, which defined medical schools as having, “the obligation to direct education, research and service towards addressing the priority health concerns of the community, region, and/or nation they have a mandate to serve”.(14) (15) The concept has been further refined in a statement in 2010 by the Global Consensus for Social Accountability of Medical Schools(16) and the 2017 World Summit on Social Accountability,(14) which has now recognised the contribution medical schools make to engaging, partnering with and responding to the needs to underserved and vulnerable populations.(14) There are significant opportunities to form community collaborations between medical schools and regional health care organisations to improve the education, research and healthcare for an entire region to the benefit of the population.(17)
Lastly, of particular interest to universities introducing new medical schools is the research potential to the region, along with local enterprise companies, pharmaceuticals and local government being acutely aware of the substantial and increased research funding opportunities available. According to Catto (2000), biomedical and pharmaceutical research is likely to be sourced not only exclusively by public funds per year, but includes an estimated 10% of pharmaceutical research expenditure being available to universities.(13) Joint infrastructure funding is critical to help strengthen research facilities and equipment required for innovative studies in biomedical sciences in which the UK Government and the Wellcome Trust play a leading role. High quality research undertaken by well-trained researchers should have a positive effect on the retention and motivation of staff.(13) Furthermore, there is a growing body of evidence to suggest that improved research activity not only has academic benefits but is directly associated with better patient outcomes.(18, 19) Embedding research into healthcare both drives high-quality patient care and is highly rated by participating staff and patients further reinforcing the relationship between research and quality of care.(20)
Our narrative review focused on what contributions new medical schools bring to a region with respect to their wider health, social, economic and research impacts. New medical schools are not only tasked with developing new doctors, but training doctors to explicitly tackle health inequalities in underserved communities and delivering relevant patient care to those communities. We chose a narrative review to synthesise the evidence deeming it an entirely suitable method to review a combination of different study types and providing a reflective lens to help deepen an understanding of the contribution new medical schools make. A narrative review does not aim to solve a problem or puzzle requiring data, but is undertaken to help formulate a view, insight or point for clarification in which a more interpretative and discursive synthesis of the literature is needed.(21) Furthermore, a narrative review can address one or more question and the selection criteria for inclusion or exclusion may not be explicit. Despite no consensus on the standard structure of a narrative review and no acknowledged guidelines available,(22) this type of review can benefit from the same methodological rigour of a systematic review, include defining the key issues, providing clear inclusion and exclusion criteria for a literature search, narrowing the focus on a set of studies and including a relevant criteria of reviewed studies.(23) Examining the indirect outcomes of new medical schools is a key motivation for our review with respect to the health impacts, economic contribution, social effects and new opportunities arising for research.