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Official Report (Hansard)

Session: 2008/2009

Date: 25 June 2009

COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY

Supplement for Undergraduate Medical and Dental Education

25 June 2009

Members present for all or part of the proceedings:

Mrs Michelle O’Neill (Deputy Chairperson) 
Mr Thomas Buchanan 
Dr Kieran Deeny 
Mr Tommy Gallagher 
Mr Sam Gardiner 
Mrs Carmel Hanna 
Mr John McCallister 
Mrs Claire McGill 
Ms Sue Ramsey

Witnesses:

Mr Norman Bennett ) Queen’s University Belfast 
Professor Paddy Johnston )

The Deputy Chairperson (Mrs O’Neill):

I welcome Professor Paddy Johnston, director of the Institute of Health Sciences and Mr Norman Bennett, director of finance, both of Queen’s University. I invite you to make a presentation and then members will ask some questions.

Professor Paddy Johnston (Queen’s University Belfast):

Thank you very much for inviting us to give evidence in relation to the supplement for undergraduate medical and dental education (SUMDE). As you have said, the SUMDE report has gone out and the public consultation is now closed. For the nine months prior to that, we spent a lot of time deliberating on how best to go forward. The review and the report were released due to the recognition that the funding for SUMDE was going in, but not in a transparent way, and in large part it was not achieving what it originally set out to do.

The whole idea behind SUMDE started back in the early 1990s with the supplement for teaching and research (STAR) programme which, throughout the UK, went into the trusts to supplement and support the teaching of medical students. It recognised that additional costs were incurred by hospitals that accommodated the teaching of medical students and supported research.

In the late 1990s, the research component came out of the funding. There then followed several reports, the first of which was the Winyard report, which stressed the importance of supporting medical education within trusts which accommodate medical students. It focused on the issues of clinical placements for students and on the facilities, or “infrastructure” as it is called.

From our point of view, 2004 was important, because we had the Chantler report, which recommended the expansion of the medical school from 154 students to 250. At that time, one of several recommendations was that SUMDE should be reviewed and a new SUMDE created to support the 96-student expansion. Thus, in 2006, we suddenly had two different SUMDEs; a new one and an old one. The new SUMDE was based on a different model called the teaching unit, which I will return to. It was also built around the idea of being transparent and auditable so that its use could be measured.

That is the background to this report. Essentially, the total funding last year, including dental SUMDE, was £34·5 million. We in the medical and dental school, and within the university, really do not know how that is being used. In particular, one of the largest blocks of that funding, approximately 65%, goes into infrastructure funding. However, our major teaching hospitals have the worst infrastructure funding to be found. Better infrastructure funding to support students is found in some of our peripheral hospitals, which get a much lesser share.

The report looked at different models for how to go about distributing funding. We were not looking for additional funding, we were looking for transparency. Our deliberations led us to recognise that the teaching unit that is currently used to support the new SUMDE is the best model, because it can be easily quantified. The old SUMDE model used student weeks, which are much more difficult to cost in a meaningful manner; whereas teaching units define the measurement and frame it very transparently as a consultant teaching six students. From a funding perspective, that can be put into a work plan that relates to the current practice of our consultant workforce.

As part of the review, we looked at best practice elsewhere, because SUMDE-type funding called SIFT (service increment for teaching) in England and Wales and ACT (additional cost of teaching) in Scotland has been reviewed recently. The most recent of those reviews was in Scotland, which follows a very similar model to the one suggested by us in the report.

The report has come up with a number of different models based around a teaching unit cost that relates to the mid level of a consultant’s salary. There are then some on-costs up to a total of 30% to support heating, lighting and various things like that in the facilities where students are taught. There are two different components: the first includes the additional infrastructure costs in the current ratio; the second removes £0·5 million against which the trusts will make case-by-case bids for capital investment.

The university’s recommendation to the Committee a couple of weeks ago was that we preferred the second option, which takes out the £0·5 million for capital bids each year. The teaching unit — around £260, with an on-cost of 30% — is also our preferred structure going forward to wrap both old and new SUMDE together into one.

The other component of the SUMDE review is joint appointments. Although not finalised, because it came out as a major issue as part of this review, it was decided that a second piece of work should be carried out to look at the appropriateness of joint appointments and how they are currently made, looking at funding from the Department of Health to, primarily, the Belfast Health and Social Care Trust, which basically matches the funding of the clinical academics that is provided by Queen’s. Unfortunately, for a variety of reasons, we are finding it hard to fill clinical academic posts, which is a major problem. It is virtually impossible to attract leading national and international figures, partly because of our structure. They cannot relate to it, and it erects barriers to career progression and, in certain respects, remuneration.

The joint appointments structure is a barrier to the development of an international medical school. One of the goals of the new medical school, which is a dental, medical and biomedical science school, is to cater for over 1,800 students and to be one of the top 10 medical schools in the United Kingdom and internationally in the next 5 to 7 years. The joint appointments structure does not facilitate that, primarily because the clinical academics see themselves as having two bosses. Working in that way, particularly where the needs of patients are paramount, as they should be, we are not going to be able to develop clinical academia in the manner in which our competitors are doing and have been doing for some time.

The overall benefits of the SUMDE report are that it produces openness and transparency in relation to what is a very important resource; it encourages transparency in the use of funding for medical student training, because the money follows the student rather than getting stuck in a trust, where we do not know what it is being used for; and, importantly, it allows for the creation of meaningful education and clinical networks across Northern Ireland. You might ask whether those already exist, and the short answer is yes and no, but really no. Yes, because of the goodwill of many practitioners, but no when it comes to their overall effectiveness.

We have the lowest clinical academic staff-to-student ratio in the UK. It would take only a small change to make it impossible for us to be able to provide the type of education that we should be providing for the number of students that we have. We are in a vulnerable position, because we no longer have the engagement with the NHS consultants and staff that we had 10 or 15 years ago. If you do not pay for it, you will not get it. I hate to say that, but that is today’s culture. The basic thinking is, in other words, if it is not in my work plan, there will be no engagement.

The GP model is the one that currently works best. When I meet GPs across Northern Ireland I am taken by their enthusiasm for being engaged with students and for allowing their practices to house students. I believe that we will see much more of that, but it contrasts with what is happening in trusts. My colleagues struggle to get people, particularly in the largest trust, to teach students and be there for them. They struggle to get it timetabled properly and to get exams done. This year’s exams took place four weeks ago. If it was not for a core group of 12 to 15 academics, this thing would fall flat on its face. We cannot ignore that, and if we do not do something concrete soon, our medical students will be in trouble. I have only really come to appreciate what the real issues are in medicine during the last two years, because, as some of the Committee will know, before that I was much more focused on cancer services.

Altnagelvin Hospital has some of our best facilities, even though they are 25 years out of date. We could place more students in Altanegelvin, but we do not have the facilities to do that. The general practice community and the consultant body in the north-west, some of whom who are internationally trained, are not really engaged with Queen’s, because they are not being facilitated to do so, partly as a result of the funding being locked down in the Belfast hospitals. However, in my view there will be an increasing spreading of students, not only geographically, but also through general practices. There are very significant challenges in that area, and that is one of the reasons why this is very important.

If we implement the SUMDE recommendations and achieve a rebalancing of the joint appointment portfolio, there will be better educational programmes for our students; an enhancement in our ability to attract national and international leaders to work here; and a real dynamic of change and innovation in the Health Service, which, in my view, is currently patchy at best — all of which will be good for patients. There will be impatience in the system, because of the type of people that we have, rather than a sense of complacency in certain quarters, which is what I currently detect. I thank the Committee for listening to me.

The Deputy Chairperson:

Are you saying that SUMDE will not, on its own, address the issue of our not being able to attract internationally renowned and excellent people?

Professor Johnston:

Without SUMDE, we will never get there. SUMDE is the beginning of getting there, but it is not the only factor. For example, Queen’s tried to attract, and appoint, someone from Toronto who was in the top four or five worldwide in the field of radiation oncology. However, delays and a lack of engagement from certain quarters led to that individual feeling disenfranchised from part of the system in which he would have been a clinical leader. I am not pointing the finger at any individuals, but I am using that example to highlight the problems.

I am not going after 100 people, but perhaps seven to 10 people internationally. However, let us be clear: those people can work anywhere in the world. They do not need to work in Northern Ireland, and we are not opening that door for them. We are using internal, archaic and arcane bureaucracy and rules that were drawn up 30 to 40 years ago to ensure that people do not come here.

Equally, in a national UK setting, I was the first person to introduce national fellowships in the Northern Ireland medical health system. At consultant level, those fellowships are seen as a badge of prestige. These people have to compete for salary and against other people and are regarded as national and international leaders. They are nurtured through their careers. However, we did not know how to appoint an honorary consultant in our system, and, as a result, the person who I referred to earlier was not eligible for merit awards three or four years later when University of Manchester approached him to be their professor of medical oncology. There are fundamental flaws in the way that we work with the outside world.

Mr Norman Bennett (Queen’s University Belfast):

At the moment, the funding, which is quite considerable, is locked up in a way that we do not understand. Its application is also quite rigid, meaning that when attempting to attract someone of the calibre that has been discussed, the mission of the university may be heading in one direction and the mission of the trust in the other, with both having quite legitimate but different aspirations and expectations.

The aims are increasingly divergent, because the trust is focused on short-term needs, whether they may be medical or surgical, which are obviously legitimate, whereas we are looking towards developing particular programmes for the medium to long term. Therefore, the missions are divergent, and it is hard to get the elements of money, wherever they happen to sit, to come together to serve a common purpose. That needs to be freed up in a more considered way.

The Deputy Chairperson:

The aim of the review and the consultation is to make it more open, accountable and transparent. There is an obvious disparity between what you get in the west and what you get in the Belfast Trust. The money is allocated to trusts, but there is no mechanism to trace that money and to follow it through to find out whether it has been used to provide the services that it should provide. Under the new arrangements, is that going to change? Can that money be traced?

Mr Bennett:

As Professor Johnston said, a new system was introduced when the medical school expanded. That is only a small component — £2 million of the £38 million that is in the system. We would like to use that same methodology for all of it. That would trace the funding, and it would follow the students; in other words, the more students who are trained in the west, or wherever, the more money they will get.

The other component that was talked about was the £38 million that will be allocated in 2009-2010. Almost £20 million of that is locked up in infrastructure, which relates to the maintenance of buildings and facilities. More than 90% of that money is allocated to Belfast, yet the distribution of students does not match that. It is historical, yet the facilities in Belfast are probably not even on a par with those in Derry, which are 25 years old. Our dental equipment is the worst in the UK. The average age of our dental chairs is 20. Therefore, young dental students are training on archaic equipment, which is more than 20 years old. That will have a serious impact on the future of our medical and dental professions.

Professor Johnston:

That is fundamental to our inability to develop as a leading medical and dental school. We have very good people. We could attract better people, but when they come and look around the facility they see that there is something wrong, and they do not hang around. Part of the problem is that we are not getting the transparency in relation to the funding pot. It is not being put to support medical students or dental students, and we need to change that. We also need the joint appointments system to be changed so that it becomes much more focused. Therefore, we can develop real clinical, academic leadership, which is sadly missing, and we can have people representing us nationally and internationally on committees showing what Northern Ireland health is all about. That is a huge challenge for us, but it is achievable. However, if we do not get SUMDE right, we will not get there.

The Deputy Chairperson:

The SUMDE review is not looking at funding for dental students, but it is assumed that it will also apply to dental students. Is that right?

Professor Johnston:

We have always been of the view that we were not allowed to deal with the dental issue, because it was part of a separate stream. However, our view is that it is exactly the same set of issues for dentistry.

Mr Bennett:

All the regions of the United Kingdom are going through a similar review. The review in Scotland has finished, and a more radical review has been put in place. What we are recommending very much follows the Scottish model and is in line with the concept of following the patients. It is not rocket science; it is something that other regions have done, or are doing, for the benefit of the whole population and for the future of doctors and dentists.

Dr Deeny:

I was listening intently to what you were saying; I can hear it in your voices and see it in your faces. The concern is that funding problems could have a detrimental effect on the education of medical and dental students in the future and on our ability to attract top medical people to Northern Ireland. That is a serious concern. I will not put words in your mouth, but it seems as if we cannot trust the health and social care trusts with the finance for the future of medical and dental students.

I have been working as a GP in the west for over 20 years and have often found that there is a Belfast orientation, even in GP recruitment, for example. There has been talk about a university in the west, which would accept students from across the border and would be good for the west. The sharing out of medical students and, if it were possible, dental students would be a good thing.

Has there been resistance from the trusts to SUMDE? We are in a political and a financial situation, both globally and here, in which everyone is talking about money. I would not like to think that the future of medical and dental students, who are so important to future populations, and our ability to attract top international professionals would be jeopardised because the trusts have far too tight a grip on the financial pot. We need the universities and those who know how to pave the right route to take the lead so that quality doctors and dentists are produced in Northern Ireland and want to stay here.

Mr Bennett:

We have no interest in destabilising the critical financial position of most of the trusts; as a member of the Committee, you know more about that than I do. Therefore, whatever has to be done may take some time, but a journey begins with the first step; we are seeking to build a better system for the future. The models that have been produced would require a marginal sum in the context of the overall budget available; a few million out of £1 billion, or whatever it is, that is allocated to the Belfast Trust.

We do not want to promote anything that would undermine or destabilise the trust or impact on patient and client care. We have said, not least in a meeting with the Belfast Trust last week, that it is not in our interests or anyone else’s to go at this in a rash way. However, we want to build a better system for the future, because the present one is not working, is not transparent and, as you rightly say, is not going to give us the sort of future doctors and dentists that we aspire to have.

Dr Deeny:

As a clinician, I feel that management, although important in the Health Service, has too much say in the production of medical and dental students, whereas senior clinicians do not have enough say. Do you agree?

Professor Johnston:

I categorically agree. That problem goes through every domain that I have talked about, including the joint appointment system. Although I was not part of the process, five years ago, we lost a top clinical ophthalmologist who was trained in Harvard and the National Institutes of Health, because several people in both the School of Medicine and the NHS ganged up to stop someone from coming here who wanted to come here, originally from Germany. It makes you wonder what is going on. Other people in the rest of the UK see that and also ask what we are doing and why we did not appoint that person.

Therefore, there are issues that we must be honest and critical about in our approach. At the end of the day, if we have a medical system that is afraid to challenge itself, we have a problem, because failing to exercise the challenge function in the Health Service is how one negates and neutralises the innovation dynamic, which is important.

To go back to the issues that you raised with respect to the west, Kieran Deeny may know that I recently spent a day there discussing this issue with a number of general practitioners and consultants. I went there because we are in danger of losing the support of large elements of the medical community west of the Bann and in the Derry region. Other schools — most recently, the Royal College of Surgeons in Dublin, which is a private college and can move more quickly than we can, but also the graduate schools in Galway and Limerick — have approached the general practice community and the consultant community in the north-west, because it is obvious that the people in Belfast are not treating those communities appropriately. To be absolutely candid, they are right. There are some outstanding, internationally trained consultants sitting in Altnagelvin. Incidentally, historically, the School of Medicine at Queen’s has been at fault, because it shunned those guys, so we have had to stop doing that. Equally, as the report indicates, Altnagelvin gets probably 3% to 5% of the total funding, and, of all the trusts, it probably uses its funding best. Until very recently, it was the only trust to have an education and training account for students; that tells you a story.

The School of Medicine, Dentistry and Biomedical Sciences must do much more with the Western Health and Social Care Trust to engage with the clinical community there, which feels disenfranchised and has a genuine problem retaining staff at all levels. Therefore, the school has a responsibility to ensure that it is visible by, for example, badging buildings and, indeed, by placing staff there. Discussions to do those things are under way with general practitioners and within the hospital. Addressing that situation and developing transparency would become easier to handle if money were to follow students. However, in the absence of that, I have no way to support such measures.

Mr Gardiner:

Thank you for your enlightening presentation. I share some of your concerns; in fact, I fully support you. You said that although the structures are all right, there are barriers. We would like to hear about those barriers and about who is obstructing the efficient working of the system.

Furthermore, you said that only a small change by the Department is required to make the system work. If that change is so small, surely we can overcome the problem and get something done by taking the matter up with the Minister. We do not want students to leave Northern Ireland; we want the best for Northern Ireland. To say that what we have is 25 years out of date but that it is the best that we can do is not good enough. We want the best; we want the rest of the world to recognise that Northern Ireland has top quality. We have the students and the personnel — people such as you — to implement the necessary changes, but does everything hinge on funding?

Professor Johnston:

No. Funding is only one element of it. In fact, a culture change is needed. In order to develop leverage, one must create momentum by at least having some things that can be done. One of the most important things that we must do immediately is to re-engage the clinical community at consultant level. For whatever reason, that community is disenfranchised. For any medical student, including me when I was being trained, working on the wards is essential. We are trying to move back now, and we have completely reorganised the fourth and the final year, which will be linked to F1, in order to get students back into a clinical setting and working with patients. Our consultant colleagues are disenfranchised, partly due to the new consultant contract and partly due to the fact that education is not being built into their work plans in a concrete way.

My view is that SUMDE allows us to set up sub-deaneries in each of the major trusts, so that there are individuals and teams who take charge of the medical, surgical, and paediatric training within those entities. They can organise the implementation of the curriculum, and arrange where students go locally. The role of the school becomes one of continuing with the education effort, but also making sure that the correct curriculum is being implemented and advanced, that we are in line with what the General Medical Council needs, and that we have people who are pushing at the boundaries of education methodology; in clinical-skill methodologies, for example, which are going to become even more important with the introduction of new teaching techniques for doctors, nurses and dentists. That is actually relatively easy to do, but there is a need for a different approach. Until very recently, there was only one trust that had an education account related to SUMDE funding.

Mr Gardiner:

What trust was that?

Professor Johnston:

It was the Western Trust. That tells one something right away, and partly answers Dr Deeny’s question. Until the money is going into those accounts, and there is an annual audit function relating to the spending of that money, we will not have got it right. That is what is needed and what we propose.

If that is done it means that the trusts will want to engage fully with the education efforts. I have already tested that with my colleagues in a number of trusts. The signal that would be sent to them would be that they must do so, and that the opportunity is there. That engagement would no longer be seen as a nuisance, and as not really a part of the responsibility of the trusts. I understand the pressure of service commitments; I have been there for a long time myself. Nonetheless, we have a responsibility to those coming behind us, whether one is in the medical school or in the NHS, to ensure that patients in the future can access top-notch physicians and surgeons, and that the right approach is taken in relation to culture.

If undergraduate students do not see engagement from the NHS leadership — in other words, the NHS consultants — or from leading GPs, there is a question mark. I am sure that those of you who are health professionals will understand what I am driving at. We all need role models, from the earliest point in our education, so that we have things to point to as we develop. I think that our recommendations will allow that to happen.

Mr Gardiner:

I fully support that. We must bring the issue to the attention of the Minister and the Department to be re-examined. We want Northern Ireland to be the best, and we want to support students. We also want our students to stay in Northern Ireland, and not to go to another country after they get their qualifications. If we are pouring money into their education we hope that those students can be persuaded to stay and work for the good of the people of Northern Ireland.

Mr Bennett:

We want the best students, and also the best people to train those students.

Mr Gardiner:

Yes, we do, naturally. I support that.

Professor Johnston:

There is a small issue with the system, which is probably a quirk of history; I do not know how it got there. It is partly because we have an odd appointment system, which may have been fine 30 or 40 years ago. If I am trying to recruit someone who is originally from Northern Ireland, who is in their mid-40s and working in one of the other major hospitals in the UK, that person will not be eligible for any merit award if they are offered the position as a joint appointment for three years. No other part of the UK works that way. If that person were funded by the Medical Research Council as a senior clinical fellow — one of the most prestigious appointments in the UK — and decided that they wanted to bring that expertise to work in Belfast, they would currently be ineligible for any of the awards, and could not receive one.

The system is set up in a way that disenfranchises those who lead elsewhere. We have already had direct experience of that. The individual from Toronto that I mentioned was in his mid-50s. We put it to our partner, the NHS, that that person would have to be considered for a senior merit award because of his international stature. However, we were basically told that that could not happen. We are using rules and regulations that suit a single purpose and that enshrine insularity rather than opening us up to real challenge and competition.

The Deputy Chairperson:

We will have an opportunity to put that to the Department, because its representatives will be next to give evidence.

Mrs Hanna:

If the new SUMDE model is put in place, the funding follows the students and clinical networks are facilitated, how can we help you to move the other things on? There is a big question about where the money goes, but someone must know where it goes. I am not sure where we should start, but presumably we could try to tease that out. We can try to change the culture and the meeting of minds of clinicians and academics. I am not sure what we can do. How best can we be of help?

Professor Johnston:

The Committee is already being helpful, because it is having an open and honest debate on the subject with us; that is very helpful, regardless of the outcome. Like other aspects of SUMDE funding, the joint appointment system is not rocket science. I am not asking for anything new; I am just asking that we come into line with best practice elsewhere.

All of the joint appointment funding should be with the university. I do not believe in working for two bosses. I believe that people should work for one boss, and work can be contracted to another person if required. That is why the rest of the UK has an academic contract in which honorary people work with a trust. People may still work five or six sessions with the trust and be very busy clinically, but they will not be taken out of that role, and, indeed, that role and function will be an individual’s primary driver.

In 2004, the Academy of Medical Royal Colleges recommended that clinical academics work in teams due to the complexities of the challenge function in clinical academic medicine. My area is cancer, but I can no longer carry a patient load due to my other responsibilities. However, I do a Monday afternoon clinic; I do my on-call; I work with three or four gastrointestinal oncologists; and I am still involved in clinical trials to some extent. Some of my colleagues want to do a lot more than that, and they have to define their role and function within their team. For example, as a clinical academic, the role of a nephrologist is to educate and give clinical leadership. That person has to break the barriers of front-end knowledge so that he or she can continually raise the bar when helping to train postgraduates.

We do not yet have a team structure to working, but it would not be hard to implement. Rather than individual work planning, there would be team job planning, particularly within teaching hospitals. That would improve a number of things, not just the quality of care. Like multidisciplinary working on cancer, a team approach to clinical work is likely to produce a better outcome for the patient than continual individual work.

Fundamentally, there is enough funding in the system for joint appointments. However, we do not get access to it. Indeed, we have found that significant funding of around £2·6 million was earmarked for joint appointments, and we knew nothing about it. That can allow us to develop, to get more numbers in, and also to have the challenge function in place, as we do now because we have a tenure review process, which means that a person must meet certain academic standards in order to continue working for the university in a clinical academic way.

I think that you are being very helpful already, Carmel, in posing the questions. There needs to be a debate with the Department about why we are not aligning with the rest of the UK in our appointments structure.

Mrs Hanna:

There is something about the relationship with your clinical and academic colleagues, and then there is the departmental element in which decisions have to be made.

Professor Johnston:

Yes; that is correct.

Mr Bennett:

Today’s forum is a major step forward. The issue has not simply arisen overnight. Professor Johnston and I were part of the Chantler review that he referred to earlier, which met and reported in 2004. Time is moving on, and we want to see that the current consultation — led by the Department, to give it credit — is not put on the shelf somewhere and forgotten about, but that something happens this time. We do not have too many more opportunities to get it sorted.

I agree with Professor Johnston that it is not a matter of insufficient money in the system. An exercise has been carried out to benchmark the amount of money in Northern Ireland’s system against Scotland, England and Wales, and we about right in quantum terms. The issue is how that money is being used at present, and we do not know that.

Mrs McGill:

I am one of the members from the west, and I have no professional expertise in medicine at any level. The tension here is surprising to someone like me. It is particularly surprising that the Department resists the expertise that experts in the field, such as you, bring to the appointment of someone of high standing and calibre. If your advice and expertise are not taken on board in the appointments system, then, as Carmel and others have said, that is clearly a big issue. It is an issue if quality people are not encouraged to come here, and then when they actually get here, they look at the system and they say, as Professor Johnston has said, that there is something wrong here and they go to Galway or elsewhere.

As one of the members of the Committee who represent the west, I was interested to hear that Altnagelvin Area Hospital is 25 years out of date but provides a better service than elsewhere. To return to a point that I raised earlier about the provision of dentistry services in the west: if education in the field of dentistry at a particular level was provided in the west, would that help with the deficit in services that there is in that area? I am keen to make that linkage. Would it make any difference?

Professor Johnston:

The problem with dentistry is multifaceted, particularly because of reimbursement issues. Nonetheless, in parallel with the general practice community in the west, it would allow certain dental practices in the west to engage more fully. Real engagement, and the facilitation of that engagement in a way that is meaningful, is what is missing. There is a problem with recruitment and retention. Retention is the bigger issue and is largely about people not being able to fulfil aspects of their professional life in the west, and moving to Belfast where they can do so.

That is one of the big issues that face the medical community and, possibly, the dental community, to some degree, in the west. I argue that clinical conditions in Altnagelvin Hospital, in particular, are among the best in these islands — certainly, they are better than those that I have seen in some Belfast hospitals. Therefore, people perceive, quite wrongly, that there is a lack of professional opportunities on their doorsteps, which may encourage them to drift back to Belfast. We need to change the perception that everything is in Belfast. We do not want everything in Belfast, and it should not all be in Belfast, especially undergraduate education.

Mrs McGill:

I welcome those comments. Not everything should be in Belfast.

The Deputy Chairperson:

I believe that we all agree on that.

Mr Buchanan:

I am sorry that I was late and missed your presentation. I have listened to the concerns around the room. I have a couple of questions. If they overlap with previous questions, I apologise for that as well.

What can the Minister and the Department do in the short term — urgently, if you like — to help to encourage students who have already come through the system to remain in Northern Ireland? You talked about the west; I, too, have concerns about services in the west. You said that more work needs to be done with the trust in that area. Can you elaborate on what that entails? What work needs to be done with the trust to strengthen and stabilise services and to retain professionals in the area?

Professor Johnston:

Overall, there are major challenges. I shall deal with the second question first, because it leads into the first one.

As regards the concrete action that must be taken, capacity must be increased. From this year onwards, there will be 1,250 medical students and almost a further 270 dental students. Therefore, there is a capacity issue as regards how we deal with that. I must say that we have had great engagement with hospitals throughout Northern Ireland that we were not fully engaged with previously, including Altnagelvin. In the main, students coming back from those hospitals are saying very good things about them, in the main. As regards Altnagelvin, we need to engage the general practice community. Therefore, one thing that we are looking at and discussing is whether to have an academic practice in Derry, where some members of staff would practice. We have the facility to do that. We would very much welcome it. In other words, Queen’s appointees would sit in one of the major practices in Derry.

As I have already said, if it makes sense, we would look at having a joint appointment structure or a clinical academic appointee in Altnagelvin Hospital to give leadership in one or two clinical areas. Then, of course, there is the sub-deanery structure, which creates the network, the identity, in the hospital. Another possibility is to badge certain buildings as being for our students. Our estates department is already working on that.

The final possibility that I have suggested is to name Altnagelvin as a university hospital. There is no reason not to do so. It has better facilities than many hospitals that I have seen throughout the UK. Therefore, why not give it that badge of academic authority and leadership? We are currently actively exploring those options. In the next while, a number of papers will come forward that will look at the implications.

Mr Buchanan:

And what can the Minister and the Department do in the short term, if you like, to encourage students to remain in Northern Ireland?

Professor Johnston:

That has two important elements. First, from the medical and, indeed, dental perspective, Queen’s University is oversubscribed. At present, we have 250 positions in medicine. For the current academic year, we received over 800 applicants. Let us be clear: we get the cream of the crop. Another 300 or 400 medical students go elsewhere in the UK to train. Many of them want to come back, but, partly for the reasons that I have already mentioned, we are putting up some artificial barriers.

Secondly, the School of Medicine, Dentistry and Biomedical Sciences was not brought together by accident. Professional schools should be moving towards enrolling only graduates, because they are better students and professionals. We are destroying our scientific base in Northern Ireland by allowing our, potentially, best scientists to become doctors, pharmacists, physiotherapists etc. We are not allowing our scientific base to flourish in the manner that it might because, as yet, we have not grasped the principle of funding graduate students. Science students who are educated here are being penalised. If they went to the University of Birmingham they could get funding to study at the graduate medical school there; however, they cannot do that here. That is a major problem and barrier.

Mr Bennett:

When the medical school expansion was approved and the first intake came in, we suggested to the Minister of Health that a small cohort of graduate-entry students should be accepted to study medicine. As Professor Johnston said, graduate-entry students would not only help in terms of our scientific base, but they would make better doctors, because they are more mature and have more life experience. As far as I am aware, that proposal is still with the Minister.

Professor Johnston:

What would they bring to the school in the short term? If that proposal were implemented, we could create a different medical structure. We already have a radically different medical school to that which we had two years ago. We have three education centres and four research centres; we are no longer running things through small clinical departments.

Every single person is quality measured on an annual basis, and research centres are up for an international site visit every two years, so there is a lot more discipline in the system now. We are looking at a whole bunch of new programmes and new degrees for students, such as master of research programmes.

If we got the proposal implemented, we could get real engagement with the wider medical community; however, it may take two to there years to achieve. Let me be clear: based on the current profile of students and staff, if we lost 10 to 12 clinical academics for reasons other than natural attrition we would have difficulty surviving as a medical school.

The Deputy Chairperson:

The British Medical Association said that it was dismayed that there was no overall increase in the number of qualified academic staff despite the 40% increase in student numbers.

Mr Bennett:

That is right. The trust was given additional SUMDE money worth £2 million to expand the medical school, but none of that has been earmarked or allocated for new staff.

The Deputy Chairperson:

Are you part of the group that is looking separately at the issue of joint appointments?

Professor Johnston:

Yes, we are.

Mr Bennett:

Yes.

The Deputy Chairperson:

I just wanted to clarify that. Thank you for coming along. You are welcome to sit in the Public Gallery and listen to the next evidence session with the Health Department.

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