Introduction
Health Education England (HEE) exists to improve the quality of care for patients by ensuring we have enough staff with the right skills, values and behaviours available for employment by providers. As part of our role we have leadership responsibility for promoting equality, diversity and enabling widening participation in relation to the development of the current and future healthcare workforce, through levers such as contracts, clinical placement funding and statutory duties. HEE will be working in collaboration with the Office for Students (OfS) to achieve a more targeted, coherent and coordinated system approach to closing the current gaps in participation and attainment in healthcare education.
The OfS regulates higher education in England. The OfS’s regulatory framework, published in February 2018, sets out the conditions providers must satisfy if they want to be registered with the OfS. The first condition (Condition A1) stipulates that any university or college wanting to charge the higher fee limit for tuition fees must have an access and participation plan approved by the OfS’s Director for Fair Access and Participation. The plan must set out what steps the provider will be taking to reduce its gaps between different groups of students in relation to access to, success in and progression beyond higher education. The Office for Students has set ambitious long-term targets to eliminate:
- the gap in entry rates at higher tariff providers between the most and least represented groups
- the gap in non-continuation between the most and least represented groups
- the gap in degree outcomes between white and black students
- the gap in degree outcomes between disabled and non-disabled students.
Widening Access and Participation – Call to Evidence Response
Between October 2020 and February 2021 we asked stakeholders with an interest in healthcare education and training to share with us work they are doing to reduce access and participation gaps in undergraduate and postgraduate healthcare education and training.
The reason we asked for this information was two-fold, to better understand the sort of activity taking place and its impact, and also to enable us to share examples of good practice with the healthcare education and training sector across the country.
Call for evidence response: Widening Access and Participation in undergraduate and postgraduate healthcare, details what the call to evidence gathered and provides a number of recommendations to further the Widening Access and Participation agenda.
To read Call for evidence response: Widening Access and Participation in undergraduate and postgraduate healthcare click here.
1. What is widening access and participation?
Depending on context, widening participation can mean different things; however, in the context of education, the term widening participation is currently being used to describe initiatives
that provide access to education, employment and development opportunities for under-represented individuals (and groups) helping them to realise their personal potential and, in doing so, reduce cultural, social and economic disadvantage[1].
The purpose of widening access initiatives is to raise expectations and attainment for students from backgrounds under-represented in higher education to aspire for carers they may have limited access to due to factors such as social and cultural capital. The aim of widening access in healthcare education is to recruit these students so that future generations of students, and therefore health professionals, more closely mirror the population that they serve[2].
In this document we refer to both widening access and participation separately, however we note some organisations use these terms interchangeably.
2. Why a call for evidence?
The NHS Long Term Plan and NHS Interim People Plan signalled support for the NHS to train more people domestically, recruit people from the widest possible range of backgrounds, and offer them satisfying and developing careers in the NHS over their working lives. HEE is working on specific and targeted actions to ensure the right number and mix of staff – with the right skills – are available to join the workforce which requires systematic action on multiple fronts. One of these actions includes widening participation in education and increasing flexibility in training. Research and studies have shown that widening participation not only helps increase student numbers but also improves employment, development and career opportunities for people from under-represented backgrounds and help address social inequalities.
Furthermore, widening access and participation initiatives can also encourage students to study closer to home which has the added benefit of boosting local health economies in more difficult to recruit areas. Evidence indicates universities play an important role in ‘growing their own’ – educating students who grew up in the city and who stay after graduation to work[3]; and similarly medical students from lower socioeconomic groups and those who originate from under-recruiting areas are more likely to train and remain in the geographical area where they grew up[4],[5],[6]. It is therefore crucial to attract and retain learners and trainees in those areas that the NHS needs them most, which in turn will have implications on the equitable distribution of healthcare services.
This call for evidence seeks to gather examples of:
- evaluated and non evaluated initiatives that have aimed to reduce gaps in access/participation in healthcare undergraduate and postgraduate education and training
and /or
- evaluated and non evaluated initiatives that have aimed to boost local health economies in hard to recruit areas through widening access/participation initiatives.
Collected evidence will contribute to the development of HEE’s strategic approach to reduce gaps in access and participation in healthcare education (particularly in hard to recruit areas) and identifying best practice approaches to strengthen and sustain a home-grown supply of the NHS workforce driven in part by Widening Access/ Widening Participation (WA/WP) initiatives for underrepresented communities across the whole student lifecycle. The success of a coherent and systematic approach to WA/WP in healthcare education and training will be fundamentally driven by local health providers.
3.Context
To provide high-quality care and improve health outcomes, today and into the future, we need to continue growing and training the workforce. Workforce growth comes from:
- new graduates,
- return to practice and,
- retention of current staff and overseas recruitment.
We recognise that today’s decisions on undergraduate and postgraduate healthcare training numbers will support a sustainable pipeline of people working in the National Health Service over the next 10 years and beyond. Currently there are shortages of NHS staff across all professions and in particular geographies attracting and retaining of students; For example, Figure 1 and 2 shows several schools with a high number of new starters and a higher proportion of doctors and dentists per population working in the London region in 2018.In comparison, the Midlands, East of England and South East regions have several medical schools with comparable or higher competitive ratios to London (defined as the number of applicants to available student places) but with lower number of doctors working in the region. Figures 3, 4 and 5 show an uneven distribution of healthcare professionals across England, with a greater number of professionals working in London.
Figure 1: Medical schools Figure 2: Dental schools
Figure 3: Nursing and Midwifery schools Figure 4: Pharmacy schools
Figure 5: Varied Allied Health Professions schools
New graduates trained through the higher education system are the key source of domestic workforce supply to the NHS. Workforce growth provides a helpful opportunity to increase the focus on widening participation and develop/ encourage new initiatives.
Whilst undergraduate healthcare students come from a range of diverse and socio-economic backgrounds, there is further action required to increase participation and progression from under-represented groups for some healthcare education programmes and entry into healthcare professions. Medicine and dentistry are key areas of focus, as the number of entrants from deprived socio-economic backgrounds remain low compared to all entrants to higher education. Of the 4,995 young people entering study for medicine and dentistry in 2017/18, just 6.3 per cent were from the most underrepresented groups, work is underway to improve this further.
Further work also needs to be taken to ensure the recent sharp decline in mature student participation in nursing, midwifery and allied health is reversed alongside implementing strategies which encourage male participation. Learning disability and mental health courses have historically had more mature students entrants, the reduction in funding has had significant impact on these disciplines and nursing courses as a whole[7]. Widening participation initiatives and increasing flexible options for undergraduate healthcare programmes are one of many ways to encourage participation from mature students.
We need to do more to close the gaps in participation and attainment in undergraduate healthcare education to ensure we attract the brightest and the best regardless of their background or circumstances, and that all students are supported to succeed.
4. What we need from you
This call asks for research, evaluation and other evidence about the impact of widening access and participation activities on access, student experience, retention and completion or outcomes in undergraduate and postgraduate healthcare education and training.
There are good examples of providers who have applied evidence and evaluation effectively to drive improvements in reducing gaps in access and participation of healthcare education in hard to recruit areas[8]. However, there is limited systematic evaluation to learn what is and isn't working and which examples of best practice could be adopted nationally to drive systemic improvements and consequently boost local health economies.
The findings from this call for evidence will allow HEE, OfS, and the sector, to understand the broader national picture, alongside the approaches and findings from institutions and third sector organisations (including the scope, nature and process of the evaluation).
This document summarises the issues identified to date on access and participation gaps within healthcare education and asks for your feedback on key areas relating to:
- Examples of evaluated and non evaluated initiatives or case studies that aimed to address socio-economic factors that negatively impact entry and retention into undergraduate healthcare education and postgraduate training for underrepresented communities.
- Examples of evaluated and non evaluated initiatives or case studies that aimed to increase male participation in healthcare education and training.
- Examples of evaluated and non evaluated initiatives or case studies that aimed to increase mature student participation in healthcare education and training.
- Examples of evaluated and non evaluated initiatives or case studies that aimed to effectively influence factors that affect discontinuation rates for underrepresented communities in medical or non-medical education and training.
This call for evidence is open to anyone who may wish to make a representation. We think it may be of particular interest to education and healthcare providers, professional and representative bodies, regulators, researchers, academics. We welcome responses from any other respondents with an interest in this work.
Please submit responses to this call for evidence using the response form, which can be found here by Monday 15 February 2021. If you have any queries, please direct them to this email address policyandregulation@hee.nhs.uk.
5.Confidentiality
Information provided in response to the call for evidence will be kept in the strictest confidence and used to write a report which will be published. Evidence submitted may be shared with HEE’s official subcontractor and with the Centre for Transforming Access and Student Outcomes in Higher Education[9] to inform their repository of best practice as part of their evidence toolkit. Information identifying individuals will be removed under the Data Protection Act 2018 (DPA). If you want all, or any part, of a response to be treated as confidential, please clearly mark your documents to that effect.
If a request for disclosure of the information you have provided is received, your explanation about why you consider it to be confidential will be taken into account, but no assurance can be given that confidentiality can be maintained (in accordance to Freedom of Information Act 2000).
By submitting a response to this call for evidence you are consenting to the use of your data as set out above.
Background
6. HEE’s work to date on WA/WP
HEE’s 2014 framework, ‘Widening participation – it matters!’ explains the national aim to develop a health and care workforce that can relate to the communities it serves, where progression and opportunities are based on merit, not social background, and equal employment opportunities are accessible for all. It includes some of the national and international evidence that links diversity to improvements in cost management, care quality and outcomes1.
HEE’s ‘What comes next?’ national strategic framework looks at how organisations can create a diverse workforce through sustained partnerships with schools and community organisations. It showcases best practice from across the NHS and outlines an approach that organisations can adopt to more strategically align their priorities with their outreach engagement[10].
It should be noted that HEE has commissioned the independent evaluation of the Widening participation- it matters strategy and findings will be published on the HEE website.
7. Socioeconomic factors
The Social Mobility and Child Poverty Commission[11] reported that, medicine lags behind other professions both in the focus and in the priority, it accords to issues around widening participation and social mobility. Since then medical schools have been making significant progress in social mobility and widening access. The Medical Schools Council’s 2018 report stated that there has been a doubling of medical entrants with disabilities, a substantial increase of places in gateway programmes targeted at young people from educationally and socially disadvantaged backgrounds, and a radical improvement in the amount and availability of guidance for potential medical students; however, much more remains to be done[12].
In addition, The General Medical Council's (GMC’s) ‘State of medical education and practice in the UK’ (2013) report highlighted that there remains limited representation from those from lower socio-economic backgrounds within medicine. The survey found that over one-third of trainee doctors attended private school compared with 7% of the general population and just 8% of trainee doctors received free school meals at any point during their schooling, compared with one quarter of the general population while 6% of participants grew up in a deprived area within the UK.
Furthermore, the 2018 GMC state of medical education report highlighted how early access to economic and social capital are contributing factors to educational attainment for different demographic groups of doctors in training. Reasons contributing differential attainment once individuals enter medical education include but are not limited to:
- possible unconscious bias or discrimination,
- stereotype threat,
- increased anxiety arising from perceived bias or discrimination within the system,
- a lack of role models and champions from diverse backgrounds in senior roles
- challenges fitting in or establishing relationships with a diverse network of seniors and peers,
- increased risk of being placed in training environments that are distant from family and friends.
Similarly, Dental Schools have been committed to enabling and achieving fair access to the profession of dentistry since the publication of data showing how applicants from Independent schools have had consistently higher rate of acceptance than those from state schools; however, much more remains to be done[13].
8. Male participation
While widening access to the medical profession is a priority the same principles and commitment for action equally apply to other professions, albeit that the level of progress needed may not be as extensive. In part, this is because in relation to widening access to nursing careers, there has already been considerable interest in developing progression pathways. However, nursing and allied health professions in the UK are typically dominated by women, although the extent to which this is the case varies by different disciplines within these careers. Male participation in nursing is currently less than 10%, and about 25% in allied health professions. Dental hygienists, therapists and nurses have traditionally been almost exclusively female, whilst the dentist workforce is increasingly female[14]. Reasons contributing to low male participation in nursing and allied health include but are not limited to[15]:
- gender stereotypes,
- low awareness for allied health subjects and careers,
- negative perceptions of pay and workload and
- status of nursing and allied health careers.
In order to ensure professionals are representative of the population they serve, and to help address the workforce shortages in these roles, it is essential to challenge gender stereotypes, design gender neutral recruitment strategies and ensure men entering these disciplines are supported and welcomed.
9. Retention of mature students
Nursing, midwifery and allied health courses have historically attracted greater numbers of mature students than any other subject area, as is evident from both the Higher Education Statistics Agency (HESA) and the University and Colleges Admissions Service (UCAS) data for reasons including but not limited to personal or family circumstances. Mature student participation to higher education courses decreased significantly from 2012 onwards, when most universities’ fees increased to £9,000[16]. Further work needs to continue to be taken to ensure the decline in mature student participation in nursing, midwifery and allied health is reversed. The vast majority of these students still have many working years ahead of them and they bring to their courses and to service invaluable life experience.
10. Discontinuation rates
Part of the challenge of widening access is not just to remove barriers to participation, effective widening participation strategies also require equal importance being placed on interventions which enable participants from under-represented groups to progress and complete their educational activities. For example, widening participation data[17] identified that the level of discontinuation for students with a Black ethnic identity from pharmacy programmes was higher than for students with a recorded White or an Asian ethnic identity. Similarly, more students with a Black ethnic identity discontinued their studies from dietetics, nursing and midwifery programmes compared to those from White, Asian or Mixed ethnic backgrounds. In relation to gender, the level of discontinuation was higher for males compared to females on speech science, nursing, midwifery, and radiography therapeutic programmes.
11. Transition points
In terms of medical foundation training a national cohort study found that students from private funded (high) schools[18], families that once received Free School Meals or income support, and Black & Asian students were unlikely to be allocated first choice of foundation school[19]. The HEE Foundation Programme Review highlighted that there can be significantly greater impact on individuals, when there are financial pressures from geographic movement at an early stage in their medical career or from a perceived need to pay for additional courses and qualifications in order to be competitive when applying for specialty training posts. HEE is aware of some students from under represented backgrounds that have left medicine for financial reasons[20].
In Pharmacy, studies have consistently shown how Black-African, Asian and mature trainees perform less well than other candidates in passing the registration assessment performance[21]. There is variation in the number of organisations who have more comprehensive policies to support Black African and minority ethnic students/trainees.
In relation to disability, the majority of students on all programmes do not have a disability (It should be noted that monitoring data for disabilities requires improvements nationally), however the proportion of all students who disclose themselves as disabled is rising. The most common type of disability is a specific learning difference, such as dyslexia, dyspraxia or Attention Deficit Hyperactivity Disorder[22]. More work is required to ensure sufficient support is available to support learners with disabilities and those with long term health conditions upon entry, during courses/placements and transition points[23].