International medical students face discrimination in the UK from a government consultation to increase places for British applicants. One overseas prospective doctor decided to crunch the numbers
The privilege of having studied in the NHS as an undergraduate is incredible. As students we learn from and model ourselves on professionals who are the lifeblood of the service, who strive to provide sincere, effective and good-quality care under considerable constraint.
I love the value ascribed to all members of the multidisciplinary team, appreciate patient advocacy, share the sense of humour that buoys a team through difficult work, and appreciate the strong foothold primary care holds in this country – a healthcare system uniquely structured, and internationally admired.
Nevertheless, having been an international medical student in the UK for the past five years, and soon to enter the workforce, I have come to better understand the meaning of institutionalised racism. I have studied here during a time of political instability, and arguably more audible anti-immigration sentiment. Our student body is diverse; I have studied alongside English, Scottish, second- and third-generation immigrants, and other international students. When I came to study in this country, little did I realise how politically conscious I would become, and how aware of my nationality as I have never previously been.
While medicine is a global enterprise, medical education and its financing are political issues. This article focuses uniquely on these points.
What are international medical students?
International students make up a significant minority of the medical student population (our numbers are capped at 7.5 per cent of total medical student places). We train in a public system, but pay private fees. In many senses, we occupy a no-man’s land during our training, neither falling into the category of home students or that of international medical graduates who join the workforce at a postgraduate level.
Many of our families will invest more than £150,000 in out-of-pocket expenses into our education. While a small sum when compared to the real cost of medical education, or indeed that of healthcare provision generally, this places inexplicable demands on individual families.
International medical students are ‘home grown’ in British institutions by training in public universities and hospitals. At the same time, we are not in receipt of government loans for tuition fees, maintenance loans, or the NHS bursary. As tuition fees for home students are capped at £9,000, ours are substantially higher to reflect the true cost of medical education. Or is this really the case?
Having become increasingly cynical and increasingly conscious of the financial underpinnings of any activity, I decided to submit a Freedom of Information request to my medical school. It decided not to release figures regarding expenditure, quoting ‘commercial interests’ in relation to ‘the competitive market for overseas students across Higher Education Institutions, nationally and internationally’. The response continued to state that, ‘while it is clearly in the public interest that the financial transactions of a public authority is dealt with in as transparent a manner as possible, we feel that the public interest in the confidentiality of the requested information in a competitive market carries more weight’. I felt ashamed to read a reply that expounded only on our commercial value. Nevertheless, they did provide information regarding their income. At present, home or EU students contribute £9,000 to their education for the first four years of medical school, usually in the form of repayable government loans. Unbeknownst to many medical students, this is subsequently matched by the Government to total £79,500 per home or EU student over the course of the five years of undergraduate, preregistration training, for their university.
For international students, the total cost of education averages out to £102,000 over the three clinical years, with an approximate additional £40,000 to cover the costs of our first two preclinical years. In summary, each international medical student contributes an additional £62,500 overall in income for a medical school over five years on top of home/EU students, as well as funds their own living and maintenance costs. All this is at no cost to the taxpayer.
However, tuition fees altogether account for approximately 30 per cent of my medical school’s income. It is clear, therefore, no matter a student’s fee status, the cost of medical education remains largely borne by the public.
What are clinical tariffs?
The Department of Health released its proposal regarding the ‘expansion of undergraduate medical education’ last year.
In addition to the grants for medical schools as outlined above, the Government also supplements the training of each student by paying approximately £110,000 to clinical care providers (placement hospitals, practices, etc.) for all medical students for the duration of their clinical training (years three to five). This is known as the clinical tariff.
In Section 3.10-3.12 of the consultation, it announces its intention to remove this funding from future international students enrolled in undergraduate medicine programmes, as well as lifting the 7.5 per cent cap on international student places. Essentially, the consultation demarcates that international students will not considered a part of the normal medical student population, who have been, thus far, integrated into workforce numbers and therefore eligible for this funding.
It does not outline how many additional places this would secure for home students, and precisely quantify how this reallocation will contribute to the target additional 1,500 places for home students, which requires an estimated £345 million of additional funding. It neglects to mention that the overall cost to the Government of one international student is approximately half that of a home student over the five years, before accounting for the additional approximate £12,500 per year international medical students contribute to their universities. One could argue that our presence allows for medical schools to accommodate more home students.
Mistakenly thought of as occupying the seats of home students in the eyes of many, I would be quick to point out that we do not receive Health Education England funding contracts and do not compete for the same seats. This quota has been pre-determined and separated.
If the entire cost of clinical tariffs were passed on, simple maths deduces that international students would have to bear an additional £20,000 per year in tuition fees. This imposes undue financial hardship on international students, placing an undergraduate medical education in the UK well out of reach. As it stands, our fees are already set well and above the tuition fees for any other degree in the UK and certainly well above that of medical degrees globally. Unfair assumptions are made about our wealth, when in reality we receive less external support than any other student. This cost is supported only through pain-staking planning and saving or, in some cases, loans.
Foreigners in the NHS
Being viewed as a privileged minority, our voice and concerns are not well represented. The outcome of these proposed changes, in my view, will fuel a sense of division and inequality between students, and the removal of the cap sets a precedent for the development of private and public medical school institutions in the UK. How exactly would this play out, given that all of us will require training seats in the NHS, at undergraduate and postgraduate levels? Additionally, what is the psychology of having one’s medical degree entirely privately funded – at astronomical levels by all standards – with a view to a career based on providing a public service?
It been difficult to cope with the misinformation and misconception of other medical students, doctors, and most recently, with our characterisation in the DH’s consultation. Few doctors are truly conscious of the real cost of medical education and training. Barred year upon year from accessing the same sources of funding, I had underestimated the psychological consequence of these inequalities, which makes me feel as if our contributions are not concretely valued on the same level as that of other students.
Are international students not deserving of funding for our clinical training, or did we simply pay our way into a seat? Hardly. We are subject to the same academic requirements on admission. I achieved nine A*s at GCSE, and 45 points on the IB diploma out of a possible 45, at a local school outside of the EU. The admissions process was equally, if not more, competitive, and we are subject to the same academic rigour as our peers as we progress through the course. The majority of us will work and complete our training in the NHS, and yet we remain politically alienated from the rest of our peers. Following graduation, we will deal with greater inflexibility regarding transitions during our training and progression, as well as have to cope with the anxiety of watching unforgiving immigration politics from the sidelines.
The UK has a long history of drawing upon the contributions of its foreign healthcare professionals, and this move is hypocritical. It has evidently not paid for the undergraduate training of 36.6 per cent of the doctors who are foreign nationals, who play an essential role in ensuring services continue provision. Is it unreasonable to pay for the clinical training of those have a fairly secured a place in its own medical schools? If not, why consider us a part of the medical student population at all?
Never mind the immeasurable, softer, benefits our presence contributes to the university and local environments, the links we make between governments, or how we support education at a tertiary level. Above any possible merits, we are highly prized, exploitable, ‘cash cows’. Indeed, I might be an international student, but I also happen to have ears and eyes that are receptive to derogatory public rhetoric. This rhetoric extends into the medical profession.
Nonetheless, money talks – 42 per cent of my university’s income from tuition fees is derived from approximately 26.8 per cent of its student population: full-time international students. In the case of my medical school, the cap of 7.5 per cent of students contribute 27 per cent of all income derived through tuition fees. Despite paying more than our fair share in tuition and leaving no economic footprint on the economy of the UK, why do we not deserve investment into our training prior to joining a workforce all of us will become part of? A FOI submitted to HEE revealed that 692 international students applied for F1 jobs in 2017. The programme receives more than 600 international applicants who have graduated from a UK medical school, annually. Unquestionably, we are not leaving the workforce.
I hope I am justifiably frustrated, then, despite being educated in the UK, that we are not integrated, in the view of the consultation, as future doctors in the local workforce from the point of view of the DH. I am angry that we will not be considered deserving of this funding for clinical tariffs as every other medical student, and that the Government feels no qualms about asking families who choose this path to take greater risks and make unheard of financial sacrifices.
What direction is medical education taking?
The reasons students from abroad choose to train here as undergraduates, following life-altering investments, are many.
I cannot profess to speak for all international students. In my view, the educational and cultural experiences I have acquired from beginning my career in the UK during my undergraduate training have been unique, and I hope to hold these closely as strengths for its remainder. While a difficult investment, this was driven by the potential to obtain a world-class education, and to practise – and to subsequently access training opportunities – in the NHS. On these fronts, I have not been disappointed. I can mentally separate this from political rhetoric.
Nonetheless, having obtained an education through this route and witnessed the sacrifices and pressures it has demanded of my family, I do not believe this is a sustainable option for training workforces, and wholeheartedly support the public funding of medical education, for a profession that essentially provides a public service. In my view, the consultation is not consistent with that ethos, at least for a subset of students.
This blog was written by an anonymous fourth-year international medical student
As a 'home' medical student with parents who immigrated from abroad before I was born, my parents would not have been able to afford my medical education without the help and support of student finance. I feel that it is highly unfair that foreign students are forced to pay so much more than home students, despite having the same grades on entry and receiving the same education and support as their peers. Having worked in admissions during clearing, I find it interesting that in some courses, admissions officers will go above and beyond to recruit foreign students just to make up the numbers on courses and provide income for the university, despite their poor grades. Foreign students are more than just cash cows, they are real people, with real families who find it hard to provide for them, and real hopes and feelings. The government needs to understand and respect that.
Thank you for contributing your thoughts – 'they are real people, with real families who find it hard to provide for them'. This is empathetic. I appreciate that you understand this perspective, and that means a lot.
Some students are of the belief that international students should foot the real cost of their education given 'they don't pay tax in the UK', and that 'if they can afford it, they should pay. If they can't, they shouldn't have come.'
I was trying to explain that the picture is more nuanced than this, and that decisions to study in the U.K. are usually grounded in specific educational, economic, and practical aims.
However, with reference to hidden clinical tariffs – on a vocational course such as medicine wherein the large majority of us graduate and join the NHS, I felt that this distinction was particularly unfair and unethical, in a context when tuition fees are already abominably high.
The government also has to think long-term with respects to their policymaking, particularly when medical graduates require postgraduate training opportunities.
– Original poster