Changes to medical education over the past 20 years

Authors: Kylie Lewington 

Publication date:  29 Jun 2012

Kylie Lewington outlines the substantial changes that have occurred in UK medical education over the past two decades

This article highlights the impact of some influential changes to undergraduate and postgraduate medical education over the past two decades. Figure 1 outlines some of the key junctures that have affected the quality and experience of medical education since 1992.

Fig 1 Timeline of milestones affecting medical education in the UK 1992-2012

Change in emphasis

In 1993, the General Medical Council (GMC) published Tomorrow’s Doctors: Recommendations on Undergraduate Medical Education.[1] This report recognised that there were disparities in what medical schools expected students to know on completing their final examinations and recommended that all medical schools moved towards working to a “core curriculum.”

This meant defining and standardising requirements that needed to be satisfied before a final year medical student became a foundation year 1 doctor—then called a preregistration house officer. Tomorrow’s Doctors signalled a change in the delivery of undergraduate medical education, with the emphasis moving from gaining knowledge through “the memorising and reproduction of factual data” and the deployment of lectures or seminars to a learning process that includes “critical study of principles and the development of independent thought” and opportunities for students to study areas in depth that are particularly of interest to them. This was accompanied by providing opportunities to develop skills to interact with patients and colleagues.

This shift of emphasis has had a positive effect on undergraduate medical education. Data from the 1995 BMA cohort study, which began two years after the publication of Tomorrow’s Doctors, and the subsequent 2006 BMA cohort study[2] indicate that undergraduate education has continued to improve as a result of the adoption of core curriculums.

When asked to rate the extent to which their undergraduate course had prepared them for their first years as doctors, the 2006 cohort indicated positive improvements for each of the different key skills compared with the 1995 cohort. The table indicates improvements in communication skills and the understanding of medical ethics.

Degree to which study participants of the BMA cohort study judged their undergraduate course to have prepared them for their first year as a junior doctor (%)

Good Adequate Poor
2006 1995 2006 1995 2006 1995
Communication with other health professionals 63 26 33 46 4 28
Communication with patients 86 50 14 41 0 10
Understanding of medical ethics issues 42 19 51 54 7 27
Patient management skills and diagnosis 48 37 49 54 4 9
Clinical skills 51 45 44 43 6 12
Laboratory skills 19 13 51 50 30 35

Change in intake

Although undergraduate medical education has changed in terms of content and delivery methods, analysis of Universities and College Admissions Service (UCAS) admission data for preclinical medicine in the United Kingdom shows that since 1996 there have been only slight variations in the characteristics, such as sex and country of domicile, of medical school students (comparative data are not available before 1996).[3]

Since 1996 applications to preclinical medicine have increased. The annual medical student intake is limited, and therefore the number of people who were accepted on to the course increased at a far slower rate. Nevertheless, the effect of increased investment in medicine in the UK[4] from 2000 is clear because the number of “accepts” to preclinical medicine has increased by 78% since 1999 (fig 2 ).

Fig 2 Applications to and accept rates for preclinical medicine (UK) 1996-2011 (at time of writing accept figures were not available for the 2011 recruitment round)

In 1993, European Council directive 93/16 was implemented, which allows European Union (EU) nationals who hold an EU primary medical qualification or specialist qualification to practise as doctors anywhere in the EU. Before this directive, EU nationals were subject to visa restrictions in the UK; however, this directive resulted in freedom of movement for EU students who wanted to apply to medical school in the UK.

Despite this directive, figure 3 illustrates that the competition ratio for securing a place in preclinical medicine in the UK is consistently greater for EU applicants. The competition ratio for EU students peaked in 1997, when just 69 of 885 EU applicants were accepted—a competition ratio of 12.8:1. Home applicants were and are considerably more likely to be accepted into preclinical medicine in the UK, with competition ratios ranging between 1.4:1 (2001) and 2.3:1 (2010). The increased competition ratio in 2010 can be attributed to a surge in applications in England by home domiciled students in anticipation of the tuition fees increase in England that took place for the 2011 application round.

Fig 3 Competition ratio for preclinical medicine (UK) by country of domicile

Women have consistently accounted for between 56% and 61% of all applicants who were accepted into preclinical medicine in the UK over the past 15 years. The most notable change in medical schools’ demographics during this time has been the age of undergraduate medical students. In 2000, just 4% of people accepted were aged 25 or older. This differs from 2005, when 10% of those accepted were aged 25 or older. This shift can be attributed to the introduction of graduate entry four year courses in the UK in 2001, which were implemented to reduce the deficit of qualified doctors in the UK (fig 4 ).

Fig 4 Age of people accepted to preclinical medicine (UK)

Change in cost

Twenty years ago most local education authorities in the UK paid for students’ tuition fees and provided a maintenance grant to help with living costs, which did not have to be repaid. Before the introduction of tuition fees that had to be paid for by the student, the average final year student debt was £7768 (€9600; $12 290).[5] However, final year student debt had steadily increased to £24 092 by 2010. The 2011-12 medical students finance survey indicates that medical students are increasingly viewing their financial situation as a heavy burden (fig 5 ).[6]

Fig 5 Final year student debt 1993-4 to 2010-11. Note: Data were derived from BMA student finance surveys and reflect self reported debt relating to student loan and commercial borrowing.

From 2012, medical students living in England will have to pay tuition fees of £9000 a year. The fee increase does not apply to students from Wales, Northern Ireland, and Scotland, where respective governments have agreed to continue to subsidise tuition fees at previous levels. The BMA projects that English medical students will be almost £70 000 in debt on graduation. (This is based on a five year course. An interest rate of 6.5% per annum (retail price index of 3.5% + 3%) has been applied. Projected total debt on graduation, including maintenance loan and cumulative interest, is £66 087.) It is too soon to establish whether the fee increases in England will have a substantial effect on the characteristics of its medical students; however, initial analysis of UCAS applications indicates that some English home students from the lowest socioeconomic group have been deterred from applying to preclinical medicine in 2012-13.[7]

Change in postgraduate education

Postgraduate medical education has also undergone important changes in the past two decades. Medical graduates used to work as preregistration house officers for a year, then in senior house officer posts for two to three years before deciding on a specialty and progressing to a specialist training programme. This programme allowed a doctor to work in a variety of specialties before entering specialist training and working as a registrar to train for the certificate of completion of training (CCT), which is required for a consultant post.

In 2003, Modernising Medical Careers (MMC) was initiated as a direct result of the chief medical officer’s report Unfinished Business.[8] This report recommended that more medical care should be provided by fully trained doctors rather than by trainees. It also said that there should be an establishment of national standards for training, comprehensive curriculums for each specialty, and regular assessment of competences and that all trainers and supervisors should be highly trained and given the right support to fulfil their roles.

In 2005, the two year MMC foundation programme began, followed by the MMC specialty training programme in 2007. Less of an emphasis was put on service delivery for trainees, and a move was made to trainees becoming supernumerary. The new specialty training structure meant an assured high quality of training, better formal supervision from fully trained clinical and educational supervisors, and continuous development of acquired competences through feedback and assessment. The structure of specialty training also reduces the amount of time that trainees take to reach their CCT.

The introduction of the specialty training programme meant that trainee doctors have to make decisions much earlier in their training—a year and a half after graduation. Doctors have more structured career paths than the cohort who completed specialist training before 2007, and the system has little flexibility for trainees who want to change specialty (fig 6 ).

Fig 6 Medical training path in specialist training (pre-2007) and specialty training (post-2007)

Data from the fourth report of the 2006 cohort study[9] show that 38% of cohort doctors indicated that their experience of the foundation programme did not allow them to make an informed choice about their specialty. Nevertheless, 83% of cohort doctors were of the view that the foundation programme equipped them with the generic skills needed in their specialty. The cohort doctors indicated that the foundation programme had best prepared them with skills in clinical care and time management but least prepared them in practical procedural skills or diagnostic patient skills.

In 2010 the Collins report Foundation for Excellence: An Evaluation of the Foundation Programme [10] highlighted concerns about the role of the foundation programme trainee in maintaining a balance between the demands of the clinical service and the requirements for their learning. Collins also commented on the quality of feedback provided to foundation programme trainees by supervisors and made recommendations about reducing the “formidable number” of work based assessments that were being carried out annually. In addition, the report suggested that foundation programme placements were not always long enough, and it questioned the distribution of specialty placements available to trainees.

Another valuable tool in evaluating the MMC training programme is the GMC’s national training survey.[11] In 2006 the GMC initiated an annual survey that is sent to all UK postgraduate trainees, designed to provide snapshots of the experience of trainees and trainers in postgraduate training. The results from the 2011 survey[12] indicate that trainees are very satisfied overall with their formal and informal training and their practical experience. However, the 2011 survey also found that 38% of trainees said they were asked to cope with clinical problems beyond their competence or experience on a monthly, weekly, or daily basis. This report also highlighted that all trainees would benefit from more feedback from their senior colleagues and supervisors.

In 1998 the European Working Time Directive was enshrined in UK law. On 1 August 2009, the directive was fully applied to junior doctors, limiting the number of hours worked to an average of 48 a week. Before the implementation of the regulations, most junior doctors worked far more than 48 hours a week. The results of the 2011 GMC survey showed that 65% of trainees continued to work more than 48 hours on average a week, and 22% of trainees indicated that their training needs were not being met within the parameters of the 48 hour week.

Application to postgraduate training changed because of MMC. Previously, specialist training required senior house officers to pass postgraduate examinations and have experience in posts to qualify for a registrar post. Under the MMC system the application system to specialty training follows an annual competitive cycle.

In 2007 the Medical Training Application Service was set up to allocate jobs in the UK to foundation officers and specialty registrars. The service was designed to appoint applicants to training. The specialty training allocation process was heavily criticised by John Tooke in his inquiry into MMC: “Some excellent candidates were not shortlisted. Many very poor candidates were shortlisted.”[13] The application system failed to allocate thousands of junior doctors’ jobs in 2007 and was abolished before the 2008 application cycle.

The UK Foundation Programme Office is now responsible for medical students’ applications to foundation year 1. Specialty training posts are advertised nationally for a limited period. Entry to some specialties is coordinated by individual deaneries, whereas other specialties recruit using nationally coordinated application systems.

Change in supply and demand

Not all doctors completing their foundation programme secure national training numbers or are offered a specialty training post. In addition, in the past two years the national recruitment process for the foundation programme has been oversubscribed; however, all UK medical school graduates have eventually been successful in securing a place.

Owing to data recording methodologies and changes to how some specialties recruit to specialty training, limited comparative data are available to explore competition ratios to specialty training. Some specialties—for example, core surgical training—previously counted the number of locations applied to; however, under nationally coordinated specialty training recruitment programmes, applications to multiple locations are counted as one application. Overall, the competition ratio for specialty training for 2012 at round one stands at 2.3:1 (Department of Health, personal communication, 5 July 2012); however, competition ratios for specialty training vary greatly between specialties.[14]

Some specialties are already facing an oversupply of holders of the CCT, introducing a further level of competition into doctors’ careers. Also, a widespread oversupply of certificate holders in hospital specialties has been projected by 2020.[15] Workforce planning is becoming more pertinent to those in medical education. The Centre for Workforce Intelligence is working with other stakeholders to deal with the problems with undersupply and oversupply of NHS staff. The centre’s remit includes making recommendations on medical student and specialty training numbers and advising on system changes to future workforce requirements through data modelling and analysis.

A positive impact

Changes made to undergraduate and postgraduate medical education have had a positive effect on the quality of education experienced by medical school students. This has been at the price of a greater cost to the trainee, greater competition throughout training, and less flexibility to change specialty.

The BMA 2006 cohort study will continue to assess the impact that changes to medical education have on our future doctors. The results of the 10 year cohort study will show the effects of a standardised trainee centred curriculum. It remains to be seen if the changes to undergraduate and postgraduate education will “improve patient care by improving medical education with a transparent and efficient career path for doctors.”[16]

Recent related articles in BMJ Careers

  • Medicine—a woman’s world? (05 Jan 2012)— [Link]

  • Specialty training competition stabilises as applications and posts rise (15 May 2012)— [Link]

  • Specialty training: the junior doctors’ views (12 Jul 2011)— [Link]

  • The CCT cul de sac? (14 Sep 2011)— [Link]

Competing interests: None declared.

Thanks to the 1995 and 2006 BMA cohorts and UCAS. The figures are all adapted from and use data from the BMA’s Health Policy and Economic Research Unit.

From the Student BMJ.


  1. General Medical Council. Tomorrow’s doctors. 1993. [Link] [Link]
  2. BMA. BMA cohort studies of medical graduates. 2006. [Link] .
  3. Universities and College Admissions Service. Facts and figures. [Link] .
  4. NHS. NHS plan. 2000. [Link] .
  5. BMA Health Policy and Economic Research Unit. Medical students finance survey 1997/98. BMA, 2003. [Available on request.]
  6. BMA Health Policy and Economic Research Unit. Medical students finance survey 2010/11. [Link] .
  7. BMA Health Policy and Economic Research Unit. Briefing on UCAS applications to pre-clinical medicine 2009 to 2011. BMA, 2011. [Available on request.]
  8. Chief medical officer. Unfinished business: proposals for reform of the senior house officer grade. 2002. [Link] [Link]
  9. BMA.2006 BMA cohort study fourth report. [Link] .
  10. Collins J. Foundation for excellence. An evaluation of the foundation programme. Medical Education England, 2010.
  11. General Medical Council. National training surveys. 2011. [Link] [Link]
  12. General Medical Council. National training survey 2011. Key findings 2011. [Link] .
  13. Tooke J. Aspiring to excellence. Department of Health, 2008. [Link] .
  14. NHS. Medical specialty training (England). Competition ratios. 2009. [Link] [Link]
  15. Centre for Workforce Intelligence. Starting the debate on the consultant workforce.   2012. [Link] .
  16. NHS. Medical specialty training (England). The past—the principles of MMC. [Link] [Link]

Kylie Lewington research analyst Health Policy and Economic Research Unit, BMA, London, UK

Cite this as BMJ Careers ; doi: