Health and Sport Committee

Meeting date: Tuesday, December 8, 2020

Official Report 586KB pdf

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University of St Andrews (Degrees in Medicine and Dentistry) Bill: Stage 1

Agenda item 4 is a stage 1 evidence session on the University of St Andrews (Degrees in Medicine and Dentistry) Bill. It is for the Health and Sport Committee to consider the bill at stage 1 and to report to Parliament accordingly.

Last week, we took evidence on the bill from key stakeholders. This week, we will hear from the Cabinet Secretary for Health and Sport, Jeane Freeman, who is accompanied by Scottish Government officials. Carmen Murray is the bill team leader; Stephen Lea-Ross is head of workforce practice; and Magdalene Boyd is a solicitor in the legal directorate. I welcome all of you.

I invite the cabinet secretary to make an opening statement on the bill.

Good morning to the committee, and thank you for inviting me to give evidence on the University of St Andrews (Degrees in Medicine and Dentistry) Bill.

I heard with interest the evidence that was presented to the committee in last week’s evidence session. I am grateful to those who have given evidence and to all those who have responded to the committee’s call for views.

The bill, which is technical in nature, has a single purpose: it seeks to remove an archaic, unfair and, arguably, anti-competitive prohibition that prevents the University of St Andrews from awarding medical and dentistry degrees. That prohibition was intended to be temporary, and it is no longer needed. It was put in place in the 1960s as a transitional provision in order to give immediate effect to the separation of Queen’s College in Dundee from the University of St Andrews to form the University of Dundee. It is clear that that purpose has been achieved.

No other higher education institute in Scotland or in the United Kingdom is prohibited by primary legislation from awarding degrees in any discipline, and it is clear that the Universities (Scotland) Act 1966 did not intend to prevent future competition between the University of St Andrews and any other higher education institute in Scotland or, indeed, the UK. The bill will embed a fairer higher education sector and enable all our valued institutions in Scotland to maximise the options that they offer to students.

The timing of our introduction of the bill is to enable the University of St Andrews to award jointly with the University of Dundee primary medical qualification medical degrees to Scottish graduate entry medicine programme students in advance of the first cohort graduating in 2022. ScotGEM is Scotland’s first graduate entry programme for medicine. It formed part of a package of initiatives that the Scottish Government announced in 2016 to enhance the national health service workforce of the future, and it is delivered in collaboration with the University of the Highlands and Islands and a number of partner health boards. It has a specific focus on general practice and remote and rural working, and it aims to retain as many doctors as possible within NHS Scotland following their graduation.

I heard concerns being raised in last week’s evidence session. I clarify that, although the University of St Andrews may well have the ambition to offer its own PMQ medical degree in the future, the bill will neither determine nor provide for that. Whether any higher education institution is able to offer a degree in either of the controlled subjects of medicine and dentistry and, if so, the number of places that it might be able to offer are matters that are subject to separate financial and regulatory controls and decision-making processes that involve the Scottish Government, the Scottish Funding Council, NHS Education for Scotland and the General Medical Council, and which take account of the views of our boards. The prohibition is therefore not required in order to prevent the university from awarding its own medical degree.

As the University of St Andrews, together with the University of Dundee, has already been awarded the Scottish graduate entry medicine programme, the immediate effect of the bill would be to allow for those universities jointly to award the ScotGEM primary medical qualification degree. As I know that the committee heard last week, that is clearly the expectation of students who enrolled for this special course and who hope to graduate shortly. The committee heard how passionately ScotGEM students feel about their unique identity as students of both universities. It is fair and right that they should be able to graduate with a jointly awarded degree that reflects the studies that they have undertaken and the incredible work that has been done at both Dundee and St Andrews to establish such an innovative programme.

That is all that I have to say at this point, convener. Of course, I will be happy to take any questions that committee members might have.

You mentioned that you had listened to the evidence that the committee received last week. You also said that the bill neither authorises nor provides for the University of St Andrews to go beyond the training and higher education that it currently provides and offer its own PMQ. That is true, but it enables that to happen. As we heard clearly last week, the context for that was the proposition that there should be a new medical school somewhere in Scotland.

Among the evidence that we heard, two concerns struck me most clearly. The first was raised by Professor David Maguire, the principal of the University of Dundee, who felt that Scotland did not need another medical school. We also heard from Aberdeenshire health and social care partnership, whose concern was that if a new medical school was established in the central belt, it would have an impact on the recruitment and retention of medical graduates in the north of Scotland. How do you respond to those concerns?

You are quite right, convener. The passing of the bill would remove the prohibition on the University of St Andrews, which is the only institution in the whole of the UK on which there is such a prohibition. That would then enable the university, if it wished to do so, to put forward a case that, should the Scottish Government introduce a new medical school, in line with its 2019 programme for government, it could house that school and provide such an offer, either alone or jointly with another institution that offers undergraduate medical education in Scotland. Removing the prohibition, as the bill seeks to do, would simply allow the University of St Andrews to be part of that discussion on the same basis as all the other higher education institutions in Scotland that have medical schools.

Although I am aware of Professor Maguire’s argument on the current bill, I also know that, with his colleagues from other institutions, he has argued for the provision of additional medical undergraduate places. He is therefore not arguing against the fact that we might want to have such places; rather, he is simply arguing that they should go to his university or one of the others. On the contrary, the principal and vice-chancellor of the University of Edinburgh sees no such difficulty or problem with how the bill might affect how his university would be placed as a deliverer of quality medical undergraduate education, nor have such concerns been expressed by our other medical schools.

As for the concern expressed by Aberdeenshire health and social care partnership, my officials have had long discussions with it. As I know that the committee knows, the process of establishing another medical school or having an institution go through the process to become approved to deliver a medical degree is a long one. The degree programme has to be developed, funding has to be secured for the additional controlled places, clinical placements need to be secured that do not—the GMC is very particular about this—detract from what else is offered by established medical schools, the GMC needs to accredit a new medical school and there is obviously on-going GMC regulation. Therefore, it is not immediately in the offing for any of our higher education institutions.

11:15  

We had begun the work to look at what propositions might come forward—all were invited to give us those—but, inevitably, we had to pause that work as we had to respond to the Covid pandemic. Because we are still in the middle of the pandemic, we have not yet finalised when we can pick that work up again and make progress on it to honour the 2019 programme for government commitment.

If we remove the prohibition, the University of St Andrews—on its own or alongside another institution—could make a case that any new medical school should be housed with it and offer a programme to that effect. However, that is not inevitable; it would have to meet all the requirements that I have mentioned, and the Government of the day would have to take a view as to whether what was offered there was better compared with what was offered by other medical undergraduate courses and institutions.

Can you briefly explain why the Scottish Government’s preference is to create an additional medical school rather than additional places at existing medical schools? Also, what do you anticipate that the impact on recruitment and retention in the north of Scotland might be if a new medical school were established elsewhere?

In response to the latter point, the University of the Highlands and Islands has expressed an interest in being part of discussions about the possibility of a new medical school. Therefore, we should not assume that, should there be a new medical school, the school will go anywhere in particular.

Partly in the spirit of what we have seen in ScotGEM—although no one should take that to imply that we favour either Dundee or St Andrews for any future location, should there be one—we were interested in finding out whether more could be offered either from existing medical schools or from a combination of them. The University of the Highlands and Islands, the University of St Andrews and the Crichton campus in the south-west were all in that discussion about whether we could widen access to Scotland-domiciled students in remote and rural areas and encourage them to work for the NHS in Scotland once qualified.

You will know that the ScotGEM course has a bursary aspect to it. That is given on the condition that the student works for the NHS in Scotland in their foundation year, and it is a test to see whether doing so would put students off; evidently, it has not. Therefore, it gives us information and evidence to decide whether that might be something that we would consider in the future as part of any increase in the number of medical undergraduate places.

Very briefly, can you explain why a new school should be created rather than those other options?

The programme for government says that we would like to have a new medical school. However, clearly my mind was open to how we might achieve an increase in the number of medical undergraduate places and what we would secure from that to address some of the issues relating to the medical workforce across the country.

My officials and I had discussions with the current medical schools as well as with the Crichton campus, the University of the Highlands and Islands and the University of St Andrews. They all made propositions and the existing medical schools argued the case that any additional places should go to them. We had not got beyond that before we had to pause the work and begin the response to the Covid virus.

Can you explain why a partial removal of the prohibition was ruled out?

There are two reasons. First, it is very clear that the prohibition was always intended only to be temporary. I am simply following through on that intention. Secondly, the prohibition, either in full or in part is fundamentally unfair. It is unfair for any academic institution to be prevented from offering a degree in a controlled subject that their counterparts elsewhere can offer. I think that I made the point about the additional implications that prohibition has for the capacity to undertake research in those areas. We know that Scotland is well placed in medical and life sciences research and I do not want one of our institutions to be prevented from playing the fullest possible part that it can in that. I see no reason for a partial removal when a full removal opens up opportunities in research and removes an unfair fettering of one of our institutions compared to its counterparts elsewhere in the UK.

Could the prohibition be amended for the purposes of ScotGEM and then amended further in the future if need be?

Technically, it could. However, I do not see any reason why we would go to all that fuss and bother given that I have heard no good argument that we should remove the prohibition in part. Either we remove it in full or we do not remove it at all. My argument is that it was never meant to be in place for as long as it has been—it was always intended to be transitional. We should follow through on that and we should remove the prohibition in its entirety, because I have heard no good reason why we should only remove it in part.

Good morning, cabinet secretary—[Inaudible.]

It appears that Mr Stewart’s connection is a little awry. We will go to Emma Harper and then come back to David Stewart if we can.

I listened with interest to the discussion about a new medical school. The cabinet secretary has mentioned the Crichton campus a couple of times, which I welcome, because I know that there is a lot of interest in establishing a new medical school affiliated with one of the established ones and placing it in a rural area such as Dumfries and Galloway. Professor David Maguire said that 80 per cent of the students who attend the University of Dundee come from deprived areas. I know that widening access is very important—it is for me in Dumfries and Galloway. What are your thoughts on whether the inclusion of the University of St Andrews, with its prestige as one of Scotland’s ancient universities, could limit progress on widening access by attracting a different demographic to the ScotGEM programme, for instance?

The bill is not about a new medical school; it is about removing a prohibition so that, should the current Government or a future Government make significant moves beyond those that I have initiated but necessarily paused towards a new medical school to provide for additional medical undergraduate places, St Andrews can compete equally in that field with any of our other medical schools that currently exist. It is not about a new medical school; it is about removing a prohibition that currently cuts out one of our higher education institutions from that discussion.

To go back to the convener’s earlier question about why the Government thinks that a new medical school is something to be discussed, part of that is about an understanding that widening access is about more than ticking a box on which areas of deprivation undergraduates come from; it is about taking practical steps that make participating in higher education more feasible for people. That is clearly the case for some of our very able students in Ms Harper’s area, in my constituency and, I am sure, in Mr Macdonald’s and Mr Stewart’s areas—in other words, in our more remote and rural areas outwith the central belt of Scotland. It is about more than simply looking at the area that a student comes from; it is about how practically to make it more likely that they can enter that degree of higher education and sustain their participation.

That is why, in the early discussions on the issue, I was keen to involve the University of the Highlands and Islands to hear what it had to say and to hear what the Crichton campus had to say. That is the way to understand what widening access is. To be completely frank, none of our institutions—I have said this to all of them when I have met them—has as good a track record as I would want on widening access to medical undergraduate courses. We need to do more. However, it is not simply about putting the burden on the institutions to tick the right boxes; it is about thinking creatively about how to deliver an undergraduate medical degree in ways that widen access to all potential students. ScotGEM is an aspect of that, but it cannot be the exclusive one.

Thank you for that clarification.

The feedback that I have had so far on the ScotGEM course is that it is doing really well and the students are great in engaging with the coursework, the learning and everything else that is part of the programme. I know that the ScotGEM students come from different backgrounds and include pharmacists and dieticians. Do we have a breakdown of those who are currently undertaking the course so that we can encourage more healthcare professionals who already have degrees to participate in ScotGEM in future?

We have that breakdown, but I do not have it with me. I am happy to ensure that it is made available to all committee members. Another aspect of the ScotGEM course is the involvement of general practitioners as clinical educators. I know that the students on the course and the GPs value that highly, and that they are keen for us to consider that in other aspects of medical undergraduate education.

I once again call David Stewart.

I apologise, cabinet secretary—I have put a pound coin in the meter, so I hope that I will be able to speak to you now.

You might have heard my point about my bid for a new medical school in the Highlands and Islands, in conjunction with UHI, Dundee and St Andrews, but that was more an observation.

I am enthusiastic about ScotGEM and I believe that it will have a vital role in the attraction and retention of rural GPs in the Highlands and Islands and across Scotland. You will be aware of the student survey in which nearly 98 per cent supported the idea of the degree coming from both institutions. What do you think of the students’ views on that?

11:30  

Yes, I have seen that. The students take a perfectly fair and reasonable position, which is that when they secured their place—that is not straightforward to do—and enrolled on the ScotGEM course, they did so on the basis that it was a joint award from both the University of Dundee and the University of St Andrews. They are enthusiastic and, as you heard, passionate about the quality of the education that they experience and the position that the award should be a joint award, because that is, in part, the basis on which they entered the course. I am keen to ensure that the prohibition is removed in order for that to be possible.

As I said to Mr Torrance, I do not see the point of, if you like, footering around with partial removal and then maybe full removal at some point in the future. That does not seem to me to get the fundamental point that it is unfair that a prohibition that was put in place to be transitional is not removed in full so that one of our institutions can then compete on an equal footing with their colleague institutions elsewhere in Scotland and the UK.

Is it fair to say that having it as a joint degree is a remarkable selling point for it and that, if we do not get the bill through, that could affect demand for the course in the future?

I have no absolute, hard data to confirm my response to that, but I think that what we have heard from successive student enrolment makes it pretty clear that the high calibre of students who are being attracted are attracted because of the nature of the programme, which comes from it being a joint exercise. The students are attracted by potentially being graduates of both universities. All of that would therefore make me think that, if it was not a joint award, that would have an impact on its attractiveness to future students.

Although you cannot make forward commitments to the committee, the course is a great success. The Scottish Funding Council would obviously have a view if the course numbers were going to be increased, but what is your general view on that? It is a Scottish success, so could the numbers be increased? That would help with the supply of not just GPs in general but GPs in rural areas in particular.

You are absolutely right that I cannot make forward commitments, but I can tell you that I am hugely enthusiastic about the ScotGEM course and how it has played out since it was introduced. It has a number of innovative aspects that are working well, not least the conditional bursary and the clinical educators from our GP community. One of the things that we are seeing anecdotally in feedback, which we will be able to track more definitively as we go forward, is that the ScotGEM undergraduates undertaking their clinical practice in GP practices in remote and more rural areas become hugely enthusiastic about the opportunities for exercising and increasing their skills as young doctors in those remote and rural practices. We always want to try to overcome the notion that the only place where it is exciting to practise as a GP is in an urban setting. Undoubtedly, that is exciting, but I am a firm believer that there is a range of enticing intellectual and skill challenges to doctors in remote and rural areas. ScotGEM is helping us demonstrate that.

Thank you. We have a bit more on the same question from Stephen Lea-Ross. [Interruption.] There seems to be a technical problem. If that is resolved before the end of the evidence session, we will come back to him. We move to Brian Whittle just now.

Much of the focus of the bill is on degrees in medicine, but the bill would also allow the University of St Andrews to award degrees in dentistry. Neither the bill’s policy memorandum nor any written submission explores the potential impact on dentistry. Why is dentistry included in the bill?

Perhaps one of my colleagues can explain that. The bill deals with medicine, dentistry and midwifery. That is taken from the 1960s act that imposed the prohibition in the first place. Generally speaking, midwifery at that time was about obstetrics—that is how it was described. Obstetrics is now part of the undergraduate degree as a whole; we do not offer a separate degree, although there are specialisms and so on. Dentistry is part of what was prohibited and is therefore covered by lifting the prohibition.

I echo what the cabinet secretary said. The full prohibition that is contained in the 1966 act relates to medical and dentistry degrees, both of which are controlled subjects. The rationale for removing the prohibition and its not being determinative of the university’s ability to award either medical or dentistry degrees applies.

The cabinet secretary has explained to the committee that we have heard no reason to leave any part of the prohibition in place, because it was intended to be transitional and it no longer serves a purpose in today’s context. The bill will put the University of St Andrews on the same footing in law as any other university in Scotland. It makes sense to remove the prohibition in its entirety rather than leave any part of it in place.

I presume that consideration has been given to the potential benefits to medicine and dentistry of lifting the prohibition. Will the cabinet secretary shine a little light on the benefits to dentistry in Scotland?

The potential benefits are the same as those for undergraduate medicine. The bill allows the University of St Andrews to move in that direction if it wishes to. However, as the bill team leader said, dentistry is a controlled subject, so significant effort, regulation and work are needed to get to the point at which any institution is considered an awarding body for dentistry. The same applies to medicine.

All that the bill does is remove the current prohibition on the University of St Andrews from considering whether to offer a medical or dentistry undergraduate degree in full. Even if it wished to do that, there are steps that it would need to go through and requirements that it would need to meet, including consideration of the impact of any additional places in those areas on other, existing dentistry or medical schools. It is about not just places but opportunities for the necessary clinical practice in the field, which is part and parcel of what students need to go through in order to graduate. As with medical places, it is a separate question. All that the bill does is take away the current block on the University of St Andrews from being part of that consideration, if it wishes to, alongside its counterpart institutions in the rest of the country.

The outcome that we are looking for will be to the benefit of medical and dentistry degrees in Scotland. Last week, we heard concerns about the impact on other medical schools in respect of the recruitment and retention of doctors. We have discussed such matters at length in the chamber, including the set quota of local medical students who can be recruited into those universities. One of the concerns that I heard last week was that the effect might be to simply spread the same number of health professionals across more universities. Will you comment on that and on whether those concerns about the impact could also be applied to dentistry?

There is quite a detailed process for determining the number of places in what have been described as “controlled subjects”. That process includes the Government’s consideration of our anticipated workforce requirements for doctors and dentists. We do the same exercise for nurses and other members of our health professions. We then look at what undergraduate places we have, what the flow through will be, and what is going out at the other end of the profession through people retiring and so on, and we try to balance those factors to ensure that we get both an increase in numbers—as we have done in recent years—and a reasonable flow through.

In those circumstances, all the medical schools want to maximise the number of places that they have, which is perfectly understandable. That is why the existing medical schools made the case to me that the additional places that may go to a new medical school—they would prefer that there was not a new medical school—should go to them as existing medical schools. That is a perfectly reasonable case for them to make. For all the reasons that I described earlier, no decisions were reached.

We have two interests in considering that request as well as whether we should have a new medical school instead. First, we have to make sure that we have the right number of undergraduates going in to meet our anticipated flow through. It takes a while to produce doctors and dentists, so we need to anticipate the flow through so that we can offer the clinical placements that they need as part of their undergraduate education and, at the other end, get the right numbers out and working in Scotland in order to meet our anticipated workforce demands.

Secondly, we have to ask whether, as a Government, we can do more with the levers that we have to widen both access and the throughput into the areas of our country that traditionally struggle to recruit and retain doctors. I am talking about GPs in remote and rural areas, and doctors in particular specialisms, for example. The committee will know how we try to use the information that we publish about the traineeships to fill gaps that are anticipated because of retiral numbers or because we are putting a greater emphasis on mental health, for example.

That is the process and exercise that we go through to ensure that we put into medical and dentistry education the numbers that we anticipate that we need to come out the other end to meet our workforce requirements. We have increased medical undergraduate education, and we pulled back a little before on undergraduate education for dentistry. Each year, we consider how we need to flex the numbers. However, this year, we have said that there are more medical undergraduate places as a consequence of the decisions that were made on the higher results. We have also said that, in funding those places, the additional numbers are not at the expense of any young people who are coming through school this year and applying to go to medical school.

We will have increasing numbers as we go forward, because the age profile balance of our medical workforce is such that I anticipate that we will need to steadily increase our medical undergraduate numbers.

The short answer is that, should we have an additional medical school, we will not spread the same number across a bigger patch.

Finally, there is a lot of chat about the potential for a new medical school in Scotland. Would that also include a new dental school?

11:45  

Not necessarily. A case has not been made to me that we need a new dental school in Scotland. As you know, we have dental schools in Glasgow and Aberdeen, and the one in Aberdeen is relatively new within the course of devolution. I have not seen a case for a new dental school, although that does not mean that one does not exist.

Colleagues need to appreciate that, although it was my hope that, following the 2019 programme for government commitment, we would undertake the initial discussions that I described, receive proposals, have a good look at them and take a view on whether we needed to put in additional places in a new school, all of that has been paused. Although I intend to pick that up and move it on a little, the time that is left in the current parliamentary session is so limited that I do not anticipate that we will reach a final view before Parliament rises for the next set of elections.

The cabinet secretary said that no case has been made for additional undergraduate dental places. I add that our workforce planning has not shown a need for such places. We have dental undergraduates at work across Scotland, as part of their clinical placements, in Stornoway, Campbeltown, Inverness and Dumfries. There is no evidence at present that there is a requirement for additional dental places.

Stephen Lea-Ross wants to respond to David Stewart’s question about the future of ScotGEM.

The number of places allocated to ScotGEM has increased from 40 to 55 in recognition of the contribution that that programme is making across the board. We are convening the medical undergraduate group to establish undergraduate intake recommendations for 2021-22. They will go to the cabinet secretary in the new year. Thereafter, we will undertake further discussions with the SFC about the total number of places and their distribution across relevant courses in Scotland. Final decisions on individual institutions rest with the SFC, but future growth in ScotGEM places will be under consideration.

Thank you. That is helpful additional information.

That concludes the committee’s oral evidence taking on the bill. We will report to Parliament accordingly. I thank the cabinet secretary and her officials for their attendance this morning.

We will move into private session and resume our meeting on a different platform.

11:48 Meeting continued in private until 12:17.