Our medical education practices not only deny us more graduates for our health service - they are placing a burden on developing countries, writes Dr Michael Turner
In 2001 and 2003, the Medical Council published two excellent reviews of medical schools here. In response, the Minister for Health and Children and the Minister for Education and Science established in November 2003 the Working Group on Undergraduate Medical Education under the chair of Prof Patrick Fottrell.
The working group believes that medical education in Ireland is at a crossroads. It makes specific recommendations for improvements in educational programmes and curriculum, entry to medical schools, clinical training, student intake and the resourcing of medical education.
Inevitably, the implementation of these recommendations has considerable financial implications, at a time when it is acknowledged that our medical schools are seriously underfunded.
Given the calibre and breadth of the membership of the working group, the analysis and recommendations of the report are wide-ranging and challenging. The recommendations are also underpinned by detailed analysis. The report has already generated considerable media attention and editorial comment (not least in The Irish Times).
I am concerned, however, that political commentary and press coverage on issues such as the criteria for entry to medical school and university fees have obscured in the public mind what are the two most important and urgent problems facing medical education in Ireland. Firstly, there has been serious financial underfunding of medical education and, secondly, there has been a severe restriction on the number of Irish students allowed to train. The responsibility for both of these problems rests with successive Irish governments.
Government investment in medical education in Britain and Canada is two to three times higher than it is in Ireland, despite the fact that over the last decade we have become one of the wealthiest nations on earth.
Our medical schools remain open simply because the universities have been compelled to subsidise the education of EU students by selling places commercially to non-EU students.
In 2003, for example, 516 of the 831 first-year places in the Republic's medical schools were allocated to non-EU students, which meant that overseas aid provided 83 per cent of fee income. The Exchequer that year provided a miserly €2.36 million of first-year fee income. In a booming economy, the Government provided only a sixth of the cost of a public educational service which is critical to the future wellbeing of its people.
Although difficult to estimate, the 2003 review reported that government funding was approximately €9,000 per annum for medical students, compared with €26,604 per annum for veterinary students. The Government is currently negotiating with the EU to protect tax breaks for thoroughbred equine reproduction - government approval to fund equestrian centres is easier to achieve than capital funding for healthcare. This all begs the question: where do our national priorities lie?
As Ireland becomes more culturally diverse, we need overseas students and graduates in our universities and hospitals. However, most non-EU graduates from Irish medical schools return to their country of origin.
At the same time, there is a serious shortage of Irish doctors to staff non-consultant hospital posts. More than half of those posts are filled by doctors who graduated overseas; the figures are higher outside the university teaching hospitals. Simply to maintain existing services, hospitals here are compelled to recruit doctors who have graduated in developing countries.
It is now widely acknowledged that this practice is highly damaging to the health services in the developing world. An editorial in July's British Medical Journal highlights that rich countries are looting doctors and nurses from developing countries. We are taking these doctors away from the countries who trained them and the people who need them most. The damage is likely to be long-term, because many will never return home to practise medicine.
What is not widely acknowledged is that we are also transferring the financial costs of training doctors for our health service from a strong Irish economy to the weak economies of developing countries. They invest, we benefit.
In Britain, Ireland, Australia and the US, recruitment of overseas doctors to meet local shortages is often from former colonies of the British Commonwealth because there is no language barrier. Britain, the former colonial power, has recognised the problem and committed itself to self-sufficiency by expanding existing schools and opening new schools. Ireland, a former colony, ironically continues to take advantage of other former colonies.
We continue to debate the political pledge to spend 0.7 per cent of our GNP on overseas aid. We take national pride as two of our rock icons strut the world stage advocating the abolition of Third World debt. Yet government policies are inflicting damage on both the health services and economies of vulnerable countries. This double whammy represents a serious double think. It needs to be stopped and as a matter of urgency.
The Fottrell report asserts that it is imperative to move towards national self-sufficiency with a future intake of between 700 and 740 EU students per annum. To implement the EU working time directive, the Hanly report (2003) concluded that we needed 767 undergraduates annually.
Based on the current gender mix in medical schools here (two-thirds of the 2003 intake were female), the Medical Council concluded that the figure of 767 "is unreliable and is probably an underestimate".
The reality is that medical schools already have the capacity to implement national self-sufficiency. The current intake is approximately 800 students per annum. Astonishingly, the cap of 315 EU students in our medical schools introduced by the Department of Education in 1978 still remains in place despite the social and economic changes that have happened over a generation.
The medical schools could accommodate 800 EU students next year, if properly funded. Nearly 500 Irish students every year are being denied the opportunity to graduate as doctors because our own Government is compelling our universities to sell places in our medical schools overseas. Is it any wonder that there is pressure on the Leaving Certificate points system?
Politicians' willingness to debate entry issues, such as the points system and graduate entry, serves only to distract from their lack of commitment to funding. I suggest that at least 72 per cent of the 800 places in our medical schools should be reserved for EU students (including Irish) and that the Government should invest approximately €25,000 per annum in each student - similar to that made in dental and veterinary education. This will cost approximately an additional €78 million per annum by 2011. This sum, however, has to be set in the context of an annual health budget of €11 billion per annum.
For their part, these EU graduates should be required to commit themselves to working in the Irish health services for a minimum of five years after graduation. This, in part, addresses the staffing issues, although post-graduate training needs further improvement. I also suggest that students receiving the same education should generate the same fee income.
Thus, cross-subsidisation of EU students by non-EU students or graduate students should cease.
If Ireland wishes to have a world-class health service, an outstanding legacy for any minister for health would be the achievement of an undergraduate medical education system which met the needs of the nation's health and no longer compromised the wellbeing of poorer nations. The current scandalous situation should not be allowed to continue.
Dr Michael Turner is a consultant obstetrician and gynaecologist and former master of the Coombe Women's Hospital.