The discontinuation of a student loan for graduate-entry medicine has highlighted access problems in medical education. David Lynch reports.
The fact that medicine has an enduring problem with access for people from less privileged backgrounds has been highlighted in recent statistics.
Just prior to the onset of the pandemic, the Higher Education Authority (HEA) published a detailed report into the socio-economic make-up of Ireland’s higher education institutions.
The October 2019 report found that medicine (along with business, finance, and engineering programmes) had a high proportion of “affluent students” while agricultural, environmental, social work, and childcare programmes had higher proportions of students from “disadvantaged” backgrounds.
A further examination of the figures made it even more apparent that medicine was a particular outlier.
While approximately 15 per cent of the wider population were defined as “affluent”, 19 per cent of the higher education student body came from this category. However, over 36 per cent of enrolments in medicine education came from “affluent” backgrounds.
The HEA report also found that 15 per cent of the second level students and 10 per cent of higher education students were classified as “disadvantaged”. However, only 3.5 per cent of enrolments in medicine came from “disadvantaged” backgrounds.
Graduate-entry medicine (GEM) is a four-year medical degree open to those who have already completed an undergraduate degree. It is seen as a very competitive course and requires high scores in the GAMSAT admission tests. While not perfect, GEM is generally regarded as having helped promote greater diversity and increased access to medicine since its introduction over a decade ago.
According to AccessMed Ireland, which campaigns for greater access to medicine, GEM courses have an “extremely diverse” student body.
“Every year there are parents who are in their late 30s and 40s studying GEM, people who experience disability, people who are first-generation Irish, ethnic minorities, and people who previously studied or worked in completely unrelated fields,” according to the group.
As GEM is considered a second degree, students are not eligible for Student Universal Support Ireland (SUSI) grants or for their fees to be covered. With fees of approximately €16,000 per year, GEM is already very costly. Bank of Ireland was the only bank offering a specialist loan for this cohort, facilitating them to borrow up to €60,000 for fees with an annual percentage rate of 6.5 per cent and a four-year moratorium on repayments.
However, the bank’s recent decision to discontinue this service for new applicants has sparked significant concerns about the impact on affordability and future diversity within the profession.
When second-year University College Dublin GEM student Ms Laura Dowling took to Twitter last month to highlight the Bank of Ireland decision, the response from doctors, current GEM students and prospective students was swift (see panel).
Ms Dowling said she “wasn’t surprised” by this reaction.
“I know of a lot of current NCHDs who wouldn’t have been able to pursue medicine as a GEM [student] without the financial support from this loan. For them and many students currently enrolled in my class, it is a lifeline,” she told the Medical Independent (MI). “A lot of prospective students’ decision to pursue GEM hinges on the availability of this loan,” added Ms Dowling, noting that it impacted her own decision to do GEM.
She said it was “not a particularly financially attractive loan to begin with”; however the four-year moratorium “meant it was our only option”.
“The discontinuation of this loan and the lack of alternative financial support options from Government also goes against the very rationale for introducing GEM as a course… which was to bring diversity and people from different career backgrounds into medicine.”
Mr Glenn Curtin, President of the Association of Medical Students, Ireland (AMSI), and final-year medical student and Quercus Active Citizenship Scholar in University College Cork, told MI: “We already lose a large proportion of our graduating doctors each year to emigration to countries with better pay and working conditions. The impact of this is seen in our hospitals and clinics every day.”
He said the discontinuation of the Bank of Ireland loan scheme would impact access and diversity within medicine. “The news of the cessation of one of the remaining financial supports for these trainee doctors adds another huge barrier to students from less privileged backgrounds accessing medical education and bringing their lived experiences to treating people in Ireland,” he said.
“Graduates without the support of financial guarantors will have no opportunity to both live and work in Ireland while repaying a large debt and often have no alternative but to leave the country in search of better pay abroad.”
Dr Brian Doyle, IMO NCHD committee member, told MI: “We’re already in a very limited diversity pool when it comes to medicine… we need more diversification in the medical workforce and we also needed to increase the number of doctors training in the country.”
However, even with the Bank of Ireland loan in place, he said many potential students from lower socio-economic groups may have been “debt adverse” and deciding not to apply for graduate-entry medicine.
However, Dr Doyle warned that “in the absence of even the possibility of getting a loan now from the banks”, GEM was now effectively ring-fenced “for those who can afford to pay”.
“I think that is a terrible indictment on the Irish education system and on the Department [of Further and Higher Education] to let this happen on their watch,” he added.
“We’ve historically had poor diversification in medical school education, in terms of socio-economic equality, in terms of access to places, but that has just been made worse….”
Dr Doyle believed that the Department of Further and Higher Education and the HSE “should have seen this coming”.
“The HSE, the Department and the HEA really need to team up here and assess how we currently do it,” he added. “Graduate-entry medicine is a fantastic programme. We need it.”
Dr Doyle said that the manner in which GEM is funded and operates “really needs to be reflected upon and changed”.
He continued: “The concern is more for my colleagues who will be joining the workforce behind me. It’s about giving options to people who might make fantastic doctors, but who have no interest when they are 17 or 18 when they’re doing their Leaving Cert.
“In lots of parts of the world, that is the norm. You can’t even do medicine until you have done another degree first [in some countries]… there is a multitude of reasons as to why having two entry modes [direct post-Leaving and GEM] is a good idea.
“But the way it’s being delivered at the moment is not equitable. It’s not fair and it goes against students from lower socio-economic groups in particular… and that’s wrong and that shouldn’t be the case.”
Ms Dowling echoed this concern about future students.
“It’s really prospective and incoming students whose financial support option is being cut off,” she said. “GEM should not be limited to those who have the means, or to those who live around the universities that offer the course. The financial barriers are already staggering, between the basic fees for the course, the current rising cost of living and the fact that universities discourage GEM students from working part-time during the term – advice which a lot of students, like myself, ignore. The discontinuation of this loan essentially will make GEM impossible to pursue without full financial means.”
Looking at the wider medical workforce and industrial relations challenge in Ireland, she told MI that “at a time when retention of doctors within our health service is presenting a major challenge, and the #StandUpforNCHDs campaign is progressing towards potential strikes, it seems absurd and nonsensical for the Department of Further and Higher Education and the Department of Health not to support financial aid for the training of future doctors of this country”.
“Nobody is suggesting that the course is cheap to run, and nobody is looking for a hand-out, merely a way for graduate students to even consider pursuing medicine as a career.”
‘This is so disappointing’ – Online reaction to loan cessation
When second-year GEM student Ms Laura Dowling took to Twitter last month to highlight that Bank of Ireland was discontinuing its GEM student loan, it sparked a huge reaction from doctors, current students and prospective GEM students. Here is a selection of the comments.
“Have been informed they @bankofireland intend on discontinuing their loan for Graduate Entry Medicine students… This is going to further limit access to the course that is already incredibly restricted.”
Laura Dowling, @lauradowling__
“I was always struck by how many in my graduate entry class were supported by family to cover the incredibly high fees, this is only going to make it even more of an inaccessible profession than it already is.”
Dr Neasa Conneally, @neasaconneally
“I took this loan of €60k and worked all through my medical degree to keep afloat. GEM has diversified medicine for the better. Loss of this loan will mean people like me will have no access to medical careers.”
Dr Aislinn Sherwin, @aislinn_sherwin
“This is so disappointing. I was interested in doing GEM here in Ireland. But the fees are ridiculous and now this. I am not so sure anymore. It’s a barrier to those who don’t have the means. Why are the fees so high for an accelerated undergraduate course?”
“Graduate entry medical students have been reliant on a single financial institution to help finance their studies (cost approx €60k), and now this is being removed. This will increase the inequity that already exists in access to medicine and limit diversity in the profession.”
“The majority of Irish students in my class would not be able to afford to study medicine without this loan and that doesn’t even cover full fees. Removing this closes the door to medicine for those who take a different path and not to mention those who don’t qualify for the loan.”
Niamh Kerslake, @niamh_kerslake
In a statement to MI, Bank of Ireland said that the loan would come to a close for new customers this summer.
“While existing customers are not impacted, the graduate-entry medicine loan will no longer be available for new applications after 31 July this year,” according to the bank’s spokesperson.
“The loan required a parental guarantee, which was not an option for all students and the deferral of repayments meant accumulated debt by the end of the term.”
Bank of Ireland stated that the special GEM loan “accounted for a very small volume of our overall lending” with an approximate figure of 50 loans for 2021.
“The number of applications has dropped in recent years, while our other loans became more popular.” The bank had other loans available for undergraduates, postgraduates, and graduates, they added.
A spokesperson for RCSI, one of the universities providing a GEM course, told this newspaper that the “proposed withdrawal of specialist loans for graduate-entry medical students is a matter of concern”.
“We are engaging with Bank of Ireland and the Department of Further and Higher Education, Research, Innovation, and Science and have outlined our concerns.”
The Department of Further and Higher Education, Research, Innovation and Science told this newspaper that it has been “made aware of reports regarding the specific loan scheme for graduate entry medicine and is seeking further information on this issue”.
The spokesperson added that Minister at the Department, Simon Harris, “has also commissioned a review into student supports and will bring this to Government shortly.”
Access all areas?
The news of the discontinuation of the Bank of Ireland’s graduate-entry medicine (GEM) loan has only served to highlight existing concerns regarding access to medical schools.
Mr Glenn Curtin, President of the Association of Medical Students, Ireland (AMSI), noted that Ireland had a “fantastic reputation for medical education for such a small country”.
“Ireland is a global leader in training with the highest number of medical graduates per 100,000 inhabitants in the world; achieving twice the average of our European counterparts,” he told the Medical Independent.
“These graduating doctors come from a wide variety of backgrounds to study here with a large number accessing the training through our graduate-entry medicine programmes, financially supported by special purpose loans that give them the opportunity to earn an income in Ireland while repaying their debt.
“However, the new reality and the future of medicine in Ireland is that patients in Ireland will not experience the benefits of our diverse workforce,” said Mr Curtin, in reference to the ending of the GEM loan.
Mr Curtin added that the “the lack of financial support highlights a bigger systematic issue in medical education in Ireland that we would like to see change”.
He said AMSI and other international medical student bodies want to see medical schools “strive for financial independence from tuition fees” to help ease financial hardship and widen the possibilities for more people to access medical education.
“Over 6,000 medical students in Ireland are joining our international colleagues and medical student bodies by calling on medical schools and the Government to create systems where people’s access to medical education is based on ability, aptitude and potential rather than their financial status,” he said.
“We want to create a world where the diversity of our future doctors and the ability of the medical profession is representative of the population it serves. Up to this point, medical schools relied heavily on one financial provider to maintain adequate access to medical education for people from less represented backgrounds.
“We want to see medical schools strive for financial independence from tuition fees to minimise their impact on medical students and create a system where medical students of low socio-economic status are exempt from tuition fees or to provide alternative means of student financing that fully cover education and living expenses.”
Outside of the financial challenges, Mr Curtin said that medical schools must also provide the “emotional support for their students” throughout their medical studies in order to support diversification of the student population.
IMO NCHD committee member Dr Brian Doyle said that in the immediate term, the HSE should consider covering the cost of fees for graduate-entry programmes, with students possibly agreeing to spend a specific length of time working in the Irish health service following graduation.
“Beyond that we need to fundamentally look at how we can make this all more equitable,” he said. “The fact is we need to train doctors. The [GEM] people who are going in as graduates are going in a bit older… they are already taking that hit of being out of the workforce for those extra years… and they are going back to do a job they obviously really want to do. The State needs to support that.”
From her perspective as a second-year GEM student, Ms Laura Dowling believes a number of measures could be considered to improve access and the financial burden.
“As GEM is the single most expensive course to pursue in the country, we would be suggesting a loan option – either via the university or the Department of Further and Higher Education, that has a four-year moratorium and covers the full cost of the fees,” she said.
Ms Dowling added that the repayment process for such a loan should be flexible.
She believes an option of some type of bursary “in exchange for commitment to the Irish health service, like the system offered to GEM students in St Andrew’s in Scotland”, should be considered.
“They can apply for a bursary of up to £5,000 per year for living expenses [their GEM course is free] in exchange for commitment to NHS Scotland. Students have been calling for an option like this for years.
“Again, at a time when retention of doctors is a challenge, a bursary would be a win-win for the health service and GEM students alike. However, it is important that if this is introduced, it should be an adjunct option that people are not tied to should they choose to pursue GEM.”
Finally, she highlighted the fact that GEM is not currently considered for Student Universal Support Ireland funding, as it is the students’ second degree and not technically a ‘postgraduate’ course.
“The immediate issue is the discontinuation of the only source of financial support there was for the course,” she said. “A bigger issue is the affordability and cost of GEM in the first place. The loan was the only thing that made it in any way accessible and that is being taken away.”