Forgiving medical student loan debt could help protect the future of a diverse NHS workforce
BMJ 2024; 385 doi: https://doi.org/10.1136/bmj.q1144 (Published 22 May 2024) Cite this as: BMJ 2024;385:q1144
In a bid to improve the supply of clinical staff to the NHS, last autumn the Nuffield Trust published the Waste Not, Want Not report.1 It proposed a forgiveness scheme for the student loan debts of nurses, midwives, and allied healthcare professionals—fleetingly also mentioning the potential to expand this to include doctors. Introducing student loan forgiveness schemes for medical students represents a unique opportunity to both tackle the ongoing NHS retention crisis and restore the career option of NHS doctor as an aspirational and affordable choice for medical students.
Medical degrees are expensive. My student loan balance sits at over £52 000, a figure that will only rise between now and my graduation in 2026. The figure when I graduate will undoubtedly dwarf the foundation year 1 basic salary of £32 398. Medical degrees are usually two to three years longer than those for nursing, midwifery, and allied health professions. Spending extra years studying not only accrues additional student loan debt for medical students but represents years of lost earnings. A study last year found that foundation year 1 doctors were graduating with debt as high as £100 000,2 more than double the average student loan debt of around £46 000.3 This leaves medical students in a uniquely precarious financial position.
All healthcare degrees, medical degrees included, also come with an obligation to complete mandatory clinical placements.45 The long and often unsociable hours associated with clinical placements, paired with longer term times than non-medical degrees, can make it more difficult for students to find and retain part time work to support their education. This financial difficulty is acknowledged for nursing, midwifery, and allied health professional students, who are eligible for a £5000 grant from the NHS Learning Support Fund each academic year.6 No such support is available to medical students, who are required to take out larger student loans (to account for the length of their degrees) and pay them back with high interest rates from the April after their graduation.7
Priced out
Medical students, particularly those from “widening participation” and under-represented backgrounds, already struggle to afford the high costs of a medical degree. With stiff competition for postgraduate training posts, and with a weak locum market, medicine no longer offers its graduates the job security and career progression that it once did.8 This makes the costs of medical school even harder for students to bear, and it reduces their motivation to pursue a medical career in the NHS.
Students with lower household incomes typically receive higher maintenance loans, which translates to a higher burden of debt on graduating.9 This is another mechanism through which students from widening participation and working class backgrounds are isolated from success in medicine and priced out of a sustainable career in the NHS. In the face of a workforce and retention crisis—but also in the face of widening health inequalities and a deepening cost of living crisis—a socially diverse medical workforce becomes even more valuable. Medical students from widening participation backgrounds tackle health inequalities by representing and serving the often underserved communities they come from. The entrenched classism in medicine, perpetuated by a student finance system that prices these students out of the career, will only deepen health inequalities further.
The Nuffield Trust’s own figures show that 96% of UK medical graduates join the foundation programme. As medical students are required to complete their foundation year 1 to become fully registered medical practitioners with the General Medical Council, and as the design of postgraduate medical training makes it extremely difficult to rejoin the foundation programme if you leave, this is essentially an unwritten commitment to two years of NHS service. Offering the forgiveness of medical students’ loan debt in return for continuing NHS service over three, seven, or 10 years—in line with proposals the Nuffield Trust has already made for our colleagues in nursing, midwifery, and allied health professions—may not be a silver bullet. It will, however, restore the sense that a career as an NHS doctor is an affordable and aspirational one for students from all backgrounds, ensuring that we don’t just train doctors but that we retain them too.
Footnotes
Competing interests: EL is a medical student enrolled at Lancaster University 2019-26.
Provenance and peer review: Commissioned, not externally peer reviewed.