Expanding the English medical schools: The politics of knowledge control

Since1997therehavebeentwoconcertedattemptstoexpandthenumberofmedicalschoolstudentsinEngland:byincreasingthesizeofexistingmedicalschools,andbycreatingnew medicalschools.Theseinitiativeshavebeenadirectresultofgovernmentpolicy,although policyimplementationwasdelegatedtothestateapparatus.Theyalsoledtoastrugglebetween highereducationinterestsandtheGeneralMedicalCouncilforknowledgecontrol.Theaim ofthisarticleistoofferananalyticalframeworkforthisconflict,andtodrawattentionto consequentshiftsinuniversitygovernanceandtheepistemologicalframingofhighereducation.

Oneofthecentralpurposesoftheuniversityistodeterminewhatcountsashigh-status knowledge (cf.Hirst and Peters, 1970;Tapper and Salter, 1992).But as the universities have performedthatpurpose,theyhaveoftenrespondedtothedemandsofwell-organizedbodies, especially professional associations, representing the concerns of particular societal interests.Theuniversity'sacademictraininghelpstosecurestatusandrespectabilityfortheprofession, while the university is likely to gain financial rewards, societal regard, and political credit (Rothblatt,1968).InEnglandthetiesbetweenthemedicalprofessionandtheuniversitieshave been particularly strong over time, with both the General Medical Council (GMC) and the British MedicalAssociation (BMA) taking a keen interest in the work of the medical schools (Salter, 2001;Salter, 2004;Irvine, 2006).Universities provide a broad-based academic course, albeitcontainingsomespecializedprofessionalrequirements,whichisthenfollowedbyaperiod ofspecializedtrainingbeforethetraineecanbecertifiedasaqualifiedprofessionalpractitioner.Thequestionthatarisesis:wouldthenew-post-1997-medicalschoolsfollowthismodel? Theaimofthisarticleistoexaminetherelationshipsbetweengovernment,thestateand quasi-state, the universities, and the GMC in the struggle to restructure the curriculum of medicalstudents.Itwillbearguedthatitisprimarilyinthecontextoffoundingnewmedical schoolsthattheharbingersofchangeinthecharacterofmedicaleducationhaveemerged,and attentionwillbedrawntoconsequentshiftsinuniversitygovernanceandtheepistemological framingofhighereducation.
The financial costs of most health-care initiatives mean that they invariably require governmentsupporttobringthemtofruition.Initsthreeinitialreports,theMWSACpointed toamoreroutinizedapproachtomanagingthesizeofthemedicalworkforce,arguingthatits augmentation should be determined by agreed criteria and that expansion should follow the dictatesofthosecriteriaratherthanbeingdrivenpolitically(althoughpresumablytherewould beapoliticalinputintodeterminingthecriteriathattriggeredexpansion,andallgovernments wouldbewaryofthepotentialfinancialburdenofmeetinginbuiltexpandingobligations).Governmentstooktheresponsibilityforfundingthesetwoinitiativestoexpandthenumber of medical students, but responsibility for policy implementation was delegated to different parts of the state apparatus and to quasi-state organizations.The Department of Health and theHigherEducationFundingCouncilforEngland(HEFCE)weregiventheresponsibilityfor implementingthepolicy,whichfollowedaparallelcourseonbothoccasions.In1997theymet toformaJointImplementationGroup(JIG),whichwascomposedof'thegreatandthegood' drawn respectively from the fields of medicine (the Chief Medical Officer, the Chairman of theJointMedicalAdvisoryCommittee,theChairoftheGeneralMedicalCouncil'sEducation Committee, and the NHS Director of Research and Development), and higher education (HEFCE's Chief Executive and its Director for Institutions).Obviously, on the university side other key negotiators who would also be drawn into the equation would be personnel who wouldhelptodetermineeitherincreasedstudentnumbersatestablishedmedicalschoolsor thefoundingofanewmedicalschool.
The Joint Implementation Group pursued a broadly similar implementation process followingboththe1997MWSACReportandtheNHS Planin2000.(Beloff,1968).But, justasthefoundationofthenewuniversitieswasattackedasbeinganexpensivewaytoexpand English higher education (Carswell, 1985), it would have been less expensive to have located all the expansion of medical student numbers in those universities with established medical schools.Thegeographicallyunevenspreadofmedicalpersonnelwouldthenhaveneededtohave beentackledinotherways-evenperhapsthroughacentralizedallocationoftrainedmedical personnel.
All three components of Salter's regulatory regime -standard setting, monitoring/ evaluation,andintervention-havecomeintoplay,withvaryingdegreesofintensity,inrecent years.Increasingly, standard setting became the primary concern of higher education as new programmes and pedagogies emerged.Monitoring/evaluation continued to be shared, with the universities assuming responsibility for evaluating academic performance while the GMC stillmonitoredwhoshouldhavetherighttoberegisteredasamedicalpractitioner.Ineffect, anuneasytrucehasbecalmedtherelationshipbetweenthetwosetsofinterestsaswehave awaitedtheGMC'sinterventionistmovetointroduceanationalqualifyingexaminationforthe registration of doctors, which is likely to have an impact on the degree programmes of the medicalschools-bothintermsoftheirappealtostudentsandthepurposestheschoolsare meanttoserve.Thisisinterventionwithasharpedge.

Conclusion
Whilethenewmedicalschoolsandtheincreaseinthenumberofmedicalstudentsisadirect result of government policy, the policy implementation process has been controlled by state and quasi-state institutions.For the universities the initiative represented an opportunity to undergosomeexpansionafteraperiodofatbestconsolidation.Theconstraintwasthatthey didnothavecompletecontroloverthecurriculaoftheirmedicalschools.However,becausethe medicalinterestswereonthedefensive,inpartduetopressurefromthegovernmentandthe state,theuniversitiessucceededinaugmentingtheirauthority.Now,though,theGMC,through its intention of imposing a national examination to determine the registration of doctors, is intheprocessofattemptingtoreassertitsauthority.Itispossiblethatflexibilitywithrespect to aspects of pedagogy -especially approaches to teaching and learning combined with an acceptanceofvariationsinexaminationmodes-willenablethemedicalandhighereducation intereststoarriveatanacceptablecompromise.

Implications
The implications of the decision to expand medical student numbers are still unfolding.The GMCstillhastoresolvethequestionofhowtheregistrationofdoctorsshouldbedetermined.Whetherornottoimplementanationalexamination,theformitislikelytotake,itsimpact uponthecurriculaofthemedicalschools,anditsimplicationsforthoseuniversitieswithmedical schools, are all issues that are in the process of being decided.As we have noted, even the stabilityofsomeofthenewlyformedjointmedicalschoolsisproblematic.Whatisnotindoubt isthecontinuingsignificanceofmedicaleducationforthefutureoftheuniversity.Itrepresents a vital area of professional knowledge that has been incorporated in higher education for a considerableperiodoftimeanditspresenceislikelytogrow.
Medical education is important because it links the university to vital societal concerns andinterestsanddirectlytogovernmentandthestate.Theuniversityisincreasinglyaboutthe pursuit of professional concerns as much as, if not more than, the pursuit of academic goals.An important segment of the future identity of the university will be determined by how it incorporatesmedicaleducation.Wehavealreadyseenthatthereisaninterestingstorytotell withrespecttothewiderpolicymakingprocess.Whatremainstobedoneistoexplorehow thatworkedoutwithrespecttoindividualinstitutionsinordertoassessitsimpactuponthe characterofBritishhighereducationatlarge.Willgovernmentandstateworktosustainthe independence of the university, partly in order to better ensure the fulfilment of their own policygoals,orwilltheysidewiththepowerfulsocietalinterestsbecausethatseemstobethe politicallyeasiestpathtotake?Indeedthereismuchatstake.
Ourania Filippakou is a Senior Lecturer in Education at the University of Hull.Her main interest is in the theoretical condition of higher education -the theory, the epistemology, and the methodology of highereducation-withparticularreferencetocomparativehistoricalanalysis,aperspectivethatseeksto combinethemethodsofhistorywiththetheoriesandconceptsofsocialscience.Sheisacouncilmember oftheSocietyforResearchintoHigherEducation(SRHE),andvisitingfellowattheOxfordCentrefor HigherEducationPolicyStudies(OxCHEPS),NewCollege,UniversityofOxford.
TedTapperhasspentnearlyallhisacademiccareerattheUniversityofSussex .Hisresearch has developed in two broad fields: the politics of secondary schooling, with a focus on the increasing authorityofthecentralstate;andthepoliticsofhighereducation,encompassingareasonablylargebody of work on the governance of higher education and the politics of policymaking.More recently, he has examinedtheroleofideasintheprocessofchangeinhighereducation.