Undergraduate medical education in the UK is dually funded. There is University funding through the Higher Education Funding Council for England (HEFCE) or the devolved governments of the UK, and a second line of funding for the teaching of medical undergraduates in National Health Service (NHS) facilities, known as the service increment for teaching (SIFT).
This study traced how these monies are actually spent, by investigating the allocation plans for these funds within both Universities and the NHS. Although the functions of Universities and healthcare providers are complex, and activities such as student teaching, clinical care and research are inter-related, most of this money is not actually spent on undergraduate medical education, but instead used as a kind of general subsidy for elite institutions, be they Universities or “teaching” hospitals.
This work argues that both funders and providers of medical education realized, and indeed intended, that SIFT was used for purposes peripheral to undergraduate education, by examining the reporting systems for SIFT spending, and the nature of accountability for these large sums of money.
This argument is situated in the history of higher education funding. The history and evolution of both medical University funding and NHS funding for medical undergraduate education are explored. The literature reviewed relates to the history, organization and funding policy of higher education in the post-war period in the UK, with medical education as a special case within this.
The effects of this funding on undergraduate medical education are substantially negative. Although large sums are committed to this activity, most of the money is used for other purposes, leaving the core activity essentially unfunded, and relying on volunteerism to actually happen. This is explored in a review of the literature as well as fieldwork, interviewing senior figures in both University and NHS who are in charge of teaching or funding allocations.
Probably no organisation or set of individuals meant to disadvantage undergraduate teaching in the NHS. However, the large sums involved discouraged any major change of the SIFT formula, for fear of destabilizing hospital finances and therefore their primary function, to treat the sick. In the University sector, it is an accepted modus operandi to use student funding to invest in prestigious and income-generating activities in the University.
An understanding of why the NHS and Universities acted as they did is attempted, by drawing on the field of behavioural economics, using concepts of mental accounting and fungibility of monetary income. As the funds were poorly accountable, and could be considered a type of windfall income, attitudes to spending it, and accounting for the spending, were markedly different to regular, earned income. This exploration of economic behaviour might touch on some of the root causes of the consequences and unintended consequences of the funding system for undergraduate medical education.
