Viewpoint: Medical student loans — why they matter to general practice

Kieran Walsh

doi:10.3399/bjgp14X680581

I was lucky as a medical student. When I was at medical school, I paid no fees and also received a grant for living expenses. As a result I qualified with minimal debt. Did this happen during more prosperous times? No — it happened in the 1980s in Ireland when the country was still in the grip of a deep recession. Today our leaders talk of the economic necessity of tuition fees and student loans to enable the payment of those fees, however economic necessity is probably less today than it was 25 years ago. Truly it is more a political necessity than an economic one.

Over the past 15 years I have often worried about the effect of tuition fees and loans on medical education. Student debt will put prospective students off medicine; it will discourage diversity; and it will encourage junior doctors to think more about the earning potential of different medical careers than about what they might like to do, or what they might be good at, or what the country’s population needs. But political circumstances make me think again. At present all the major political parties have signed up to the concept of tuition fees and student loans. The prospect of a reversal of policy is nil; this makes me wonder whether tuition fees and student loans could be made to work better, for students and ultimately for patients and the public. Certainly the more you find out about student loans, the more you find potential for reform.

First of all could the system be improved so that it is less likely to put off poor students from studying medicine in the first place? Students currently get a tuition fee loan (to pay their tuition fees) and a maintenance loan (so that they can live). Students from very low-income households can apply for their maintenance loan to be increased, but only by relatively small amounts. This could be increased and, if it was sufficiently targeted, would be unlikely to have a significant effect on the exchequer. Students from low-income households are also entitled to a maintenance grant, which they don’t have to pay back. This is also a relatively small amount of money that could be increased with little effect on national finances. There is also the question as to whether having a maintenance grant plus a maintenance loan adds to bureaucracy unnecessarily. Couldn’t the two forms of support be amalgamated? Other grants are also available; undoubtedly helpful but which inevitably present a byzantine puzzle to school-leavers. A simpler system would be better, perhaps with mentors who could encourage poorer applicants and help steer them through the system.

Secondly, the way loans are repaid could be improved. At present repayment starts when the student reaches a certain level of income which could be increased; the loan would still be repaid albeit over a slightly longer period.

Thirdly, there are certainly problems with the way in which student loans are administered. There have been problems with the application website and telephone support system. Many graduates have paid back too much when repaying their loan. At the opposite end of the scale is non-repayment. Debts are paid back via the tax system in the UK and so when non-UK graduates return to their home country there is no easy way of collecting repayments. Default rates among non-UK students are thus high which of course increases the cost of the entire system to UK students.

Finally, there is the issue of graduates choosing high-earning specialties in an attempt to repay their debt. This happens more often in the US than the UK at present, but there is a risk of us following suit with workforce planning problems a number of years down the line. There are two potential choices: we could simply make specialties that the population needs more lucrative, or debt forgiveness schemes could be introduced for those opting for such specialties or who choose to work in territories within the UK facing a shortage of healthcare professionals.

Why does all this matter to general practice? Well if we want sufficient quantities of high quality GPs in the future, we are going to have to go back to the start and put ourselves in the shoes of an 18-year-old school leaver wanting to be the first in their family to go to medical school. It really is that simple.