The costs of clinical education

Healthcare professional education is expensive (Frenk et al. 2010). It costs significant amounts to provide undergraduate and postgraduate education to undergraduate students and postgraduate trainees in all the health professions. This is a certainly economic challenge for all the countries; however, there is another problem on top of that. Up until now no one has really known exactly how much it costs to provide healthcare professional education. Some figures are available – but they often fail to cast a great deal of light. In England, for example, it is known that £5 billion is allocated to the education of healthcare professions (Walsh 2010). This ‘‘top down’’ figure is much quoted, but its usefulness is limited. No one really knows how it breaks down or whether all of it is really spent on education. A ‘‘bottom up’’ figure is that many medical students in England now pay fees of £9 000 per year for their education. However the problem with this figure is that it does not account for all of the costs of undergraduate medical education. Up to now there has been inadequate knowledge on what is actually spent on education or to put it another way how much education is provided and how much that education costs. In fact up to now there have been few attempts to discover these numbers. Some work has been done at a micro-level – for example, to work out the costs of e-learning resources or objective structured clinical examinations – but there have been few if any attempts to do it at a national level (Sandars 2010; Brown et al. 2015). However in England, Health Education England – the body that is responsible for healthcare professions education – has started to take on this task (Calculating the Costs of Education and Training, 2013–14). The purpose of this article is to explore their approach and evaluate the advantages and disadvantages of this approach. Health Education England has started by looking at the costs of clinical education. Their aim is to find out the true costs of clinical education at undergraduate and postgraduate levels. Health Education England is certainly to be praised for the transparency of their approach. They have published their methodology for establishing costs and have issued detailed guidance to education providers to help them define the education that they are providing and the costs associated with it. The relevant paper is Calculating the Costs of Education and Training: 2013–14 Year-End Collection Exercise (Calculating the Costs of Education and Training, 2013–14). They should also be praised for their attempts to be comprehensive. The paper runs to 60 pages and covers all the steps necessary to cost education and training. These steps include identifying training programmes, establishing ‘‘amount of activity’’ across the training programmes, defining ‘‘what information is required against each programme’’, conducting ‘‘the costing work in conjunction with education leads’’, and adding the information in the costing templates (Calculating the Costs of Education and Training, 2013–14). The exercise is all-encompassing in its scope. It includes salaried and nonsalaried training programmes for different healthcare professions. The cost components include pre-placement costs, direct teaching staff costs, costs of teaching staff time spent on training courses, costs of staff teaching while delivering patient care, facilities costs, administration costs, central education costs, overheads, costs of checking a trainees’ work, course fees and expenses for courses and examinations, total trainee staff costs, proportion of trainee time in training, costs of providing additional education activities outside of clinical placements, and library and knowledge services costs. They have done all of this to ensure accuracy. According to Health Education England ‘‘ensuring that the data submitted in this exercise is as accurate as possible, is vitally important’’. The training programmes that Health Education England has looked at are broadly those that involve undergraduate education and postgraduate training. The trainees in undergraduate education are not paid a salary; those in postgraduate training are. The review does not cover continuing professional development. The detailed methodologies used to identify activities and associated costs appear sound. But what is more open to question is the philosophy and assumptions about learning and providing care that underlie their approach. Health Education England assumes that unsalaried undergraduate students ‘‘spend 100% of their time learning whilst on clinical placement, and no time delivering service. ’’ However, this assumption has one underlying weakness – namely, that some students will be doing some caring for patients and indeed that learning by doing should be a part of all education – if that education is to be effective (Chi & Verghese 2013). For salaried postgraduate trainees, the story is also complex. Postgraduate trainees are expected to learn and to deliver a service at the