Mumford, David B. MD, MPhil, MA
In this article, I describe clinical academies, a new model of clinical education at our medical school in Bristol, England, and how these were developed and successfully implemented during the last five years. Also discussed are the changes to the curriculum and other practicalities involved in setting up our clinical academies, issues around academic governance, the problems we encountered, and early evaluation findings. Because the title academy carries different connotations, I make a comparison of clinical academies with academies of medical education in the United States.
The University of Bristol Medical School
Bristol is a historic port and the largest city in southwest England, situated 120 miles west of London. The medical school was founded in 1828 at the Bristol Royal Infirmary and became part of the university college in 1893; the University of Bristol received its royal charter in 1909. The University of Bristol is a popular choice with United Kingdom (UK) students and is always near the top of the national league tables for the number of applicants per place. The University of Bristol Medical School has had a rather traditional medical undergraduate curriculum, delivered by semiautonomous academic departments. The curriculum was partially reformed in the 1990s along the lines advocated by the UK General Medical Council in Tomorrow’s Doctors.1 (The UK General Medical Council is the statutory body that is responsible for regulating doctors, ensuring good medical practice, and safeguarding high standards of medical education.) Many current students say that they chose our medical school because of its lecture-based teaching, particularly in medical sciences in years one and two.
For most British medical students, medicine is a first-degree program taking five years to complete, although many medical schools (including Bristol’s medical school) now also offer an accelerated four-year program for graduate entrants. Clinical training takes place entirely within the nationalized health system, the National Health Service (NHS), which continues to be by far the largest provider of health care in the UK.
Six years ago, Bristol’s medical school faced significant challenges to the effective delivery of the clinical curriculum, similar to those faced by other medical schools in the UK2 and the United States.3 The growing preoccupation of the university with success in the UK Research Assessment Exercise (a national audit of research quality that determines government funding to universities for research) meant that many clinical academic staff could offer less time and commitment to medical education.4 At the same time, our principal teaching hospital had become more focused on tertiary care, with an increasingly specialized patient-case mix. The medical staff at that hospital, under pressure to deliver national clinical service targets set by the government, seemed to be losing motivation to make the education of medical students at our school a priority.
Then came the university’s decision, in autumn 2000, to bid for a 75% expansion in the number of medical students, in response to the UK government’s plan to enlarge the future medical workforce. (In the event, Bristol’s medical school was awarded a 50% expansion, increasing its annual intake of students from 165 to 250.) How were we to accommodate all these extra medical students? By this time, local NHS hospitals were full almost to capacity with our students. Furthermore, our historic clinical placements in the adjacent counties of Devon and Cornwall, representing almost 20% of the total, would inevitably transfer to the newly created Peninsula Medical School (Exeter and Plymouth, UK). This required a radical rethinking of the pattern of our student placements and of the structure of clinical teaching.
Toward a New Model
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With more students, fewer placements, and less time for medical academic staff, how was clinical education to continue and thrive? We began to consider the potential teaching resource in the counties surrounding Bristol. Our clinical students in years three and four, who were on short placements in district general hospitals outside Bristol, reported obtaining useful clinical experience. However, very few doctors in these hospitals were trained medical teachers, and coverage of our core curriculum was often haphazard. Students were resistant to spending long periods of time away from the home university before their final year. And yet, initial exploration suggested that there was enthusiasm amongst NHS medical staff in these counties about the prospect of greater involvement in medical education.
Around this time, I was visiting medical schools in Canada and discovered that the University of Toronto Faculty of Medicine had been reconfigured into three academies based around each of the major Toronto teaching hospitals.5 The city of Toronto has a population of 2.5 million, and the staff at its hospitals were already experienced in medical education. The Toronto experience could not exactly be translated into our situation. However, the concept of devolution from a single university base to several centers of equal status was similar to the expansion plan that I had proposed to the school’s planning committee—and the name academy seemed the ideal term for this development.
It was thus that the idea of the clinical academy was born. We asked ourselves, “Why not reconfigure our clinical teaching by taking Bristol’s medical school directly into the surrounding counties and establishing part of it in new centers? We decided to work to create new partnerships with the local NHS, to engage and prepare a new cadre of clinical teachers—principally hospital consultants (specialists) and general practitioners (family physicians)—to share in our educational endeavor. It was our hope that, given adequate time, resources, and guidance, NHS hospital consultants and general practitioners could deliver virtually every aspect of our medical curriculum.
During the autumn and winter of 2000–2001, there was an intensive period of discussions with hospital consultants and senior management of NHS hospital trusts and primary care trusts in the counties surrounding Bristol. (Trusts are the semiautonomous managerial and financial organizations within the NHS that employ most of the local NHS workforce and provide hospital- and community-based health services.) We put on local “road shows” to present the vision and discuss the viability of each new proposed clinical academy. In some places, such as Gloucestershire, the chief executive of the acute-care hospitals trust led from the start. In others, our plans met with initial skepticism, and we had to identify a group of enthusiastic hospital consultants to provide the main impetus. Everywhere, partners needed to be convinced that the available funding (from the NHS educational levy and the university) would genuinely cover all the costs of clinical education.
The Clinical Academy Model
The principal feature of the model is the decentralization of both the formal academic and clinical components of clinical medical education. Peripheral placements in district general hospitals and in primary care settings have long been a part of UK medical education. We have taken this much further. Thus, not just bedside teaching but academic leadership, seminars, administration, and support for students have all been transferred into local centers.
What, then, is a clinical academy? It is essentially a local college of medical teachers and students. The teaching staff comprise NHS hospital consultants and general practitioners; within the city of Bristol, there are also university-funded clinical academic staff. Each clinical academy is led by an academy medical dean (AMD), a locally recruited senior hospital consultant or general practitioner. This key person provides leadership of staff and supervision of students in that academy and acts as an intermediary between the faculty of medicine and the local NHS trusts. Each clinical academy includes at least one acute-care hospital trust, one mental health trust, and local primary care trusts as full partners. For a comparison of clinical academies and academies of medical educators in the United States, see the sidebar.
The University of Bristol Medical School now has seven clinical academies, all within 50 miles by road from Bristol. They consist of two academies based in traditional acute-care teaching hospitals in the city of Bristol (Bristol South and Bristol North) and five academies in the surrounding counties—Gloucestershire (Gloucester and Cheltenham), Somerset (Taunton and Yeovil), North Somerset (Weston super Mare), Bath, and Swindon. (For a map showing the locations of these academy centers, see Figure 1.) The choice of locations for our clinical academies was determined largely by geography: the academy centers are in acute-care hospitals that serve substantial local populations and that have historic links with our medical school. We negotiated with other medical schools in the region (Southampton Medical School, Oxford Medical School, and the Peninsula Medical School) to rationalize our clinical placements and to avoid any unseemly territorial disputes. Medical sciences continue to be taught at the main Bristol university campus in a systems-based curriculum during years one and two, alongside the teaching of basic clinical skills.
For the new out-of-Bristol academies, the arrival of large numbers of Bristol medical students would involve a huge cultural change, both for medical staff and the hospital management. Some indication of the scale of these numeric increases can be gained from Figure 2, which shows the changes in student-placement weeks by clinical academy between 2001–2002 and 2006–2007. The two Bristol academies would experience much smaller changes in percentage terms.
Curriculum Design and Organization
A major feature of our clinical academy system is the increased length of time medical students reside away from Bristol as apprentice members of local health service communities. We originally envisaged yearlong rotations. However, because half of the placements would be in clinical academies outside Bristol, this plan led to considerable unease on the part of students. Third-year medical students in particular are still very much part of the university campus community in Bristol. It was therefore decided that medical students should belong to one clinical academy for half an academic year before rotating to another, spending equal time within and away from Bristol. Rotations would be designed to allow each student to experience the full range of academies during years three to five to ensure as much as possible that each student had an equivalent educational experience during the overall program.
Our curriculum had to be radically revised for delivery in the clinical academies. Years three to five were restructured so that each year consists of four curriculum units of equal length that students undertake in rotation. This gives continuity of student presence within academies and makes the most efficient use of all available clinical placements.
The content of the curriculum had to be specified in much more detail to ensure that the same curriculum was delivered in all seven clinical academies. Academic staff from Bristol and NHS colleagues from the academies worked together to decide how each learning objective and each component of the curriculum would be delivered. Clinical academies have also begun to exploit new opportunities for interprofessional learning with students of nursing and other health professions.
Teaching, learning, and assessment
Before the establishment of the clinical academy system, students were given lectures by the university clinical departments, followed by a clinical placement, usually within Bristol. Now, after an introductory day or days in Bristol, most of the formal teaching in years three to five is delivered in the academies, by seminars backed up by online tutorials. The motto is: if it can be done in the clinical academies, it should be done there. Only in cases of some specialized lectures is the teaching delivered at the main university campus.
In their clinical academy, students are assigned to a tutorial group for each unit that assists self-directed learning and allows facilitated discussion of structured clinical problems.6 The unit handbook specifies the clinical experience the student is expected to gain and the range of clinical cases to be seen.
All students take the same end-of-unit assessments, organized centrally and mostly administered in Bristol at present. Professional attitudes and behavior, and some clinical skills, are assessed in the clinical academies.
It is important to ensure that students feel adequately supported when they are away from Bristol. Academic supervision and personal support of medical students are provided by each AMD and the local unit coordinators and tutors, on behalf of the faculty. As the number of our students in each year of the program increases from 165 to 250, the clinical academies are intended to preserve a “human-scale” educational environment, in which students are welcomed and known as individuals by their clinical teachers.
Ensuring consistently high standards
When the clinical academy system was proposed, there was some initial concern about the quality and consistency of the clinical education that students would receive. The university was, perhaps understandably, reluctant to loosen its central control of key academic functions. To ensure good organization and robust standards, we have adopted a structure in which each unit of the curriculum is led centrally by an academic unit director and is delivered in each academy by a unit coordinator. The unit director and academy coordinators together share the task of developing and enhancing the unit curriculum. Major curriculum changes are submitted for faculty and university approval.
Student feedback data are collected at the end of each unit, allowing the unit director and unit coordinators rapidly to identify and address any problems. Because students take the same assessments at the end of each curriculum unit, comparisons of marks between clinical academies enable us to highlight areas of underperformance.
Creating Clinical Academies
Clinical medical education in the UK is funded from two sources: via the university (from the higher education funding councils and student fees) and via the NHS educational levy for medical undergraduates known as the Service Increment for Teaching (SIFT). The SIFT funding stream comprises NHS funds going directly to NHS trusts; the distribution of SIFT funds is based on where the medical school determines to place its students.7,8
A cardinal principle of the development of the clinical academies has been financial transparency and equity of funding across all our partner NHS trusts. A single rate of SIFT funding (£615 per student-week in 2006–2007) was derived from previous surveys in the NHS southwest region on the actual costs of medical student clinical placements. This formula has been applied uniformly to both “new SIFT” funds awarded to fund the expansion of the medical school and the previously existing SIFT funds.
The university, in partnership with the NHS regional management, has tried to ensure that approximately 55% of the formula-based SIFT income should underwrite the direct costs of teaching (mostly salaries of clinical teachers and administrative staff) and 45% to cover overheads and facilities costs, including residential accommodation for students in clinical academies outside Bristol. This division has been embodied in detailed business cases drawn up by every academy; these cases were the basis for releasing SIFT capital funds for new buildings and facilities.9
In the clinical academies outside Bristol (i.e., with no university-funded academic posts), the university is committed to providing new funding to contribute to the direct costs of teaching curriculum units. In addition, the university reimburses the local NHS trusts for part of the salary of each AMD (generally for two days per week) and for their administrative support. This total package of university funding for the new clinical academies currently amounts to £1.3 million per annum.
Government decisions about medical school expansion in England were made by a joint implementation group of the Department of Health and the Higher Education Funding Council for England. Bristol’s medical school was awarded £8.3 million in SIFT capital to underpin its expansion, which has allowed a substantial investment in the physical learning environment in the clinical academies. Our plan from the outset was to enhance existing educational facilities in the NHS trusts and to share them with medical postgraduates and students of other health professions. These enhancements have included new seminar rooms and clinical skills centers, enlarged libraries, and new computing facilities. The plan is now fulfilled, with building programs completed in Gloucester, Cheltenham, Taunton, Yeovil, Bath, Weston super Mare, Swindon, and North Bristol.
With this distributed model of clinical medical education, a fast and effective information technology network is crucial to support a virtual learning environment accessible from all clinical academy sites. The university has made a substantial investment from its new funds to connect each academy site to the national university network. In each clinical academy, a local information technology network supports students’ access to central learning resources, online tutorials, videoconferencing, etc.
The NHS regional management has taken a great interest in the development of our clinical academies and has been keen to extend our concept to support the education and training of the whole local NHS workforce. However, issues remain about the identification of further funding streams to realize these aspirations.
Key role of the AMD
The key role in the successful creation of each clinical academy has been the AMD. For each academy, we set out to recruit a local senior hospital consultant or general practitioner who would have the confidence and respect of local medical colleagues. Each appointment was made jointly by the university and local NHS trust partners. AMDs are accountable to the faculty dean through the director of medical education, whom they meet monthly at the academies management group meeting.
In making AMD appointments, we regarded a qualification in medical education as desirable, but a proven track record of clinical leadership and good management skills as essential. In the setting-up phase, knowledge and familiarity with the management structure of their local NHS trusts have been critical to success, including the confidence to utilize and monitor locally the funding streams for medical education. The AMDs have overall responsibility for identifying and recruiting suitable clinical teachers in their academy and for ensuring that their teaching sessions are clearly specified in their current job plans. The appointment and line management of unit coordinators is a joint responsibility of the AMD and the appropriate unit director.
When the clinical academies opened in September 2004 and medical students started to arrive, the AMDs assumed responsibility for local curriculum delivery and personal support and supervision of students. AMDs have a key role in quality assurance of educational delivery, a responsibility shared with the unit coordinators of each curriculum unit. Each AMD provides leadership of the teaching staff in his or her academy and acts as an intermediary between the local NHS trusts and the university.
The Centre for Medical Education in Bristol
The General Medical Council has strongly encouraged the development, in every UK medical school, of a center, or unit, of medical education to provide a focus of curriculum leadership and innovation.10 The new Centre for Medical Education was opened on the University of Bristol campus in 2002. This provides curriculum coordination and pedagogical leadership for the whole medical undergraduate program and for the clinical academies in particular. The center is responsible for the effective administration of the program, including the assessment processes, and increasingly undertakes research and evaluation.
The Centre for Medical Education also incorporates the Bristol certificate/diploma/masters program in medical education, which was established with funding from the NHS regional office to train new cadres of teachers for the clinical academies. Now renamed the Teaching and Learning for Health Professionals program, it is open to members of all health professions. Over 500 doctors and other health professionals are currently enrolled or have completed courses within the past five years.
Formal evaluation of the clinical academies is in progress; the findings will be published separately. The results of students’ unit assessments across the whole cohort reveal no deterioration in standards of student achievement since 2004 and no significant difference in any unit between in-Bristol and out-of-Bristol academies. Feedback data collected from students for quality-assurance purposes at the end of each curriculum unit show that out-of-Bristol academies have consistently obtained more positive ratings than have clinical academies in Bristol from the first year of their operation.
There have been a few “teething problems”; for example, there was a shortage of residential accommodation for students in one clinical academy. And delays in appointing additional hospital consultants have compromised teaching delivery in two smaller specialties in another academy. Mechanisms have been agreed on for making an occasional, limited redistribution of students to other academies, with pro rata compensations in SIFT funding.
For many faculty in Bristol, the introduction of clinical academies has meant a significant change in their roles. Although the additional student numbers in years three to five have been absorbed by the new out-of-Bristol academies rather than by increased clinical teaching in Bristol, the unit directors now carry overall responsibility for delivering their units at all these sites. Providing vigorous central leadership of the curriculum, conducting assessments for larger numbers of students, and monitoring the quality of dispersed educational delivery have made new demands, whilst the pressure of routine teaching has undoubtedly been diminished for most faculty. The existing university teaching facilities in the Bristol teaching hospitals continue to be used by students based in the Bristol academies.
At the annual medical program reviews in 2004–2005 and 2005–2006, the opinion of students and faculty was that the clinical academies had been a great success in their first two years of operation. Students spoke very highly of the quality of teaching and its organization in the clinical academies. This outweighed the inconvenience of travel from Bristol and within the academy area. Colleagues from the clinical academies applauded the key roles of unit directors and unit coordinators in bringing the University of Bristol to the academy.
A Useful Model
Clinical academies represent not so much a devolution of responsibility for curriculum delivery as a widening participation in medical education. Bristol Medical School is no longer confined to Bristol but embraces seven clinical academies as full partners in curriculum delivery. Within the faculty’s new governance structures for medical education, clinical academies have a status similar to that of academic departments.
The clinical academies are intended to preserve a human-scale educational environment in which students are welcomed and known as individuals by their clinical teachers. The medical school is able to ensure that our increased numbers of students will develop their clinical competence in high-quality clinical placements.
Clinical academies represent a new kind of partnership between our medical school and regional NHS trusts. This involves a greater teaching role for NHS doctors in these trusts and the fostering of local medical education skills and leadership.
Several medical schools in the UK (Newcastle Medical School, Leicester Medical School, Peninsula Medical School), North America (University of Washington School of Medicine Seattle, University of Toronto Faculty of Medicine, University of British Columbia Faculty of Medicine, University of Montreal Faculty of Medicine), and Australia (James Cook University School of Medicine) have also developed multiple, or distributed, campuses.11,12 However, the Bristol clinical academies have some unique features, and our experience may provide a useful model for other medical schools to consider.
The author thanks David Cahill and Elizabeth Mumford for their helpful comments whilst preparing this article.