Apprenticeships in health care are trending. The NHS (National Health Service) in England is considering an apprenticeship model for training aspiring doctors and nurses to help alleviate workforce issues.[1] The BBC is calling this a radical plan though it has been the training approach for some health professionals in the past. Indeed, clinical education of doctors even now is sometimes labelled ‘the apprenticeship model’ though strictly speaking the term is incorrect.
An apprenticeship is a remunerated position during which the employee has on-the-job training while also providing a service that increases in responsibility over the term of the experience. So this differs from student health professionals in clinical settings who are or have been paying for their education until qualification, and who frequently have large student debts.
Apprenticeships are common in other industries, leading to a formal qualification and including some classroom-based education (typically about 20% of the time) as well as practical work-experience. This format was the norm for nursing qualifications prior to nursing becoming a university-based degree in many countries in the last century. Student nurses were part of the paid hospital workforce from their first year rather than being supernumerary.
The apprenticeship proposal would require students to meet the qualification standards of their respective professional boards but does not go into detail how their education would compare to university-based programs. Under the plan, school leavers are likely to work on hospitals wards in their first few months of training raising the question about what health professional learners need to know before they interact with patients and what they need to be able to do before they provide paid healthcare. Such a route may be more attractive for teenagers from lower income families who do not want to take on large student loans but would rather be paid from age 18. They will miss out on the university experience, which they may not see as a bad outcome.
University-based programs leading to medical qualifications have been increasing in length over the last decades. While medical school courses that still take students straight from school, such as in the UK and Australia, last from 5-6 years, graduate entry programs in the same countries now last 7 years in total (3 years first undergraduate degree and 4 years medical degree) similar to the 7-8 years in Canada and the United States. The apprenticeships will last 5 years.
The Flexner model of medical education introduced in the United States in the early 20th century, based on an existing German approach, was widely adopted globally in subsequent years.[2] This biomedical model divided the medical program into pre-clinical (biomedical sciences in the classroom and laboratory) and clinical (hospital-based education). While this model is still followed in many countries, others have recognised the need for patient contact in the early years and therefore students do have interactions with patients in hospital and community settings. Modern medical programs have also embraced innovative educational approaches such as problem-based learning, group-based communication skills training and simulation. However, there is still a major emphasis on science particularly for the first two years.
How much biomedical science do aspiring doctors and nurses require and how will this be met via an apprenticeship model? Is the science best learned before clinical immersion, or during/after it (a type of flipped model)?
It would certainly be interesting to compare the outcomes of the ‘traditional’ medical school model to this type of apprenticeship, but that would take many years. How will the two streams of students interact with each other? Will there be competition for clinical experiences? The major issue however is who provides the education, supervision and assessment in the workplace during the apprenticeships.
The model is proposed because of workforce issues but it is that workforce which would need protected time to engage with the apprentices and monitor their tasks. The medical workforce is already supervising medical students, interns, doctors in specialist training, international medical graduates, and other health professionals. Senior nurses also have a major educational role in hospitals.
Universities provide much of the infrastructure for education including timetabling, student support and assessment. Who will have these tasks in a hospital-based model and ensure that apprentices have a general health professional education including community-based experiences rather than solely being placed where there are workforce shortages?
Educators, clinicians, consumers and students will watch this unfold with interest and perhaps some trepidation.
[1] https://www.theguardian.com/society/2023/may/10/school-leavers-could-join-nhs-via-apprenticeships-in-plan-to-fix-staff-shortages
[2] For an interesting summary of the Flexner reforms see: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3178858/
Health professional education and practice 