Medicine is an elite profession, traditionally dominated by white, male, middle- or upper-class people, frequently from medical families.
In 2014, the Medical Schools Council (MSC) created a Selection Alliance (SA), and published Selecting for Excellence (SfE), to address inequities in access to medical degrees in the UK for those from “widening participation” backgrounds.
Fostering Potential: 10 years on from Selecting for Excellence , published in December of 2024, reports on progress made, with welcome achievements that are testament to the commitment of the community. The report rightly notes that focus on widening access has meant support for diverse students once they commence studies has been neglected.
Recently, medical student activism – #LiveableNHSBursary , and #FixOurFunding – have highlighted the peculiar funding situation medical students find themselves in , and the financial pressures they experience during their studies.
Fostering Potential asserts that WP needs to be reconceptualised away from a deficit framing of individuals as lacking ambition or aptitude to excel, to understanding lack of participation as the product of systemic and institutional failures around inclusion. For me, one of the main barriers to success for students from a disadvantaged socio-economic background studying medicine is the degree was designed and developed for a financially comfortable student. Its current structure excludes students from diverse backgrounds, and part of this is financial.
The earnings gap
One might argue that the financial hardship experienced by student medics is the temporary cost of what will become a lucrative career. However, once qualified, doctors from a lower socio-economic background will experience an average class pay gap of £3,640. This means their degree is both harder won and less remunerative.
Current research and initiatives on financial barriers to success mostly treat money as a discernible object that can be quantified. It is a thing we either have enough of, or not; something we earn for ourselves as individuals. Hence proposed solutions tend to focus on maximising individual students’ abilities to earn alongside studies, while recognising that lack of time due to part-time work or caring responsibilities means some students cannot take advantage of extracurricular career development opportunities.
I find this contradictory and suggest it misses a key point – money is also a relationship; it shapes our experiences of the world far beyond how much we have. It is a condition of success, not a result of it. Developing support for a student from a financially disadvantaged background should be informed by research that explicates how poverty impacts students’ opportunities to learn and exploit the advantages higher education allegedly offers.
A student’s-eye-view
I lead a project at Lancaster Medical School called Medicine Success, providing funds to mitigate the hidden costs of a medical degree for students from diverse backgrounds – purchasing a stethoscope, professional attire and funding the compulsory elective.
Five years of project evaluation data reveal much about the role money plays in students’ sense of belonging and success. A student’s-eye-view of the degree reveals how unexpected its hidden costs are, how difficult it is to cover the cost of living and studying without financial support, and how choices about career development are constrained by cost. Further, the data shows students with scarce resources are keenly aware of how wealth is a vector of exclusion and inequity shaping their experience of the degree differently to their wealthier peers:
Receiving these funds made a massive difference as it took me by surprise how much of a financial burden studying at university was. It seems that every aspect of it requires you to spend money that you don’t have and I feel at times it’s not all inclusive (2nd year, 2024)
Their evaluations of the funding show that money transforms our lived experience of the world, and in turn, shapes our thoughts and feelings. They explain how scarcity can impact mental health and mental bandwidth, and the funding alleviates financial anxiety and paid-work commitments so they may focus on their studies.
But it means more than just being able to afford essentials, it means being able to participate equally and with pride in their degree in comparison to their wealthier peers. This directly impacts self-esteem and addresses feelings of unworthiness or lack of belonging.
A good example of this is the professional attire fund:
I know professional attire might not seem serious but not having the right attire when it’s necessary leads me to overthink about how I’m dressed and feeling insecure during sessions. It’s often to the point where instead of focusing on learning I can’t help but to think about my appearance. (1st year, 2020)
It is well-established that class can be read through a multitude of symbols. Respondents describe how their “lower” social status feels revealed through clothing, making them feel insecure in the learning environment. Students relate having their cheap and tired-looking clothes pointed out to them by peers, others worried about wearing the same outfit every day and what that said about their finances, while some feel that their patients have less respect for their opinion when they don’t present well-dressed. Meanwhile, ill-fitting clothing and shoes also interfere with the ability to focus on studies, causing pain and making long shifts additionally exhausting.
Widening participation initiatives that focus on belonging from a social, cultural or academic skills perspective miss this crucial element – money. One student articulates a point made repeatedly by many of their peers:
Funds like these make students like myself feel more heard and seen and gives us the opportunity to come from a lower socio-economic background and not feel as if we don’t belong here simply due to lack of finance. It gives us the confidence and the ability to work hard for what we want as we know there is always support available for students like us. (1st year, 2022)
Recipients of Medicine Success funding attest that financial support levels the playing field with their more privileged peers in numerous, significant, and yet, subtle ways. Providing financial support is essential to make the learning environment, social activities, and career development accessible to students from all backgrounds. Belonging is in part financial; you can’t participate fully without money.
Wider Context
Recent reports show that the government is making a loss on student loans due to higher interest rates . This means private lending institutions are making a profit from the scheme funded by tax-payers and graduate repayments. In Why We Can’t Afford the Rich, Andrew Sayer explains that our current political system “supports rentier interests, particularly by making the 99 per cent indebted to the 1 per cent” , in which wealthy people are less likely to earn money through paid work, but accrue wealth through financial activities. The student loans scheme is one example.
Higher education is presented as a means of social mobility, while extracting wealth into a financial sector that shores up its and its investors power. It does so by making already poor people pay to access education but without the conditions to participate fully. The promise of breaking the cycle of poverty with a university degree is so powerful that it deflects attention from what is really happening, despite extensive evidence that education has yet to prove itself as a solution to class inequalities. For these reasons, even with WP policies, HE has financial injustice embedded within it, resulting in deleterious effects on students’ mental health, degree experiences and outcomes.
I see this as an example of “financial trauma,” defined by Chloe McKenzie as “the cumulative effect of being required to experience economic violence, financial abuse, financial shaming, and/or (chronic) financial stress to attain or sustain material safety”.
Social mobility is a problematic term; it requires individual people to increase their position in an established hierarchy that is itself integral to maintaining socioeconomic inequality. This is why I welcome the MSC’s push to reconceptualise improving participation as a systemic issue, not one focussed on changing individuals to fit into the status quo. At the same time, we must apply this thinking to financial barriers to success, by recognising that money is far from a private issue but a matter of justice.
