Key points

  • Examines the factors that have influenced dental and medical school applications and admissions over the last 20 years.

  • Identifies trends in sociodemographic, academic and geographical influences on dental and medical admissions in the UK.

  • Highlights the importance of the tariff score in gaining entry to UK dental and medical school.

  • Highlights the significance of these trends within a culture of widening participation.

Introduction

University in the United Kingdom (UK) has a long and particularly interesting history. In the eighteenth and nineteenth centuries, higher education (HE) was the preserve of the social elite, closely associated with public/private schools,1 access was controlled by class and money, and from the mid-nineteenth century, examinations. While the Beveridge plan, followed by the Education Act of 1944, opened university access to wider society, access to the elite universities remains strongly associated with socioeconomic status. Successive government reports also highlight inequity in access to the elite courses, particularly the professions.2,3,4,5

The HE landscape has changed dramatically over the past few decades, with implications for dental and medical school applications and ultimately these professions. First, diversification of policies has occurred following the devolution of greater political powers to Scotland, Northern Ireland and Wales.6,7,8 This has resulted in different university tuition fees and differing approaches to widening participation.9,10,11 All medical and dental schools in England and Wales, as part of Russell group universities, opted to charge students the maximum fees. Therefore, these universities have been required to implement widening participation initiatives to encourage and support students from disadvantaged backgrounds to enter medical and dental courses.12,13

Second, new dental and medical schools were opened to build workforce capacity14,15,16 and university places were expanded,5,17 together with the introduction of graduate-entry programmes.18,19 All four UK nations have had a policy of increasing the proportion of young people entering higher education.20,21,22 While aspirations have been set at 50% for England,23 and the number of available university places has risen overall, only one third of school leavers in England currently secure a university place.24

Third, developments within the admission process have included the introduction of UKCAT and GAMSAT, the former is used by the majority of dental and medical schools.25,26 All schools use a combination of the UCAS application including their personal statement, academic predictions and an academic reference,27 along with the outcome of their UKCAT or GAMSAT test and admissions interviews/assessment.

Fourth, wider global influences, such as the increasing perception of the commodification of education as well as the economic recession have influenced education across the UK.28 Despite devolution establishing four governing bodies responsible for higher education within each constituent country,6,7,8 all UK students apply to university through UCAS, enabling them to apply to any establishment in the UK.29 Education is largely restricted to home/EU students, with a 5% cap on international student admissions in England and 7.5% for medicine.30

Past cross-sectional analyses of the two courses suggest that dentistry attracts and admits more females than males, in parallel with medicine and universities as a whole.13,31 Also, it has been found that dentistry is more attractive to minority ethnic applicants than medicine and university in general, with gender, ethnicity, maturity and school-type associated with probability of acceptance for dentistry.32 There are also challenges associated with the introduction of higher fees.13 While a recent paper highlights certain trends in medicine, no analyses, to the knowledge of the authors, have explored and compared trends over time and the implications of the tariff on admission.33

Trend analysis will provide the opportunity to examine the predictors of acceptance to these two courses, enabling comparisons and thus informing the current debate on access to higher education for dentistry and medicine.

Objective

To examine and compare: i) trends in application and admission to dentistry and medicine by sociodemographic status (age, gender, ethnicity, socioeconomic classification), geography (country/region), academic experience (school), and attainment (tariff scores) for UK-focused, and successful, applicants; and ii) the odds of gaining admission.

Methods

UCAS is the central organisation through which applications are processed for entry to full-time higher education courses in the UK. This paper involves secondary analysis of individualised UCAS data for all applicants whose preferred subject line was dentistry during academic years 1996-2011, and all successful applicants. The term 'applicants' is used to denote focused applicants and refers to students with dentistry as their 'preferred subject choice' on their UCAS application. 'Successful applicants' or 'admissions' refers to students who accepted a place on a dental course. Ethics committee approval was not required as this research involved secondary analysis of anonymised data.

Applicants aged 21 years or over were classified as 'mature', in line with UCAS procedures. In the data provided between 2001 and 2004, the 'White' classification of ethnic origin was expanded to five separate categories: White British, White Irish, White Scottish, Irish traveller, and other White. For the purposes of analysis, applicants from these five groups were combined into a single 'White' category from 2001 onwards. Additionally, the 'Mixed' ethnic category was available for analysis.

Socioeconomic status was provided according to the professional background of the head of the applicant's household. For the years 1996-2001, UCAS assigned social class based on the applicant's parental occupation (or the occupation of the person contributing the highest income to the household if the applicant was aged 21 years or over) using the Standard Occupational Classification 1990.34 From 2002, UCAS assigned social status according to a simplified version of the National Statistics Socio-economic Classification 2001 (employment status and size of organisation information is not collected), using the Standard Occupational Classification 200035 up to 2008, after which information on the socioeconomic status of students was no longer available.

School type was derived from the National Schools register, which changed in 2007, condensing the number of categories of schools from nine to five, with the reintroduction of a sixth form category in 2010. Schools were recoded into five categories: state, independent, grammar, further education, and other, to facilitate analysis over time.

From 2002 entry, UCAS tariff replaced A-level points as the main qualification in UCAS data. The UCAS tariff score includes all A-level points (including AS points), although with a different point structure for each A-level grade. Points are also awarded for other/equivalent 'benchmark' qualifications (for example, international baccalaureate diplomas and certificates, and other degrees) to allow established agreed equivalences between distinct types of qualifications, and reports achievement for entry to HE in a numerical format. This allows comparisons between applicants with different types and volumes of achievement.36 It should be noted that tariff points are also awarded for other diverse qualifications which provide 'added value', ranging from music examinations (grades 6-8) to Sports Leaders UK and even British Horse Society certificates. Thus, tariff points (from 2002) and A-level points (provided by UCAS 1996-2001) are non-comparable.

Statistical analyses

Descriptive statistics were used to summarise the applicant population characteristics and admissions by year for each discipline. The Z-test for independent proportions was used to compare the application success rates. Applicants during the study period were coded as either accepted or not accepted, and logistic regression was used to identify the significant predictors of successful applications. The first model (1996-2011) included maturity, gender, ethnicity, UK region, school and socioeconomic classification as predictors. The second model tested the same predictors for the time period 2002-2011. The third model (2002-11) included academic achievement, as denoted by tariff score. All analyses were carried out using SPSS version 24.0. Additionally, ARIMA (autoregressive integrated moving average) models were constructed to observe the change over time. All models were run for dentistry and medicine independently.

Results

Over the 16-year period, there were 33,773 focused and 15,427 (45.7%) successful UK applicants to dentistry (Table 1), representing an admissions ratio of 2.19:1. The admission ratio was slightly lower at 2.01:1 for medicine, with 199,845 UK applicants and 99,478 admissions. While the number of students admitted to both courses increased during the 2000s (from 2003 onwards for medicine and from 2004 for dentistry), there has been fluctuation in popularity over time, with a marked dip in applicant numbers in the early part of this decade (2002 for medicine and 2003 for dentistry), rising thereafter to more than double by 2011. The trends over the time period are presented in the ARIMA models (Supplementary figures). When exploring trends in the characteristics of those accepted students in the coming sections, the fluctuation in the popularity of both courses is generally apparent.

Table 1 Characteristics of UK applicants and accepted applicants to dentistry and medicine, 1996-2011
Full size table

Variation in the profile of students applying for, and admitted to, both courses are outlined as follows, starting with gender. First, while males have traditionally formed the majority of applicants and admissions, females exceeded males for the first time from 1999 in dentistry and consistently for medicine over this period. The proportion of successful female applications to dentistry was significantly higher (p <0.05) than males in all years, except 1998. Whereas in the earlier years, there was a similar picture for medicine, this has not been the case from 2008 onwards. This pattern is observed over time (Table 2) (S2 and S3 in Supplementary figures).

Table 2 Percentage of successful UK applicants to dentistry and medicine by sex,1996-2011
Full size table

Second, the average age of applicants over the 16 years was 19.7 years (range 16-55 years) for dentistry and 20.4 years (range 16-57 years) for medicine. Admissions from mature students were more common for medicine from 2003 onwards and dentistry from 2004, although a lower proportion of mature applicants were accepted to both courses compared with applicants under 21 years for every year (S4 and S5 in Supplementary figures).

Third, while over half of all applicants to dentistry were from minority ethnic groups, one third of applicants to medicine were from black and minority ethnic backgrounds. Acceptance rates for people of Black ethnicity were markedly lower than their White counterparts for dentistry (25.5% cf 55.7%) and medicine (23.4% cf 56.2%), consistently over the time period (S6 and S7 in Supplementary figures).

Fourth, dentistry attracted about one quarter of their applicants from London, while this was one fifth for medicine. A higher proportion of applicants from Scotland and Northern Ireland were successful than from England and Wales in each course. Similarly, the success rate was lower from London (38.5% dentistry; 38.7% medicine), and other areas in England (43.8% dentistry; 51.0% medicine). The ARIMA models for region clearly show the greater proportion of applicants accepted from Scotland (and for medicine, Northern Ireland); this notably contrasts with students from London (S8 and S9 in Supplementary figures).

Fifth, applicants from selective schools had the highest admission rates for dentistry (54.1% independent, 55.5% grammar) and medicine (63.9% independent, 60.9% grammar) observed every year over the time period (S10 and S11 in Supplementary figures).

Sixth, and finally, a clear social gradient was present for dentistry and medicine, with students from low socioeconomic backgrounds having only a 40.3% chance of being selected for dentistry and 44% for medicine compared with higher socioeconomic groups, (cf 51.4% and 57%, respectively). Although the proportion of acceptance for applicants from high socioeconomic backgrounds was greater for both courses than students from lower ones, this was more apparent for medical applicants each year (S12 and S13 in Supplementary figures).

Predictors of dental admission in UK, 1996-2011; 2002-11

Logistic regression analyses of variables predicting the success of applications for dentistry and medicine are presented in Table 3, without tariff scores for the 16-year period (Model 1), and the ten-year period up to 2011 (Model 2), and then including tariff scores (Model 3). Comparing the results of Models 1 and 2, which represent 16- and 11-year time periods, respectively, using the same variables, the patterns are largely similar.

Table 3 Logistic regression model for admissions to dentistry and medicine, without and with tariff, as a predictor
Full size table

In Model 3 (with tariff, 2002-11), while students whose tariff points are medium or low have very low odds of admission to dentistry (OR = 0.16 and OR = 0.03 for medium and low tariff scores, respectively) or medicine (OR=0.21 and OR = 0.11 for medium and low tariff scores, respectively), inequity remains clearly present as outlined below.

The results are presented in turn for each characteristic, initially without the inclusion of tariff (Models 1 and 2), and then with tariff (Model 3).

First, in relation to gender, while males had a significantly lower chance of being successful when compared with females in both courses across all models, the differences were less marked for medicine (OR = 0.82-0.86) than dentistry (OR = 0.74-0.76).

Second, in relation to age, while overall mature students were less likely to gain admission to dentistry (OR = 0.74; 0.81), and much less to medicine (OR = 0.45; 0.46), the inclusion of the tariff in the model showed that mature students had a much higher chance of success when compared with younger applicants for both programmes; dentistry (OR = 2.01) more so than medicine (OR = 1.66).

Third, in relation to ethnicity, compared with White applicants, all minority ethnic groups had lower odds of admission, most notably Black students; this was the case for dentistry and medicine (OR = 0.37). In relation to ethnicity, while the tariff moderated the difference, White applicants were twice as likely to be accepted as Black students to both courses.

Fourth, the odds of admission to dentistry and medicine were significantly lower for all areas of the UK other than Scotland and particularly for dentistry where the odds were less than half. The inclusion of the tariff has the effect of moderating admission rates so that Northern Ireland is similar to Scotland and the difference with Wales is reduced, while applicants from London and the rest of England continued to have significantly lower odds of admission to both courses.

Fifth, there was a clear social gradient, with students from high social status having significantly greater odds of admission to dental and medical school. The tariff clearly moderates the difference for students of medium status to dentistry, this was not apparent for medicine.

Sixth, in relation to school, applicants from selective (independent and grammar) schools had significantly higher odds of gaining admission to dentistry (OR = 1.81 and OR = 1.62, respectively) and medicine (OR = 1.86 and OR = 1.61, respectively) than pupils from state schools, while applicants from further education colleges had a lower rate. When the tariff was included (Model 3), students from independent schools had even higher odds of acceptance for dentistry (OR = 1.98) and medicine (OR = 1.94), while admission from further education colleges was moderated for both courses, particularly dentistry (OR = 0.83).

Summary

This unique study highlights the differences, and parallels, between dentistry and medicine during a period of immense social and professional change across the UK. It is clear that first one must apply and second, having received an offer, obtain the necessary tariff score (grades) in support of entry; however, the presence of persistent social, geographic and ethnic inequalities, both in applications for and admissions to dentistry and medicine, over time is stark. It demonstrates that the social gradient is more marked in medicine than dentistry and, for both subjects, the odds of entering medical or dental school are doubled by attending an independent school rather than a state school. That said, the social gradient in dentistry is not as marked as medicine, as exemplified by attracting a higher proportion of state school students, whilst medicine is attracting more representative levels of white and black students and achieving greater balance between females and males. This paper provides robust evidence that the patterns reported in previous cross-sectional research in relation to gender, social status and ethnicity13,32 are clearly evident over time and builds on the research in medicine.33 Additionally, it highlights major differences between the devolved nations and England, and that both programmes are very attractive to Londoners and least attractive to English pupils outside of London, which has implications for our future healthcare workforce.

Strengths and limitations

While its strengths include consideration of patterns for medicine and dentistry over time, care must be taken in the interpretation of the findings on the socioeconomic status, school type and ethnicity of students, as the categories used by UCAS changed between 1996 and 2011. The continual changes in UCAS variables over time presents a challenge, and one which makes this analysis unique. UCAS now uses the POLAR system (a regional marker of participation) and from 2016, the multiple equality measure (a combination of several 'equality characteristics') instead of a socioeconomic group.37 Together with the move to only provide summary data to researchers, longer-term analysis is impossible. If we really are serious about tackling inequity in the UK, these data should be more readily available to researchers, as with current NHS data, as they have implications for the health of society. Finally, it has to be acknowledged that there are no data on admissions interviews and UKCAT scores which contribute to an offer; these points have been covered in more detail in an earlier publication by the authors.32

Who applies and what does the data tell us?

For dental and medical schools to admit, and subsequently educate and train, a representative workforce and satisfy notions of social justice, capable students from all backgrounds must first apply for the courses.38 As well as social equality, a diverse student body has been shown to enrich the learning environment of medical schools, with some evidence of students from minority ethnic groups being more likely to practise in underserved areas.39,40,41 Although state schools produce the largest group of applicants to dentistry, those from lower socioeconomic groups and those from non-Asian minority ethnic groups, notably Black students, are not applying in the first place. Neither are White students, who represent four out of five young people in the national 18-24-year-old age bracket.42 This may be due to concerns of attainment, low aspirations or possibly, for Black students, a poor connection to the dental profession, as demonstrated by the lack of uptake of dental care.43 For medicine, the cultural divide is very clear,44,45,46 representing an ongoing challenge to society.

A stark challenge facing both programmes is that London residents are overrepresented among UK applicants to dentistry and medicine, comprising one quarter of applicants to dentistry and one fifth of applicants to medicine, compared with 12% of the 18-year-old population of the UK.47 The high application rate from London may be explained by the diverse ethnicity of London's school children who seek to enter professions,48 family pressures to live at home,49 and the financial pressures associated with a five- or six-year degree programme. They may also be encouraged by the range of opportunities present in London, together with the fact that London schoolchildren outperform the rest of the country academically50,51,52 and are thus in a good position to access high tariff programmes. The reasoning behind the low application rate from the rest of England warrants urgent consideration, as raised in recent media coverage,53,54 and must be considered in future workforce planning initiatives for England.55 An attempt to distribute the workforce more evenly was behind the establishment of new medical and dental schools outside of London. Clearly there needs to be further urgent action, as this has implications for the distribution of dentists and doctors nationally in the longer-term; particularly in underserved areas, dental schools need to take responsibility for promoting dentistry as a career option in their communities. Local professional networks can and should assist with this process, linking to widening participation (WP) initiatives of most local dental schools in the country. We don't need more dental schools; rather individuals and teams willing to serve the local populace. There is some evidence from low-income settings that loyalty to serving the population can help with drawing dentists back to serve their home communities.56

Who is admitted and who is under-represented?

The influence of the tariff on dental admission is clearly demonstrated from this analysis (Table 3). Irrespective of background, to be successful, students need to achieve high grades for these demanding degrees. The effects the tariff had on other variables within the model included the maturity of students (having a degree) increases the odds of acceptance over younger counterparts. However, there are concerns over the negative impacts of university fee increases on the quantity of mature applicants to university being voiced,57,58 and with the number of dental graduate-entry programme places decreasing (with Plymouth University Peninsula Dental School no longer providing four-year graduate entry) this finding is an important message to continue to attract potential graduate applicants. Male students had, and still have,13 lower odds of acceptance than female students to dentistry; although this imbalance has not been noted in more recent years for medicine.33 The under-representation of men in dentistry has implications for the gender balance over the longer term and may potentially influence workforce capacity. The odds of acceptance for students from independent schools was greater than for students from state schools in all three models, increasing in the more recent ten-year period, and even further when the tariff was incorporated, highlighting the importance of academic standards. While there is high competition for places at high performing selective schools, it is only those able to afford the fees or who gain a scholarship, that are able to compete. The advantage for these students may in part be because independent schools are much more likely to provide additional activities to increase tariff score, as well as significant academic and admissions support. Medical schools face similar, if not greater, social challenges with the majority of UK medical students from the highest socioeconomic groups and one fifth from independent schools (compared with less than 10% of UK secondary school pupils).38,45,59 The resultant influence on student background and identity and, in particular, the disjuncture between working-class perceptions of medicine and individual identities are key to understanding the reasons behind the low number of working-class applicants to medical school.44,49,60

Geographic disparities are apparent. The UK is unique in that it consists of four devolved nations with different fee systems, which potentially influences the applications of students from within those countries. The influence of varying fees and location (and size) of dental schools may account in some part for these disparities. It is important to note that the tariff appears to moderate the number of London applicants entering dentistry and they have significantly lower odds of acceptance, thus rebalancing the application rates. However, overall, we need to maintain a secondary focus of how best to provide equitable access to health care across the UK.

Dentistry and medicine courses consistently fail to attract and accept Black students; only 2.3% of applicants to dentistry between 1996 and 2011 were Black, and 5.2% of applicants to medicine, with only one quarter of these students being offered places (1.5% of accepted applicants to dentistry and 2.5% to medicine). This compares with all applicants through UCAS in 2011, where 8% of applicants and 7% of accepted applicants were Black.13 These challenges have been recognised in ministerial policies, whereby the Minister for Universities and Science recently stated that, through their OFFA access agreements, universities will be required to focus their outreach activities on White males from lower social backgrounds.61

Implications

It has been suggested by Angel and Johnson62 that our healthcare workforce should reflect the diversity of the UK patient population, with the professions having a responsibility to 'make access fairer, diversify their workforce and raise social mobility'.63 We need to take seriously this challenge in order to ensure that White male students and Black students, as well as people in England (outside of London), are encouraged to consider and supported to enter dentistry. Medical and dental schools should perhaps not just consider the characteristics of gender, social and ethnic balance but also regional factors. There are no regional quotas for applicants/admissions, but it does raise the question as to how greater engagement from the shires can be stimulated.

While some advances have been made in widening participation to dentistry in recent years (for example, the increases in mature students, those of Asian ethnicity and from state schools), marked ethnic, socioeconomic and regional disparities remain. With regards to widening participation to dentistry, measures to broaden the appeal of the career and support in the whole admissions process must continue for students who are male, Black, from non-selective schools, live in England (outside of London) and from lower socioeconomic groups, not just in regards to aspiration-raising, but also in attainment, as only those who achieve the necessary tariff points will be considered for admission. Concerns remain that, as in other courses, the financial challenges of studying at university, particularly in England, negatively impacts certain groups of students,5 particularly those from lower socioeconomic backgrounds and mature students,64 and firmly challenge efforts to widen participation at the present time.

Further research should explore the motivation of, and barriers to, applying to dental and medical education among young people in order to inform policymakers and admissions policies. Additionally, the experiences of those from under-represented groups who have successfully gained access to dental and medical schools through widening participation initiatives should be explored, to ensure that learning about challenges, barriers and facilitators are well understood and inform change, with a view to facilitating social justice and providing a workforce that meets demand through these changing times.

Finally, in summary, over a period when there was an expansion of higher education places and the popularity of dentistry and medicine fluctuated, this unique analysis comparing medicine and dentistry demonstrates the extent to which certain groups remained under-represented among applicants. Social inequalities clearly reflected in admissions; the findings highlight that females, mature students and White students, as well as applicants from Scotland and Northern Ireland, were most likely to gain admission. While there is an academic standard to be achieved for entrance to dentistry and medicine, the complexity of the societal challenge in accessing these two elite professions in healthcare must not be underestimated. The fact that social status, region of residence and selective schools remain such important determinants of entry to these elite professions emphasises the importance of educational reform in support of equity, with major implications for society.