BACKGROUND

  1.  The 1995 report of the House of Lords Select Committee on Medical Research and the NHS Reforms first drew attention to the problems developing in Clinical Academic medicine. It concluded that "the disincentives to an academic medical career are now so great as to warrant an immediate enquiry in their own right". The Government did not act on this recommendation but the Committee of Vice-chancellors and Principals (CVCP) did, by commissioning an independent task force to address the problems highlighted in the Select Committee report. Sir Rex Richards chaired the task force which reported in July 1997. After hearing evidence from Sir Rex and members of the task force in November 1997, the Select Committee reported that "we are persuaded more than ever that there is a genuine threat to academic medicine in the UK and therefore to health care as a whole". The Committee has recently expressed its continuing concern about the state of clinical academic medicine in the UK, and the issues covered in the Richards report.

  2.  This then was the position when the Academy of Medical Sciences was established in 1998; it now has 450 fellows drawn from all branches of academic medicine and medical science. The wide expertise of the fellows enables the Academy to represent authoritatively the interests of academic medicine across traditional clinical and scientific boundaries. A major concern for the Academy is the overall health and vitality of the clinical academic profession which, it believes, is critical to the advancement of both biomedical research and the practice of clinical medicine. It is conscious (and proud) of the current high reputation of the UK in this field but aware of how easily this position could be lost. Whilst aware of the wide ranging recommendations put forward in the Richards Report, the Academy considered that the most crucial issues were those affecting the clinical and research training of aspiring clinical academics. This is because there is still widespread concern that the recruitment of young, talented, research-minded clinicians into UK academic medicine is insufficient to maintain the current impetus and standard of medical research in the UK and the translation of this into improved patient care. In order to stimulate action to sustain the clinical academic workforce in specialist medicine and to establish it in generalist medicine, a Working Party was established.

The Working Party

  3.  The Academy of Medical Sciences Working Party on Career Structure and Prospects for Clinical Scientists was constituted under the chairmanship of Professor John Savill and assigned two main tasks:

(1)  "to assess any barriers to academic training associated with recent changes in clinical career structure."

(2)  "to develop constructive suggestions for developing career pathways for trainees in academic medicine."

  4.  The Working Party first met on 7 April. It is currently exploring a number of options and consulting some of the key organisations and individuals involved in policy-making in this area (eg the MRC, the Wellcome Trust, the Association of Medical Research Charities (AMRC), the Chief Medical Officer, the Director of Research and Development for the NHS and the Academy of Medical Royal Colleges). It plans to submit its final report by the end of the year.

Summary of findings to date

A.  In relation to hospital specialist practice

  5.  The Working Party believes that (i) inadvertently inflexible implementation of Specialist Registrar (SpR) clinical training and (ii) changing perceptions of the role and value of clinical lectureships to universities driven by the Research Assessment Exercise are foremost among many factors contributing to strong disincentives for young clinicians contemplating a career in academic medicine in the hospital specialities. These disincentives are seen to be:

(a)  Lack of a clear career structure in clinical academic medicine with resulting uncertainties in the prospects of ultimately obtaining a tenured senior post. This contrasts strongly with the clear career structure for a specialist registrar (SpR) with a National Training Number (NTN) who, typically, is qualified for an NHS consultant post after five years of training leading to a certificate of completion of specialist training (CCST).

(b)  Lack of the flexibility in clinical and research training needed to encourage the development of individuals who are not only competitive in research but also able to undertake broad-based practice in the clinical front line and thereby serve as role models to promote further recruitment into academic medicines. Lack of flexibility is a particular problem for women and others with domestic commitments.

(c)  Inappropriate pressure to start intensive research training early in the clinical career track, not because it is judged to be the optimal time, but because trainees in the Senior House Officer (SHO) grade believe that resulting publications and theses will improve the chances of gaining entry to an SpR programme and hence acquire the "grail-like" NTN essential for progress.

(d)  The prolonged time taken to achieve "registrable" status in both the clinical and research aspects of training to enable a senior tenured post to be obtained.

B.  In relation to general practice

  6.  The working party recognises that for general practice, the main issue is how to support and encourage research excellence in a young, emerging academic discipline, rather than how to maintain specialist academic excellence in the face of resource constraint and organisational change. Although training in general practice is different in structure to that in hospital specialities, similar disincentives also face the aspiring academic general practitioner:

(a)  Lack of a clear career structure is also a strong disincentive to the young generalist. Not only is there a lack of appropriately resourced research environments in which to train but there is also continued difficulty in recruiting high class senior academic staff in general practice. In part, this reflects the status of full time university clinical academics in general practice, which is usually percieved as inferior to that of academic specialist colleagues, a problem compounded by current ineligibility for merit awards.

(b)  The lack of flexibility in academic general practice derives particularly from difficulties in retaining principal status while pursuing an academic career. The apparent lack of support from the Medical Practices Committee exacerbates this situation.

Summary of recommendations

  7.  The Working Party appreciates the very different requirements for optimal training in research and clinical practice in the different specialities (compare for example, public health, paediatrics, neurosurgery or pathology) and in general practice. It considered carefully whether these could usefully be grouped into pure and applied research disciplines, but concluded that a flexible generic scheme was preferable to more specialised schemes. The Working Party is close to consensus on the following proposals but a final report is not anticipated until December 1999:

  (1)  A "two stage" career track

  A "two stage" career track in clinical academic medicine should be adopted in as many hospital-based specialities as is practicable and considered also as a model for development of academic general practice (TheWorking Party is aware that the Royal College of Physicians of London has put forward a similar scheme for discussion):

(a)  A pluripotential first "doctoral" phase of about five years

    Individuals awarded prestigious full-time research training fellowships (ideally for 3 years) funded by the MRC, the Wellcome Trust or other AMRC approved medical research charities, or the NHS, should automatically be entitled to up to two years SpR training and an NTN. This would enhance the attractiveness of research training to the young whilst providing the safety net of straightforward transition to a conventional NHS career if trainees decided not to pursue an academic career and progress to—

(b)  A second "clinician scientist" pase of about five years

    Our key proposal is the establishment of a new centrally managed training grade dedicated to those committed to a clinical academic career, which will effectively offer the scrutiny of a "tenure track" post to trainees of the highest quality. This clinician scientist grade would be entered by obtaining an approved competitive intermediate (ie post-doctoral) MRC/research charity/NHS research fellowship or a university-funded clinician scientist post; either should provide a flexible combination of post-doctoral research training (much of this full-time), completion of clinical training leading to a CCST and carefully circumscribed opportunities to participate in clinical teaching.

  (2)  Providing flexibility and security for our very best trainees

  Although mechanisms are currently available to deliver the career track outlined above, their flexibility is often found (or perceived) to be inadequate, especially in the second clinician scientist phase. Greater flexibility could, we think, achieved by provision for second phase trainees of prospective ad hominem clinical training programmes to allow optimum intermixing of clinical and research training and, for doctors with domestic commitments, periods of part-time working. Such flexibility could be achieved most easily by each Royal College setting up an academic training committee which, in consultation with appropriate specialist advisory committees would assume responsibility for training in the clinician scientist phase. This new scheme would require a small dedicated pool of clinician scientist NTNs to support trainees of such high quality that they would effectively be on a "tenure track" for senior academic positions. Since there are currently around five MRC/AMRC/NHS clinician scientists appointed each year, and because we anticipate that most medical schools will wish to establish one such post per year in anticipation of a senior retirement or to support plans to develop research excellence, we propose that around 50 dedicated "clinician scientist" NTNs would be needed per year.

  (3)  Retention of clinical lectureships as a "bridge" to academic medicine

  We view the proposed clinician scientist grade as an attractive addition to the range of career opportunities available to academically-minded young doctors and a means by which to foster future leaders in clinical research. However, upon completion of the first phase some trainees will still be uncertain as to whether they wish to commit themselves to a research-led clinical academic career. Others may wish to develop a major interest in teaching, which the Working Party values very highly. Finally, in some specialities there are currently very few individuals with the training track record necessary to compete successfully for clinician scientist positions. In all these instances existing clinical lectureships recognised for honorary SpR training offer an important career opportunity and should be retained; immediate and wholesale conversion of clinical lectureships to clinician scientist posts is not our intention and could impair flexibility.

  (4)  Competency-based assessment of clinical training

  We applaud the moves now being made by various bodies to investigate competency-based assessment of fitness to qualify for specialist registration, rather than measures based on time served, numbers of procedures undertaken and formal examinations passed. We are aware of the difficulties and dangers of moving in this direction but it could undoubtedly help to introduce more flexibility into academic programmes.

  (5)  Academic flexibility SpR posts to provide early specialist training

  Urgent action is also needed to encourage more young clinicians to seek a first research training fellowship (RTF) and enter the "doctoral" phase, especially in specialities with limited academic activity or a "blocked" SpR grade. Consideration should be given to providing postgraduate deans with a limited pool of "academic flexibility" SpR salaries capable of supporting up to two years', "up front" SpR training before starting research training. This incentive scheme would, we estimate require a total of 100 SpR salaries each with a NTN. The Academy is well aware of the reluctance of the responsible authorities to create "extra" NTNs but the number required to create the flexibility we seek would be small but vital if we are to maintain a credible R&D function in the NHS. Current manpower planning is not a precise art and it is likely that such numbers would be within the margins of error (noise) of the present system.

  (6)  Building academic general practice

  Further resourcing and development of relevant research training environments for clinical scientists in general practice are urgently needed. The lack of flexibility in the early years of general practice would benefit from funding of protected time to prepare research training fellowship applications at this stage while retaining principal status. The status of clinical academics in general practice should be brought fully into line with that of their colleagues in other clinical disciplines.

Conclusion and key points for action

  8.  Recruitment to Academic Medicine is at a crossroads. With some relatively simple changes, largely involving more flexibility in training programmes and assessment procedures, and redeployment of existing funding, we believe that academic medicine can be made more attractive to some of the best young doctors who are trying to decide which career path to follow. Failure to achieve this will have dire consequences, so we look for support and action from the relevant Government departments to:

—  Support establishment of a new tenure track grade for clinical scientists who hold a research degree, are keen to complete clinical training and committed to a career in academic medicine. This would require a dedicated pool of about 50 NTNs per year and special recognition from the Royal Colleges. It should require little additional salary funding since, in addition to existing fellowships funded by the MRC, the Wellcome Trust and other AMRC charities, some posts could be created by upgrading existing clinical lectureships in universities keen to improve their clinical research status or anticipate a senior vacancy. However the Academy is keen to see the establishment of "portable" clinician scientist salaries in order to facilitate exploitation of training opportunities in the UK.

—  Provide up to 100 protected "academic flexibility" SpR posts with NTN status for up to two years to enhance the attractiveness of research training by facilitating "upfront" clinical training for appropriate SHO "high flyers" prior to starting a research training fellowship. Funding for these posts might be obtained centrally from the R&D levy to acknowledge the importance to the R&D function of the NHS of maintaining clinical academic strength.

—  Recognise that additional funding will be required to strengthen academic general practice and some of the "shortage" disciplines in secondary care. These funds will be required not only to support research training and the infrastructures needed in a "well-found" environment suitable for such training, but also to address the differences in salary once a permanent career post is obtained.

November 1999