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So I'll have a at.

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Thank you, everybody, for coming to this combined crunch round,

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I thought it was timely to say a little bit about clinical academic training and the role the two Cox plays.

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I'm afraid it's a single handed presentation from the front of the room,

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but I am very grateful to the rest of the UK team, who I will mention as we go through.

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I said, Let's start with this slide, which is page one of the NHS Constitution, and it states that research is at the heart of the NHS.

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It specifically says commitment to innovation and to the promotion,

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conduct and use of research to improve the current and future health and care of the population.

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And I think that is sometimes forgotten by people who we work with, shall I say, rather than four.

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I think it's important to recognise that academic clinicians and I'm saying academic here,

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both in the capital and the little they are in the right place to know which questions in health care are important and tractable,

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which solutions are practical and beneficial, and to teach and implement the solutions when they're eventually found.

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I also think it's really important to think about links between an academic ethos and important professional values.

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The midst of disaster taught us quite a lot about some of those professional values, and I suspect they were already inculcated in academic practise.

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We have a much more questioning attitude, much more flat and hierarchy. And on the whole, we're good at building teams.

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And overall, there's increasing evidence now that academic activity correlates with good patient outcomes.

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Whether that's causal or associative, I'm not going to say, but that correlates.

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So in that context,

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it's a little bit depressing if we start looking at what's been happening to careers in academic medicine over the last 15 or 20 years,

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and this is data from Medical Schools Council on the positive side.

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This is a graph which shows numbers of individuals against time and the lilac line that shows the number of full time NHS consultant equivalents,

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which is increased by some 40 percent between 2000 and 2015.

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The red line towards the bottom shows the number of clinical academic consultants over the same time.

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It looks pretty flat. But let me zoom in on it.

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Actually, that red line translates to yellow line on this graph, which shows quite a significant fall in the first five years.

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And despite all the efforts of NIH, Cox, et cetera, the line has only really flattened out.

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Subsequently, it hasn't climbed back to previous levels. And this is in the face of the government wanting to open new medical schools,

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20 percent expansion in the number of medical students to be taught, and all sorts of excitement around academic industrial strategies,

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etc. There is perhaps a little glimmer of hope that the Green Line of professors is going up,

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but I think that's actually because we've renamed readers and senior lecturers,

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professors and you'll see a sort of mirror image between the purple and the green lines there.

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And this looks a little bit more even more worrying when we look at the age profile of current clinical academics in the UK.

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So the yellow line at the bottom shows the numbers of clinical academics who are already over 66.

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The Red Line shows those between 56 and 65 and the so-called Z Blue Line 46 to 55.

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So we're kind of an ageing population of academics that may be very valuable for the

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younger people in the room because it may mean that some space will come along.

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And I say that both partly in jest and importantly, because actually the absence of secure long term posts is said in our survey of current clinical

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DPhil students to be a major reason for people not going into academic careers at the moment.

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So just this this is not something I alone have noticed.

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It was noticed a decade ago and it was that was a concern that a lack of a clear route of entry and a transparent career

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structure was part of the problem that led to modernising medical careers and best research for best health research reports,

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both of which had good things and bad things about them,

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but ultimately led to the foundation of an agile and the generation of the integrated academic training programme, which links me into new, I suppose.

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So historically, we had extremely flexible training pathways. We had a clinical pathway from medical degree through to consultant or GP.

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We have an academic pathway from doctorate to senior fellowship and onto a tenured post and no meat in the sandwich in between to join them together.

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And what the UK Foundation programme and the integrative academic training programmes have

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done is provided a link between those two in the form of the Academic Foundation programme,

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academic clinical fellowships and clinical lecturer roles.

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And I would emphasise that although all these posts exist, they're not linked together specifically in a.

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They provide a set of opportunities, and there are a number of routes through this pathway that are perfectly acceptable.

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So in the hopes that there would be people in the audience who might not already know this.

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I'm just going to run through a little bit about each of those three types of post.

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The Academic Foundation programme offers 480 posts across the entire UK per year, 24 of which we have in Oxford or the Thames Valley.

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These are a two year programme in keeping with the foundation programme, and that precise configurations vary quite a lot in different regions.

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But in Oxford, many of our posts have four months of designated academic time enough to put some half day release instead.

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The appointment process here is through a local interview process,

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and I'm very grateful to people who participated in that last week and the employees.

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The trainees are NHS employees with visiting academic university privileges.

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The whole foundation programme is currently the subject of a review,

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and I'm waiting to hear what that review says about the academic foundation programme.

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At the moment, I understand the review, but is still trying to agree what their terms of reference are going to be,

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which doesn't throw me because I think they ought to know what they are already.

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So one of the dilemmas we face with the academic foundation programme is it really is for.

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It was originally envisaged as a taste for those who had not had any research opportunities up until that point of qualification,

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they'd gone to a medical school where in circulation was uncommon. And that's less commonly the case now.

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The Academy of Medical Sciences Inspire programme has done quite a lot to try and do that,

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so it's also being used now to support those people who are already on an academic trajectory.

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But I do feel quite strongly it's not for people with extensive research experience

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who have few new ideas and aren't actually going to use the time profitably.

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The next step in the pathway of the academic clinical clinical fellowships of which and often 250 per year in the UK.

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And we've got roughly 17 here in Oxford.

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And the important features of these are that they provide 25 percent of time protected for academic endeavours,

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with the aim of people preparing a fellowship leading either to a higher degree or if they already have a doctorate,

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postdoctoral research and generally a three year duration.

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And the way we've run them in Oxford has sometimes extended people's training again.

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We have a local interview process, but candidates have to benchmark in national recruitment to be employed,

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and importantly, posts in this scheme can be additional to those in conventional training.

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So if you happen to know at ICF on your programme, you effectively have 75 percent of an extra pair of hands for your clinical service.

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In recruiting these posts, we usually put three GMC specialities against each post and the strongest candidate ever,

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irrespective of speciality wins the post and shall specify the recruitment window.

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The recruitment is run through the deanery processes and there is still this issue of national benchmarking and access.

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Remain NHS employees. And then the third step in the pathway and chocolate in the collection ships and child funds 100 per year,

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and we get around 7:00 in Oxford and I'll explain how we get these posts in a moment or two.

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And these are restricted to people who already holds a doctorate.

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They have to have submitted their doctorate at the point of application, and they have to have been awarded it before they can take up the post.

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They provide a 50 50 split between academic training and clinical training,

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although it is possible to count some of the academic time in some specialities towards clinical training.

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They last for up to four years and the end point at the moment is marked by KTI, although not reconsidering that for the 2019 entry.

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One of the terms and conditions is that for every post and child fund, we are meant to try and generate a local matched post,

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and I'm extremely grateful to those people who have supported me in generating those sorts of posts.

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In contrast to the earlier posts, these ones are recruited by the university and clinical lecturers become university employees.

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And there has been a little bit of tension around maintenance of statutory employment rights across to employers,

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but I think that's now been resolved. And again, these posts are able to be additional to those in conventional training.

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So the sales by the time people are being selected for clinical lecture ships, we expect to see commitment to a clinical academic career.

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And really, we see them as a transition towards independence for people who are not yet ready to get a personal fellowship.

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But we hope that by the end of their four years as a clinical lecturer, they will be able to get more.

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We don't. There are restrictions around awarding them to people very late in their training.

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And so that is one sort of contra indication and alternatives do exist in terms of the other fellowships.

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But I would note that there's been quite a lots of great inflation in the CV required

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to get some of these fellowships since I was a candidate for them 20 or 25 years ago.

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So they are quite difficult now, I think. And so the recruitment process is in some ways similar to that phrase shifts in some ways different.

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Again, we put three special teams against each post.

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There's more flexibility because the appointments are made through the university and there's no specific appointment window.

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But appointments are made by a local interview process,

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and we quite often use the the quality of the second ranked candidate as a lever to generate a local clinical lectureship post.

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So where do these posts come from? Well, the majority of them are funded by CHAS,

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and 60 percent of the posts that we get in the Thames Valley are awarded for a magical thing called the formula.

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The formula is something that is known to somebody in the Department of Health.

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It's a very well kept secret,

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and I actually asked specifically people in the Department of Health to tell us what it was the other day and got the normal silence.

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I'm wondering whether Freedom of Information request would or would not be valuable,

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but it is in some way linked to the total amount of income that the partnership between the Deanery and the local universities earn.

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Interestingly, our formula allocation didn't change when the BRC became hugely more valuable last time round,

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and Oxford got the clock for the first time and Oxford Health got two new BRC.

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So there are obviously some constants and variables within the formula,

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but I think politically handled and the other 40 percent of the posts are now awarded through a competition.

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And when the competition started, it was only 20 percent of the posts and those posts were targeted at what one might call Cinderellas specialities.

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But I know I have now taken a different approach, and they are now aiming for the competition posts to be awarded to particular

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research themes and the current research themes of the seven mentioned that.

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In addition to these and child posts in Oxford,

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we're fortunate in getting a small number of hypothecated posts from NHS Blood and Transplant and Public Health England.

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So how did this all work out last year? Well, these were our competition results.

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We were only allowed to bid for 10 posts altogether, three clinical ActionScript and seven assists,

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and we managed to get six out of the seven and all three clinical lectureship.

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And they were, as you might expect in Oxford, somewhat biased towards the sort of wet lab end of the themes that were available.

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We took a strategic decision not to bid in medical education,

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although that's something that I think we will keep under review because I suspect that's a relatively soft

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target nationally and that the only ICF we lost was one relating to older patients and complex needs.

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And in reality, nowhere in the country did any better than us. I think we were going to have to lose one somewhere in the equation.

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But I do worry that the absence of a single department of Gerontology probably weakens our ability to bid in that area of.

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I'm sorry, I mentioned local clinical lectureship earlier and the expectation that we will produce a fair number of these.

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The rules around them can be a little bit more flexible. We don't have to find all the funding for four years, but we do need to have a 50 50 split.

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And I'm, as I say, grateful to people for helping negotiate these,

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and we've done reasonably well in producing local clinical ActionScript over the last few years.

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And that's really important to me because this is now a metric in the assessment of our competition bids,

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and we're actually told that we scored well or badly on the number of local posts with managed to generate.

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So I don't want to spend too long on this slide,

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but I do think it's quite interesting to balance some of the pressures in research against those in clinical training.

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And an awful lot of clinical training is around minimising risk,

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making things very fair nationally certainty over core competency competencies, etc. and some of the science and research are a bit different.

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I think we've calculated risk the wish to recruit into particular niches where things are strong and uncertainty.

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And I think let's just produce a little bit of a tension between competence and safety and excellence.

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Or perhaps aspiration is a better word for the purposes of this slide.

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So that brings me on to some of the pressures that trainees feel and some of the structures that

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they're having to work into and the reasons for the founding and the continuance of the tax.

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So when you have an integrated academic training pathway, you really need an integrated structure.

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And that structure falls somewhere between the University Health Education in the Thames Valley and the NHS service providers.

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And of course, each of those has slightly different mission statements.

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The university is driven by research and education, health, education, Thames Valley by training and governance,

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and the NHS providers by service delivery and training and support trainees sit in the middle of this triangle,

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being pulled in each and every direction.

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And that can be illustrated by some of the pressures I think trainees feel and challenges the preference of serving two or three masters,

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uncertainties over contract, uncertainties over future training and the shape of training review is pertinent from that point of view.

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The difficulties of securing funding decisions about whether they stay in training or whether they go out of programme,

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joint appraisal and financial pressures. And what we're trying to do a new tax is turn the trainee who's wobbling around

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on the wobble board into the Syrian yoke performing trainee in the bottom right.

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Perhaps so the tax sort of fits in the middle of this triangle, holding it either together or apart, depending on your viewpoint.

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And Ken Fleming must take the credit for setting up with Katz and seeing the need for it.

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I guess our mission statement, the statement is to attract, train and retain the very best clinical academics we can.

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And we do that through raising the profile of clinical academic careers generally and trying

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to make sure we have a good infrastructure to enable those people to realise their potential.

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Along the way, we're trying to identify ways of promoting and broadening access to academic training.

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I've mentioned this aspiration to excellence and along the way,

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and I guess that's one of the reasons why I'm standing here and glad that there is a recording of this and

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potential podcast is trying to provide this information to as wide an audience as possible with the ultimate aim,

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which may be motherhood and apple pie of improving patient outcomes and benefits and research at the heart of the NHS.

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But these are sort of slogans that others are banding around, and I think we're part of the engine that might do those things.

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So it's great to have Paul Johnson sitting in the audience here.

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This is who we are in the UK.

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We are a joint organisation between the University of Oxford Medical Sciences Division and Health Education in the Thames Valley.

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I've had the privilege of leading this for five or six years now, and I'm backed up by a team of academic training programme directors.

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Paul, who covers the surgical specialities Allison Simmons,

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Matthew St. and Kiltie Suzy Tanhaji and we're all very ably supported by Denise Best as well.

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And just as a little bit of promotion,

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we have one or two or maybe even three vacancies for academic training programme directors, which will be advertised shortly.

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In addition, we help with the academic foundation programme where the academic leads us are running Jones and Kate Saunders,

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and we have an admin team that helps keep us all on the straight and narrow.

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So what does it try to do when it tries to provide a bit of research training some career support?

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Importantly, I think it tries to provide a community for our trainees and link them to senior academics and to

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provide a sort of communication role and to put a bit of flesh on that in terms of research training.

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The integrated academic training trainees have access to the Postgraduate Certificate or Diploma in

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Health Research and other modules from Masters courses run in continuing education across the division.

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There are also opportunities to provide through the medical forum and academic opportunities.

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Seminars and trainees are able to access the medical sciences graduate skills training.

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In terms of career support, we've set up some research funding bursaries,

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and I'm delighted that some of those have now been adopted by the medical sciences division.

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So those secured longer term funding for them. We've had particular programmes to support career development for female clinical lecturers,

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and we do quite a lot of mentorship, both formally and informally.

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The community aspect, I think, is popular, providing a central point for advice and having regular both formal and informal meetings.

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It might sound a bit odd to hold monthly dinner parties for trainees, but that's one of the things we do and actually on the feedback,

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it's one of the things that is very greatly appreciated and we have various communication strategies.

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So how many people are in kayaks? The numbers in the next few slides may not add up quite because the first slide is a census on a specific date,

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and the subsequent slides refer to the number of trainees through the 12 month period leading up to that date.

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But roughly speaking, we have a one third, one third, one third split between academic foundation acts and clinical lecturers.

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And in the face of the overall academic climate and not too bad male to female split.

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Although there's always room for working on that, I suspect this stage is probably a little bit small to read.

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But this is the speciality spread of programme.

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And the reason it's small is because we have ACF's and clinical lecturers across quite a wide range of different clinical specialities.

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Appreciating this was the combined ground round. I put the surgical specialities in red to make that clear.

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And I don't know, and it'll be interesting to see how the audience feels,

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whether that proportion of 17 out of attacks and 13 out of 65 schools is fair or unfair or whatever,

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and we can debate how these posts get awarded to specialities if people wish.

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And then how do we do? Well, this is a measurement of immediate outcomes from these different programmes and to emphasise the word immediate,

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because I think quite a lot of people doing combined clinical and academic training will alternate between the two strands.

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And so it's not that uncommon for people to come out of an academic period and concentrate on clinical for a little while.

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But as one might expect, the immediate progression of academic foundation trainees into an academic post is a bit lower than the later stages.

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I think the 50 to 60 percent for CFS is not too bad.

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I would like to see the percentages for sales a little bit higher.

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And I'm just watching the 54 percent last year to see whether that's just a wobble or not.

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It does vary an awful lot, depending on what stage we appoint people to.

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Clinical lectureship are two three point them early in their clinical training.

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It's much more likely that they will go back to a clinical post afterwards,

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whereas if they're later on, there's perhaps a bigger chance of them moving on to a fellowship.

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So I just wanted to reflect on some national and local data on what works and what doesn't work in this space.

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And in 2017, there was a UK wide survey of clinical and health research fellowships funded by the expected players.

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And this found some positives, but also some concerns.

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And the positives were an overall increase in the number of clinical fellowships over this period.

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But that was mainly fuelled by NIH are inventing this integrated academic training programme,

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and there was a significant but relatively small increase in the total number of the training fellowships available,

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not enough to match the increased number of ACF posts.

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And most of that increase came from an trial which has a relatively narrow remit in terms of what it will fund for doctoral fellowships.

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It's around research that is expected to impact on patients within five years,

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so it doesn't fit terribly well with the more basic science threat of a lot of the research that goes on in Oxford.

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The concerns were a reduction in what you might call destination posts, the removal of the hefty clinical senior lectureship posts.

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Another concern around the decline in the percentage of female fellows with increasing seniority and a third concern around the relative

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dearth of people involved in some of those specialities that are perhaps critical to both the UK research and thus the clinical pace.

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Primary care pathology, public health, clinical pharmacology and particularly.

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A second review that's taken place actually looked at what trainees thought were enablers and barriers.

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And this was some of the data that came out showing that there's quite a lot of concern around maintaining research activity,

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the availability of positions, availability of funding, and that's fairly balanced in terms of male female ratios.

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The lady trainees have an increased level of concern about the level of institutional support available to them.

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Concerns over contract issues when changing between employers, which I think links to maternity leave rights,

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and that's sort of highlighted by a specific line that on maternity rights when changing employers and family commitments.

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But most of the other barriers were actually felt relatively evenly between the sexes.

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So I don't think we have an explanation for the reduced number of ladies who go on to the

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higher fellowships in the academic pathway and not in the Academy of Medical Sciences.

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MRC and the Wellcome Trust and Cancer Research UK are just about to announce a call for some qualitative research to try and investigate that further.

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This was a graph and factors that would have made it easier.

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And not surprisingly, having more grants, more fellowships, more money, more opportunities comes up the list.

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I'm not quite sure how realistic that is, but there are also some things that around integration across clinical and academic departments,

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which I think we should all work on and flexibility in the clinical training module model, which are actually beginning to acknowledge.

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And then finally, we did a piece of research here, which Denise and Joanna led,

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which was the questionnaire based piece of research surveying clinical defence students

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in Oxford and clinical Ph.D. students at UCL and got a reasonably high response rate.

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320 out of 523 people filled in the questionnaire,

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and that showed us some suggestions of things that might help broadening access to clinical ActionScript posts instead of these strict rules

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about for years and providing actually a little bit more clinical mentorship to clinical academic students while they're doing their doctorate.

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Some of the students tucked away in basic science labs with only non-clinical supervisors seemed to get a little bit lost.

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Encouraging doctors to have multiple pre doctoral research experiences might improve those wanting to go forward,

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so I suspect that was an association rather than a causative link.

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And undoubtedly, generating a few extra senior posts would, I think, facilitate passage through the pathway.

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And that was one of the main reasons cited for people being anxious about pursuing a clinical academic career.

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So I now just have a few slides left in which I want to just think about current challenges and future aims at local level and national level,

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and perhaps philosophically and locally.

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I want to carry on working hard to maintain the flexibility where we can to attract the best possible trainees,

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and that involves protecting trainees from bureaucratic hurdles wherever we can.

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But acknowledging that some of those are immutable and people just have to knuckle down and do the.

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We have had a very good run in terms of protecting research time,

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but we all know the strains that this and other hospitals in the locality are under and on our surveys,

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the signal is beginning to come out above the noise in terms of service pressures impinging on academic time.

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And that's something we have to work to resist.

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I think it's also important that we make sure China is linked to good projects and skill sets needed for the future,

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it's very easy to get people to just carry on doing some of the same things.

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And I don't think it's very imaginative for me to believe that mathematics, computing, statistics, engineering,

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chemistry and so on are increasingly going to be required skill sets not

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necessarily to be as good as the mathematicians and computer sciences scientists,

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but at least have enough understanding to be able to work as a good interpreter

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between the relevant disciplines and hopefully a little bit more of that.

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I'm also concerned locally about the number of technical training fellowships that are available through national changes in the welcome scheme.

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Actually, there is no longer a national welcome scheme.

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And so locally were restricted to the five or six posts that the local doctoral training scheme can offer.

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So that's what this does.

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About half of the welcome funded DPhil posts that we used to have the last of the cancer research major centre status also has lost some posts,

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although I'm delighted that the UK have now decided to double their funding for clinical DFL posts.

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And I know Matt Middleton's in the middle of putting together an application. So this is an area that I think we have to watch.

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And then an exciting possibility we have to look to the positive in the Perry Brexit era is of strengthening international exchanges,

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and some in the room know about links between the university and the Mayo Clinic.

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But there is a memorandum of understanding in existence to facilitate research,

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education and training exchanges, and I think that may be valuable in this space at a national level.

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There is an interest in how one facilitates trainees getting involved in big

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science and that in some way links to just the day to day logistics of that.

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But it also links, and I think this is important for all of us into problems around the reward systems.

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We're used to first author, last author gaining gaming prowess.

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But what happens if you're 40 seconds out of 84, but the whole thing wouldn't have happened without you?

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And also, I suppose the test might be a small step in this direction.

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You know, we want academics to be educators, and yet we don't really have reward structures around those.

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It's recognised that there are problems around managing expectations,

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crews around whether there are enough post senior levels and currents around the pressures that the new medical schools are going to bring in,

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not in that regard. And I'm going to bring you a glimmer of light in a moment or two from the MRC towards the end of my presentation in that regard.

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And then there's the whole issue of whether clinical academia is simply about providing

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academic input into the NHS or whether it should be supplying the life science sector.

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Obviously, our richest professor has a strong view on that.

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But all be very well equipped to do it. And are we doing the right things?

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And it's important to note that in discussions I've had with industry,

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they're very concerned that our traditional academic training pathways make people specialised too much, too early.

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We don't keep people broad long enough from that perspective,

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and we end up with people who they regard as relatively unemployable because although they're the world expert on something,

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the something isn't big enough to be flexible. If you're a large pharma company that wants to switch from bone metabolism one week to renal failure,

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another week to transplant biology to six months time. I'm also interested in encouraging medical students engagement,

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obviously in a city where the medical school has an insect related requirement for everyone.

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There isn't that much of a problem, although I would note that in my year of medical students here,

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which is quite a long time ago, 12 percent of us went straight on from pre-clinical medicine to do D cells.

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Currently, that number is around two or three percent, and we have to think about why that is,

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I can't help thinking that fee pressure is part of that. But that there's perhaps something in the environment that's not quite right,

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that there's an interest in broadening access to research training for all trainees.

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And the CNN is doing quite a lot in that space.

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But I would also point out that research, training and research abilities are in the curriculum virtually every year old college.

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And I would ask whether anybody in this room has ever seen those assessed as an ICP process.

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Our secret process focuses on the number of bronchoscopy somebody has done, the number of hernias they prepared.

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Does it ever ask whether they've passed that research landmarks?

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And then there are some challenges around the emergence of the new medical schools. Who will emerge them?

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Who will staff them? What is their research culture? What research opportunities can be provided for trainees going through those medical schools,

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many of which are now based in non research intense institutions?

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So I promised a glimmer of light, and some of you may know about the Mercy Corps programme.

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I'm sure they spent a lot of time deciding to put the letters in that order rather than changing the order around.

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This was announced last Friday, and it's a scheme.

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It's a pilot scheme in which 10 million pounds from the MRC and two million pounds from Nigel Hayes has been made available to

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buy out time for established NHS consultants to do research in partnership with other academics in honour of our institutions.

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And I think that's an exciting development. They already have such a scheme in Scotland.

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It is set to be an overwhelming success in Scotland. I'm not absolutely sure why they're only piloting it here,

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but I think there are some complicated politics around where the money's coming from

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and a forthcoming CSR and possibly the bottom falling out of the market with Brexit,

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etc. But I think this is an important scheme,

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and I think we should be promulgating it around this city and beyond to make sure that there are a lot of high quality applicants.

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Of course, if we do that successfully, there'll be a lot of disappointed people.

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I think there must be quite well because I think there'll be a clamour for more of the same.

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And then the current challenges on a more philosophical level are perhaps the obvious ones.

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How do we select? How do we assess? How do we anticipate scientific and clinical developments?

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Can we do better? And a slight concern I have that some of the support structures that we're producing may be anti evolutionary.

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If we make it too easy for people to climb up this pyramid only knowing that they aren't ever going to get to the top,

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they'll just fall off from higher up, and that'll hurt a bit more. And we have to be a little bit mindful of that, I think.

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So I'm going to finish there, a lot of what I've said is available through our website if people want to get in touch, I put my email address there,

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not that it's that difficult to find and I'd be very happy to enter into a discussion with those of you in the room about anything I've said,

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anything I've provoked or anything I've omitted. Thank you very much.