So I'll have a at.
Thank you, everybody, for coming to this combined crunch round,
I thought it was timely to say a little bit about clinical academic training and the role the two Cox plays.
I'm afraid it's a single handed presentation from the front of the room,
but I am very grateful to the rest of the UK team, who I will mention as we go through.
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.
It specifically says commitment to innovation and to the promotion,
conduct and use of research to improve the current and future health and care of the population.
And I think that is sometimes forgotten by people who we work with, shall I say, rather than four.
I think it's important to recognise that academic clinicians and I'm saying academic here,
both in the capital and the little they are in the right place to know which questions in health care are important and tractable,
which solutions are practical and beneficial, and to teach and implement the solutions when they're eventually found.
I also think it's really important to think about links between an academic ethos and important professional values.
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.
We have a much more questioning attitude, much more flat and hierarchy. And on the whole, we're good at building teams.
And overall, there's increasing evidence now that academic activity correlates with good patient outcomes.
Whether that's causal or associative, I'm not going to say, but that correlates.
So in that context,
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,
and this is data from Medical Schools Council on the positive side.
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,
which is increased by some 40 percent between 2000 and 2015.
The red line towards the bottom shows the number of clinical academic consultants over the same time.
It looks pretty flat. But let me zoom in on it.
Actually, that red line translates to yellow line on this graph, which shows quite a significant fall in the first five years.
And despite all the efforts of NIH, Cox, et cetera, the line has only really flattened out.
Subsequently, it hasn't climbed back to previous levels. And this is in the face of the government wanting to open new medical schools,
20 percent expansion in the number of medical students to be taught, and all sorts of excitement around academic industrial strategies,
etc. There is perhaps a little glimmer of hope that the Green Line of professors is going up,
but I think that's actually because we've renamed readers and senior lecturers,
professors and you'll see a sort of mirror image between the purple and the green lines there.
And this looks a little bit more even more worrying when we look at the age profile of current clinical academics in the UK.
So the yellow line at the bottom shows the numbers of clinical academics who are already over 66.
The Red Line shows those between 56 and 65 and the so-called Z Blue Line 46 to 55.
So we're kind of an ageing population of academics that may be very valuable for the
younger people in the room because it may mean that some space will come along.
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
DPhil students to be a major reason for people not going into academic careers at the moment.
So just this this is not something I alone have noticed.
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
structure was part of the problem that led to modernising medical careers and best research for best health research reports,
both of which had good things and bad things about them,
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.
So historically, we had extremely flexible training pathways. We had a clinical pathway from medical degree through to consultant or GP.
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.
And what the UK Foundation programme and the integrative academic training programmes have
done is provided a link between those two in the form of the Academic Foundation programme,
academic clinical fellowships and clinical lecturer roles.
And I would emphasise that although all these posts exist, they're not linked together specifically in a.
They provide a set of opportunities, and there are a number of routes through this pathway that are perfectly acceptable.
So in the hopes that there would be people in the audience who might not already know this.
I'm just going to run through a little bit about each of those three types of post.
The Academic Foundation programme offers 480 posts across the entire UK per year, 24 of which we have in Oxford or the Thames Valley.
These are a two year programme in keeping with the foundation programme, and that precise configurations vary quite a lot in different regions.
But in Oxford, many of our posts have four months of designated academic time enough to put some half day release instead.
The appointment process here is through a local interview process,
and I'm very grateful to people who participated in that last week and the employees.
The trainees are NHS employees with visiting academic university privileges.
The whole foundation programme is currently the subject of a review,
and I'm waiting to hear what that review says about the academic foundation programme.
At the moment, I understand the review, but is still trying to agree what their terms of reference are going to be,
which doesn't throw me because I think they ought to know what they are already.
So one of the dilemmas we face with the academic foundation programme is it really is for.
It was originally envisaged as a taste for those who had not had any research opportunities up until that point of qualification,
they'd gone to a medical school where in circulation was uncommon. And that's less commonly the case now.
The Academy of Medical Sciences Inspire programme has done quite a lot to try and do that,
so it's also being used now to support those people who are already on an academic trajectory.
But I do feel quite strongly it's not for people with extensive research experience
who have few new ideas and aren't actually going to use the time profitably.
The next step in the pathway of the academic clinical clinical fellowships of which and often 250 per year in the UK.
And we've got roughly 17 here in Oxford.
And the important features of these are that they provide 25 percent of time protected for academic endeavours,
with the aim of people preparing a fellowship leading either to a higher degree or if they already have a doctorate,
postdoctoral research and generally a three year duration.
And the way we've run them in Oxford has sometimes extended people's training again.
We have a local interview process, but candidates have to benchmark in national recruitment to be employed,
and importantly, posts in this scheme can be additional to those in conventional training.
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.
In recruiting these posts, we usually put three GMC specialities against each post and the strongest candidate ever,
irrespective of speciality wins the post and shall specify the recruitment window.
The recruitment is run through the deanery processes and there is still this issue of national benchmarking and access.
Remain NHS employees. And then the third step in the pathway and chocolate in the collection ships and child funds 100 per year,
and we get around 7:00 in Oxford and I'll explain how we get these posts in a moment or two.
And these are restricted to people who already holds a doctorate.
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.
They provide a 50 50 split between academic training and clinical training,
although it is possible to count some of the academic time in some specialities towards clinical training.
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.
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,
and I'm extremely grateful to those people who have supported me in generating those sorts of posts.
In contrast to the earlier posts, these ones are recruited by the university and clinical lecturers become university employees.
And there has been a little bit of tension around maintenance of statutory employment rights across to employers,
but I think that's now been resolved. And again, these posts are able to be additional to those in conventional training.
So the sales by the time people are being selected for clinical lecture ships, we expect to see commitment to a clinical academic career.
And really, we see them as a transition towards independence for people who are not yet ready to get a personal fellowship.
But we hope that by the end of their four years as a clinical lecturer, they will be able to get more.
We don't. There are restrictions around awarding them to people very late in their training.
And so that is one sort of contra indication and alternatives do exist in terms of the other fellowships.
But I would note that there's been quite a lots of great inflation in the CV required
to get some of these fellowships since I was a candidate for them 20 or 25 years ago.
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.
Again, we put three special teams against each post.
There's more flexibility because the appointments are made through the university and there's no specific appointment window.
But appointments are made by a local interview process,
and we quite often use the the quality of the second ranked candidate as a lever to generate a local clinical lectureship post.
So where do these posts come from? Well, the majority of them are funded by CHAS,
and 60 percent of the posts that we get in the Thames Valley are awarded for a magical thing called the formula.
The formula is something that is known to somebody in the Department of Health.
It's a very well kept secret,
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.
I'm wondering whether Freedom of Information request would or would not be valuable,
but it is in some way linked to the total amount of income that the partnership between the Deanery and the local universities earn.
Interestingly, our formula allocation didn't change when the BRC became hugely more valuable last time round,
and Oxford got the clock for the first time and Oxford Health got two new BRC.
So there are obviously some constants and variables within the formula,
but I think politically handled and the other 40 percent of the posts are now awarded through a competition.
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.
But I know I have now taken a different approach, and they are now aiming for the competition posts to be awarded to particular
research themes and the current research themes of the seven mentioned that.
In addition to these and child posts in Oxford,
we're fortunate in getting a small number of hypothecated posts from NHS Blood and Transplant and Public Health England.
So how did this all work out last year? Well, these were our competition results.
We were only allowed to bid for 10 posts altogether, three clinical ActionScript and seven assists,
and we managed to get six out of the seven and all three clinical lectureship.
And they were, as you might expect in Oxford, somewhat biased towards the sort of wet lab end of the themes that were available.
We took a strategic decision not to bid in medical education,
although that's something that I think we will keep under review because I suspect that's a relatively soft
target nationally and that the only ICF we lost was one relating to older patients and complex needs.
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.
But I do worry that the absence of a single department of Gerontology probably weakens our ability to bid in that area of.
I'm sorry, I mentioned local clinical lectureship earlier and the expectation that we will produce a fair number of these.
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.
And I'm, as I say, grateful to people for helping negotiate these,
and we've done reasonably well in producing local clinical ActionScript over the last few years.
And that's really important to me because this is now a metric in the assessment of our competition bids,
and we're actually told that we scored well or badly on the number of local posts with managed to generate.
So I don't want to spend too long on this slide,
but I do think it's quite interesting to balance some of the pressures in research against those in clinical training.
And an awful lot of clinical training is around minimising risk,
making things very fair nationally certainty over core competency competencies, etc. and some of the science and research are a bit different.
I think we've calculated risk the wish to recruit into particular niches where things are strong and uncertainty.
And I think let's just produce a little bit of a tension between competence and safety and excellence.
Or perhaps aspiration is a better word for the purposes of this slide.
So that brings me on to some of the pressures that trainees feel and some of the structures that
they're having to work into and the reasons for the founding and the continuance of the tax.
So when you have an integrated academic training pathway, you really need an integrated structure.
And that structure falls somewhere between the University Health Education in the Thames Valley and the NHS service providers.
And of course, each of those has slightly different mission statements.
The university is driven by research and education, health, education, Thames Valley by training and governance,
and the NHS providers by service delivery and training and support trainees sit in the middle of this triangle,
being pulled in each and every direction.
And that can be illustrated by some of the pressures I think trainees feel and challenges the preference of serving two or three masters,
uncertainties over contract, uncertainties over future training and the shape of training review is pertinent from that point of view.
The difficulties of securing funding decisions about whether they stay in training or whether they go out of programme,
joint appraisal and financial pressures. And what we're trying to do a new tax is turn the trainee who's wobbling around
on the wobble board into the Syrian yoke performing trainee in the bottom right.
Perhaps so the tax sort of fits in the middle of this triangle, holding it either together or apart, depending on your viewpoint.
And Ken Fleming must take the credit for setting up with Katz and seeing the need for it.
I guess our mission statement, the statement is to attract, train and retain the very best clinical academics we can.
And we do that through raising the profile of clinical academic careers generally and trying
to make sure we have a good infrastructure to enable those people to realise their potential.
Along the way, we're trying to identify ways of promoting and broadening access to academic training.
I've mentioned this aspiration to excellence and along the way,
and I guess that's one of the reasons why I'm standing here and glad that there is a recording of this and
potential podcast is trying to provide this information to as wide an audience as possible with the ultimate aim,
which may be motherhood and apple pie of improving patient outcomes and benefits and research at the heart of the NHS.
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.
So it's great to have Paul Johnson sitting in the audience here.
This is who we are in the UK.
We are a joint organisation between the University of Oxford Medical Sciences Division and Health Education in the Thames Valley.
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.
Paul, who covers the surgical specialities Allison Simmons,
Matthew St. and Kiltie Suzy Tanhaji and we're all very ably supported by Denise Best as well.
And just as a little bit of promotion,
we have one or two or maybe even three vacancies for academic training programme directors, which will be advertised shortly.
In addition, we help with the academic foundation programme where the academic leads us are running Jones and Kate Saunders,
and we have an admin team that helps keep us all on the straight and narrow.
So what does it try to do when it tries to provide a bit of research training some career support?
Importantly, I think it tries to provide a community for our trainees and link them to senior academics and to
provide a sort of communication role and to put a bit of flesh on that in terms of research training.
The integrated academic training trainees have access to the Postgraduate Certificate or Diploma in
Health Research and other modules from Masters courses run in continuing education across the division.
There are also opportunities to provide through the medical forum and academic opportunities.
Seminars and trainees are able to access the medical sciences graduate skills training.
In terms of career support, we've set up some research funding bursaries,
and I'm delighted that some of those have now been adopted by the medical sciences division.
So those secured longer term funding for them. We've had particular programmes to support career development for female clinical lecturers,
and we do quite a lot of mentorship, both formally and informally.
The community aspect, I think, is popular, providing a central point for advice and having regular both formal and informal meetings.
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,
it's one of the things that is very greatly appreciated and we have various communication strategies.
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,
and the subsequent slides refer to the number of trainees through the 12 month period leading up to that date.
But roughly speaking, we have a one third, one third, one third split between academic foundation acts and clinical lecturers.
And in the face of the overall academic climate and not too bad male to female split.
Although there's always room for working on that, I suspect this stage is probably a little bit small to read.
But this is the speciality spread of programme.
And the reason it's small is because we have ACF's and clinical lecturers across quite a wide range of different clinical specialities.
Appreciating this was the combined ground round. I put the surgical specialities in red to make that clear.
And I don't know, and it'll be interesting to see how the audience feels,
whether that proportion of 17 out of attacks and 13 out of 65 schools is fair or unfair or whatever,
and we can debate how these posts get awarded to specialities if people wish.
And then how do we do? Well, this is a measurement of immediate outcomes from these different programmes and to emphasise the word immediate,
because I think quite a lot of people doing combined clinical and academic training will alternate between the two strands.
And so it's not that uncommon for people to come out of an academic period and concentrate on clinical for a little while.
But as one might expect, the immediate progression of academic foundation trainees into an academic post is a bit lower than the later stages.
I think the 50 to 60 percent for CFS is not too bad.
I would like to see the percentages for sales a little bit higher.
And I'm just watching the 54 percent last year to see whether that's just a wobble or not.
It does vary an awful lot, depending on what stage we appoint people to.
Clinical lectureship are two three point them early in their clinical training.
It's much more likely that they will go back to a clinical post afterwards,
whereas if they're later on, there's perhaps a bigger chance of them moving on to a fellowship.
So I just wanted to reflect on some national and local data on what works and what doesn't work in this space.
And in 2017, there was a UK wide survey of clinical and health research fellowships funded by the expected players.
And this found some positives, but also some concerns.
And the positives were an overall increase in the number of clinical fellowships over this period.
But that was mainly fuelled by NIH are inventing this integrated academic training programme,
and there was a significant but relatively small increase in the total number of the training fellowships available,
not enough to match the increased number of ACF posts.
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.
It's around research that is expected to impact on patients within five years,
so it doesn't fit terribly well with the more basic science threat of a lot of the research that goes on in Oxford.
The concerns were a reduction in what you might call destination posts, the removal of the hefty clinical senior lectureship posts.
Another concern around the decline in the percentage of female fellows with increasing seniority and a third concern around the relative
dearth of people involved in some of those specialities that are perhaps critical to both the UK research and thus the clinical pace.
Primary care pathology, public health, clinical pharmacology and particularly.
A second review that's taken place actually looked at what trainees thought were enablers and barriers.
And this was some of the data that came out showing that there's quite a lot of concern around maintaining research activity,
the availability of positions, availability of funding, and that's fairly balanced in terms of male female ratios.
The lady trainees have an increased level of concern about the level of institutional support available to them.
Concerns over contract issues when changing between employers, which I think links to maternity leave rights,
and that's sort of highlighted by a specific line that on maternity rights when changing employers and family commitments.
But most of the other barriers were actually felt relatively evenly between the sexes.
So I don't think we have an explanation for the reduced number of ladies who go on to the
higher fellowships in the academic pathway and not in the Academy of Medical Sciences.
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.
This was a graph and factors that would have made it easier.
And not surprisingly, having more grants, more fellowships, more money, more opportunities comes up the list.
I'm not quite sure how realistic that is, but there are also some things that around integration across clinical and academic departments,
which I think we should all work on and flexibility in the clinical training module model, which are actually beginning to acknowledge.
And then finally, we did a piece of research here, which Denise and Joanna led,
which was the questionnaire based piece of research surveying clinical defence students
in Oxford and clinical Ph.D. students at UCL and got a reasonably high response rate.
320 out of 523 people filled in the questionnaire,
and that showed us some suggestions of things that might help broadening access to clinical ActionScript posts instead of these strict rules
about for years and providing actually a little bit more clinical mentorship to clinical academic students while they're doing their doctorate.
Some of the students tucked away in basic science labs with only non-clinical supervisors seemed to get a little bit lost.
Encouraging doctors to have multiple pre doctoral research experiences might improve those wanting to go forward,
so I suspect that was an association rather than a causative link.
And undoubtedly, generating a few extra senior posts would, I think, facilitate passage through the pathway.
And that was one of the main reasons cited for people being anxious about pursuing a clinical academic career.
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,
and perhaps philosophically and locally.
I want to carry on working hard to maintain the flexibility where we can to attract the best possible trainees,
and that involves protecting trainees from bureaucratic hurdles wherever we can.
But acknowledging that some of those are immutable and people just have to knuckle down and do the.
We have had a very good run in terms of protecting research time,
but we all know the strains that this and other hospitals in the locality are under and on our surveys,
the signal is beginning to come out above the noise in terms of service pressures impinging on academic time.
And that's something we have to work to resist.
I think it's also important that we make sure China is linked to good projects and skill sets needed for the future,
it's very easy to get people to just carry on doing some of the same things.
And I don't think it's very imaginative for me to believe that mathematics, computing, statistics, engineering,
chemistry and so on are increasingly going to be required skill sets not
necessarily to be as good as the mathematicians and computer sciences scientists,
but at least have enough understanding to be able to work as a good interpreter
between the relevant disciplines and hopefully a little bit more of that.
I'm also concerned locally about the number of technical training fellowships that are available through national changes in the welcome scheme.
Actually, there is no longer a national welcome scheme.
And so locally were restricted to the five or six posts that the local doctoral training scheme can offer.
So that's what this does.
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,
although I'm delighted that the UK have now decided to double their funding for clinical DFL posts.
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.
And then an exciting possibility we have to look to the positive in the Perry Brexit era is of strengthening international exchanges,
and some in the room know about links between the university and the Mayo Clinic.
But there is a memorandum of understanding in existence to facilitate research,
education and training exchanges, and I think that may be valuable in this space at a national level.
There is an interest in how one facilitates trainees getting involved in big
science and that in some way links to just the day to day logistics of that.
But it also links, and I think this is important for all of us into problems around the reward systems.
We're used to first author, last author gaining gaming prowess.
But what happens if you're 40 seconds out of 84, but the whole thing wouldn't have happened without you?
And also, I suppose the test might be a small step in this direction.
You know, we want academics to be educators, and yet we don't really have reward structures around those.
It's recognised that there are problems around managing expectations,
crews around whether there are enough post senior levels and currents around the pressures that the new medical schools are going to bring in,
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.
And then there's the whole issue of whether clinical academia is simply about providing
academic input into the NHS or whether it should be supplying the life science sector.
Obviously, our richest professor has a strong view on that.
But all be very well equipped to do it. And are we doing the right things?
And it's important to note that in discussions I've had with industry,
they're very concerned that our traditional academic training pathways make people specialised too much, too early.
We don't keep people broad long enough from that perspective,
and we end up with people who they regard as relatively unemployable because although they're the world expert on something,
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,
another week to transplant biology to six months time. I'm also interested in encouraging medical students engagement,
obviously in a city where the medical school has an insect related requirement for everyone.
There isn't that much of a problem, although I would note that in my year of medical students here,
which is quite a long time ago, 12 percent of us went straight on from pre-clinical medicine to do D cells.
Currently, that number is around two or three percent, and we have to think about why that is,
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,
that there's an interest in broadening access to research training for all trainees.
And the CNN is doing quite a lot in that space.
But I would also point out that research, training and research abilities are in the curriculum virtually every year old college.
And I would ask whether anybody in this room has ever seen those assessed as an ICP process.
Our secret process focuses on the number of bronchoscopy somebody has done, the number of hernias they prepared.
Does it ever ask whether they've passed that research landmarks?
And then there are some challenges around the emergence of the new medical schools. Who will emerge them?
Who will staff them? What is their research culture? What research opportunities can be provided for trainees going through those medical schools,
many of which are now based in non research intense institutions?
So I promised a glimmer of light, and some of you may know about the Mercy Corps programme.
I'm sure they spent a lot of time deciding to put the letters in that order rather than changing the order around.
This was announced last Friday, and it's a scheme.
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
buy out time for established NHS consultants to do research in partnership with other academics in honour of our institutions.
And I think that's an exciting development. They already have such a scheme in Scotland.
It is set to be an overwhelming success in Scotland. I'm not absolutely sure why they're only piloting it here,
but I think there are some complicated politics around where the money's coming from
and a forthcoming CSR and possibly the bottom falling out of the market with Brexit,
etc. But I think this is an important scheme,
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.
Of course, if we do that successfully, there'll be a lot of disappointed people.
I think there must be quite well because I think there'll be a clamour for more of the same.
And then the current challenges on a more philosophical level are perhaps the obvious ones.
How do we select? How do we assess? How do we anticipate scientific and clinical developments?
Can we do better? And a slight concern I have that some of the support structures that we're producing may be anti evolutionary.
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,
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.
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,
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,
anything I've provoked or anything I've omitted. Thank you very much.