20
Examination of witnesses
Dr Jamilla Hussain, Professor Paul Stewart and Professor Charlotte Summers.
Q1 The Chair: It is great to welcome our witnesses this morning to the committee’s first evidence session for its inquiry into clinical academics in the NHS. We have Dr Jamilla Hussain, consultant and honorary senior research fellow at Hull York Medical School, Professor Paul Stewart, vice-president, clinical, at the Academy of Medical Sciences, and Professor Charlotte Summers, interim director of the Heart and Lung Research Institute at the University of Cambridge.
The session is being broadcast on parliamentlive.tv and a full transcript is being taken, which will be made available to our witnesses shortly after the meeting for them to make any minor corrections. If there is any information that you do not get a chance to tell us about that you think would be useful to us, we would be delighted to receive more evidence from you after the session.
I will kick off with the first question. We are looking into clinical academics in the NHS and whether these roles and their research are under threat. We are keen to understand the value that clinical academics bring to the NHS and to know how you think they improve the NHS. We would like to hear about the role that clinical academics currently play, and their importance.
Dr Jamilla Hussain: Thank you for the invitation. Like any researcher, our role as clinical academics is to question what we are doing and how we can improve it and to consider how we can do it as well as possible. In particular, we are steeped in practice, so our questions are much more relevant to what is happening on the ground. We also understand the complex system within which the NHS works: we are already thinking about what will be implementable and make the most change. There is an urgency about that for us as clinical academics, because we see the impact on the ground.
We also bring a lot to the clinical field, in that we support our teams to take a step back every now and then and say, “How are we doing this, and can we do it differently?” I do not think we are any better as clinicians than clinical colleagues who do not do research, but our role is to bring the evidence to the front line and say, “This is what we should be doing right now”. More broadly, we influence policy. We are asked to influence policy even outside our research field—such as today—because we have a foot in each camp and can bring a broad perspective.
Professor Charlotte Summers: It is important for us to be clear what we mean by clinical academic. There is a bunch of people, such as those of us sitting here, who work for higher education institutes in substantive academic roles where that is our main job, but there are also people within the NHS, across all sections of the workforce, who are active researchers—clinician researchers, if you like. They are both leading and, importantly, delivering research.
A really good illustration of both these roles is the recent pandemic, and things such as the RECOVERY trial. It was led by Peter Horby and Martin Landray, who are clinical academics, but delivered by clinician researchers across the entire NHS. The treatments for Covid were pretty much found within 100 days as a result of clinical academics and clinician researchers working together to improve the care of people across the world; 1 million lives have been saved just as a result of dexamethasone.
The Chair: That is a great example. I think Lord Krebs will ask for more examples shortly.
Professor Paul Stewart: I look at this as having three important facets. First and foremost, and uniting us all as healthcare professionals, it is about enhancing patient care. There is a very strong evidence base that engaged research-participating organisations have better clinical outcomes than those that are not. This is perhaps best quantified for patients with colorectal cancer, among whom mortality rates are 30% better in a research-intensive environment. Clinical academics span many different facets of research, from fundamental discovery science and translation through to more outcomes-based research. I like to think of them as the clinical front door of our universities. They can draw on the immense assets across engineering, computation science, arts and humanities, and channel them through translation to improve human health.
A second facet is the economic aspect. Clinical academics are a key and critical engine for the life sciences industry sector. We can perhaps talk more about the value of that to the UK economy, but clearly it was endorsed by the Chancellor last week in his Autumn Statement.
Finally, and we might come on to this later, clinical academics are a key part of future innovation in the NHS. If we are to break the dilemma we have of escalating healthcare costs set against a flat economy, we need to do things differently. We need to embrace technology—for example digital technology-enhanced healthcare, and clinical academics are at the core of the delivery of that. Again, we have examples we can share with you.
Those are the three key parts of the importance of clinical academics in the National Health Service.
The Chair: If you do not get a chance to share those examples, we would be delighted if you could drop us a note to add them to our evidence base.
Q2 Lord Krebs: In a way, our witnesses have started to answer the question I wanted to ask, but perhaps I can invite a little more elaboration. What kinds of research projects do clinical academics conduct? Charlotte, you have already given us the example of the Covid RECOVERY trial, but maybe you could give us a few more examples and, in doing so, perhaps highlight how the dual role of researcher and clinician is important.
Paul, you began to answer my question about the extent to which the research is basic inquiry-led research, and to what extent it is translational. Maybe you could expand on that a bit. Also, to what extent is it focused on clinical practice now, or clinical practice out there in the future? Perhaps you could tease out some of those points.
Professor Charlotte Summers: I will reflect on my own work over the last three years. I am a researcher who specialises in why lungs fail in acute circumstances, and the pandemic has been a particular focus for me. The range of activities that I personally have contributed have improved care, both in the UK and beyond.
I was one of the advisers to the Cabinet Office and Department of Health ventilator challenge. Almost all the advisers to that programme—all five of us—were clinical academics. We understood what it took to innovate, and could explain and think about it in an evaluation and a regulatory context, alongside us all being full-time clinicians at that point in the pandemic. We could communicate what was needed and discuss how one might evaluate it and get it into practice rapidly with regulators, industry, government and funders.
Another example was overseeing the drug trials. I was part of the UK Covid-19 Therapeutics Advisory Panel, which, again, was made up almost exclusively of clinical academics. We reviewed the therapeutic landscape and all the compounds that were recommended to UKRI as being potentially deployable for clinical trials, and with strong support worked out what therapies we should test in RECOVERY, REMAP-CAP and the other clinical trials—there were nine platform trials in the UK—as well as leading and delivering some of that research in the intensive care unit and writing clinical guidelines. It was a very broad contribution to the health and, potentially, the wealth of the nation.
Dr Jamilla Hussain: A lot of the big institutes, such as Oxford, Cambridge and the London universities, have a lot of funding to do these big studies. In Bradford, we were helping to deliver them. In particular, clinical academics in Bradford were the ones to lead and understand how we could get better representation. Professor Saralaya, one of our respiratory physicians, ensured that people from ethnic minority communities were represented by up to 35% in one of the treatment trials. He has done great work in getting more people from ethnic-minority backgrounds and the most deprived areas in Bradford to benefit from and access trials early to improve their health outcomes.
We have the Born in Bradford cohort study, which for many years has worked really hard to build relationships with our community. During Covid, we had a huge issue with mistrust, with people not coming into the hospital because they were so worried that we were killing them. By using the infrastructure that the research institute had built over many years, we were able to go out, collect evidence on why people were so hesitant to come to hospital—including vaccine hesitancy—and use those links to address inequalities right there, right then when we needed it in our community.
Professor Paul Stewart: On that point, the committee can draw on a very strong evidence base from the recently published research excellence framework. As you will be aware, that exercise effectively evaluates research across universities. Clinical academics are mainly returned in the first two units of assessment in that exercise, in clinical medicine and public health. As an example, there are over 400 impact cases and clinical vignettes, of which 70% have been graded world leading by international experts.
I will not go through all 400, but to give you a flavour of their diversity, there are new therapies for depleting immune B cells to treat rheumatoid arthritis, new treatments for patients with disabling blood disorders, new ways of assessing fracture risk among patients with underlying osteoporosis, as well as new therapies for heavy menstrual bleeding and uterine fibroids. As Charlotte and Jamilla alluded to, these are coming from universities up and down the UK, not just London, the south-east and the golden triangle.
One of the most impactful examples was mitochondrial transfer therapy, pioneered by colleagues in Newcastle, which is now saving lives and improving the quality of life of many patients with disabling neurological disorders, through a pioneering IVF technique. There is a very strong evidence base for the impact that is having locally but now nationally and internationally; the reach and significance of these impacts is significant.
You talked about balance. Broadly speaking, as I alluded to, clinical academics span the spectrum of basic science to translation to more implementation research. It is important that we realise that without basic discovery science there will be nothing to translate in future years. Thanks to investment, particularly from the NIHR and the Wellcome Trust, we now have outstanding clinical research facilities in the major hospitals to undertake those “first-in-man” experimental medicine studies, which are often the very first experiment that takes discovery science through into patient care. There is a very rich cadre of that activity going on across the United Kingdom.
Q3 Baroness Blackwood of North Oxford: Thank you to the panel for those fantastic examples of the impact of clinical academics and the research community, particularly during Covid. I know the committee will be very grateful for the work that was done in very pressing times.
We are conducting this inquiry, because we have heard that the clinical academic workforce may be under threat, that their time may need to be protected for research and that that is suffering due to the immense pressures on the NHS due to Covid and the post-Covid backlog. Obviously, it was also under threat during Covid, but there was prioritisation of research. Do you think that is the case? Is it your experience and that of your colleagues that in this post-Covid period clinical academic work is being deprioritised?
Professor Charlotte Summers: It is important to recognise that, between 2011 and 2021, the proportion of the NHS consultant workforce who are clinical academics reduced from about 8.5% to about 5.5%, so before the pandemic there was a decrease in the proportion of NHS consultants who were substantively funded to do research. The number of consultants had increased, while the number of academics had reduced by about 150, which increased that gap. In my experience, those people are, in the main, currently able to access their research time.
The people who are most under strain at the moment are what I call the clinician researchers: the people funded by the NHS who deliver and lead large amounts of research. They come from across the medical, nursing, midwifery and every possible part of the healthcare workforce. They are all getting squeezed, and trainees—people who are in both clinical and academic training programmes, including the world-leading NIHR programme in the UK—are also coming under pressure. Nearly 1,500 of them redeployed from research to the front line during the pandemic, and many of them have not necessarily got back all that lost research time or restarted their careers.
We are at great peril with the pipeline. There are pressures on the service now, but if we are not incredibly careful, in 10 or 15 years there will be no cadre of clinician researchers to do what has always been done, and which has contributed to our healthcare and research system being so vibrant in the UK.
Dr Jamilla Hussain: For those who get into the NIHR-MRC framework, once you have that money you are more likely to get more funding, and your research time is protected, because those funders do a great job in ensuring that. The issue is for the people who want to get into those funding streams but cannot. The distribution of those people is unequal. Women are less likely to go on to secure positions at the most senior level, and people from ethnic minority backgrounds are less likely both to apply and to get those funds.
At the moment, only 1% of professors in the UK are Black. We have to consider the intersectional perspective and also the geographical distribution: most of the research funding is not equitably distributed across the UK. If we want to address really big issues such as health inequalities, we need to make sure that that funding is distributed more equitably.
Professor Paul Stewart: Charlotte summarised this very well. The only thing I would add is that this particularly affects the so-called clinical researchers in the NHS. I draw the committee’s attention to the fact that, when the new consultant contracts came into place in the early 2000s, the intention in the model contracts supported by the GMC and the colleges was that, on average, consultants would have about two and a half programmed activities to support research, teaching and leadership. We have seen a progressive attrition in that protected time as the pressures of direct service care have taken their toll. Most consultant contracts are now operating on a 9:1 pattern of balance between direct clinical care and time to do other things such as research.
Baroness Blackwood of North Oxford: Do you think we have the right kind of systemic data to understand this picture? Do we understand how the time is used by clinical academics and clinical researchers? Do we understand publication rates? Do we understand the impacts on recruitment and retention, given the points that have been raised about recruitment and prioritisation in different geographical and diverse communities?
Professor Paul Stewart: I think Charlotte has some data on the NHS clinical researchers. On the clinical academic side, we have a lot of data; because they are employed by universities, we have an accurate annual staffing survey, from which we know exactly how many there are in the system. As I have alluded to, there are also exercises such as the research excellence framework, which give us an independent evidence base for the trajectory of that community of researchers. As we discussed, the key issue for clinical academics is not that their balance of workload has significantly changed; it is the flatlining of numbers. The expansion of the consultant grade from 36,000 to 53,000 over 10 years is set against no expansion of clinical academics at all which has remained static at ~3000.
Baroness Blackwood of North Oxford: Yes, but that is about the numbers. Does it show you use of time and the recruitment and retention question? I am aware that the REF is very detailed, but does it show you the state of the employee base, as it were?
Professor Paul Stewart: We have very good data on demographics and the age profile, and the proportion of time they are spending in the NHS versus academic work against that balance. My gut feeling is that the proportion of clinical versus research time has not changed too much in that group of individuals over the 10 years; it is more the numbers that are in the system.
Professor Charlotte Summers: Although there is good and granular data around the higher education institute-employed researchers, there is much less granular data around the breadth of NHS clinician researchers. As I said before, not all of them are medical and many are doing research in their spare time and extra to their full-time clinical roles. Often, the time, commitment and even the outputs of that work are not captured. Recently, there was a really telling report from the Royal College of Physicians that suggested that the majority of consultant physicians in the UK want more time for research than they have, which means there is a whole research capacity that we are not managing to harness that would enable innovation, development and transformation of care pathways.
I know that things are far worse for my nursing, allied health professional, pharmacy and other colleagues, and that it is not the same across all the devolved nations. The systems in England are not the same as those in Scotland, Wales or Northern Ireland, so there is widespread variation that needs to be accounted for.
Dr Jamilla Hussain: I agree with everything that has been said so far. Even in the NIHR, I think it was only last year that they started to produce more granular data about ethnic minority and gender disparities in funding. We have not really started to get to grips with the intersectionality. What about women who are ethnic minority and from deprived backgrounds? I know that the NIHR is looking into that. Covid-19 has opened our eyes to that, so work is going on to address it.
In Bradford, there are few clinical academics; two of us are funded and have dedicated research time. My research time is funded through the NHS trust; I do not have funding through a fellowship. Some of the areas with the worst health outcomes have very little funding for this kind of thing.
Q4 Baroness Sheehan: Thank you very much for coming along to present evidence to the committee today. We have heard in quite a lot of detail that the number of clinical academics has declined in recent years and as a proportion of consultants within the NHS. You have already mentioned several reasons, but can you put together in one place the reasons behind it? In particular, can you address whether funding is an issue?
Professor Paul Stewart: It is an excellent question and, as indicated, probably the nub of some of the issues. We have already referred to the data on clinical academics numbers in secondary care. Many of us can see the benefits of moving healthcare to have a greater emphasis on prevention and early diagnostics and the importance of integrated care systems in delivering a research mandate for the NHS. For general practitioners, the numbers of clinical academics are even more woeful. Of the 36,000 GPs currently in the system, only 260 designate as clinical academics, which is less than 1% of the workforce. Going back to what Charlotte said, this is not just about medical staff in secondary care trusts but also about nursing, allied health professionals and doctors elsewhere in the system, including public health doctors. It is about increasing the research capacity across all healthcare professions.
On the factors that are responsible for this, we have data on the number of trainees in the system and, thanks to the impressive funding streams from the NIHR, we now have a large number of academic trainees in the system: 7,000 in total. However, the funding has been directed far more towards PhD and pre-doctoral programmes, research exposure and early research training than to post-doctoral career support.
There we have seen a progressive attrition of support from funders who, as I said, have prioritised pre-doctoral support, but also from other stakeholders, including universities, which have been increasingly nervous about employing clinical academics in so-called permanent posts with the financial challenges that they are under, as well as the NHS with its pressures on direct clinical care. It is not that the pipeline is not there; it is there, but the post-PhD career development and run-through support rapidly needs fixing.
Baroness Sheehan: The incentives are misplaced, in your view.
Professor Paul Stewart: As someone who has been the dean of undergraduate medical schools, I see the thirst and desire of our new graduates to take on an academic career; that is still there. We may talk a little more about the headwinds involved in academic training, but the real issue is the pull-through academic career structure post PhD.
Baroness Sheehan: To probe a little further before I move on, do you think enough is being done to publicise those roles?
Professor Paul Stewart: I think so. The Clinical Academic Training Forum is a multistakeholder group that tries to mitigate and act on many of the issues that we are talking about today. In partnership with the Medical Schools Council, we have just embarked on a great virtual resource called CATCH, which is a website that has all the resources for clinical academics aspiring to be in training. It has vignettes from role models, signposts what career options are available at various stages and highlights some of the issues we have discussed on the immense impact you can have in those roles. The feedback has been excellent; it has been well used. Of course, there is more we can do, but as a community we are signposting the benefits of this career to the next generation—very much so.
Dr Jamilla Hussain: Again, I would add that representation matters. People who come through, very early on, thinking they want to be clinical academics usually have someone behind them who might have introduced them to a clinical academic career, or they might have seen someone like them. For years, I have looked for a mentor from a similar background to me; I still have not found one. There is work to be done to support better representation so that we can have greater diversity.
We need to consider the significant pressures in the NHS. Seeing what it is like currently to work on the ground in the NHS, medical students, including people who have aspirations to be clinical academics, are considering whether they want their future career to be in the NHS. People are moving abroad, so addressing the pressures in the NHS is important to prevent a brain drain.
There are women I know in Bradford who want to do research and look up to someone like me, who is still in their early career, and say, “Yes, I want to do this. How can you support me to do it?” But we also need to consider the financial costs for them. Not going straight into being a consultant has cost me over £100,000, given the way I have gone about doing my clinical academic training, having children and so on. In addition, having fought for my local trust to recognise my research training and start me higher up on the pay band, I am now expecting a pension bill estimated to be between £20,000 and £25,000.
That is me, who started as a consultant in April, so I say to people coming from deprived backgrounds that they need to consider the financial costs. Maybe I would have made different decisions if I had known the cost implications, because that is a huge amount of money for someone like me to soak up.
But importantly people like us also ask different research questions. When we think about huge issues such as inequalities, we have an urgency about answering those questions. It is really important that we are there, driving clinical academia. It comes at a great cost to us, and we need to consider those broader issues too.
Professor Charlotte Summers: I am delighted that Jamilla raised the issues she did, because there is a risk that we make clinical academic and research careers, in both HEIs and the NHS, the privilege of only a few who can afford that rank. I went to a comprehensive school and neither of my parents went to university, so, like Jamilla, I come from a background that is not overly represented in universities.
It was not easy. There were very few role models, it was more expensive than I had anticipated, and my training was long—longer than it would have been if I had taken an NHS consultant post, as I could have in 2012. As a result of having a Wellcome Trust fellowship and going to work for a while in San Francisco with my young family, which was not a small upheaval, I did not start a substantive post until the end of 2015, which meant that I delayed starting and climbing up the consultant salary scale. I ended up with the same thing, starting a bit higher up, and I too have a pension tax bill, at the same time as being mother of a young family and trying to balance all those things. It does matter, and there are obstacles, rather than disincentives, to us widening participation in research careers.
Baroness Sheehan: That is very useful. Thank you for educating me. Am I right in thinking that these posts are regarded as elite postings within academia and the NHS, and come at a cost?
Professor Charlotte Summers: Securing a substantive university academic post is hard. It should be hard; it is a competitive process. But we need to make sure that the competition is not based on those who can afford it, and that women and people from underrepresented backgrounds all have equal access to those kinds of posts, so that they contribute greatly, as diversity does, to improving the science base in the UK.
The Chair: We need to move on, but those are some very interesting points.
Q5 Lord Winston: Thank you so much for the evidence that you have given, which has been eloquent and really valuable. We are very grateful.
So many of the questions that I would have asked you have largely been answered that I am wondering where to start. I will start with something that Robert Lechler, who was president of the academy, said. He felt that every consultant should do 20% research, which is a great ideal. The real issue, of course, is that as a clinical academic, if you do not do much more research and do not have proper time for research, you are underrated and cannot get published. Would you like to address that sort of issue?
You made the very interesting point that, in the structure of Covid, all of you, no doubt, were suddenly involved in clinical care and had to neglect the research that you were doing. Was it difficult to get back to your research? Did you find that your colleagues managed to get back in time? Are there people who have just been lost to research in consequence?
Professor Charlotte Summers: I am the head of a research institute that has about 390 researchers as part of it. We are a mix of non-clinical and clinical researchers. When it comes to outputs and assessments for promotion and all the other things that go into any career, the playing field is level between the non-clinical and the clinical academics. The bar that they have to reach is very similar. However, the clinical academics are doing that in less time than their full-time researcher colleagues. Full-time researchers have 100%, whereas most clinical academics probably have no more than 50% of their time protected for research. Some of them, while they are in training fellowships, have 80% protected. There is a mismatch.
That means that lots of extra work gets done in people’s spare time and on their weekends. For a lot of people, it is not so much 50% to 50%, but more 100% to 100%, which again disadvantages many people who work less than full-time or who have family or other caring responsibilities. I am sorry, but I will have to ask you to remind me what the second part of your question was.
Lord Winston: It was about the time spent on actual research compared with clinical work. In most areas, I would suggest, quite often you cannot do both together.
Professor Charlotte Summers: In my experience, most of us probably spend about half our time doing clinical work or NHS-related duties and half our time doing research.
In the pandemic, turning 100% to doing clinical service for months at a time meant that entire research programmes came to a halt. That was disproportionate across the landscape. Some specialities were required to be there doing full-time clinical care, whereas other clinical services where there might have been clinical academics stopped almost entirely or were paused for a while, so they were able to spend much more time doing research. However, laboratories across the country shut and working from home on anything other than Covid research pretty much came to a halt, so even researchers who were not returning to the front line did not have access to do their usual research portfolio.
Some studies and some work have never been able to restart. We had months of laboratories being shut and cells being frozen down, vital resources lost and contracts coming to an end. People have had to move on. We have lost time and momentum for a lot of programmes.
Professor Paul Stewart: In answer to the question about balance, fundamentally it is about local university-NHS relationships. In a previous roles, where I was line-managing a large number of clinical academics, who, incidentally, went through the same joint clinical appraisal process as an NHS consultant, there was a coming together of the medical director and a dean to look at those job plans going forward. There can be great flexibility. As Charlotte said, although the norm would be a 50:50 split between clinical (NHS funded) and research (University funded), if somebody had just got a large major grant and needed a bit more time, there was an opportunity to be flexible to make sure that those deliveries were met. By and large, that joint appraisal process, if implemented properly, works extremely well.
The 20% of 20% comes from an Academy of Medical Sciences report that we published in 2018, which largely addressed the issue of the clinical researcher capacity in the NHS with some evidence based-work we did with the University of York. The 20% of research activity to 20% of the healthcare workforce was the sweet spot we came to that would not only dramatically change research culture across the NHS but deliver much-needed research capacity and research delivery. That is where that figure came from.
Lord Winston: Jamilla, what about you? Did you find that the research bit of clinical work with your colleagues shrunk sometimes, not during Covid but at other times, generally, with the pressures on the NHS?
Dr Jamilla Hussain: Again, it is the disparity. I was lucky. I was an integrated academic trainee as a clinical lecturer post PhD, funded by the NIHR. That was great, because, first, they gave us the opportunity to do the clinical work, which is absolutely what we as trainees wanted to do during Covid. But then the NIHR wrote letters to the heads of research and the TPDs to say, “It’s really important that this research is restarted”. Those letters carried weight. The training programme directors really took that and supported us to pick up our research again.
But there were disparities in how much it impacted different people’s research, for sure. It impacted people who were doing lab-based research because labs were completely closed down, even once we were into the second and third waves. What helped me was that, after that, I changed my research focus to inequalities because of Covid. I was able to write to the NIHR—
Lord Winston: Forgive me for interrupting you. I fully understand that. I am talking about non-Covid times, in a normally functioning NHS. Does the clinical work sometimes suppress the sort of research that you would like to do because you find that you cannot leave patient care that easily? That is one of the issues. I am asking about a tension that I feel there might be.
Dr Jamilla Hussain: There is a tension, for sure. As clinicians, we are personally dedicated to clinical care. It is what we want to do and what stimulates us to do the research, but we also know the value of research. With the NIHR integrated academic training programme, we have mentoring really early on that this is a career-long issue. You will always have to balance it.
The NIHR provides us with mentors to support us to learn how to do that, because it is important that we do not neglect the clinical side. That is what makes us different in our approach to research—the questions that we ask and all the things that we have discussed—but that tension is always there. Currently, it really is there, especially in places like Bradford, where we struggle to recruit and have poorer health outcomes, so there is greater pressure for those of us who are trying to do research in institutes that are not large. That tension will always be there, but it can also be fruitful, in that researchers who are committed to clinical work bring something different.[1]
Professor Charlotte Summers: I want to highlight that currently there are rota gaps in the NHS for staffing of junior doctors in particular, in almost every speciality in every hospital, which means that there is constant pressure for people to do more than their usual clinical amount. Without doubt, that impacts on people who are trying to balance both clinical and academic needs at the moment. It may not be in a formal, easily quantifiable way; they might receive an email or a text message saying, “There’s no one to cover the on-call tonight. Would you do it?” Sometimes the academics are the first port of call because it is thought that they are not doing anything else, they are doing their research. That is very much an experience that has been shared with me repeatedly and increasingly over the last five years. I am a director of clinical academic training in Cambridge, and it is something that I have been hearing with greater regularity over recent years.
Lord Winston: I must admit that that is what I was getting at.
The Chair: I have to ask everybody whether we can manage to move through the next batch of questions a little more quickly. We move to Baroness Rock, who joins us virtually.
Q6 Baroness Rock: We can probably be quite swift on this particular question, as we have touched on the multiple stakeholders already.
We have heard that there is difficulty and that the funders of research and clinical academic positions have different interests from universities and postgrad deans, whose interests differ again from those of hospitals or NHS trusts. Everyone has different interests. How do we better co-ordinate all these different interests in order to bring a more harmonious side of things? Perhaps Professor Summers could start.
Professor Charlotte Summers: Professor Stewart may be the best person, given that he has a leadership role that is very much about co-ordinating lots of these things.
Baroness Rock: Perfect. That is very kind.
Professor Paul Stewart: You ask a very relevant question. Juggling the many different stakeholders as a clinical academic can be a nightmare, with the funders, the universities and the direct professional care aspect, as well as, of course, the GMC, the regulators in our responsibility to the public.
As regards where the funders come together to effect much-needed change, there is an organisation already in existence. It is called OSCHR, the Office for Strategic Coordination of Health Research, and is currently chaired by Lord Kakkar. It brings together the chief executives of the MRC, the Wellcome Trust and NIHR, universities and other stakeholders, largely to try to ensure that the health research ecosystem is doing what it is contracted to do. I believe that it is an organisation that can act as a co-ordinator in this space. Indeed, the Academy was discussing this with Lord Kakkar just last week. OSCHR may need some modification to its terms of reference, accountability and what happens afterwards to implement change.
Better co-ordination is really important, not least a forum where one funder can share priorities with another, particularly as we have talked about the balance between pre-doctoral and post-doctoral support.
Baroness Rock: It is very encouraging to hear that work is already under way on co-ordination. Dr Hussain, do you have anything to add? Lord Chair, I am conscious that in the interests of time you may want to move on.
Dr Jamilla Hussain: I am happy to move on.
Q7 Baroness Walmsley: I will come to Professor Summers first, if I may, although she might just want to say, “Please refer to my answers to Baroness Blackwood and Lord Winston”. The question is this. How much can the problems facing clinical academia be resolved only by reducing pressures on the healthcare system generally and addressing issues such as the Covid backlog, delayed transfers of care, et cetera? Professor Summers, do you want to add anything to your very cogent responses to my colleagues?
Professor Charlotte Summers: Just to recapitulate that, in my view, to say that the situation as it stands is merely a function of the pandemic would be a mistake. There were systemic issues before that. In this situation, as in many others, the pandemic has applied pressure to a system that perhaps was not working as intended in the first place.
Baroness Walmsley: Professor Hussain?
Dr Jamilla Hussain: I do not have much to add. We have covered it. For the sake of time, I am happy to move on.
Baroness Walmsley: Professor Stewart, would you like to comment on the leadership role that you have?
Professor Paul Stewart: I will just highlight one thing. It is something I touched on in my introduction and involves slightly flipping the question. I am someone who brings 40 years of experience as a clinical academic, and it has always been like this. The NHS has always been a complex organisation that has been busy and probably without the workforce that it needs. What I see as clinical academia is the opportunity for us to become part of the solution, rather than part of the problem. We can help for example with issues such as workforce retention. We heard from Charlotte about some of the college surveys that have been done on how introducing research into people’s working job plan would dramatically impact on current issues such as job retention and recruitment.
You also look at what clinical academics do to transform the landscape—for example, what has happened across the north of England, on digital pathology implementation with incidentally similar technologies now in operation with digital radiology. Instead of having a very large workforce analysing and reporting on pathology samples and X-rays, with machine learning algorithms and digital data AI solutions, we have been able to dramatically improve pathways of care that also help address workforce issues. In many examples, clinical researchers are a cadre that can be the solution to some of the challenges we are talking about, rather than being something that we need to provide as and when we can afford it and when service pressures permit.
Baroness Walmsley: Can I clarify that? You think that it is a combination of job satisfaction and retention, and the ability to make the NHS more efficient and effective by using your input and the input of research.
Professor Paul Stewart: Exactly so.
Q8 Lord Mitchell: Good morning. Thank you for coming. Continuing from the previous question, what can be done, aside from easing pressure on the NHS? For example, would it be helpful to change the contracts of clinical academics? Should hospitals and university trusts be incentivised to give them specific, dedicated research time, as we understand they do for the teaching profession?
Professor Charlotte Summers: There is probably a list of things that could be done. One that we have raised so far is that at the moment there is the enormous issue, not just for clinical academics but across the NHS, of the pension tax that many of us are facing. That urgently needs addressing, both for retention of NHS workforce and for clinical academics, for the reason that we have discussed.
There is good practice in some areas of the NHS that could be disseminated. The salary funding for both Jamilla’s role and my role comes 100% from the NHS. In my case, the salary is given to the university to pay for me to spend part of my time doing research and part of my time doing clinical work because my NHS trust, Cambridge University Hospitals, has an enlightened approach and realises that research contributes greatly and that it is not just about being at the bedside delivering care. That is not an experience that is common everywhere.
Looking at the value of research and valuing it in the NHS workforce needs to happen not just in the health workforce for doctors in health and care. We will not improve public health and social care without research being embedded there, too. We need to look at embedding research across the entire health and care workforce as part of standard delivery of high-quality care.
Lord Mitchell: Professor Stewart, do you have any comment on the point about changing the contracts of clinical academics?
Professor Paul Stewart: I think we have dealt with that in previous questions. The principles are there, through the Follett principles, for the oversight of clinical academics with their NHS partner. That works effectively, but it needs local negotiations and partnerships to make it work. It is not consistent up and down the country. As we have already alluded to, there are slightly different practices in operation across the devolved nations, so it is by no means consistent. Where it does work, it works well.
Professor Charlotte Summers: There is one thing that I forgot to mention that would be addressable. If a medical clinician goes to work for a university, access to the NHS pension scheme remains open to them while they are working for their university. That is not the same for all healthcare workers. If a nurse does the same, they lose access to their NHS pension rights that have been built up over time. There is an inequality gap between medical university academics and non-medical academics that could be addressed, because we need everybody to be research-active.
Lord Mitchell: Is that for historic reasons? It does not seem very fair to me.
Professor Charlotte Summers: It does not, does it?
Dr Jamilla Hussain: There are inequalities across gender and ethnic minority groups and where people are doing the research. The major funders protect our time. It is about people being able to get into those major funding schemes and getting other research funders to recognise the importance of dedicated research time and it being protected. If we do 20% for the 20%, those clinicians will be the most squeezed, so protecting them to be able to do that 20% would increase our research capacity considerably.
Teaching is very different, in that you can turn up and do that bit for the day, if you do it one day a week. For research, it takes so much longer to think up your question and your study design, to get the funding and to make sure that it is done to the highest level. It is a different beast from teaching. That is why often researchers have to do much more than 50% to be able to compete with the other researchers who are focusing only on research.
Q9 Lord Rees of Ludlow: I have a question about funding. We heard from Professor Stewart about the role of Wellcome and OSCHR. Are there any tensions involving the various charities that exist to promote research in particular areas and on particular diseases? Do our other two panellists have any experience of or comments on that?
Professor Charlotte Summers: I can comment in my own area on heart and lung research. The major heart and lung research charities in the UK were seriously impacted by the pandemic. Lots of them rely on events and charitable donations, so the British Heart Foundation, what was the British Lung Foundation and places such as Cancer Research UK were all adversely affected over the last three years and have had to decrease the amount of money that they have available for research in recent times.
Lord Rees of Ludlow: Do charities ever constrain the kind of research that you do so that you do it differently from the way you would if you were making an optimum choice?
Professor Charlotte Summers: When people donate money to charity, sometimes it is unrestricted and sometimes the bequests are restricted for particular purposes, so that is quite a complex question to answer.
Dr Jamilla Hussain: My experience is the same. Palliative care is my area of expertise. Funding for palliative care is much more constrained than funding for a lot of other medical specialties. Marie Curie is one of our major research funders, we have to rely more on charitable research funding. There was a squeeze during Covid-19, but Marie Curie and other charitable funders have recognised that research is core to informing policy and practice. They are doing the best they can, but there are limitations on what they can fund versus a major funder like the NIHR or the MRC. Our aim as researchers is to get more funding, so we do not always go to charitable funders, but I have been quite impressed by charities that have come out of Covid-19, and despite fundraising constraints, have centred research and said, “Actually, this is core”. Marie Curie is one of those.
Lord Rees of Ludlow: Professor Stewart, do you have any further thoughts?
Professor Paul Stewart: Just one very quick snippet. First, the charity sector is an invaluable sector for our research. Something like 150–160 medical charities fund £1.4 billion a year to support medical research and of course provide a key link back to patients and the population at large. Most of them are small, and funding people becomes expensive, but there are areas of outstanding practice where a charity will partner with say the Medical Research Council, so that it does not have the overhead of administering the process but can also embark on joint funding schemes while still making sure that the charity’s mandate is delivered through the research. That is an excellent way of leveraging the charity research that we have at our disposal.
Q10 Lord Holmes of Richmond: Good morning to the witnesses. Thank you for taking the time to be with us this morning. Thank you particularly for your evidence on inequality, diversity and pensions, which are all incredibly important points.
To what extent do we need to integrate research more fully into the NHS and/or to change the culture of the NHS to have a greater focus on research? What good examples of initiatives in this area have you seen?
Professor Charlotte Summers: The NIHR investment in the clinical research network over decades is without doubt a stellar example of what can be built. Then the pandemic was able to leverage investment to enable us to deliver—I hesitate to use this word—world-beating research from the UK because of a decade’s-worth of investment. That meant that participants could be offered the opportunity to take part in research across the entire NHS infrastructure.
In my own case, I lead the UK’s post-acute Covid clinical trial. We are open at 110 hospital sites across all four nations of the United Kingdom. The biggest recruiters into that trial are small district general hospitals. We have worked very hard, amply supported by the NIHR CRN, to deliver research for patients across the nation. That would not be possible anywhere else in the world at that scale and that speed. Over the last few years, making research everybody’s business has shown exactly what can be achieved. In 2020-21, 1 million people, or more than that, went into NIHR portfolio research studies. That is an enormous achievement.
Dr Jamilla Hussain: The research institute I work at, the Bradford Institute for Health Research, is actually based on an NHS site. It is not associated with a higher education institute. Its core remit is to do research that will improve the health of people in Bradford and to work closely with the NHS. They did not have a consultant post for me, but because they recognise the importance of clinical academics and there is such a paucity of them in areas such as Bradford, they created a post for me and are funding me to do research. There are institutes, especially in areas that have poorer health outcomes, that are really trying and want to attract these people. The difference is that over many years the Bradford Institute for Health Research have developed relationships with the NHS and the local authority, and research is a core part of all of those. There are different ways of doing it.
Professor Paul Stewart: In addressing this question, perhaps the higher-level solution is to go back to looking in greater detail at NHS culture. Although the NHS is a truly wonderful organisation and has as one of its seven pillars research and innovation driving patient care, sadly, in its day-to-day operation, research and innovation play second fiddle to direct clinical care.
Many reports in the system have addressed that. A fundamental issue goes back to how Research & Innovation is represented across our trusts, their boards and at executive level. There is a much discussion and early work going on as to whether we should have CQC-type research metrics at board level, which might at least create greater awareness of the importance of research and innovation across our NHS organisations. To me, this is a critical issue. It needs culture change so that research is seen as mainstream, not something that can be afforded if someone else pays—in this case, the NIHR and other funders—or if service pressures allow.
Lord Holmes of Richmond: It is about leadership and culture. Thank you very much.
Q11 Viscount Hanworth: Mine is a catch-all question for the end of the session. If the NHS is to be considered a testbed for medical research, are we using it to its full potential? Are there instances where more can be done to exploit the opportunities?
Dr Jamilla Hussain: As we have discussed already, Covid-19 opened our eyes to what the NHS could do. We were doing world-leading research. The key thing was that clinicians on the ground were collecting the data. I could feel the buzz. People who had not been engaged with research before were collecting data, seeing the outputs coming back and noticing that their collection of data was making an impact on something that was so important right now.
There is a risk that that buzz is dying down because of the new pressures and what we are dealing with currently in the NHS, but Covid-19 sparked something. It is important that we try to maintain that and, as we have discussed, try to include those who are not on academic pathways. We have the clinical academics, who have dedicated time and are leading the research, but there is a whole host of clinicians working on the front line who want to be part of research. Giving them the capacity and the skills to do that would really help to make it a core part of the NHS’s business.
Viscount Hanworth: It has been said that the NHS generates much valuable data for epidemiological studies. Are we exploiting the resources sufficiently? Indeed, are we protecting our ownership of the data?
Professor Paul Stewart: The simple answer to your question is no. I come back to something I touched on before, which is that better health also signifies better wealth, and vice versa. We are talking about the NHS potentially being at the epicentre of the life sciences industry. This sector is one of the most rapidly growing globally; in 2022 the sector employed 268,000 people in the UK alone and had over 6,000 businesses, with a turnover of £89 billion. Greater digital connectivity across the NHS, greater organisation for doing research, with less bureaucracy, in an appropriate culture that values it, driving better patient care and, simultaneously, economic growth is a goal we all aspire to. There are examples where we are getting there, but we are certainly not maximising the opportunity ahead.
We have put forward a proposal from the Academy of Medical Sciences that would significantly help capacity and address many of the challenges that we have talked about today. It would be a new cadre, effectively, building on a prior initiative called the “New Blood” scheme, so called clinical innovator posts, that would be right at the interface of driving the pull-through of research career posts for clinical researchers post PhD in an interdisciplinary fashion in partnership with industry, with equality, diversity and inclusivity very much at its core.
We think that is much needed. It is an ideal opportunity to launch such a scheme and would ensure that the 7,000 trainees in the system have an appropriate pull-through career, so that that talent is not lost.
Viscount Hanworth: To come back to the data, some time ago it was suggested that drug companies were trying to pre-empt NHS data, and that it had to be protected. Do you have anything you can offer on that, Charlotte Summers?
Professor Charlotte Summers: The NHS is an invaluable resource as a testbed for innovation and research. One of the things that it has is a universal payer across the system, so there is a unique data network. Concerns have been raised about who might have access to that data, and there was a lot of publicity around whether people, at patient level, were happy to have their individual data shared or not. Sometimes, there was more heat than light in that discussion.
Coming back to the pandemic as an example, the regulations were suspended in some parts for us to be able to link data across the NHS so that we could understand what was happening, in both testing and genetic sequencing of the virus and with people and their healthcare outcomes, by linking data sources via the electronic health records. That had not been done before, and it has enabled us to deliver research at scale and results at scale, and inform the clinical care of patients in a way that was not delivered anywhere else in the world.
Balancing the opportunities and the challenges is really important, but to say that we should not share data or that that is not a commercially and research-valuable resource for the NHS would be unwise.
Viscount Hanworth: We are collecting and handling the data much better than we were in the past, because there were major computer disasters.
Professor Charlotte Summers: Yes. In my own clinical trial—the primary endpoint for the 110 hospitals that I talked about—nobody, once they have left hospital, ever has to do a clinic visit. The endpoint for the trial is collected by routine clinical data from things like NHS Digital or the equivalent in Scotland and the other devolved nations. Yes, it works much better than it ever has.
The Chair: That is very interesting. You have mentioned a number of things that have happened because of Covid that we need to hang on to and make sure that they do not disappear again. Patrick Vallance has talked about a number of other areas where we did things in Covid that we did not think we could do. We need to learn from that.
Q12 Lord Krebs: As a very final point, how are things done in other countries? Is our arrangement unusual, or are there clinical academics in France, Germany or the United States?
Professor Paul Stewart: I have some insight of so-called clinician scientists elsewhere through leadership roles in the US and other international organisations. I was at an advisory board of Aarhus University in Denmark last week. I have to say that there was a very similar discussion. The pressures on service care are immense across many of our international partners.
Some have slightly more rigorous ways of protecting research time in healthcare organisations. I am not sure that there are any models that I have seen internationally that would be the go-to solution. Indeed, usually in these conversations we are all sharing best practice. It is definitely an international issue.
Professor Charlotte Summers: Having spent time working in the United States, I echo what Paul said. The issues that I and my colleagues encountered there are very similar to those we have here.
Professor Paul Stewart: We do have a terrific health ecosystem, though, to get it right.
The Chair: Lord Winston, are there any final, follow-up questions you want to ask?
Lord Winston: No, thank you.
The Chair: In which case, I thank our panel very warmly, for a very interesting session. You mentioned one or two things that perhaps you did not have time to tell us about. If you could send us some further evidence, we would be delighted to see it, if you have a chance to do that. The meeting is now concluded. Thank you very much.
