Collapsing clinical academia, unemployed doctors and a crisis in commercial clinical research

Opinion
The NHS and life sciences sector in the UK are undergoing a period of existential introspection. The Labour government has been energetic; producing policy papers that set out the path back to world-leading excellence. The NHS Ten Year Plan, The Life Science Sector Deal, the MRC report ‘Clinical researchers in the United Kingdom: Reversing the decline to improve population health and promote economic growth in the UK’ (and specifically the sub report on medically qualified researchers) and many others have all been published in recent months and continue to be poured over and digested.

A recent opinion piece in the British Medical Journal (The UK is rapidly losing medical academics and without them the NHS 10 year plan is at risk | The BMJ) by our colleagues David Strain and Jonathan Gibbs points out that without a clear plan to reverse the accelerating collapse of medical academia in the UK, these plans will be undeliverable. I agree.

But how did we get here, and where do we go next?

Erosion of Specialty Training and Research Posts
The recent passing of Sir Kenneth Calman gave me pause to think about how we ended up here. As Chief Medical Officer in the 1990s, Calman was a central architect of the reforms that eventually became Modernising Medical Careers (MMC); changes that, at the time, promised to streamline training but in practice upended career pathways.

These changes to training flattened out all the little pauses where you used to be able to kick off a research post, build your CV, flood Nature with abstracts, and get your foot in the academic door. Now trainees are thrown into service with limited opportunity to develop an academic career. The COVID years created even greater pressure on all our medical staff to simply deliver service.

What was intended as a tidier, faster system too often left talented trainees without the means to strengthen their CVs, and in some cases, without a clear route forward at all.

Fast forward twenty years and we can see now ever more clearly the consequences: not just a waning academic workforce, so eloquently described by Strain and Giobbs, but an actual fear of unemployment among resident doctors, with (according to recent BMA reports) 30,000 doctors competing for 10,000 training spaces and with no obvious place to go (except, perhaps, the Antipodes) if they aren’t successful (BMA seeks deal on doctor unemployment as survey reveals half of resident doctors finishing foundation training have no job for next month – BMA media centre – BMA). Many of those who don’t secure a training post would previously have done a research post to strengthen their cv and come back for another go the following year. Some would have fallen in love with academic medicine and would have kept it on through their career. That’s what we lost.

The Waning of Clinical Academic Workforce
And the consequence is a crisis in clinical academia. A recent UKRI-commissioned report starkly illustrates the scale of decline: medically trained clinical researchers are both shrinking in number and failing to keep pace with NHS expansion. The response? A clarion call for a national clinical research career framework, flexible entry/exit pathways, visible mentorship, equitable pay, and transparent career progression.

Similarly, the Medical Schools Council reports that clinical academics are an ageing workforce with over one-third now aged over 55. Despite growth in Lecturer-grade posts, mid-career positions like Reader and Senior Lecturer have seen a 25% decline between 2011 and 2021. These trends jeopardise both research and teaching capacity.

These points, and more, are well made by Strain and Gibbs in their recent article.

Calman’s Legacy and the Undoing of a Balanced Model
Sir Kenneth Calman exemplified the “complete clinician”. A doctor equally at home in teaching, research, policy, and public engagement. His generation benefited from a world where trainees could engage in funded Clinical Research Fellowships, commercial or charity trials, and academic roles; all contributing to both career development and health innovation.

Now imagine a trainee of similar drive: denied access to research time, lacking a clear academic trajectory, and cut off from the commercial trial ecosystem. The contrast is not just personal; it reflects a systemic failure.

And it may be set to get worse. The NHS ten year plan talks a lot about medical education and the future workforce. The plan puts digital assistance and competency based assessment at the heart of medical workforce training. It envisages, in my reading of it, a world of more protocolized health care delivery, more generalised care delivered in neighbourhood health services (as opposed to hospital care), with doctors as supervisors of even more complex multi-disciplinary teams incorporating those in more traditionally social care roles.

Medical training in the UK is already shorter than it was pre-Calman, and considerably shorter than other comparable countries. Further streamlining of training, greater reliance on simulation and further moves away from the traditional apprenticeship model are unlikely to reverse the problems we have described in medical academia, and indeed are likely to accelerate the existing trends.

Restoring Opportunity: A Practical Framework
So what can we do?  Well, any future workforce plan needs to think very carefully beyond the narrow constraints of NHS service delivery and build on the vision the Government rightly has of the UK as a leader in life sciences, fueling future economic growth.

Of course, there are some practical steps that we can take. These include reintroducing funded research posts within training programs, both academic and commercial, to rebuild the CV-building opportunities that trainees once relied on and creating a national clinical academic career framework; enable flexible training pathways with exit and re-entry; and mandate mentorship and equitable pay.

But actually I think we must try and somehow return to the holistic model of clinician–academic–leader that we’ve lost since Calman; valuing not just technical expertise, but empathy, mentorship, and public service.  We must acknowledge that developing those skills takes time, and ensure our system is built to give security and reassurance to trainees that if they are patient and build their skills they will go on to work in a UK health care system that is truly world class.

Conclusion
The current crisis in UK medical academia didn’t happen overnight, but it can be reversed. By reinvesting in research training, rebuilding clinical academic pathways, and embracing commercial trial reactivation, we can reclaim the best of what medical education once offered.