Post-PhD milk and honey

“What is there after the PhD?” is probably the question people who are thinking about doing a PhD most commonly ask me. When people ask me this question there is a look on their faces that tells me they have been looking for an answer for a long time yet have not found one. Or sometimes they have found one but they remain healthily sceptical of its credibility.

My basic answer is that nobody knows. My honest belief is that the future certainly is not what the fancy brochures would have us believe. In my experience the picture sold as a post-PhD NMAHP clinical academic career is very much a hopeful vision, not a current reality. What do I mean by this?

The common vision describes a post-PhD life in which one is meaningfully clinically active and influential while also leading exciting, substantial research projects. Where one makes important national contributions, and plays a key role in supporting (and later working with/in) an NHS senior clinical leadership team. It’s a great vision, and one I am fully signed up to. It’s just that I am still waiting to see it actually happening.

The thing is, where it looks like it’s happening it is usually in the very early post-PhD stages. It’s the person with a PhD who is still happy to work in the 8a or 8b post, with the idea (quite rightly) that they need to develop further. But the problem is that this isn’t really the proper, full post-PhD progression… this is just the first steps.

Show me a senior NMAHP (on 8c or above, on a jointly funded NHS-HEI contract) who is both genuinely clinically active (with weekly patient contact and a proper senior leadership role within their NHS organisation) AND academically leading work (externally funded >£200k grants), and I will be delighted. Delighted that they exist, and keen to learn how they have done it and how we can roll it out.

In the meanwhile, recognising that we can’t expect others to sort this out for us, I have spent a lot of time thinking about why are we struggling to make this work – and what can we do differently.

There seems to be wide support for such senior roles, there are impressive national tasks forces doing great work to advance this, and this has been on the agenda for at least a decade now. So why are we struggling to create these roles?

I have a few thoughts on what some of the remaining issues might be… One is, I wonder if the vision we are trying to sell, about what a senior clinical academic adds, is too vague. We talk about more educated staff, better care, and better patient outcomes. And people like it – but not enough to open purse strings. And not enough to put up with the stir that introducing such roles would bring to the established NHS power hierarchies. To tackle this, I feel we need more specific data. Quantifiable change in productivity, difference in quality of care (mapping on the national standards that Trusts are audited on), and measured impact on patient health outcomes. But to have these we need a senior insider access, and even then for many NMAHP outcomes these data simply do not exist. So easier said than done.

Another thing is, I am not convinced that many managers genuinely buy the idea that a research active service produces better patient care and outcomes. Instead, research is seen as a fancy, unnecessarily expensive icing that the services can do without. Especially in the current financial, policy and governance climate where everyone is too busy worrying about survival to care about any icing, and too deep in the defences to realise that research and innovation is the very straw to survival. In my experience the only way to tackle this is through slow relationship building and demonstration of what we can do. But this comes at a huge professional and personal cost as this takes a lot of (usually unpaid) time and emotional effort over several years. That is time one could use to advance other goals, such as to generate the much needed evidence our fields need.

Finally, I feel none of this is helped by the NHS funding structures. Many AHP services continue to be funded based on activity (i.e. what people do) not on outcomes. For as long as the focus continues to be solely on the number of patients I see, without any attention to what I actually do with them (the content of my interventions) and whether I actually achieve anything positive (the outcomes), then it is hard for me to quantifiably demonstrate any added value compared to a much cheaper, lower band clinician. And these structures are hard for individual clinical academics to change. My current attempt is integrating health economics to my research, but that will take a 5-year study…

So where does all this leave the post-PhD future? As said, I honestly do not know. Do I think it’s still worth doing a PhD? Oh yes – as things get more and more difficult in the NHS, a PhD is a way to open more options for yourself. But I do encourage people to do it with open eyes – it’s no ticket to milk and honey.