Alan Maynard (below) and Michael Rees (right) suggest cures for two ills of the NHS on its 50th birthday

The report commissioned by the Committee of Vice-Chancellors and Principals from Sir Rex Richards in response to mounting concern about the future of academic medicine was published in June 1997. This confirmed widespread malaise in academic medicine, including difficulties recruiting doctors and several factors adversely affecting working conditions, particularly at the interface between universities and the National Health Service.

The malaise was exacerbated by the implementation of the specialist registrar training grade which provided no incentives for traditional patterns of research and academic activity. The report confirmed the few advantages and many disincentives of an academic medical career compared to one in the NHS. It listed 35 recommendations to meet the continuing needs of developing a thriving clinical medical workforce in universities and to allow these doctors to dovetail their academic and NHS duties.

Many of the recommendations were commonsensical: the adequate provision, for instance, of secretarial support for NHS duties and reimbursement of the costs of relocation.

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But the impact of some of the recommendations is of fundamental importance, including that "any increase in the target numbers for medical student admissions must be accompanied by a corresponding increase in the numbers of clinical academic staff and the facilities to accommodate them".

This central issue has been forgotten in the rush by universities to bid for the increase in the numbers of medical students following the Campbell report, which recommended increasing the medical student intake by 1,000 per year.

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Understandably, doctors and managers in the NHS are expressing concern that the burden of educating these new students will fall on the NHS as there are already too few clinical academics to teach the current numbers of students.

Since the Richards report was published there has been silence from the CVCP and the departments of health and education, and, despite positive soundings from the House of Commons science and technology committee, there has been no visible discussion of the Richards report and no implementation of its findings.

Does this matter? It certainly matters to the hard-pressed clinical academics that they should have working conditions that allow them to carry out their duties effectively and to balance their research, teaching and clinical commitments. Most clinical academics are finding this an impossible task, particularly as a result of the skewed priorities that have resulted from the research assessment exercise. It also matters to doctors thinking of taking up a career in academic medicine who have been increasingly thin on the ground as it becomes harder and harder to persuade them of the virtues of an academic career.

As time has passed the crisis has deepened and the need for more fundamental changes than those identified by Richards has emerged.

One of the most urgent is to establish a workable career structure in academic medicine that allows for the pursuit of research and teaching together with the ability to obtain the necessary clinical training and qualifications which will enable doctors with an academic interest to obtain specialist status.

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At present there is no structure to provide the clinical academics of the future. Doctors are understandably reluctant to take research posts when these do not have national training numbers which is the prerequisite for attaining specialist status.

One solution would be to have some national training numbers reserved in each speciality for doctors to undertake academic training. These posts could then incorporate research experience in the form of undertaking a PhD or teaching-based training in addition to fulfilling the requirement for completion of the certificate of specialist training.

This would involve a seven or eight-year contract between the NHS and the university, the clinical training component of which would take a similar form to the flexible training scheme that already exists for those doctors eligible to undertake part-time training in the NHS.

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This could be accompanied by a fresh look at academic titles and grading to provide career incentives such as an adoption of the European system of promotion so a training/ research grade doctor would be appointed as a lecturer progressing to assistant professor dependent on academic progress with the aim of further promotion in an academic career to associate and full professorial status.

Promotion should be based on both teaching and research and can be linked to NHS grades via honorary contracts, which would determine pay. The adoption of this type of system would make academic interchange with Europe easier and foster international research and development.

A constant theme of Richards's recommendations is that vice-chancellors, deans and chief executives of NHS trusts should work together to ease the difficulties in academic medicine. One year on it is not too late for this to happen and it is timely to rescue this valuable report from the dusty shelves of the CVCP to give it the consideration that it is due.

Michael Rees is professor in the department of clinical radiology at the University of Bristol and a consultant at Bristol Royal Infirmary.

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