Richard Hobbs is a Pro-Vice-Chancellor at the University of Oxford, where he holds the inaugural PCRT Mercian Chair in Primary Care (2022-)
Previously the inaugural Nuffield Professor of Primary Care (2011-22) at the Nuffield Department of Primary Care Health Sciences (2011-2024), he remains Director of the Oxford Institute of Digital Health (2020-) and is Lead for Global Partnerships for Oxford Primary Care. He delivered 42 years of service to the NHS as a doctor, 38 years committed to a disadvantaged and challenging inner-city practice until 2019, and 34 years of leadership and excellence as a clinical scientist focussed mainly upon primary care, clinical epidemiology, and vascular disease.
He is one of the world’s foremost primary care academics and has held many national and international leadership roles, leading the development of two of Europe’s most highly rated centres for academic primary care, firstly at Birmingham and since 2011 at Oxford, now one of the largest and most successful centres for academic primary care in the world. He has made major contributions to growing primary care academic capacity, in terms of people development and research networks. He was the fifth recipient of the RCGP Discovery Prize in 2018 (occasional awards since 1953) and was awarded a CBE for services to medical research in 2018 in the Queen’s New Year’s Honours List. He has an outstanding track record in cardiovascular disease research, delivering trials that changed international guidelines and practice, especially in the areas of stroke prevention in atrial fibrillation (BAFTA, SAFE, and SMART trials), heart failure burden and diagnosis (ECHOES and REFER trials), and hypertension self-management (TASMINH 1-5).
He made many non-remunerated contributions to educational charitable boards, serving as trustee on some 7 learned societies and universities. Within universities, he has led several major change initiatives and the associated people management within Oxford University. He also leads a new Institute of Applied Digital Science at Oxford.
At the onset of COVID-19 he re-tasked much of his research to urgent COVID studies and is co-Chief Investigator of all the UK National Urgent Public Health Priority Studies in primary care, namely the national repurposed therapies platform trial (PRINCIPLE), national COVID Surveillance (Oxford-RCGP RSC), the national PC diagnostics platform trial (RAPTOR/CONDOR), and the national COVID novel anti-viral platform trial (PANORAMIC). Several papers during Covid ranked top 10 in the world for downloads by SSRN, who also list him as a ‘highly cited global researcher’.
He has authored over 600 peer reviewed publications, has an h-index of 121, i10-index of 498, with >140,000 citations (>60,000 since 2019), with 136 papers with >100 citations, 20 papers >1000, and 15 papers >2000.
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“…it’s our responsibility as a discipline to become more certain about which clinical pathways are worth considering and which are those we should not pursue and contributing to those holes in our evidence base was a natural fit for my interests.”
Domhnall MacAuley: Welcome to MedicsVoices.com where we talk to the key opinion leaders and health and medicine around the world. Today I’m talking to Richard Hobbs in Oxford. Richard is the Mercian Professor of Primary Care. But he has another title – Pro-Vice-Chancellor without portfolio. What does that mean?
Richard Hobbs: The Pro-Vice-Chancellor role is an non-executive position within the university but I’m not responsible for a designated functional area, such as the designated Pro-Vice Chancellors in areas like research, teaching, for personnel etc. The ‘without portfolio’ roles are largely ceremonial. I will sometimes deputize for the Vice Chancellor at certain events, particularly things like matriculation or, most importantly, graduation. There are other events such as lectures or occasions that require a ‘procession’ i.e. a senior representative of the university, processing (leading a group of people) to the point at which somebody does something. It might be giving a lecture, it might be giving a sermon, those sorts of occasions. And the final responsibility is that Pro-Vice-Chancellors without portfolio can act as a chair on appointment committees for statutory chairs, which are the most senior academic appointments within the university. Oxford is a very big university and the Vice Chancellor is incredibly busy so it’s necessary therefore to have a sufficient cohort of people who are capable of taking on those largely ceremonial roles, although these do carry key responsibilities in some of the most important processes of the university.
DMacA: Pro-Vice-Chancellor at Oxford is clearly a very senior academic position. But, let’s take you back to the very beginning. Tell us about where you grew up, where you were at school, and were you academic at that stage?
RH: I but spent most of my schooling in Birmingham, actually. My family moved around quite a lot until I was primary school age and then they settled down in Birmingham. I went to a pretty small primary school but it’s such a long time ago, I don’t remember too much about that. I did the ‘11 plus’ which got me into a grant maintained, effectively a grammar school, in Birmingham which was quite well endowed in terms of buildings and facilities. I would say I did moderately well. I was probably in the top sort of quarter if I remember rightly, but not the top student. I did win a couple of prizes around biology and, at that age, I was very keen to go to university, largely to become an independent adult. A big motivation for me to go to university for quite a long time so I was looking at medicine and architecture as my preferred courses. And, I ended up doing medicine.
DMacA: Any reason for choosing medicine?
RH: I suppose I did have a sort of vocational interest in a caring subject. I thought architecture would have been interesting from the point of view of designing communities but I thought it would probably be easier to be a successful doctor than a successful architect. Nobody in my family had done medicine previously so it wasn’t a subject I knew very much about, to be honest.
(As a student) “I spent huge amounts of time on topics that have had no relevance for me in my clinical career. And even, frankly, when I started doing my medical rotations, I found that a lot of what we were taught was wrong. It was presented as factual and immutable but this was before evidence-based medicine and opinion-based medicine ruled the roost.”
DMacA: You went to Bristol Medical School, tell us about that experience.
RH: That was an interesting place. I loved Bristol, I made a lot of friends. It was quite a small cohort in Bristol. I was in halls of residence in year one, which meant I developed a lot of friendships outside of medicine. I actually didn’t have that many friends within the medical program. And, in retrospect, I think that was a good move because I think it socialized me and created, me thinking about things I hadn’t really thought about or experienced during my life. I think I was a fairly passive sort of individual but mixing with quite a wide range of subject areas. I have to say that I think this is also one of the huge benefits of an Oxford education where, within a college environment, you are naturally exposed to all sorts of disciplines beyond the topic that you are studying.
I have to say, I think the course at Bristol was in retrospect useless for medicine. I spent huge amounts of time on topics that have had no relevance for me in my clinical career. And even, frankly, when I started doing my medical rotations, I found that a lot of what we were taught was wrong. It was presented as factual and immutable but this was before evidence-based medicine and opinion-based medicine ruled the roost. So, it didn’t equip me very well for my first house jobs, or rather year four of my five year programme when I rotated to my District General Hospital attachment in Bath. When I turned up as the fourth year medical student, the consultant greeted me saying “Oh, I’m glad that you’ve come on time because the houseman is sick and you’re doing his locum for two weeks.” That was a baptism of fire but I think that made me as a clinician. That two weeks was unbelievably stressful, unbelievably frustrating, but it really taught me what I needed to know in my final year of medicine. It would be illegal now, of course, but it was indeed a baptism of fire and, I learned many things about myself and about my relationship with patients.
DMacA: Let’s talk about that because you are speaking about an era in medicine where general practice wasn’t held in the highest esteem, and yet you steered towards general practice. Tell us about that career development.
RH: Yes. You’re quite right. It was really viewed as a lesser discipline. In fact, I didn’t even imagine that general practice was a career option until my final year. We had a two-week attachment in Bristol in the final year of the program, and for the first week I was attached to an inner-city general practice in Montpellier, where I was a bit shocked to be honest. Money changed hands with virtually every consultation. If you wanted 2 or 3 sick notes you could get them. For my second week I was attached to a practice in Bath, which was absolutely transformative because it was a perfectly ordinary general practice but they practised real medicine and I thought, you can actually practise medicine outside of hospitals; clinical acumen, home visits, they were nice to patients, patients were grateful for the care they were receiving. It was a complete revelation since I’d never even contemplated general practice. That was quite important for me because, up to that point, I wanted to do Cardiology in Bristol which was very elitist subject at the time. I got on quite well with the cardiologists. I don’t know why because I quite long hair and wore clogs, and they were unbelievably fierce with medical students on their rounds. But I think I must have been reasonable in my responses on ward rounds because I had no problems with the consultants and they were quite encouraging during the rotations. In my first year I did a four month rotation which included acute cardiology. Historically that was really interesting because I was the first cohort that actually covered the coronary care units. They didn’t have coronary care units in Bath prior to 1977, and that was quite a baptism of fire as well. At that time, I thought I was going to have a career in cardiology.
I think I was the last year of doctors who did not have to do vocational training if they chose general practice. It became compulsory. either the following year or the year after that. But, I had enjoyed my experience of general practice in Bath so I decided to join a GP vocational training scheme. Many consultants actually did do GP sessions part time at that point and many of them gravitated to general practice at some point in their career. So, I thought I might as well get the training, even though I didn’t actually need it. And the rest is what happened to me…
DMacA: You’ve steered towards general practice, but you also returned to Birmingham and you worked in Bellevue practice and you’ve spent your entire clinical career there.
RH: I had been accepted onto a GP rotation just outside London and I thought I was going to be London based after Bristol, but my father died very suddenly and I thought I’d move back to do my three years vocational training there in order to support my mother but, as you say, I just got stuck.
DMacA: That wasn’t an ordinary general practice because you had some interesting partners.
RH: My vocational training practice was actually the university practice. And, as you say, they were quite an interesting bunch of individuals. The practice population was undergraduates, so you could argue that that was not a very good training environment. But my trainer was an interesting clinician and he made sure I went all over the region. During that year I think I visited about 25 practices or so. I developed an interest and I decided to defer my cardiology interest and stick with general practice for a little while.
I was pretty socialist at that point in my life as well, and I decided that I wanted to pay back my dues to society by applying to a single handed inner city practice. And I thought, well, if I do it couple of years there, I’ve done my equivalent of National Service and I could go and do something else for the rest of my career. But I got committed to that inner city practice. It was a single-handed practice where the partner wanted to appoint a sessional doctor. She had 4000 patients on the list and I said that, unfortunately, I couldn’t afford to do that- ‘I can’t accept a part time position but I’m absolutely certain that if you did appoint me that we would make more money individually with the two of us than you’re making as one person’. She wasn’t completely convinced because she wanted to appoint a consultant but her husband, who was a professor at Birmingham, was calling down from upstairs and said- ‘don’t be so stupid, appoint him’. I ended up there and the year eventually turned into 38 years.
“I think the investment in creating a durable infrastructure is probably what I should be most proud of. … I had a fairly good idea how you could create an environment that was self-replicating but also delivered serious academic outputs and had serious impact. And, I think we’ve achieved that in the department over the last 12 to 13 years.”
A selection of some of the books authored by Richard Hobbs
DMacA: Together with your 38 years in clinical practice in Birmingham, you had an academic career. And, interestingly, your academic career veered back to cardiology. So, tell us about the progress of your academic career.
RH: It was a really busy practice, with 11 consulting sessions a week, and I had been doing 100 hour weeks in hospital and I thought, I’m going to get terrible burnout if I just do this. Early on I knew I wanted to do something that was not only in general practice but linked to general practice and I applied to become a trainer within nine months of getting into general practice. This caused a bit of a problem for the Region because at that point you had to have been a GP for two and a half years before they’d let you be a trainer. After a bit of discussion, they agreed to appoint me as a trainer after 12 months, and we took a trainee into the practice. I then applied for an unusual appointment at the university, which included a couple of sessions in the undergraduate department and a couple of sessions for the Region so I became an Associate Advisor and ran the regional study days for trainees for several years. That was based in the academic department at Birmingham which was tiny. There was a part-time associate professor Robin Hull, a part time professor, Michael Drury and there was me. I think it comprised less than one full time equivalent between the three of us in medical academic roles. It was a tiny department with two small rooms in the medical school. Almost immediately after I’d been appointed, both of my seniors left me to it. Michael, a very charismatic and politically astute academic, was appointed as President of the College and had to devolve most of the work to me. Robin, the other senior academic, who was a lovely guy and a talented educationalist, took a secondment for a year to the Free University in the Netherlands. And, I was left, basically, on my own. From that grew my academic career.
DMacA: You’ve had a stellar academic career, what are the highlights for you?
RH: I think the investment in creating a durable infrastructure is probably what I should be most proud of. I’d built up a very successful large department at Birmingham but Birmingham used to swing from autocratic leadership to devolved responsibility. I didn’t really prosper when there was autocratic leadership but really prospered during the time of devolved responsibility. When eventually I left Birmingham I was actually looking for something completely different, but I was approached by Sir John Bell from Oxford. They had tried to appoint to the vacant chair in the Primary Care unit at Oxford and had failed to do so. So I was approached about whether I had any interest in it. I wasn’t certain because, to be honest, it was a bit of a sideways move at the time. I had been thinking about doing something completely different but I thought I would look at it. I’d considered moving to Imperial College a couple of times but hadn’t moved there and then this came along. Once I’d left Birmingham, tragically, the department largely folded, which taught me a lesson about the durability of infrastructure. I knew that if I did move to Oxford, I would want to make sure that that didn’t happen again. I had a fairly good idea how you could create an environment that was self-replicating but also delivered serious academic outputs and had serious impact. And, I think we’ve achieved that in the department over the last 12 to 13 years.
DMacA: You’re completed three, and perhaps more, major randomized controlled trials in cardiology that have been absolutely ground-breaking. How did that develop.
RH: Evidence based medicine had just got going after I qualified and I did feel that quite a lot of the factual knowledge I was given at medical school did not equip me for practicing medicine because, as it turned out, a lot of it was wrong. A lot of it was disabling, actually, because I think it was harming patients. There were patients that I’d had to sit beside when they were dying in a hospital bed having had horrendous procedures. I worked for some heroic surgeons, and at the time you think these are fantastic people, men principally, who undertook surgery on these patients when there was nothing else to try. In retrospect, I decided this was really poor medicine and informed consent was lacking. So I felt that I would want my practice to be guided by a reasonably secure evidence base. There is so much of medicine that has not been subject to rigorous evaluation that it’s been natural for me to think about how we could make a contribution. Another factor, right back to what you started with, was that general practice did not have a good reputation for much of my career. It did get better, although it’s now actually got worse again now. Part of that is a perception, that is wrong now, that we have a discipline that is not strongly rooted in science and is therefore, by definition, a craft discipline rather than a scientifically based discipline. I disagree with that. But I also think it’s our responsibility as a discipline to become more certain about which clinical pathways are worth considering and which are those we should not pursue and contributing to those holes in our evidence base was a natural fit for my interests.
To do these things properly you do have to have significant infrastructure. You do have to have an investment in skills training and opportunities to progress, and you need to specialist skills, whether they be statistics, health economics or, increasingly, information science but also the social sciences. It’s inherently multidisciplinary and you need to invest in people and infrastructure. Those are natural interests of mine. I do quite like sort of organizing things, whether it’s designing a building or working at how an investment over a few years might achieve certain objectives. And that is effectively what you do when you design a clinical trial. So, that was the main reason for those.
The BAFTA trial, which was pivotal, was a trial of warfarin regulation versus low dose aspirin in relation to stroke prevention in atrial fibrillation. That came from a clinical case because I had been caring for an elderly patient, a lovely lady of about 85 who was completely independent, who was on warfarin for AF and she said ‘I don’t really want to carry on taking these pills. Do you think it’s necessary?’ And I said, ‘Well, to be honest, there isn’t an evidence base for it and I don’t know. I can’t tell you if it’s definitely advantageous for you to continue’. Anyway, she decided to stop. Two weeks later, she came in having had a saddle embolus which blocked both her common iliac arteries, and she was very lucky that she didn’t lose her legs. That made me wish I’d known what the evidence was. Hers was not a stroke prevented but it was a thrombotic episode prevented by warfarin. Hence, a stimulus for the trial. It was a difficult trial to recruit to and the MRC repeatedly tried to stop the study. It was difficult to recruit to and it was difficult to get the necessary follow up. However, we did manage to stagger to the finishing line in the end. And, in the end it was a very significant trial result which basically showed that low dose aspirin has no place in thromboprophylaxis as an alternative to existing evidence based treatment. The thinking at the time had been to just use low dose aspirin in the elderly which although it might be less beneficial, was at least it’s safer. It’s really important to test those assumptions because that was not the case. Aspirin had a similar risk profile to warfarin. Amusingly, that clinical trial would have made us quite famous internationally, if it hadn’t been for the onset of the new direct thrombin inhibitors and the unbelievable billions of dollars that was spent promoting those. Otherwise, we would have probably had more invitations to speak at major congresses around the world and become a bit more famous. We had killed off aspirin for them but they had drugs which were better than warfarin. We were beaten to it- there you go.
“I really do think that academic general practice currently punches above its weight. If you look at the volume of investment in academic primary care, it’s paltry compared to other disciplines.”
DMacA: Let’s bring you back up to date, or almost up to date, because you’ve had a number of awards and prizes through your career, and you were awarded a CBE. At the end of your career, it must be rewarding to have your work recognized.
RH: Yes. I think it is. And, I think it’s important for the discipline as well. I really do think that academic general practice currently punches above its weight. If you look at the volume of investment in academic primary care, it’s paltry compared to other disciplines. You might have a Department of Cardiology of a similar size to a successful research based Primary Care department but I think our impact in terms of recognition is minuscule. For example, if you look to the honours award system, and there hasn’t been an FRS from general practice yet. I think recognition is important for the discipline and the relatively low proportion of awards the discipline receives is probably a reflection of systematic under estimation of its importance to health care and to academic pursuits, including the training of a future generation of doctors whether they go into general practice or not.
DMacA: That’s a very good note to end on. Richard, thank you very much for sharing so much of your career and giving us those insights into what has driven you to such high achievement. Thank you very much.
